Pianka Kurt, Zhao Beiqun, Lee Katherine, Liu Shanglei, Eisenstein Samuel, Ramamoorthy Sonia, Lopez Nicole
School of Medicine, University of California San Diego, La Jolla, CA.
Department of Surgery, University of California San Diego, La Jolla, CA.
Surgery. 2022 Nov;172(5):1309-1314. doi: 10.1016/j.surg.2022.05.035. Epub 2022 Aug 26.
Increasingly, patients with rectal cancer receive nonoperative management. A growing body of retrospective evidence supporting the safety of this approach has likely contributed to its growing popularity. However, patients may also undergo nonoperative management because of refusal of surgical resection. We hypothesize that patients who refuse surgery are more likely to be from groups who traditionally face barriers accessing care.
We used the National Cancer Database (2006-2017) to analyze patients with nonmetastatic rectal adenocarcinoma who underwent nonoperative management following radiation. We identified 2 groups: (1) planned nonoperative management and (2) nonoperative management because of refusal of surgery. We performed logistic regression to compare the groups along patient, socioeconomic, and facility-level factors.
In total, 9,613 and 2,039 patients were included in the planned nonoperative management and refused nonoperative management groups, respectively. Of the total study cohort (ie, planned nonoperative management + refused nonoperative management), 21% of these patients diagnosed in 2017 underwent refused nonoperative management, versus 12% in 2006. Patients who were Black (adjusted odds ratio 1.47, 95% confidence interval 1.26-1.71) or Asian/Pacific Islander (adjusted odds ratio 1.51, 95% confidence interval 1.18-1.92), age ≥65 years (adjusted odds ratio 1.55, 95% confidence interval 1.37-1.77), with more advanced disease stage (stage III adjusted odds ratio 1.30, 95% confidence interval 1.10-1.53), and government insurance (adjusted odds ratio 1.19, 95% confidence interval 1.04-1.36) were associated with increased utilization of refused nonoperative management. Conversely, lower education (adjusted odds ratio 0.62, 95% confidence interval 0.50-0.76) and female sex (adjusted odds ratio 0.88, 95% confidence interval 0.79-0.97) were associated with planned nonoperative management.
Our findings suggest that the refused nonoperative management group is demographically distinct. Outreach efforts to better understand the rationale behind patient decision making in rectal cancer will be paramount to ensuring appropriate implementation of nonoperative management.
越来越多的直肠癌患者接受非手术治疗。越来越多的回顾性证据支持这种治疗方法的安全性，这可能是其越来越受欢迎的原因。然而，患者也可能因拒绝手术切除而接受非手术治疗。我们假设拒绝手术的患者更有可能来自传统上面临就医障碍的群体。
我们使用国家癌症数据库（2006 - 2017年）分析接受放疗后进行非手术治疗的非转移性直肠腺癌患者。我们确定了两组：（1）计划性非手术治疗组和（2）因拒绝手术而进行非手术治疗组。我们进行了逻辑回归分析，以比较两组患者在患者、社会经济和机构层面因素方面的情况。
计划性非手术治疗组和拒绝非手术治疗组分别纳入了9613例和2039例患者。在整个研究队列（即计划性非手术治疗组 + 拒绝非手术治疗组）中，2017年诊断的患者中有21%接受了拒绝非手术治疗，而2006年这一比例为12%。黑人（调整后的优势比为1.47，95%置信区间为1.26 - 1.71）或亚太岛民（调整后的优势比为1.51，95%置信区间为1.18 - 1.92）、年龄≥65岁（调整后的优势比为1.55，95%置信区间为1.37 - 1.77）、疾病分期较晚（III期调整后的优势比为1.30，95%置信区间为1.10 - 1.53）以及拥有政府保险（调整后的优势比为1.19，95%置信区间为1.04 - 1.36）的患者，拒绝非手术治疗的使用率更高。相反，低教育水平（调整后的优势比为0.62，95%置信区间为0.50 - 0.76）和女性（调整后的优势比为0.88，95%置信区间为0.79 - 0.97）与计划性非手术治疗相关。
我们的研究结果表明，拒绝非手术治疗组在人口统计学上具有明显差异。开展外展工作以更好地理解直肠癌患者决策背后的理由，对于确保非手术治疗的恰当实施至关重要。
