title: Refusal of Recommended Chemotherapy for Ovarian Cancer: Risk Factors and Outcomes; a National Cancer Data Base Study.
abstract: To identify risk factors associated with refusal of recommended chemotherapy and its impact on patients with epithelial ovarian cancer (EOC).
  
  
  
  We identified patients in the National Cancer Data Base diagnosed with EOC from January 1998 to December 2011. Patients who refused chemotherapy were identified and compared with those who received recommended, multiagent chemotherapy. Univariate and multivariable analyses were performed using chi-square test with Bonferroni correction, binary logistic regression, log-rank test, and Cox proportional hazards modeling. The threshold for statistical significance was set at a P value of less than 0.05.
  
  
  
  From a cohort of 147,713 eligible patients, 2,707 refused chemotherapy. These patients were compared with 92,212 patients who received recommended multiagent chemotherapy. Older age, more medical comorbidities, not having insurance, and later year of diagnosis were directly and significantly associated with chemotherapy refusal when analyzed using multivariable logistic regression. In addition, lower-than-expected facility adherence to NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Ovarian Cancer, treatment at low-volume center, lower grade, and higher stage were all significantly and independently associated with chemotherapy refusal. Median overall survival of patients who received multiagent chemotherapy was significantly longer than that of those who refused chemotherapy (43 vs 4.8 months; P<.0005). After controlling for known patient, facility, and disease prognostic factors, chemotherapy refusal is significantly associated with increased risk of death.
  
  
  
  Refusal of recommended chemotherapy carries significant risk of early death from ovarian cancer. Our data demonstrate that the decision to refuse chemotherapy is multifactorial and, in addition to unalterable factors (eg, stage/grade, age), involves factors that can be changed, including facility type and payor. Efforts at addressing these discrepancies in care can improve compliance with chemotherapy recommendations in the NCCN Guidelines for Ovarian Cancer and outcomes.
authors.affiliation: Mayo Clinic, Rochester, Minnesota
authors.forename: Sumer K
authors.initials: SK
authors.lastname: Wallace
authors.affiliation: Magee-Womens Hospital of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
authors.forename: Jeff F
authors.initials: JF
authors.lastname: Lin
authors.affiliation: Mayo Clinic, Rochester, Minnesota
authors.forename: William A
authors.initials: WA
authors.lastname: Cliby
authors.affiliation: University of California Davis Medical Center, Sacramento, California
authors.forename: Gary S
authors.initials: GS
authors.lastname: Leiserowitz
authors.affiliation: New York-Presbyterian Hospital/Columbia University Medical Center, New York, New York
authors.forename: Ana I
authors.initials: AI
authors.lastname: Tergas
authors.affiliation: University of California Irvine Medical Center, Orange, California
authors.forename: Robert E
authors.initials: RE
authors.lastname: Bristow
mesh_terms: D000368:Aged; D000077216:Carcinoma, Ovarian Epithelial; D005260:Female; D006801:Humans; D008875:Middle Aged; D009375:Neoplasms, Glandular and Epithelial / Q000188:drug therapy* / Q000473:pathology; D010051:Ovarian Neoplasms / Q000188:drug therapy* / Q000473:pathology; D012307:Risk Factors; D016896:Treatment Outcome; D014481:United States