Prognostic significance of marital status in breast cancer survival: A population-based study

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.

Fig 1. Kaplan-Meier curve of all-cause survival by marital status and neighborhood SES, California, 2005–2012.

Fig 2. Hazard ratios for total mortality and marital status plus neighborhood socioeconomic status (SES), California, 2005–2012.

Hazard ratios estimated from Cox proportional hazard models adjusted for: age at diagnosis (continuous), race/ethnicity, subtype (for analysis of all patients), lymph node involvement, tumor size, grade, histological subtypes, first course of treatment, insurance status; AJCC stage I-IV or unknown is included as a stratifying variable. High SES group includes neighborhood SES quintiles 4–5 and low SES group includes quintiles 1–3. Numbers represent hazard ratio and bars represent 95% confidence interval for each group. *Denotes statistical significance, whereby the confidence intervals do not include 1. Abbreviations: MRR = hormone receptor; HER2 = human epidermal receptor 2; Ref = reference group.