“Stage is the most important prognostic factor in melanoma,” explains Saleh Rachidi, MD, PhD. “Melanoma in situ and early invasive melanoma can be treated with simple excision in the office, but prognosis becomes more guarded in advanced disease. Any information we can gather to increase melanoma awareness and early detection saves lives and limits suffering.” Previous studies have indicated a connection between marital status and patient outcomes, suggesting that unmarried patients are more likely to present with later-stage melanoma than married patients. However, it is unknown if the link between marital status and stage at diagnosis is affected by anatomic site.
Important Variables to Consider
For a paper published in the Journal of the American Academy of Dermatology, Dr. Rachidi and colleagues conducted a retrospective cohort study of patients with cutaneous melanoma in the Surveillance, Epidemiology and End Results (SEER) database, diagnosed from 2010-2016, as well as patients at Johns Hopkins diagnosed from 2003-2017. The study team hypothesized that patients with melanoma in easily visible anatomic sites, such as the face, would have a similar stage at diagnosis whether married or unmarried. Patients were separated into married, never married, divorced, and widowed, while tumors were stratified by anatomic location.
The Marital Status Discrepancy in Melanoma Outcomes
The data suggest that married patients with cutaneous melanoma are less likely to present with later stages of disease than unmarried patients. Anatomic location, including the face, was not an influencing factor. “This trend was strongest in men and those younger than 68 but was significant in women and those older than 68 as well,” notes Dr. Rachidi. “Importantly, overall survival continued to be worse among unmarried patients within each stage group. In practice, marital status is an important variable to consider when counseling patients with melanoma or planning follow up.”
SEER data indicate that unmarried men were 29% to 69% more likely to present in stages 3-4 compared with married men, while unmarried women were 28% to 39% more likely to present with advanced disease compared to married women. Percentages were consistent across anatomic locations. Data from Johns Hopkins confirmed the SEER findings. Additionally, the team found that in all stages combined, cancer-specific mortality was higher in unmarried patients (37% to 49%), both in men and women (Table). “Unmarried patients display worse overall survival not only because they present at later stages, but the trend persists even within each stage group,” notes Dr. Rachidi.
The data analyzed for this study suggest that marital status affects more factors in melanoma than partner-dependent identification. “Factors studied include higher adherence to sun-protective measures among married patients, better insurance coverage in married patients that translated to better outcomes, and social support and encouragement by a partner to seek medical attention,” says Dr. Rachidi. These factors are highlighted in melanoma since it is so common, especially among young, otherwise healthy individuals, he adds.
More Work to Be Done
Dr. Rachidi believes physicians should work to prevent delays in diagnosis. “Future research can hopefully dissect the different confounding variables to highlight the strongest drivers of the marital status discrepancy in melanoma outcomes, such as behavioral patterns, insurance, and socioeconomic status,” says Dr. Rachidi. “Additionally, some anatomic sites in this study were not very specific. For example, the trunk includes readily visible areas like the chest and abdomen versus the less visible back. Combing them as one site dilutes their contrast with the face. Comparing the back versus the face would more accurately gauge the importance of visual recognition by a partner.”