Partner status and survival after cancer: A competing risks analysis
Introduction
The protective effect of marriage on overall cancer survival [1] has been well established. Emerging evidence also suggests that the survival benefit for married patients may be increasing over time [2]. The protective effect of marriage may reflect increased social support over the cancer continuum from diagnosis to survivorship to buffer the adverse effects of stress-related biological processes and immune responses [1], [3]. Having a partner may also provide a source of financial, practical and emotional support while undergoing treatment and has been linked to more timely care, increased receipt of curative therapies, greater compliance with multi-modal treatments and improved psychosocial outcomes [1], [3], [4], [5], [6], [7], [8], [9].
Results from studies that combine cancer sites may be affected by too much aggregation across different diseases. However findings to date on the impact of being married on cause-specific survival for individual cancer sites are equivocal with non-significant [6], [10], protective [4], [5], [11], [12], [13], [14], [15] and mixed effects [16], [17] being reported after adjusting for various combinations of known survival determinants. Some [4], [12], [16] but not all [15], [18] studies also reported that the partner effect varied by gender. These inconsistencies likely reflect the heterogeneity in time period, cohort characteristic, covariates included in statistical models and definition of marital status across studies. While several categorized patients as married or unmarried based on official marital status categories [4], [5], [13], [14] or extended the married group to also include partnered patients [11], [12], others split the unmarried category into sub-groups (single, widowed, divorced or separated) [6], [15], [16], [17].
The impact of partner status has typically being reported using net survival [4], [10], [12], [15], describing the hypothetical situation where the diagnosed cancer is the only cause of death [19]. In the real world, however patients are at risk of death from various mutually exclusive causes. Hence partitioning overall mortality into different causes has the potential to provide a richer understanding of the impact having a partner has on survival after a cancer diagnosis [20], [21]. To date, only a few studies have reported on the beneficial effects of having a partner on both cancer-specific [5], [22], [23], [24] and competing mortality causes [22], [24], however none have systematically compared these effects across multiple cancer sites. In this study we quantified the survival benefit of being partnered for each of the ten leading cancers diagnosed in Queensland, Australia using population-based data and competing risk methods [21].
Section snippets
Methods
Approval for the use of these de-identified data was obtained from the data custodian, Queensland Health. In addition, ethics and data custodian approval for the extraction of stage information was obtained by The University of Queensland Social and Behavioural Sciences Ethical Review Committee and Queensland Health.
Data were extracted from the population-based Queensland Cancer Registry, to which notifications of any cancer diagnosis (except keratinocyte cancers) is a statutory requirement [25]
Results
Out of 176,050 patients in the final cohort, 68% had a partner. Partnered patients were, on average, three years younger at diagnosis than unpartnered patients (median age 63 versus 66 years), were more likely to be males (61% versus 39%, p < 0.001) and had a lower 10-year cumulative probability of death (46% versus 58% for males and 40% versus 48% for females) over combined sites (Table 1).
Discussion
We have systematically evaluated the impact of partner status on survival following a cancer diagnosis using state wide population-based cancer registry data. The results of the competing risks analysis illustrated the beneficial effects of being partnered on survival for cancer patients with unpartnered patients being not only at increased risk of deaths from their diagnosed cancer but also from competing causes. A consistent pattern of higher total estimated 10-year cumulative probability of
Conclusions
Our analysis suggests that the subgroup of cancer patients who are without a partner when diagnosed with cancer are at increased risk of mortality within ten years from both their primary cancer and competing mortality causes. As such health professionals managing cancer patients should be aware of the increased mortality risk among unpartnered patients and tailor follow-up accordingly. In particular, it is important to better understand the mechanisms by which having a partner is beneficial
Contributors
PDB conceived the study. PD performed the analysis. PD and PDB drafted the manuscript. All authors contributed to, read and approved the final manuscript.
Funding
Professor Gavin Turrell is supported by a NHMRC Senior Research Fellowship (ID 1003710). The NHMRC is an external funding agency that provided funds to conduct this research. They had no input into the content or conclusions of this paper.
Conflict of interest
Conflicts of interest: none.
Ethics approval
University of Queensland Social and Behavioural Sciences Ethical Review Committee and Queensland Health.
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