Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA.
Department of Surgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA.
Ann Surg Oncol. 2021 Feb;28(2):663-675. doi: 10.1245/s10434-020-08761-7. Epub 2020 Jul 9.
The aim of this study was to understand factors associated with refusal of local therapy in esophageal cancer and compare the overall survival (OS) of patients who refuse therapies with those who undergo recommended treatment.
National Cancer Database data for patients with non-metastatic esophageal cancer from 2006 to 2013 were pooled. T1N0M0 tumors were excluded. Pearson's Chi-square test and multivariate logistic regression analyses were used to assess demographic, clinical, and treatment factors. After propensity-score matching with inverse probability of treatment weighting, OS was compared between patients who refused therapies and those who underwent recommended therapy, using Kaplan-Meier analyses and doubly robust estimation with multivariate Cox proportional hazards modeling.
In total, 37,618 patients were recommended radiation therapy (RT) and/or esophagectomy; we found 1403 (3.7%) refused local therapies. Specifically, 890 of 18,942 (4.6%) patients refused surgery and 667 of 31,937 (2.1%) refused RT. Older patients, females, those with unknown lymphovascular space invasion, and those uninsured or on Medicare were more likely to refuse. Those with squamous cell carcinoma, N1 disease, higher incomes, living farther from care, and those who received chemotherapy were less likely to refuse. Five-year OS was decreased in patients who refused (18.1% vs. 27.6%). The survival decrement was present in adenocarcinoma but not squamous cell carcinoma. In patients who received surgery or ≥ 50.4 Gy RT, there was no OS decrement to refusing the other therapy.
We identified characteristics that correlate with refusal of local therapy. Refusal of therapy was associated with decreased OS. Patients who received either surgery or ≥ 50.4 Gy RT had no survival decrement from refusing the opposite modality.
本研究旨在了解与食管癌局部治疗拒绝相关的因素，并比较拒绝治疗和接受推荐治疗的患者的总生存期（OS）。
汇总了 2006 年至 2013 年国家癌症数据库中患有非转移性食管癌患者的数据。排除 T1N0M0 肿瘤。采用 Pearson's Chi-square 检验和多变量逻辑回归分析评估人口统计学、临床和治疗因素。通过逆概率治疗加权（inverse probability of treatment weighting）进行倾向评分匹配后，采用 Kaplan-Meier 分析和双重稳健估计的多变量 Cox 比例风险模型比较拒绝治疗和接受推荐治疗的患者的 OS。
共推荐 37618 例患者接受放疗（RT）和/或食管切除术；我们发现有 1403 例（3.7%）拒绝了局部治疗。具体来说，18942 例患者中有 890 例（4.6%）拒绝手术，31937 例中有 667 例（2.1%）拒绝 RT。年龄较大、女性、未知脉管侵犯、无保险或医疗保险的患者更有可能拒绝治疗。患有鳞状细胞癌、N1 疾病、较高收入、居住地离治疗中心较远、接受化疗的患者则不太可能拒绝。拒绝治疗的患者五年 OS 降低（18.1% vs. 27.6%）。该生存下降仅见于腺癌，而不存在于鳞状细胞癌中。在接受手术或≥50.4Gy RT 的患者中，拒绝另一种治疗方式并不影响 OS。
我们确定了与拒绝局部治疗相关的特征。拒绝治疗与 OS 降低相关。接受手术或≥50.4Gy RT 的患者，拒绝另一种治疗方式并不会导致生存下降。
