Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
Harvard Medical School, Boston, MA.
JCO Oncol Pract. 2021 Oct;17(10):e1489-e1501. doi: 10.1200/OP.20.00839. Epub 2021 Feb 25.
We assessed sociodemographic factors associated with and survival implications of refusal of potentially survival-prolonging locoregional treatment (LT, including radiotherapy and surgery) despite provider recommendation among men with localized prostate adenocarcinoma.
The National Cancer Database (2004-2015) identified men with TxN0M0 prostate cancer who either received or refused LT despite provider recommendation. Multivariable logistic regression defined adjusted odds ratios (AORs) with 95% CI of refusing LT, with sociodemographic and clinical covariates. Models were stratified by low-risk and intermediate- or high-risk (IR or HR) disease, with a separate interaction analysis between race and risk group. Multivariable Cox proportional hazard ratios compared overall survival (OS) among men who received versus refused LT.
Of 887,839 men (median age 64 years, median follow-up 6.14 years), 2,487 (0.28%) refused LT. Among men with IR or HR disease (n = 651,345), Black and Asian patients were more likely to refuse LT than White patients (0.35% 0.29% 0.17%; Black White AOR, 1.75; 95% CI, 1.52 to 2.01; < .001; Asian White AOR, 1.47; 95% CI, 1.05 to 2.06; = .027, race * risk group interaction < .001). Later year of diagnosis, community facility type, noninsurance or Medicaid, and older age were also associated with increased odds of LT refusal, overall and when stratifying by risk group. For men with IR or HR disease, LT refusal was associated with worse OS (5-year OS 80.1% 91.5%, HR, 1.65, < .001).
LT refusal has increased over time; racial disparities were greater in higher-risk disease. Refusal despite provider recommendation highlights populations that may benefit from efforts to assess and reduce barriers to care.
我们评估了与局部前列腺腺癌男性在提供者建议的情况下拒绝潜在生存延长的局部区域治疗（LT，包括放疗和手术）相关的社会人口学因素以及生存意义。
国家癌症数据库（2004-2015 年）确定了 TxN0M0 前列腺癌男性患者，他们接受或拒绝了 LT，尽管提供者建议。多变量逻辑回归定义了拒绝 LT 的调整优势比（AOR）及其 95%置信区间，包括社会人口统计学和临床协变量。模型按低风险和中危或高危（IR 或 HR）疾病分层，并在种族和风险组之间进行了单独的交互分析。多变量 Cox 比例风险比比较了接受与拒绝 LT 的男性的总生存率（OS）。
在 887839 名男性（中位年龄 64 岁，中位随访 6.14 年）中，有 2487 人（0.28%）拒绝了 LT。在 IR 或 HR 疾病患者中（n=651345），黑人患者和亚洲患者比白人患者更有可能拒绝 LT（0.35% 0.29% 0.17%；黑人与白人 AOR，1.75；95%CI，1.52 至 2.01；<0.001；亚洲与白人 AOR，1.47；95%CI，1.05 至 2.06；=0.027，种族*风险组交互作用<0.001）。诊断较晚的年份、社区机构类型、无保险或医疗补助，以及年龄较大，与 LT 拒绝的可能性总体上和按风险组分层时都增加有关。对于 IR 或 HR 疾病患者，LT 拒绝与较差的 OS 相关（5 年 OS 80.1% 91.5%，HR，1.65，<0.001）。
LT 拒绝的情况随着时间的推移而增加；在高危疾病中，种族差异更大。尽管提供者建议，仍拒绝治疗突显了那些可能受益于评估和减少护理障碍的人群。
