Disparities in refusal of surgery for gynecologic cancer

Abstract

<h3>Objectives:</h3> To characterize socioeconomic and clinical factors associated with refusal of gynecologic cancer surgery. <h3>Methods:</h3> The National Cancer DataBase (NCDB) was surveyed for patients with uterine, cervical, or ovarian cancer treated at participating Commission on Cancer sites between 2004 and 2017. Demographic and clinical data were abstracted, descriptive statistics and Pearson's chi squared tests performed. Univariate and multivariate logistic regression were performed to examine the association between variables and refusal of surgery, with the threshold for two-sided significance set at p<0.05. <h3>Results:</h3> Of the 938 773 patients with gynecologic cancer included in the NCDB, 5875 patients (0.6%) did not undergo surgery and had documented refusal. On univariate analysis, age, race, Hispanic ethnicity, rural residence, lower median household income, regional high school graduation rate, facility type (academic vs community), geographic location and distance to treating hospital, disease site, stage, and increasing Charlson comorbidity index were all associated with refusal of surgery (p<0.05).On multivariate analysis, patients who refused surgery were older at diagnosis (72.3 ±16.1 vs 60.8 ±13.7 years, p<0.001), more likely Black (OR 1.86 95% CI 1.72-2.01), Native Hawaiian or Pacific Islander (OR 3.24 95% CI 2.24-4.70) or Native American (OR 1.66 95% CI 1.05-2.61). Refusal of surgery was associated with uninsured status (OR 2.40 95% CI 2.09-2.76), Medicare as primary payer (OR 1.43 95% CI 1.32-1.55), and residence in an area in the lowest national quartile of high school graduation (OR 1.17 95% CI 1.05-1.30). Treatment location <10 miles from primary residence was associated with refusal as receiving treatment (OR 2.46 95% CI 2.02-3.01), as was treatment in the Northeast (OR 1.24 95% CI 1.13-1.36), and at a community hospital (OR 2.2 95% CI 2.0-2.38). Patients who refused surgery were more likely to have ovarian or primary peritoneal cancer (OR 1.38 95% CI 1.25-1.51), and more likely to have advanced stage disease (OR 2.88 95% CI 2.64-3.15) or a Charlson comorbidity index >3 (OR 1.34 95% CI 1.16-1.56). Clinical trial enrollment was not associated with refusal. <h3>Conclusions:</h3> Multiple social, racial, economic, and systematic factors that impact marginalized members of society are independently associated with refusal of NCCN guideline-indicated surgery. Refusal of surgery is more common in underserved patients and may represent another aspect of healthcare disparity that deserves closer attention.