Treatment of stage I‐III rectal cancer: Who is refusing surgery?

Abstract

Background and Objectives Surgical resection is a cornerstone in the management of patients with rectal cancer. Patients may refuse surgical treatment for several reasons although the rate of refusal is currently unknown. Methods The National Cancer Database was utilized to identify patients with stage I‐III rectal cancer. Patients who refused surgical resection were compared to patients who underwent curative resection. Results A total of 509 (2.6%) patients with stage I and 2082 (3.5%) patients with stage II/III rectal cancer refused surgery. In multivariable analysis for stage I disease, older age, Black race, and Medicaid/no insurance were independent predictors of surgery refusal. Patients were less likely to refuse surgery if they had a higher income or lived further distances from the treatment facility. In multivariable analysis for stage II/III disease, older age, Black race, insurance other than private, and rural county were independent predictors of surgery refusal. Patients were less likely to refuse surgery if they had higher Charlson comorbidity scores, lived further distances from the treatment facility, or underwent chemoradiation. There was a significant decrease in survival for patients refusing surgery compared to patients undergoing recommended surgery. Conclusions A small proportion of patients refuse surgery for rectal cancer, and this treatment decision significantly affects survival.

Refusal of Surgery in Pituitary Adenoma Patients: A Population-Based Analysis

“…We noticed the opposite trend, with larger tumors necessitating surgery receipt. Regarding distance from patient to provider, our findings are in agreement with a prior report on stage I–III rectal cancer, which reported increased surgery receipt in individuals who lived further from their provider’s location [ 22 ]. Our findings also are in agreement with a previous study on esophageal cancer that reported increased odds of surgery receipt with increased patient to provider distance [ 16 ].…”

Oncological Outcomes of Transanal Endoscopic Surgery for the Surgical Management of T2 and T3 Rectal Cancer

“…This proportion of patients who refused conventional treatment (2.1%) is similar to a previous large US population database review, which determined that the rate of surgical refusal in stage I and III rectal cancer ranged from 2.6% to 3.5%. 13 Conversely, 8.4% of patients in our database were deemed unfit for surgery, which is comparable to a recent British study that found 10% of their patients with bowel cancer were unfit to tolerate major resection. 14 Because of the rarity of treatment refusal, oncologic outcomes in these patients are relatively unknown.…”

“…Similarly, patient refusal of surgical resection is associated with refusal of chemotherapy and radiation treatments as well. 13 Based on this past literature, it is possible that future advances in nonoperative alternatives will be most applicable to patients who would have undergone radical resection to begin with.…”

Current trends in nonoperative management for rectal adenocarcinoma: An unequal playing field?

“…Additionally, we found the lack of insurance, which is also associated with lower likelihood of receiving surgery for rectal cancer, 23,24 to be associated with higher odds of NOM compared with privately insured individuals. Some studies suggest that Black patients and patients with nonprivate insurance were significantly more likely to refuse surgery, offering a possible explanation 22,25 . However, we excluded patients who refused surgery from this analysis, suggesting that other factors may be at play.…”

“…Some studies suggest that Black patients and patients with nonprivate insurance were significantly more likely to refuse surgery, offering a possible explanation. 22,25 However, we excluded patients who refused surgery from this analysis, suggesting that other factors may be at play. We found that patients in the lowest income group did not have a significant difference in NOM compared with patients in the highest income group, whereas those in the middle-income groups had slightly lower rates of NOM.…”