title: The Refusal of Palliative Radiation in Metastatic Non-Small Cell Lung Cancer and Its Prognostic Implications.
abstract: BACKGROUND
  Patients with metastatic non-small cell lung cancer (NSCLC) have limited survival. Population studies have evaluated the impact of radiation refusal in the curative setting; however, no data exist concerning the prognostic impact of radiation refusal in the palliative care setting.
  
  
  OBJECTIVE
  To investigate the patterns of radiation refusal in newly diagnosed patients with metastatic NSCLC.
  
  
  METHODS
  Patients with Stage IV NSCLC diagnosed between 1988 and 2010 were identified in the Surveillance, Epidemiology, and End Results database. Univariate and multivariate analyses were used to identify predictors for refusal of radiation and the impact of radiation and refusal on survival in the palliative setting.
  
  
  RESULTS
  A total of 285,641 patients were initially included in the analysis. Palliative radiation was recommended in 42% and refused by 3.1% of patients. Refusal rates remained consistent across included years of study. On multivariate analysis, older, nonblack/nonwhite, unmarried females were more likely to refuse radiation (P < 0.001 in all cases). Median survival for patients refusing radiation was three months vs. five months for those receiving radiation and two months for those whom radiation was not recommended.
  
  
  CONCLUSIONS
  Patients with metastatic NSCLC who refuse recommended palliative radiation have a poor survival. Radiation refusal or the recommendation against treatment can serve as a trigger for integrating palliative care services sooner and contributes greatly to prognostic awareness. Further investigation into this survival difference and the factors behind refusal are warranted.
authors.affiliation: Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, USA. Electronic address: mark.j.stavas@vanderbilt.edu.
authors.forename: Mark J
authors.initials: MJ
authors.lastname: Stavas
authors.affiliation: Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
authors.forename: Kyle O
authors.initials: KO
authors.lastname: Arneson
authors.affiliation: Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
authors.forename: Matthew S
authors.initials: MS
authors.lastname: Ning
authors.affiliation: Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
authors.forename: Albert A
authors.initials: AA
authors.lastname: Attia
authors.affiliation: Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
authors.forename: Sharon E
authors.initials: SE
authors.lastname: Phillips
authors.affiliation: Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, USA.
authors.forename: Stephanie M
authors.initials: SM
authors.lastname: Perkins
authors.affiliation: Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
authors.forename: Eric T
authors.initials: ET
authors.lastname: Shinohara
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D002289:Carcinoma, Non-Small-Cell Lung / Q000175:diagnosis / Q000453:epidemiology* / Q000473:pathology / Q000532:radiotherapy*; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D017533:Marital Status; D008875:Middle Aged; D015999:Multivariate Analysis; D009367:Neoplasm Staging; D010166:Palliative Care / Q000379:methods*; D011379:Prognosis; D012737:Sex Factors; D016312:Treatment Refusal / Q000706:statistics & numerical data*
keywords: Palliative radiation; Stage IV; non-small cell lung cancer; refusal