The Effect of Marriage on Stage at Diagnosis and Survival in Women with Cervical Cancer
Creators: name: El Ibrahimi, Sanae 
Publisher: name: University of Nevada, Las Vegas
Year: 2013

description: Marriage is associated with improved health outcomes for many conditions. Married persons enjoy financial stability, social and emotional support, and tend to have better control of health risk behaviors compared to the unmarried. The marriage scene is changing continuously. Americans are marrying less or delaying the engagement to an older age. They are divorcing more, they choose cohabitation as an alternative to marriage, or engage in premarital relationships. As a consequence, barely half of Americans were married in 2011 compared to close to three quarters of Americans were married in the sixties. With the increase of the unmarried population - including those who cohabitate, the never married, the divorced, and the widowed - understanding whether marriage is an independent determinant of health outcomes is an important public health matter. 
The relationship of marriage and health outcomes has been studied for many health conditions and cancer sites. However, this association has not been fully explored for cervical cancer outcomes. In addition, studies with recent data are lacking. This study aimed at investigating whether marriage has a protective effect from late stage of diagnosis and whether it independently improves survival in women with cervical cancer with more recent population-based data. 
The National Cancer Institute program Surveillance, Epidemiology, and End Results (SEER) was used to identify women with cervical cancer diagnosed between 2000 and 2010. Statistical analyses were conducted to assess the effect of marriage on stage and survival. The Logistic regression modeling was used to calculate the odds ratios of advanced stage - defined as regional and distant - accounting for socio-demographic and clinical covariates. Hazard ratios were obtained by the Cox Proportional Hazards modeling to compare death risk between married and unmarried women. Additional modeling was conducted with cases diagnosed between 2007 and 2010 to account for insurance status at diagnosis. Kaplan Meier survival curves and Log Rank test of difference in survival between marital groups were executed. Interactions between marital status and age; between marital status and race; and between marital status and stage were tested. 
In terms of stage of diagnosis, Single [adjusted odds ratio (aOR) 1.41; 95% CI = 1.33-1.49], separated/divorced [aOR 1.44; 95% CI = 1.34-1.55], and widowed women [aOR 1.43; 95% CI = 1.31-1.58] were significantly more likely to be diagnosed at an advanced stage compared to married women after controlling for age, race/ethnicity, period of diagnosis, histology, and SEER area. Marital status was found to be an independent factor for survival. Single (aHR 1.35; 95% CI = 1.28-1.43), separated (aHR 1.22; 95% CI = 1.15-1.29), and widowed women (aHR 1.28; 95% CI = 1.19-1.36) had increased death risk compared to married women adjusted for socio-demographic (age, race/ ethnicity) and clinical factors (stage, histology, and period of diagnosis). Even after controlling for insurance status, married women continued to be more likely to be diagnosed early and have favorable survival over the unmarried. 
Findings from this study support the rising body of literature of the protective effect of marriage on cancer outcomes. Particularly for cervical cancer, based on its sexually transmitted etiology, unmarried women are more likely to have multiple sexual partners and are, therefore, at increased risk of developing this cancer. Moreover, unmarried women are more likely to have inadequate access to health care, which reduces their chance of receiving recommended cervical screening services and timely treatment. In addition, unmarried women lack spousal emotional and social support, which contribute to psychosocial stress and unfavorable health outcomes. 
National guidelines on cervical cancer risk factors may need to be revised to include marital status as an independent predictor for stage of diagnosis and survival. Further qualitative and quantitative research is needed to determine how to improve health outcomes for the unmarried population in the clinical and the community settings.