H.K. Manaise1, K.B. Sukniam2, J.C. Bowers3, R. Popp4, G. Kowkabany5, P.B. Jimenez6, F. Mubarak7, E.P. Ekpeh8, K. Popp3, R. Shekouhi7, E. Gabriel9 1University of Texas San Antonio, Surgery, San Antonio, TX, USA 2Duke University Medical Center, Surgery, Durham, NC, USA 3Florida State University College Of Medicine, Biology, Tallahassee, FL, USA 4University of Florida College of Medicine, Medicine, Gainesville, FL, USA 5University of Alabama, Biology, Tuscaloosa, AL, USA 6University Of Puerto Rico, Medicine, San Juan, Puerto Rico, Puerto Rico 7Aga Khan University Medical College, Medicine, Karachi, Sindh, Pakistan 8University of North Florida, Biology, Jacksonville, FL, USA 9Mayo Clinic – Florida, Surgery, Jacksonville, FL, USA
Introduction: While contemporary management of many cancers requires a multidisciplinary approach, surgery still often remains an integral part of cancer treatment. For many malignancies, surgery is performed upfront and can offer cure. Some patients, however, will refuse surgery for a variety of reasons, including high risk of complications due to the nature of the procedure or associated comorbidities, elderly age, or fear or misconceptions about surgery. The purpose of this study was to determine the impact of the refusal of surgery on overall survival (OS) across a wide range of cancers.
Methods: This was a retrospective study that utilized the National Cancer Database (NCDB) from 2004 to 2019. The following cancers were investigated: breast cancer (ER+ HER2-, HER2+, and triple negative subtypes), thyroid cancer (papillary, follicular, and medullary), esophageal adenocarcinoma, gastric adenocarcinoma, pancreatic adenocarcinoma, colorectal adenocarcinoma, melanoma, and Merkel cell carcinoma. The main outcome measure was OS, which was compared between groups who underwent surgery and those who did not undergo surgery for the following reasons: contraindicated due to patient comorbidities, not part of planned treatment, patient refusal, or reason unknown. Patient demographics (age, sex, race, socioeconomic variables) and tumor characteristics (size, stage, etc) were tabulated. OS was analyzed using standard Kaplan-Meier methods. Associations between patient demographics and receipt of surgery or no surgery were performed.
Results: For every cancer that was analyzed, patients who refused surgery only comprised < 5% of the respective cancer subtype cohort. However, the OS among patients who refused surgery was statistically significantly worse for each type of cancer, with the most striking differences in median OS listed in the accompanying table. Patients who refused surgery were more likely to be older, male, racial/ethnic minorities, and have lower socioeconomic status (i.e., lower income, uninsured status, and non-private or government insurance) than those who received surgery as part of standard of care. Patients who refused surgery were also less likely to receive multimodal therapy, including chemotherapy and/or radiotherapy.
Conclusion: Refusal of surgery was significantly associated with worse OS among several cancer subtypes. Although the NCDB does not specify exact reasons for the refusal of surgery, these findings demonstrate a quantifiable detriment to outcomes when surgery is not followed as part of standard of care. Further research and interventions are needed to elucidate on the reasons that patients refuse surgery in the hopes of improving OS outcomes.