Refusal of gynecologic cancer surgery is a surgical and oncologic disparity, not an issue of noncompliance (055)

Abstract

<b>Objectives:</b> To characterize socioeconomic and clinical factors associated with refusal of gynecologic cancer surgery. Secondary objectives were to estimate the effect of the refusal of surgery on overall survival and determine trends in refusal over time. <b>Methods:</b> The National Cancer Database (NCDB) was surveyed for patients with uterine, cervical, or ovarian cancers treated at participating Commission on Cancer sites between 2004 and 2017. Demographic and clinical data were abstracted. Descriptive statistics and Pearson's Chi-square tests were performed. Univariate and multivariate logistic regression analyses were performed to examine the association between variables and refusal of surgery, with the threshold for two-sided significance set at p <0.05. Overall survival (OS) was estimated using the Kaplan-Meier method and compared using the log-rank test. To evaluate changes in refusal over time, we performed joinpoint regression analysis using Joinpoint version 4.9.0. <b>Results:</b> Of the 788,164 women with gynecologic cancer included in our analysis, 5875 (0.75%) patients refused surgery recommended by their treating oncologist. In univariate analysis, age, race, Hispanic ethnicity, metropolitan residence, lower median household income, regional high school graduation rate, insurance status, treatment center type, 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 (72.4 ± 16.1 vs 60.3 ± 13.1 years, p<0.001) and more likely Black (OR: 1.77, 95% CI: 1.62-1.92). Refusal of surgery was associated with uninsured status (OR: 2.94, 95% CI: 2.49 - 3.46), primary insurance by Medicare (OR: 1.78, 95% CI: 1.62-1.96), or Medicaid (OR: 2.79, 95% CI: 2.46-3.18) and residence in an area in the lowest national tertile of high school graduation (OR: 1.18, 95% CI: 1.05-1.33). Patients who refused surgery had inferior overall survival (1.0 vs 14.0 years, p<0.01), and this difference persisted when stratified by primary disease site. There were significant differences in survival between patients who refused only surgery but not chemotherapy or radiation therapy and those who refused all treatment modalities (5-year OS: 29.4%, 95% CI: 27.5 - 31.2 vs 9.2%, 95% CI: 7.9-10.6). The rate of refusal of surgery decreased from 2004 to 2008 (-4.4% annual percent change, p<0.05) but increased between 2008 and 2017 (+1.4% annual percent change, p<0.05).Fig. 1 <b>Conclusions:</b> Multiple non-clinical social determinants of health are independently associated with refusal of surgery for gynecologic cancer. Given that patients who refuse surgery are more likely to be underserved, marginalized members of society and have lower survival compared to those who do not, refusal of surgery should be considered an example of oncologic and surgical disparity and tackled as such.