title: Refusal of curative radiation therapy and surgery among patients with cancer.
abstract: OBJECTIVE
  Surgery and radiation therapy represent the only curative options for many patients with solid malignancies. However, despite the recommendations of their physicians, some patients refuse these therapies. This study characterized factors associated with refusal of surgical or radiation therapy as well as the impact of refusal of recommended therapy on patients with localized malignancies.
  
  
  METHODS
  We used the Surveillance, Epidemiology, and End Results program to identify a population-based sample of 925,127 patients who had diagnoses of 1 of 8 common malignancies for which surgery and/or radiation are believed to confer a survival benefit between 1995 and 2008. Refusal of oncologic therapy, as documented in the SEER database, was the primary outcome measure. Multivariable logistic regression was used to investigate factors associated with refusal. The impact of refusal of therapy on cancer-specific mortality was assessed with Fine and Gray's competing risks regression.
  
  
  RESULTS
  In total, 2441 of 692,938 patients (0.4%) refused surgery, and 2113 of 232,189 patients (0.9%) refused radiation, despite the recommendations of their physicians. On multivariable analysis, advancing age, decreasing annual income, nonwhite race, and unmarried status were associated with refusal of surgery, whereas advancing age, decreasing annual income, Asian American race, and unmarried status were associated with refusal of radiation (P<.001 in all cases). Refusal of surgery and radiation were associated with increased estimates of cancer-specific mortality for all malignancies evaluated (hazard ratio [HR], 2.80, 95% confidence interval [CI], 2.59-3.03; P<.001 and HR 1.97 [95% CI, 1.78-2.18]; P<.001, respectively).
  
  
  CONCLUSIONS
  Nonwhite, less affluent, and unmarried patients are more likely to refuse curative surgical and/or radiation-based oncologic therapy, raising concern that socioeconomic factors may drive some patients to forego potentially life-saving care.
authors.affiliation: Harvard Radiation Oncology Program, Boston, Massachusetts. Electronic address: aaaizer@partners.org.
authors.forename: Ayal A
authors.initials: AA
authors.lastname: Aizer
authors.affiliation: Department of Statistics, University of Connecticut, Storrs, Connecticut.
authors.forename: Ming-Hui
authors.initials: MH
authors.lastname: Chen
authors.affiliation: Boston University School of Medicine, Boston, Massachusetts.
authors.forename: Arti
authors.initials: A
authors.lastname: Parekh
authors.affiliation: Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Toni K
authors.initials: TK
authors.lastname: Choueiri
authors.affiliation: Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Karen E
authors.initials: KE
authors.lastname: Hoffman
authors.affiliation: Department of Urology, Mayo Clinic, Rochester, Minnesota.
authors.forename: Simon P
authors.initials: SP
authors.lastname: Kim
authors.affiliation: Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Neil E
authors.initials: NE
authors.lastname: Martin
authors.affiliation: Department of Urology, University of California, Los Angeles, California.
authors.forename: Jim C
authors.initials: JC
authors.lastname: Hu
authors.affiliation: Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Quebec, Canada.
authors.forename: Quoc-Dien
authors.initials: QD
authors.lastname: Trinh
authors.affiliation: Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Paul L
authors.initials: PL
authors.lastname: Nguyen
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D005260:Female; D006801:Humans; D007182:Income; D016015:Logistic Models; D008297:Male; D017533:Marital Status; D008875:Middle Aged; D015999:Multivariate Analysis; D009369:Neoplasms / Q000208:ethnology / Q000401:mortality / Q000532:radiotherapy* / Q000601:surgery*; D018426:SEER Program / Q000706:statistics & numerical data; D017678:Sex Distribution; D012959:Socioeconomic Factors; D016312:Treatment Refusal / Q000706:statistics & numerical data*; D014481:United States