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

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.

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.

Increasing age (p < 0.0001 for all four cancer types), non-Hispanic Black race/ethnicity (OR_adjBREAST 2.00, 95% CI 1.68-2.39; OR_adjCOLON 3.04, 95% CI 2.17-4.26; OR_adjLUNG 2.19, 95% CI 1.77-2.71; OR_adjPROSTATE 2.02, 95% CI 1.86-2.20; vs non-Hispanic White), insurance status (uninsured: OR_adjBREAST 2.75, 95% CI 1.89-3.99; OR_adjPROSTATE 2.10, 95% CI 1.72-2.56; vs insured), marital status (OR_adjBREAST 2.16, 95% CI 1.85-2.51; OR_adjCOLON 1.56, 95% CI 1.16-2.10; OR_adjLUNG 2.11, 95% CI 1.80-2.47; OR_adjPROSTATE 1.94, 95% CI 1.81-2.09), and stage (OR_adjBREAST 1.94, 95% CI 1.70-2.22; OR_adjCOLON 0.13, 95% CI 0.09-0.18; OR_adjLUNG 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.

More vulnerable patients are at higher risk of refusing recommended surgery, and this decision negatively impacts their survival.