Disparities in surgery for early-stage cancer: the impact of refusal

Abstract

Background: For early-stage cancer surgery is often curative, yet refusal of recommended surgical interventions may be contributing to disparities in patient treatment. This study aims to assess predictors of early-stage cancers surgery refusal, and the impact on survival. Methods: Patients recommended surgery with primary stage I and II lung, prostate, breast, and colon cancers, diagnosed between 2007–2014, were identified in the Surveillance, Epidemiology and End Results database (n = 498,927). Surgery refusal was reported for 5,757 (1.2%) patients. Associations between sociodemographic variables and surgery refusal by cancer type were assessed in adjusted multivariable logistic regression models. The impact of refusal on survival was investigated using adjusted Cox-Proportional Hazard regression in a propensity score-matched cohort. Results: Increasing age (p < 0.0001 for all four cancer types), non-Hispanic Black race/ethnicity (ORadjBREAST 2.00, 95% CI 1.68–2.39; ORadjCOLON 3.04, 95% CI 2.17–4.26; ORadjLUNG 2.19, 95% CI 1.77–2.71; ORadjPROSTATE 2.02, 95% CI 1.86–2.20; vs non-Hispanic White), insurance status (uninsured: ORadjBREAST 2.75, 95% CI 1.89–3.99; ORadjPROSTATE 2.10, 95% CI 1.72–2.56; vs insured), marital status (ORadjBREAST 2.16, 95% CI 1.85–2.51; ORadjCOLON 1.56, 95% CI 1.16–2.10; ORadjLUNG 2.11, 95% CI 1.80–2.47; ORadjPROSTATE 1.94, 95% CI 1.81–2.09), and stage (ORadjBREAST 1.94, 95% CI 1.70–2.22; ORadjCOLON 0.13, 95% CI 0.09–0.18; ORadjLUNG 0.71, 95% CI 0.52–0.96) were all associated with refusal; patients refusing surgery were at increased risk of death compared to patients who underwent surgery. Conclusions: More vulnerable patients are at higher risk of refusing recommended surgery, and this decision negatively impacts their survival.