title: Factors associated with lung cancer patients refusing treatment and their survival: a national cohort study under a universal health insurance in Taiwan.
abstract: BACKGROUND
  Lung cancer is the leading cause mortality among all cancers in Taiwan. Although Taiwan offers National Health Insurance (NHI), occasionally, patients refuse treatment. This study examined the patient characteristics and factors associated with lung cancer patients refusing cancer treatment in four months after cancer diagnosed and compared the survival differences between treated and non-treated patients.
  
  
  METHODS
  The study included 38584 newly diagnosed lung cancer patients between 2004 and 2008, collected from the Taiwan Cancer Registry, which was linked with NHI research database and Cause of Death data set. Logistic regression was conducted to analyze factors associated with treatment refusal. The Cox proportional hazards model was used to examine the effects of treatment and non-treatment on patient survival and the factors affecting non-treatment patient survival.
  
  
  RESULTS
  Among the newly diagnosed cancer patients, older adults, or those who had been diagnosed with other catastrophic illnesses, an increased pre-cancer Charlson Comorbidity Index (CCI) score, and advanced stage cancer exhibited an increased likelihood of refusing treatment. Compared with treated patients, non-treated patients showed an increased mortality risk of 2.09 folds. The 1-year survival rate of treated patients (53.32%) was greater than that of non-treated patients (21.44%). Among the non-treated patients, those who were older, resided in lowly urbanized areas, had other catastrophic illnesses, a CCI score of ≥4, advanced cancer, or had received a diagnosis from a private hospital exhibited an increased mortality risk.
  
  
  CONCLUSIONS
  Despite Taiwan's NHI system, some lung cancer patients choose not to receive cancer treatment and the mortality rate for non-treated patients is significantly higher than that of patients who undergo treatment. Therefore, to increase the survival rate of cancer patients, treatment refusal should be addressed.
authors.affiliation: Department of Health Services Administration, China Medical University, Taichung, Taiwan, R.O.C; Hospital and Social Welfare Organizations Administration Commission, Ministry of Health and Welfare, Taiwan, R.O.C.
authors.forename: Hsiu-Ling
authors.initials: HL
authors.lastname: Huang
authors.affiliation: Department of Healthcare Administration, Asia University, Taichung, Taiwan, R.O.C.
authors.forename: Pei-Tseng
authors.initials: PT
authors.lastname: Kung
authors.affiliation: Department of Internal Medicine, China Medical University, Taichung, Taiwan, R.O.C.
authors.forename: Chang-Fang
authors.initials: CF
authors.lastname: Chiu
authors.affiliation: Department of Health Services Administration, China Medical University, Taichung, Taiwan, R.O.C.
authors.forename: Yueh-Hsin
authors.initials: YH
authors.lastname: Wang
authors.affiliation: Department of Health Services Administration, China Medical University, Taichung, Taiwan, R.O.C.
authors.forename: Wen-Chen
authors.initials: WC
authors.lastname: Tsai
mesh_terms: D000328:Adult; D000368:Aged; D015331:Cohort Studies; D006801:Humans; D007348:Insurance, Health / Q000706:statistics & numerical data*; D008175:Lung Neoplasms / Q000191:economics / Q000453:epidemiology* / Q000401:mortality / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D012306:Risk; D015996:Survival Rate; D013624:Taiwan / Q000453:epidemiology; D016312:Treatment Refusal / Q000706:statistics & numerical data*