Refusal of surgery results in inferior survival in esophageal cancer.

Abstract

364 Background: Trimodality therapy with chemoradiation followed by surgery is the standard of care for non-metastatic esophageal cancer. Some patients refuse surgery and this information is captured in the National Cancer Database (NCDB). We sought to understand factors associated with refusal of surgery in these patients and to compare their survival rates with those who undergo surgery. Methods: Data from the NCDB for patients with pathologically proven non-metastatic esophageal cancer from 2006 to 2013 were pooled and screened. Patients with T1N0M0 disease were excluded. Pearson’s chi-squared test and multivariate logistic regression analyses were used to assess the distribution of demographic, clinical, and treatment factors. After propensity-score matching with inverse probability of treatment weighting, overall survival (OS) was compared between patients who refused surgery and those who had surgery using Kaplan Meier analyses and doubly-robust estimation with multivariate Cox proportional hazards modeling. Results: We found 890 of 18,942 patients (4.6%) refused surgery. Older patients, females, those with squamous histology, patients insured by Medicare and those who received radiation therapy (RT) were more likely to refuse. Patients who had N1 disease, high incomes, those who received chemotherapy and those who lived farther from care were more likely to have surgery. The initial 6 month OS was not significantly different between patients who refused surgery and those who had surgery (93.5% vs 95.1% P= 0.064). However, five-year OS was significantly lower in patients who refused (16.4% vs. 38.4% P< .01). This survival decrement was observed uniquely in patients with both adenocarcinoma and squamous cell carcinoma histology. Among those who refused surgery, the OS decrement was mitigated by increasing RT doses. In those who received over 54 Gy of RT, there was no statistical difference in OS between the groups (HR = 0.84, 95% CI 0.65-1.09). Conclusions: We identified a number of patient characteristics that are related to the refusal of surgery in esophageal cancer. Refusal of surgery was related to a decrease in OS in propensity weighted cohorts. This survival decrement may be mitigated by RT in a dose dependent fashion.

Refusal of Surgery in Pituitary Adenoma Patients: A Population-Based Analysis

“…Regarding distance from patient to provider, our findings are in agreement with a prior report on stage I–III rectal cancer, which reported increased surgery receipt in individuals who lived further from their provider’s location [ 22 ]. Our findings also are in agreement with a previous study on esophageal cancer that reported increased odds of surgery receipt with increased patient to provider distance [ 16 ]. Additionally, our findings revealed that surgery receipt was associated with receiving care at an academic facility, which is consistent with prior studies in individuals with esophageal and oral cavity cancer [ 16 , 18 ].…”

“…Many sociodemographic factors have been previously reported as predictors of surgery refusal in patients with various cancers. For example, advanced age as a predictor of surgery refusal has been well documented in various malignant tumors, including breast cancer, esophageal cancer, colon cancer, HSNCC, and oral cavity cancer [ 11 , 12 , 14 , 16 , 18 ]. African American race is another sociodemographic factor associated with increased risk of surgery refusal in prostate cancer, colon cancer, HNSCC, laryngeal cancer, and hepatocellular carcinoma [ 12 , 14 , 15 , 19 , 20 ].…”

“…One other important sociodemographic factor associated with surgery refusal in this study is having government insurance or being uninsured. The presence of government insurance has also been associated with surgery refusal in individuals with HNSCC, prostate, esophageal, colon, and oral cancers [ 12 , 16 , 18 , 19 , 21 ]. Furthermore, lack of insurance has been reported as a factor for surgery refusal in HNSCC, esophageal, colon, and oral cancers [ 12 , 16 , 18 , 21 ].…”

“…The presence of government insurance has also been associated with surgery refusal in individuals with HNSCC, prostate, esophageal, colon, and oral cancers [ 12 , 16 , 18 , 19 , 21 ]. Furthermore, lack of insurance has been reported as a factor for surgery refusal in HNSCC, esophageal, colon, and oral cancers [ 12 , 16 , 18 , 21 ]. While these clinical and sociodemographic factors have not been previously reported for pituitary adenomas or other anterior skull base tumors, it is important to recognize the influence of these factors on surgery receipt.…”

“…However, not all PA surgical candidates elect to undergo surgery. The role of surgery refusal on patient clinical outcomes has been previously reported in the setting of colon, breast, thyroid, head and neck squamous cell carcinoma (HNSCC), and laryngeal cancers [ 11 , 12 , 13 , 14 , 15 ] While these studies have reported poor outcomes in eligible patients electing for surgery refusal [ 11 , 12 , 15 , 16 ] to our knowledge, there are no reports on clinical outcomes in PA patients refusing surgery. Therefore, this study aims to characterize the factors associated with and clinical outcomes of surgery refusal in PA patients.…”