SOCIODEMOGRAPHIC DISPARITIES AND SURVIVAL IMPLICATIONS OF REFUSAL OF SURGERY AMONG U.S. PATIENTS WITH RESECTABLE COLON CANCER: AN NCDB COHORT ANALYSIS, 2004 - 2016
Isaac G. Alty*1, Edward C. Dee1, Lawrence S. Blaszkowsky2, Jennifer Y. Wo2, Motaz Qadan2
1Harvard Medical School, Brookline, MA; 2Newton-Wellesley Hospital, Newton, MA
INTRODUCTION:
Disparities in care access can manifest in the refusal of potentially survival-improving therapies such as surgery for resectable colon cancer. We aimed to identify sociodemographic factors associated with treatment refusal among patients with AJCC stage I-III colon cancer.
METHODS:
Using the National Cancer Database from 2004—2016, we identified 170,594 patients with AJCC stage I to III colon cancer for whom surgery was recommended, who either underwent surgery or refused it. Multivariate logistic regression defined adjusted odds ratios (AORs) with 95% confidence intervals (95CI) of refusing treatment, with sociodemographic and clinical covariates including sex, age, race, income, educational attainment, rural/urban facility, facility type, Charlson-Deyo comorbidity coefficient (CDCC), geographic location, insurance status, year of diagnosis, and clinical stage of disease. Separate models were stratified by stage. Treatment propensity-adjusted Cox proportional hazard ratios defined differential survival among patients who underwent vs. refused surgery, stratified by clinical stage and controlling for potential clinical and sociodemographic confounders.
RESULTS:
Of the 170,594 patients who were recommended surgery (78,668 stage I, 55,955 stage II, 35,971 stage III), 1,116 refused it (0.65%). For all stages, patients were more likely to refuse treatment if they were of higher age (65 and older compared to <50, AOR 7.07, 95CI 3.81 – 13.12, P<0.001), African American race (compared to White race, AOR 2.11, 95CI 1.78 – 2.49, P<0.001), CDCC> 3 (compared to CDCC=0, AOR 2.24, 95CI 1.77 – 2.84, P<0.001), female sex (AOR 1.40, 95CI 1.24 – 1.58, P<0.001), and later year of diagnosis (2014 or later compared to 2006 or earlier, AOR 1.26, 95CI 1.04 – 1.53, P=0.02). Patients were less likely to refuse treatment if they were of higher income (top quartile vs. lowest quartile, AOR 0.70, 95CI0.55 – 0.88, P=0.003) and had private insurance (compared to no insurance, AOR 0.30, 95CI 0.19 – 0.47, P<0.001).
Many of these sociodemographic disparities persisted when stratifying by clinical stage. Notably, African Americans were more likely to refuse treatment than White Americans across each AJCC stage (stage I: 1.51% vs. 0.85%; stage II: 0.79% vs. 0.38%; stage III: 0.66% vs. 0.38%; P<0.01 for all). When stratifying by stage, overall survival was worse for patients who refused recommended surgery compared to those who underwent recommended surgery (P<0.001 for all).
CONCLUSION:
Differences in age, sex, race, income quartile, and insurance status were associated with disparities in refusal of surgery. As treatment refusal was associated with poorer survival even when stratifying by disease stage, our findings highlight patients who may benefit from increased efforts to encourage adherence to recommended treatment.
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