Disparities in Refusal of Locoregional Treatment for Prostate Adenocarcinoma

Abstract

PURPOSE: We assessed sociodemographic factors associated with and survival implications of refusal of potentially survival-prolonging locoregional treatment (LT, including radiotherapy and surgery) despite provider recommendation among men with localized prostate adenocarcinoma. METHODS: The National Cancer Database (2004-2015) identified men with TxN0M0 prostate cancer who either received or refused LT despite provider recommendation. Multivariable logistic regression defined adjusted odds ratios (AORs) with 95% CI of refusing LT, with sociodemographic and clinical covariates. Models were stratified by low-risk and intermediate- or high-risk (IR or HR) disease, with a separate interaction analysis between race and risk group. Multivariable Cox proportional hazard ratios compared overall survival (OS) among men who received versus refused LT. RESULTS: Of 887,839 men (median age 64 years, median follow-up 6.14 years), 2,487 (0.28%) refused LT. Among men with IR or HR disease (n = 651,345), Black and Asian patients were more likely to refuse LT than White patients (0.35% v 0.29% v 0.17%; Black v White AOR, 1.75; 95% CI, 1.52 to 2.01; P < .001; Asian v White AOR, 1.47; 95% CI, 1.05 to 2.06; P = .027, race * risk group interaction P < .001). Later year of diagnosis, community facility type, noninsurance or Medicaid, and older age were also associated with increased odds of LT refusal, overall and when stratifying by risk group. For men with IR or HR disease, LT refusal was associated with worse OS (5-year OS 80.1% v 91.5%, HR, 1.65, P < .001). CONCLUSION: LT refusal has increased over time; racial disparities were greater in higher-risk disease. Refusal despite provider recommendation highlights populations that may benefit from efforts to assess and reduce barriers to care.

Factors Associated With Patient's Refusal of Recommended Cancer Surgery: Based on Surveillance, Epidemiology, and End Results

“…In addition, we identified that API patient was also a population with high odds of refusing recommended surgery. A latest study by Dee et al ( 13 ) found that black and Asian patients are more likely to refuse locoregional treatment (radiotherapy and surgery) than white patients in prostate cancer; locoregional treatment refusal rate for prostate adenocarcinoma has increased over time. For Lung/bronchus cancer patients, Mehta et al ( 14 ) found that blacks and “other” races are more likely to refuse recommended surgery than whites; refusal of surgery is influenced by county variations.…”

In pursuit of equity in cancer care: Moving beyond the Affordable Care Act

“…Mistrust of the medical institution resulting from historical injustices as well as prior direct interactions may lead to avoidance of the health care system until symptoms are progressed, 65 with consequent delays in cancer diagnosis and treatment. Racial differences in rates of mistrust toward the medical system persist among people with cancer, 66 likely affecting not just rates of screening but also the decision to adhere to treatment recommendations 41, 44 . Although the medical system has made efforts to protect marginalized populations given these difficult prior lessons, injustices persist, and consequent mistrust may understandably still linger.…”

“…It is important to note that although the work of Snyder et al 33 does not explicitly examine cancer outcomes (indeed, the National Cancer Database reports only overall survival and not cancer-specific outcomes), disparities in stage at presentation may only represent the "tip of the iceberg"; disparities in treatment and the survivorship setting after diagnosis lead to more disparate cancer outcomes. [40][41][42][43][44][45] The persistence of cancer disparities despite interventions aimed at improving access to care highlight that despite Cancer September 15, 2022 improvements in insurance coverage, there are other factors at play that mediate cancer disparities.…”

“…Racial differences in rates of mistrust toward the medical system persist among people with cancer, 66 likely affecting not just rates of screening but also the decision to adhere to treatment recommendations. 41,44 Although the medical system has made efforts to protect marginalized populations given these difficult prior lessons, injustices persist, and consequent mistrust may understandably still linger. Higher rates of medical mistrust are associated with lower rates of colorectal cancer screening, 67 breast cancer screening 68 and treatment, 69 and possibly, lung cancer screening.…”

Shorter Radiation Regimens and Treatment Noncompletion Among Patients With Breast and Prostate Cancer in the United States: An Analysis of Racial Disparities in Access and Quality

“…[17][18][19][20][21] Despite these advances in radiotherapy techniques, inequities in their utilization and subsequent disparities in oncologic outcomes persist for Black versus non-Black patients with BC and PC in the United States. [22][23][24][25][26] This is attributable in part to systemic bias and barriers in access to care. 27 One important potential benefit of shorter fractionation schemes is an improvement in treatment completion rates among patients receiving radiation therapy (RT).…”