Abstract
Research shows that married cancer patients have lower mortality than unmarried patients but few data exist for breast cancer. We assessed total mortality associated with marital status, with attention to differences by race/ethnicity, tumor subtype, and neighborhood socioeconomic status (nSES). We included, from the population-based California Cancer Registry, women ages 18 and older with invasive breast cancer diagnosed between 2005 and 2012 with follow-up through December 2013. We estimated mortality rate ratios (MRR) and 95% confidence intervals (CI) for total mortality by nSES, race/ethnicity, and tumor subtype. Among 145,564 breast cancer cases, 42.7% were unmarried at the time of diagnosis. In multivariable-adjusted models, the MRR (95% CI) for unmarried compared to married women was 1.28 (1.24–1.32) for total mortality. Significant interactions were observed by race/ethnicity (P<0.001), tumor subtype (P<0.001), and nSES (P = 0.009). Higher MRRs were observed for non-Hispanic whites and Asians/Pacific Islanders than for blacks or Hispanics, and for HR+/HER2+ tumors than other subtypes. Assessment of interactive effect between marital status and nSES showed that unmarried women living in low SES neighborhoods had a higher risk of dying compared with married women in high SES neighborhoods (MRR = 1.60; 95% CI: 1.53–1.67). Unmarried breast cancer patients have higher total mortality than married patients; the association varies by race/ethnicity, tumor subtype, and nSES. Unmarried status should be further evaluated as a breast cancer prognostic factor. Identification of underlying causes of the marital status associations is needed to design interventions that could improve survival for unmarried breast cancer patients.
Highlights
A growing body of evidence shows that mortality following a cancer diagnosis is higher in unmarried than married patients [1,2,3,4]
Among the 145,564 breast cancer patients included in the analyses, 22,610 deaths from any cause occurred during a total of 620,692 person-years of follow-up
Larger associations among non-Hispanic white (NHW) and Asians/Pacific Islanders (APIs) women, US-born Hispanics and APIs, and patients diagnosed with HR+/HER2- tumors were observed
Summary
A growing body of evidence shows that mortality following a cancer diagnosis is higher in unmarried than married patients [1,2,3,4]. Some published reports included marital status as a covariate in multivariable analyses [7,8,9], but, to our knowledge, a focused examination of the specific effect of marital status on breast cancer survival in different racial/ethnic populations or by tumor subtype has not been reported. A more recent study conducted in a safety net hospital reported an over 2-fold increase in breast cancer mortality in single versus married breast cancer patients [5]. None of these studies examined whether the marital status effects on survival differ across patient subgroups or tumor subtypes
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