Cancer mortality following widow(ER)hood: Some further results from the Office of Population Censuses and Surveys Longitudinal Study

“And there's Always this Great Hole Inside that Hurts”: An Empirical Study of Bereavement in Later Life

Stage theoretical approaches to bereavement have long been used in both academic and clinical work. Their impact has been so great that they have permeated lay understanding of bereavement, to become, as Tony Walter puts it, the “clinical lore” of bereavement. This paper examines this clinical lore from the perspective of older women's narratives of widowhood. We suggest that, though these widows experience the sorts of emotions stage theories predict, there is little evidence to support the notion of steady progression from one stage to another. Nor is there evidence to support the idea that widows “recover” from their loss in the sense of surrendering their attachment to the dead, nor that “renewal” equates with a fully restored sense of wellbeing. The widows themselves argue cogently that the idea of “recovery” is an inappropriate (and indeed insensitive) aim for them to strive for. They feel uncomfortable with the pathologizing of lasting grief; they also express strong views about those who try to “help” them. It concludes that, though stage theories are useful in identifying some of the physical effects and emotions associated with bereavement, they do not adequately reflect the experiences of women widowed in later life.

Institutionalization of older adults after the death of a spouse

OBJECTIVES

We investigated the risk of entering long-term institutional care after the death of a spouse in relation to the duration of widowhood among older Finnish men and women. We also examined whether high levels of education or household income buffered the effects of bereavement on institutionalization.

METHODS

We used linked register-based data on Finnish adults 65 years or older who were living with a spouse at the beginning of the study period (n=140902) and were followed from January 1998 to December 2002.

RESULTS

The excess risk of institutionalization was highest during the first month following a spouse's death compared with still living with a spouse (adjusted hazard ratio=3.31 for men, 3.62 for women). This risk decreased over time among both men and women. The relative effect of the duration of widowhood on institutionalization did not significantly vary according to the level of education or income.

CONCLUSIONS

Risk of institutionalization is particularly high immediately after the death of a spouse, demonstrating the importance of loss of social and instrumental support.

Longitudinal insights into the ageing population

In several countries the fraction of the population who are very old is increasing dramatically. Interest in this phenomenon in part reflects concern about the burdens this section of the community will place on younger people. Views of the elderly are generally based on cross-sectional data on generations who 'aged' in quite different circumstances to those who will be old in 20 or 40 years time. This paper describes recent findings relevant to the changing experiences of older men and women during the 1970s and early 1980s from the Office of Population Censuses and Surveys Longitudinal Study. This is a new source which enables researchers to study the sociodemographic histories of a representative sample of the population of England and Wales. The period after retirement from formal employment is one which sees men and women experience more changes to their domestic circumstances than is commonly appreciated. Many of these changes are related to earlier socioeconomic circumstances which also influence people's abilities to cope with change and their need for support.

Psychological factors and cancer development: Evidence after 30 years of research

The question whether psychological factors affect cancer development has intrigued both researchers and patients. This review critically summarizes the findings of studies that have tried to answer this question in the past 30 years. Earlier reviews, including meta-analyses, covered only a limited number of studies, and included studies with a questionable design (group-comparison, cross-sectional or semiprospective design). This review comprises only longitudinal, truly prospective studies (N=70). It was concluded that there is not any psychological factor for which an influence on cancer development has been convincingly demonstrated in a series of studies. Only in terms of 'an influence that cannot be totally dismissed,' some factors emerged as 'most promising': helplessness and repression seemed to contribute to an unfavorable prognosis, while denial/minimizing seemed to be associated with a favorable prognosis. Some, but even less convincing evidence, was found that having experienced loss events, a low level of social support, and chronic depression predict an unfavorable prognosis. The influences of life events (other than loss events), negative emotional states, fighting spirit, stoic acceptance/fatalism, active coping, personality factors, and locus of control are minor or absent. A methodological shortcoming is not to have investigated the interactive effect of psychological factors, demographic, and biomedical risk factors.

On the role of immunological factors as mediators between psychosocial factors and cancer progression

Thirty-eight prospective studies on the role of psychological factors in cancer initiation and progression are reviewed. Despite the availability of many prospective studies, there is no certainty about the role of any specific factor. An important reason might be that the interactions among several psychological factors, and the interactions of psychological and biomedical risk factors, have rarely been studied. Some evidence has been found that a low level of social support, a tendency towards helplessness, and repression of negative emotions are factors that promote cancer progression. The effect of psychological factors has been more convincingly demonstrated with respect to cancer progression than cancer initiation, and more convincingly in intervention than in natural history studies. Possible mechanisms mediating associations between psychological factors and disease outcome are discussed. The role of immunosurveillance seems modest overall, and alternative pathways are suggested.

A longitudinal study of wellbeing in widowed women

Changes in mental and physical health, morale and social functioning were assessed in a random sample of elderly women widowed during the course of an 8-year study, compared with never-married and still-married controls. The sample as a whole showed age-related declines in mental and physical health. As a function of ageing there were increases in personal disturbance and in physical health problems and declines in both morale and social engagement. However, over and above these age-related changes the windows showed significant changes in mental health. There were decreases in morale after widowhood, followed by slight increases in morale in the longer term. Similarly, there were increases in personal disturbance following widowhood, with slight decreases later. The results confirm that, even after several years, widowhood has differential effects on wellbeing and morale.

Mortality after death of spouse in relation to duration of bereavement in Finland

STUDY OBJECTIVES

(1) To assess the extent to which death of a spouse causes excess mortality by controlling for the effects of confounding and other sources of bias. Three possible sources of bias are considered: accidents common to spouses, common socioeconomic environment, and common lifestyles. (2) To assess the duration specific effects of death of a spouse on mortality.

DESIGN AND SETTING

Prospective study of mortality in Finland among all 35-84 year old married Finnish men and women (1,580,000 people). Baseline sociodemographic measurement from the 1985 census records. Follow up by computerised record linkage to death certificate registers for the period 1986-91 (about 116,000 deaths, of which almost 10,000 among the bereaved) using personal identification codes.

RESULTS

(1) After controlling for confounding effects, excess mortality was 17% in men and 6% in women. (2) Excess mortality was higher for short durations than long durations of bereavement. (3) Excess mortality after bereavement was higher in men than women.

CONCLUSIONS

Controlling for confounding does not seem to have a crucial modifying effect on the relationship between spousal bereavement and mortality. It seems that death of a spouse has a causal effect on mortality. However, although spousal bereavement is a major stressful life event, this causal effect seems to be relatively small and short lived.

Widowhood and divorce related to cancer risk in middle-aged women. A nested case-control study among Norwegian women born between 1935 and 1954

We have examined whether the risk of cancer among divorced or widowed Norwegian women born between 1935 and 1954 was any different from that of married women. Among a total of approximately 600,000 women, we applied a nested case-control design. Thus, the study was population-based and included 17,235 incident cases of cancer with 34,460 age-matched controls. For widowed women, there was no overall relation with cancer. For divorced women, 2 strikingly different associations were apparent. A reduced risk was seen for cancers of a number of sites, including thyroid, endometrium, colorectum, and breast, as well as malignant melanoma and hematologic malignancies, with statistically significant estimates of relative risk ranging from 0.64 to 0.84. In contrast, divorced women had a strongly elevated risk of lung and cervical cancer. Moreover, there was a gradual reduction in the relative risk of cancer at some sites with increasing age at divorce, and with duration of marriage prior to divorce. In this study of middle-aged women, the risk of cancer among widows was no different from that of married women. Divorced women had an increased risk of cancers which are related to cigarette smoking but, simultaneously, a reduced risk of cancer at a number of other sites. Since the negative associations for some cancers were strongly related to increasing age at divorce and to duration of marriage, the results may indicate that the reduction in risk is related to factors which characterize the marital period preceding divorce.

Cancer rates after the Three Mile Island nuclear accident and proximity of residence to the plant

BACKGROUND

In the light of a possible link between stress and cancer promotion or progression, and of previously reported distress in residents near the Three Mile Island (TMI) nuclear power plant, we attempted to evaluate the impact of the March 1979 accident on community cancer rates.

METHODS

Proximity of residence to the plant, which related to distress in previous studies, was taken as a possible indicator of accident stress; the postaccident pattern in cancer rates was examined in 69 "study tracts" within a 10-mile radius of TMI, in relation to residential proximity.

RESULTS

A modest association was found between postaccident cancer rates and proximity (OR = 1.4; 95% CI = 1.3, 1.6). After adjusting for a gradient in cancer risk prior to the accident, the odds ratio contrasting those closest to the plant with those living farther out was 1.2 (95% CI = 1.0, 1.4). A postaccident increase in cancer rates near the Three Mile Island plant was notable in 1982, persisted for another year, and then declined. Radiation emissions, as modeled mathematically, did not account for the observed increase.

CONCLUSION

Interpretation in terms of accident stress is limited by the lack of an individual measure of stress and by uncertainty about whether stress has a biological effect on cancer in humans. An alternative mechanism for the cancer increase near the plant is through changes in care-seeking and diagnostic practice arising from postaccident concern.

Psychological aspects of cancer and chemotherapy

Research in the psychological aspects of cancer and chemotherapy has reached an exciting stage of development. More acceptable standards of scientific rigour are being applied to thinking and research, spanning a wide range of important issues from prognostic indicators to the evaluation of treatment trials. It is important to remember that patients do not exist in isolation and that the impact of disease and treatment is also felt by their care givers. The burden which falls on spouses and other primary carers and the importance of their contribution to patients' adaptation to illness should not be underestimated. By the same token the emotional demands particularly on nursing and junior medical staff are increasingly recognized with developing interest in optimal means of providing staff support. Thus the field is still expanding. It requires the continuing collaborative effort of a wide range of professional disciplines to improve our understanding of the psychological aspect of oncology for all cancer patients and those who care for them.

Heart disease mortality following widowhood: some results from the OPCS Longitudinal Study. Office of Population Censuses and Surveys

Many studies have suggested that following the experience of 'stressful' life events the risks of myocardial infarction, accidents and perhaps other diseases are elevated. In the OPCS Longitudinal Study routinely collected data on deaths, and deaths of a spouse occurring in a 1% sample of the population of England and Wales in the period 1971-1981 are linked together, and with 1971 census records of sample members. The timing and patterns of death following the potentially very stressful event of conjugal bereavement may thus be analysed. Overall the mortality (from ischaemic heart disease) was less than 10% in excess of that in all members of the LS sample. As in many earlier studies, some increases in death rates shortly after widowhood are observed. Unusually, for deaths from all causes these increases are more marked in widows than in widowers with, for example, a two-fold increase in mortality from all causes in the first month after widowhood. However, no peak of post-bereavement mortality from ischaemic heart disease is clearly established in either sex. Although the study is large, with a well-chosen control group, only a limited characterisation of study members from data collected in the census is possible. In particular, no measures of personality, behaviour or diet are available. Investigation of potential effects of social or familial support, as measured by household structure and numbers of children, led to equivocal results. Several possible explanations for the increased mortality rates are examined. Hypotheses based on common marital environment, homogamy or simultaneous accidental death are seen to be of very limited value. The observed patterns, although consistent with an early effect of a stressful life event, do not suggest that stress following bereavement leads to an excess of ischaemic heart disease mortality.

Cause of death in widow(er)s and spouses

Many studies have suggested that following the experience of ‘stressful’ life events the risks of accidents, myocardial infarctions and other diseases are elevated. In the OPCS Longitudinal Study, routinely collected data on deaths, and deaths of a spouse occurring in a 1% sample of the population of England and Wales in the period 1971–81 are linked together, and with 1971 Census records of sample members. The timing and patterns of death following the very stressful event of conjugal bereavement may thus be analysed.

Overall the mortality of widowers was about 10% in excess of that in all males in the sample whereas that of widows was only slightly raised. Some increases in death rates shortly after widow(er)hood are observed. Unusually, these increases in all-cause mortality rates are more marked in widows than in widowers, with a two-fold increase in mortality from all causes in the first month after widowhood. Marked peaks of post-bereavement mortality from accidents and violent causes are clear in both sexes. Possible explanations for the increased mortality rates are examined.