Role of Race in Survival among Patients Who Refuse the Recommended Surgery for Early Stage Non-Small Cell Lung Cancer: A Seer Cohort Study

Abstract

Introduction: Blacks are more likely than whites to refuse potentially curative surgery for early stage non-small cell lung cancer (NSCLC). We sought to compare survival among blacks and whites in this population, as patients who refuse the surgery are expected to be different from others. Also, racial differences are known to exist in the end-of-life care preferences. Methods: Surveillance, Epidemiology, and End Results (SEER) database was used to create a cohort of 970 patients diagnosed with stage I and II NSCLC between 1988 and 2002 who refused surgery. The outcome was overall and lung cancer-specific survival, while race was the key predictor variable. Kaplan-Meier survival analysis was performed to estimate crude survival differences. Potential confounders were adjusted for in Cox-proportional regression analysis. Results: A majority (78%) was white and 11% were blacks. In the crude analysis of all-cause mortality, blacks tended to have lower mortality than whites (p-value 0.075). In the adjusted model, blacks had 19% lower risk of mortality than whites (HR 0.81, 95% C.I. 0.67, 0.99, p-value 0.045). There were no differences in cancer-specific mortality in either crude or adjusted analysis. Females, individuals who receive radiotherapy and those with higher education in a county had lower risk of overall and cancer-specific mortality. Conclusions: Among patients who refused surgery for early stage NSCLC, blacks have a lower risk of all-cause mortality than whites, but there are no differences in the cancer-specific mortality. This should be interpreted with caution due to lack of chemotherapy data and information on quality of life.