Characteristics of Breast Cancer Patients Who Refuse Surgery

Discussion

Our study results show that there is a number of patient and disease characteristics associated with refusing surgical treatment. These characteristics include higher age at diagnosis, female gender, black and Asian race, government or no insurance, living in zip codes in which a higher percentage of the population did not graduate high school, disease stages II and III, adenocarcinomas, and non-triple-negative breast cancer. It has been shown that refusing surgery for breast cancer, at any stage, can significantly decrease survival and therefore, it is important to understand what factors may impact a patient's choice of refusing surgery (2).

Our findings that medical treatment is more often refused by patients with higher age have been also found in other cancer studies (7, 8). Previous studies have demonstrated that higher age independently increases the odds of refusing cancer surgery (2, 9, 10). This could be caused by different factors, such as shorter life expectancy, higher likelihood of surgical adverse events, or higher rate of comorbidities. It has also been demonstrated that elderly patients are less likely to get surgery for cancer than younger patients (11).

An interesting finding of this study is that women have independently higher odds of refusing breast cancer surgery than men. Although not easy to explain, it could be due to the deformity and greater psychological impact that mastectomy can have on women when compared to men. A previous study on patients with resectable pancreatic cancer showed that women had higher odds of refusing surgery (OR=1.52; 95% CI=1.33-1.73) when compared to men (3). Additionally, previous research has identified that body disfigurement caused by the surgery can affect the psychological state of female breast cancer patients (12, 13).

In our study, when compared to white patients, black and Asian patients were shown to have an independently higher risk of refusing surgery when diagnosed with breast cancer. There may be cultural or access to care components secondary to socioeconomic disparities (14). Furthermore, studies have reported independently increased odds of refusing cancer-directed surgery in black and Asian patients in pancreatic, breast, and hepatocellular carcinomas (2, 3, 10).

Another important study finding is that patients with no insurance or those with government insurance had independently increased odds of refusing breast cancer surgery. This result is supported by Gaitanidis and colleagues (2) who performed a study using the Surveillance Epidemiology and End Results (SEER) database in which the lack of insurance was found to increase the odds of surgery refusal (OR=2.11; 95% CI=1.59-2.8; p<0.001) (2). Tohme and colleagues (3), using the NCDB, found that patients with resectable pancreatic cancer were more likely to refuse surgery when they had government insurance (OR=2.75; 95% CI=1.54-4.92) when compared to patients with private insurance (3). Further health economic analysis is required to understand the real or perceived economic impact of breast cancer surgery on patients with government or without insurance options.

Higher stage of disease was found to be an important risk factor for refusing breast cancer surgery. Multiple reasons may be driving this situation. Patients who have lower survival chances might consider that surgery will decrease their quality of life and decide not to have it. Also, higher stage of disease could imply a bigger surgical resection, which would increase cosmetic deformity, and patients might consider this unacceptable. Patients with hepatocellular carcinoma have also been shown to increase surgery refusal at higher stages (10). However, prostate cancer patients with higher stage of disease have been reported to embrace surgical treatment more often (9).

Our study is not without limitations. Our analysis was conducted using the NCDB because it encompasses approximately 70% of all the cancer population in the US; however, due to the nature of large national databases, the fidelity of the information can be affected by incorrect or incomplete reports. Furthermore, the number of patients who refused surgery was considerably smaller than the number of patients who refused treatment. However, the large number of patients included in our study allows us to perform an analysis that is comparable to the United States cancer population and draw conclusions.

In conclusion, this study describes demographic and disease-specific characteristics related to breast cancer surgery refusal, which could be of immediate use to clinicians counseling selected populations. Further studies are needed to elucidate the underlying reasons for surgery refusal in the identified demographic and disease-specific populations.