title: Noncompliance to guidelines in head and neck cancer treatment; associated factors for both patient and physician.
abstract: BACKGROUND
  Decisions on head and neck squamous cell carcinoma (HNSCC) treatment are widely recognized as being difficult, due to high morbidity, often involving vital functions. Some patients may therefore decline standard, curative treatment. In addition doctors may propose alternative, nonstandard treatments. Little attention is devoted, both in literature and in daily practice, to understanding why and when HNSCC patients or their physicians decline standard, curative treatment modalities. Our objective is to determine factors associated with noncompliance in head and neck cancer treatment for both patients and physicians and to assess the influence of patient compliance on prognosis.
  
  
  METHODS
  We did a retrospective study based on the medical records of 829 patients with primary HNSCC, who were eligible for curative treatment and referred to our hospital between 2010 and 2012. We analyzed treatment choice and reasons for nonstandard treatment decisions, survival, age, gender, social network, tumor site, cTNM classification, and comorbidity (ACE27). Multivariate analysis using logistic regression methods was performed to determine predictive factors associated with non-standard treatment following physician or patient decision. To gain insight in survival of the different groups of patients, we applied a Cox regression analysis. After checking the proportional hazards assumption for each variable, we adjusted the survival analysis for gender, age, tumor site, tumor stage, comorbidity and a history of having a prior tumor.
  
  
  RESULTS
  17 % of all patients with a primary HNSCC did not receive standard curative treatment, either due to nonstandard treatment advice (10 %) or due to the patient choosing an alternative (7 %). A further 3 % of all patients refused any type of therapy, even though they were considered eligible for curative treatment. Elderliness, single marital status, female gender, high tumor stage and severe comorbidity are predictive factors. Patients declining standard treatment have a lower overall 3-year survival (34 % vs. 70 %).
  
  
  CONCLUSIONS
  Predictive factors for nonstandard treatment decisions in head and neck cancer treatment differed between the treating physician and the patient. Patients who received nonstandard treatment had a lower overall 3-year survival. These findings should be taken into account when counselling patients in whom nonstandard treatment is considered.
authors.affiliation: Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus University Medical Center, 's Gravendijkwal 230, room D112, 3015 CE, Rotterdam, The Netherlands. e.dronkers@erasmusmc.nl.
authors.forename: Emilie A C
authors.initials: EA
authors.lastname: Dronkers
authors.affiliation: Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus University Medical Center, 's Gravendijkwal 230, room D112, 3015 CE, Rotterdam, The Netherlands. messteven@gmail.com.
authors.forename: Steven W
authors.initials: SW
authors.lastname: Mes
authors.affiliation: Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus University Medical Center, 's Gravendijkwal 230, room D112, 3015 CE, Rotterdam, The Netherlands. m.vandenbrink@erasmusmc.nl.
authors.forename: Marjan H
authors.initials: MH
authors.lastname: Wieringa
authors.affiliation: Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus University Medical Center, 's Gravendijkwal 230, room D112, 3015 CE, Rotterdam, The Netherlands. m.vanderschroeff@erasmusmc.nl.
authors.forename: Marc P
authors.initials: MP
authors.lastname: van der Schroeff
authors.affiliation: Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus University Medical Center, 's Gravendijkwal 230, room D112, 3015 CE, Rotterdam, The Netherlands. r.j.baatenburgdejong@erasmusmc.nl.
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Baatenburg de Jong
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000066491:Clinical Decision-Making; D015897:Comorbidity; D019468:Disease Management; D005260:Female; D019983:Guideline Adherence; D006258:Head and Neck Neoplasms / Q000175:diagnosis / Q000453:epidemiology* / Q000628:therapy*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D016017:Odds Ratio; D017063:Outcome Assessment, Health Care; D010349:Patient Compliance; D010820:Physicians; D012189:Retrospective Studies; D012307:Risk Factors