Predictors and Consequences of Refusing Recommended Surgery for Non-small Cell Lung Cancer
Zaid Muslim1, Joanna Weber1, Cliff Connery2, Faiz Bhora1.
1Rudy L. Ruggles Biomedical Research Institute, Nuvance Health, Danbury, CT, USA, 2Vassar Brothers Medical Center, Nuvance Health, Poughkeepsie, NY, USA.
OBJECTIVE: We aimed to identify predictors of refusal of recommended surgery for non-small cell lung cancer (NSCLC) and determine the downstream effects of refusal on treatment and survival.METHODS: We queried the National Cancer Database for patients who were recommended surgery for stage I-III NSCLC during 2004-2016. We compared demographic and clinicopathological factors between patients who did and did not undergo recommended surgery. We fitted multivariable models to identify predictors of refusal of surgery and compare survival between the two groups.RESULTS: From a total of 325,125 patients who were recommended surgery, 11,456 (3.5%) refused surgery. Predictors of refusal included advanced age, black race, non-private insurance, residence in a rural county, treatment at a non-academic center, a travel distance of <15 miles to the treating center, lower Charlson-Deyo comorbidity score, squamous cell histology, and advanced tumor stage (p<0.01). Those treated at centers in Middle Atlantic states were less likely to refuse surgery (p<0.01). Refusal was associated with a greater hazard of death (Hazard ratio: 2.06, 95% confidence interval 1.99-2.14, p<0.01). For patients who refused recommended surgery, subsequent radiation for stages I and II and chemoradiotherapy for stage III improved survival compared to those who received no treatment at all (p<0.01). Still, these treatments were associated with inferior survival compared to those who underwent recommended surgery (p<0.01).CONCLUSIONS: Refusal of recommended surgery for NSCLC is associated with worse survival. Special attention should be paid to better understand the socioeconomic, clinical, and facility-specific predictors of refusal in order to facilitate shared decision-making and improve outcomes.
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