Department of General Surgery, University of Pittsburgh, Pittsburgh, PA, USA.
Ann Surg Oncol. 2018 Nov;25(12):3427-3435. doi: 10.1245/s10434-018-6680-6. Epub 2018 Jul 24.
To identify factors associated with refusal of surgery in patients with early-stage pancreatic cancer and estimate the impact of this decision on survival.
Using the National Cancer Data Base, 26,358 patients were identified with potentially resectable tumors (pretreatment clinical stage I: T1 or T2 N0M0). Multivariate models were employed to identify factors predicting failure to undergo surgery and assess the impact on survival.
Of early-stage patients who were recommended surgery, 7.8% (N = 992) refused surgery for resectable early-stage pancreatic cancer. On multivariable analysis, patients were more likely to refuse surgery if they were older [odds ratio (OR) = 1.18; 95% confidence interval (CI) 1.16-1.19], female (OR = 1.52; 95% CI 1.33-1.73), African American (vs White, OR = 1.79; 95% CI 1.37-2.34), on Medicare/Medicaid (vs private, OR = 2.75; 95% CI 1.54-4.92) or had higher Charlson-Deyo score (2 vs 0, OR = 1.33; 95% CI 1.03-1.72). Patients were also significantly more likely to refuse surgery if they were seen at a center that is not an academic/research program (OR 1.9; 95% CI 1.6-2.27). Patients who were recommended surgery but refused had significantly worse survival than those with stage I who received surgery [median survival 6.8 vs 24 months, Cox hazard ratio (HR) 3.41; 95% CI 3.12-3.60].
The percentage of patients refusing surgery for operable early-stage pancreatic cancer has been decreasing in the last decade but remains a significant issue that affects survival. Disparities in refusal of surgery are independently associated with several variables including gender, race, and insurance. To mitigate national disparities in surgical care, future studies should focus on exploring potential reasons for refusal and developing communication interventions.
确定与早期胰腺癌患者拒绝手术相关的因素，并评估该决定对生存的影响。
利用国家癌症数据库，确定了 26358 例具有潜在可切除肿瘤的患者（预处理临床分期 I：T1 或 T2 N0M0）。采用多变量模型确定预测手术失败的因素，并评估其对生存的影响。
在建议手术的早期患者中，7.8%（N=992）因可切除的早期胰腺癌而拒绝手术。多变量分析显示，如果患者年龄较大[比值比（OR）=1.18；95%置信区间（CI）1.16-1.19]、女性（OR=1.52；95%CI 1.33-1.73）、非裔美国人（与白人相比，OR=1.79；95%CI 1.37-2.34）、医疗保险/医疗补助（与私人保险相比，OR=2.75；95%CI 1.54-4.92）或Charlson-Deyo 评分较高（2 分 vs 0 分，OR=1.33；95%CI 1.03-1.72），则更有可能拒绝手术。如果患者在非学术/研究计划的中心就诊，他们拒绝手术的可能性也明显更高（OR 1.9；95%CI 1.6-2.27）。与接受手术的 I 期患者相比，建议手术但拒绝手术的患者生存状况明显更差[中位生存期 6.8 个月 vs 24 个月，Cox 风险比（HR）3.41；95%CI 3.12-3.60]。
在过去十年中，拒绝接受手术治疗的可手术早期胰腺癌患者比例有所下降，但仍然是一个严重影响生存的问题。手术拒绝的差异与性别、种族和保险等多个变量独立相关。为了减轻全国范围内手术治疗的差异，未来的研究应重点探讨拒绝手术的潜在原因，并制定沟通干预措施。
