Understanding Surgery Refusal in Patients with Colorectal Liver Metastases

Abstract

Purpose: To investigate the risk factors, reasons, and survival outcomes associated with refusal of surgery for colorectal liver metastases (CRLM). Surgery is the only curative treatment for CRLM, however, some patients refuse. The risk factors and reasons for refusal remain uninvestigated in patients with CRLM. Methods: Patients with resectable and operable CRLM referred for treatment at Copenhagen University Hospital (2013–2023), were identified through the Danish Liver Cancer Group registry. Those who refused surgery were matched 1:4 by WHO performance status with patients who accepted surgery. Data were retrieved from medical records. Risk factors were evaluated using Conditional Logistic Regression. Reasons for refusal were described by frequencies. Survival was analyzed using the Kaplan-Meier estimator and Cox Regression. Results: Among 2,727 patients referred for treatment, 1,478 were resectable and operable. Twenty-one patients (1.4%) refused surgery. Lower BMI and longer time since the primary tumor diagnosis increased the odds of refusing surgery by 15% per kg/m2 (95% CI 0.76–0.99) and 3% per month (95% CI 1.01–1.06), respectively. Reasons for refusal included declining further surgery, logistical priorities, preference for chemotherapy and self-assessed unfitness. Patients who refused surgery had significantly lower overall survival (p < 0.003) and higher mortality risk (HR: 1.87; 95% CI: 1.02–3.43). Conclusion: This study is the first to identify risk factors and reasons for refusal of surgery in CRLM. The findings provide insight into motivational and prognostic considerations that may support shared decision-making. Further research across cancer types is needed to optimize patient care.