Survival Outcomes and Disparities in Surgery Refusal for Papillary Thyroid Cancer

Discussion

This study assessed the impact of surgery refusal on OS in patients with PTC and identified factors associated with refusal. This analysis revealed that patients who refused surgery had lower one-year and five-year OS rates and shorter median survival times than patients who underwent surgery. Surgery refusal was associated with older age, male sex, Black and Asian race, Hispanic ethnicity, lower income, and uninsured or non-private insurance status.

Patients who refused surgery were significantly older, with a mean age of 55.2 years, which was 6.5 years older than the mean age of 48.7 years among all patients with PTC. These results align with existing research demonstrating higher treatment refusal rates among older adults (14). Previous studies have found that concerns about side effects are a significant factor influencing older adults’ decisions to refuse cancer treatment (7, 14). This is particularly relevant as older adults are at a higher risk of experiencing complications from thyroid surgery compared to younger patients (15, 16). A reduced desire to prolong life and concerns regarding safety, impacts on quality of life, and treatment efficacy also contribute to higher refusal rates among older adults (7, 8). Addressing these concerns is crucial to enhancing surgical care utilization and improving survival outcomes in this demographic.

A larger proportion of males declined surgery compared to females, a trend consistent with prior research on thyroid cancer (6). Sex disparities in surgical utilization have also been observed in other cancer types, such as lung and colon cancer, reflecting broader patterns in healthcare where males are generally less likely to seek medical care compared to females (9, 17).

This analysis also found higher surgery refusal rates among Black, Asian, and Hispanic patients. This finding is consistent across studies examining racial disparities in surgery refusal for thyroid cancer and other solid tumors, including breast, colorectal, lung, gynecologic, and prostate cancers (6, 9-11, 18). Studies have demonstrated higher cancer surgery refusal rates among Black and Asian patients, even when controlling for insurance status and socioeconomic factors (10, 11).

Addressing these disparities will likely require concerted efforts to bridge gaps in access, utilization, and outcomes through culturally competent communication and education. Prior studies indicate that shared decision-making utilizing decisional aids can significantly benefit racial and ethnic minority patients, increasing their medical knowledge and likelihood of undergoing surgery (19). Decisional aids tailored for PTC are currently being developed to aid patients in making informed choices about surgical intervention (20, 21).

Lower income and lack of insurance were strongly associated with higher surgery refusal rates. Out-of-pocket costs can create a significant financial barrier to surgical treatment for uninsured and low-income patients (22). Non-private insurance coverage, mainly Medicaid and Medicare, was also associated with surgery refusal. These findings underscore the urgent need for interventions aimed at improving affordability and expanding insurance coverage to reduce barriers to essential surgical care. Patient navigation programs, which assist patients in overcoming barriers to cancer care, have been shown to increase the likelihood of patients receiving recommended cancer treatment (23). Addressing financial and insurance barriers through policy changes and support programs can improve access to surgical care for lower-income and uninsured patients. Efforts to expand insurance coverage and reduce out-of-pocket costs for surgical procedures are critical to mitigating disparities in treatment acceptance.

Patients who refused surgery for PTC had lower median survival times and one-year and five-year OS rates compared to those who underwent surgical intervention. The impact of surgery refusal on OS rates highlights the urgency of addressing disparities in the acceptance of surgical treatment to ensure optimal outcomes for all patients. These results are consistent with prior literature demonstrating inferior survival outcomes for patients who refuse surgery for thyroid and other cancers (6, 9-11, 18).

This study contributes to the existing literature by specifically focusing on PTC, which presents distinct clinical features and management considerations compared to other types of thyroid cancer. By analyzing recent data from the NCDB, a database with extensive case coverage, this research provides updated insights into surgery refusal patterns and outcomes.

Future prospective research is needed to explore patients’ reasons for refusing surgery. Interventions such as patient navigator programs and decisional aids aimed at reducing surgery refusals and enhancing treatment utilization are necessary to address disparities and improve patient outcomes. By building upon existing knowledge and leveraging comprehensive database resources like the NCDB, further studies can advance our understanding of surgery refusal in PTC and inform strategies to mitigate these disparities with the ultimate goal to improve patient care.

This study included a robust sample size derived from an extensive, multicenter database covering approximately 70% of patients with cancer. However, we acknowledge that there are important limitations to consider. The NCDB lacks data on recurrence, cause of death, or specific reasons for surgery refusal, limiting deeper analysis into these aspects. Additionally, factors such as cultural and religious backgrounds, which could influence surgery refusal, are not captured in NCDB data. Patient comorbidities were not systematically assessed, although patients unable to undergo surgery due to comorbidities or frailty were analyzed separately from those who refused recommended surgery. The retrospective design of this study may have also affected its ability to reflect current treatment practices, including shifts towards active surveillance for PTC, and evolving patient attitudes toward surgery, potentially impacting the generalizability of findings to contemporary clinical settings.