Oncologic outcomes after declining lung cancer surgery: mixed methods analysis of a prospective pilot cohort

The standard treatment for early-stage non-small cell lung cancer (NSCLC) is lung cancer resection. Unfortunately, some patients decline to undergo recommended surgery. The aim of this study is to evaluate patient oncologic outcomes after declining surgery.

Patients were enrolled in a prospective, mixed-methods study. Surveys and semi-structured interviews assessed patient-provider relationships and outcomes. Qualitative analysis identified key themes, and mixed-methods analyses compared those who received surgery with those who declined surgery.

The cohort included 29 patients with NSCLC (63 years, 55% male, 59% White and 41% Black race). A participant survey indicated that food insecurity (n=6, 21%), lack of reliable transportation (n=4, 14%), and housing instability (n=2, 7%) were common. Five patients (17%) declined the recommended surgery and were more likely to be Black and have low-income (all P<0.05). They also reported poor patient-physician relationships reporting lack of trust in their physician (n=3, 60%) and inadequate communication (n=2, 40%). Qualitative analysis identified common themes among patients who declined surgery, such as lack of understanding of cancer and previous poor relationships with physicians, which impacted their decision to decline surgery. Patients who declined cancer surgery had treatment delays (60% vs. 16.6%), worse recurrence-free survival (40% vs. 95.8%), and lower 5 years overall survival (40% vs. 91.7%), (all P<0.05).

Declining recommended lung cancer surgery was associated with lower income, Black race, poorer patient-physician relationships along with treatment delays, and worse overall survival. Interventions are needed to strengthen patient-provider relationships to improve lung cancer outcomes for all patients.