to the editor: I enjoyed reading the article on lifestyle interventions to reduce cancer risk by Dr. Demark-Wahnefried and colleagues. One subject the authors did not include that I believe is worthy of mention is social support. Specifically, marital status has been shown to predict incidence of diagnosis, benefits of treatment, and length of survival in patients with cancer.

One study of an American population showed, after controlling for age, race, and treatment, that patients who were married had better survival rates than patients who were single, divorced, or widowed when examining all major primary site cancers.¹ Another study produced comparable findings in a Norwegian population.² Goodwin and colleagues attempted to explain these findings by showing that unmarried persons were more likely to be diagnosed with a regional or distant stage metastasis and were more likely to be untreated for cancer. After controlling for these two factors, unmarried persons still had poorer survival rates.³

In addition to cancers that occur later in life, younger married populations also benefit. For example, testicular cancer was shown to have a higher incidence among single men than married men after 30 years of age.⁴ Aside from life expectancy and stage of cancer, quality of life is improved significantly based on marital status in patients with breast cancer.⁵

Marriage and social support is an area often overlooked in national guidelines. Despite a majority of our patients having a marriage-based lifestyle, marital status is an area that family medicine has not focused on for intervention. With the divorce rate continuing to hover around 50 percent, should family physicians include support of marriage in our care of the family unit? Could earlier interventions help married patients navigate the challenges that often lead to divorce? Can the medical benefits be retained if interventions are successful? Would brief interventions similar to those we use for tobacco cessation and exercise prescriptions prove to be feasible in a primary care appointment?

With the continued emphasis on the bio-psychosocial model of medicine and family relationships making up the core of most of our patients' social support, why aren't we working to maintain that benefit? Family physicians would seem the obvious choice to research, study, and define tools to be used to maximize the benefit of marriage in decreasing incidence and increasing survival of patients with cancer.

in reply: We appreciate Dr. Bailey's comments on our synopsis of the American Cancer Society's guidelines on diet and physical activity to promote cancer prevention and control. We strongly concur with his premise that social support plays a key role in promoting healthy lifestyle behaviors. Therefore, we have invited Dr. Hoda Badr, an expert in family social support, to join us in commenting on the role of marital dynamics in the promotion of healthy lifestyle behaviors.

Few studies have examined the influence of married partners on their spouse's health. The dearth of research in this area is reflected, as Dr. Bailey notes, by national guidelines advocating lifestyle changes to reduce cancer risk without considering the effects of the immediate family environment in which these changes occur.

It is true that lifestyle behavioral change often involves adjustments for both partners and that spouses can be an important source of influence on patients' lifestyle behaviors; but, most of the evidence linking marital status to better health comes from large-scale epidemiologic studies that do not measure other potentially important aspects of the marital relationship. Studies that focus on the contribution of different marital variables show that not all marriages are equally beneficial for health, and that better marital quality (as indicated by less conflict, better communication, and greater marital satisfaction) predicts better health outcomes.^1,2 Thus, rather than focusing on the protective effects of marital status, we should first develop a better understanding of how marital relationships act to promote health.²

Despite the consistently demonstrated positive associations between marriage and health, lifestyle change and nutrition programs that have attempted to leverage spousal influence have yielded mixed results.^3,4 Spouse involvement in such programs often is confined to merely attending or being enlisted as the motivator or enforcer of change. Therefore, identifying one partner as the “target” often can create a relationship power differential leading to coercion or control tactics that may adversely affect the spousal relationship and impede behavioral change. Married partners' lifestyle behaviors (e.g., diet, smoking, physical activity) are also highly correlated.⁵ Thus, there may be value in research that examines the effectiveness of behavioral interventions that: (1) actively involve both partners; (2) focus on what each partner can do to modify his or her own behavior and subsequent cancer risk; and (3) provide patients and partners with adaptive communication strategies and behavioral skills to support each other's behavior change efforts. Unlike interventions that focus exclusively on one person, couple-based interventions consider the context of lifestyle behaviors at the family and household level, which may hold great promise for future cancer prevention efforts.