Abstract
Background/Aim: Surgery is the primary treatment for melanoma, but some patients refuse it, potentially affecting survival. This study examines demographic and clinical factors associated with surgery refusal to inform targeted interventions.
Patients and Methods: We conducted a retrospective cohort study using the National Cancer Database (NCDB) to analyze factors linked to surgery refusal in melanoma patients. Demographic, clinical, and treatment characteristics were compared using Pearson Chi-square and Wilcoxon Rank Sum tests.
Results: Among 1,048,575 melanoma patients considered for surgery, 605 (0.1%) refused. Those who refused were older (mean age 75.8 years), had more comorbidities, and were more likely to be racial minorities or socioeconomically disadvantaged (p<0.001). Survival analysis showed a lower overall survival rate in the refusal group, with 66.0% alive at follow-up compared to 78.3% in the non-refusal group.
Conclusion: Surgery refusal in melanoma patients is associated with advanced age, frailty, and socioeconomic disadvantages, including racial minority status and lower income. Addressing these barriers may improve treatment acceptance and survival outcomes.
Introduction
Melanoma, a malignant tumor originating from melanocytes, is recognized as one of the most aggressive forms of skin cancer, with increasing rates of incidence observed globally. Recent statistical analyses indicate that the age-standardized incidence rate for melanoma was 3.4 cases per 100,000 people worldwide in 2020, accompanied by a mortality rate of 0.55 per 100,000 (1). Australia and New Zealand continue to report the highest rates of both incidence and deaths related to melanoma. Several factors contribute to these trends, such as increased prevalence of smoking, alcohol consumption, poor dietary habits, and metabolic disorders. While there has been an overall decline in melanoma mortality rates, the incidence continues to rise, particularly among older adults and men (1).
Surgical treatment remains a fundamental aspect of melanoma management, providing a curative option for the majority of localized cases (2). It is crucial for the accurate diagnosis, staging, and treatment of both in situ and invasive primary cutaneous melanoma. Effective surgical approaches, including wide local excision and sentinel lymph node biopsy, are vital for achieving favorable outcomes and minimizing the likelihood of local recurrence. In cases of localized invasive melanoma, surgical intervention is associated with a 5-year survival rate of approximately 92% (2). However, despite the established benefits, some patients refuse surgery, presenting distinct challenges in the clinical setting and potentially leading to worse health outcomes.
Prognosis for melanoma can vary greatly, especially for patients who decline surgical treatment. Key factors such as tumor stage, demographic characteristics, and underlying health conditions significantly influence survival outcomes. When melanoma is diagnosed in its early stages and effectively surgically removed, survival rates are notably improved. For instance, the 5-year survival rate for localized melanoma is approximately 98.4%, whereas it drops to 63.6% for regional melanoma and falls further to 22.5% for metastatic melanoma (3). Despite the clear advantages of surgical treatment, some patients choose not to undergo the recommended procedures. In a cohort study of patients with cutaneous malignant melanoma (CMM), approximately 9.7% did not receive wide local excision post-biopsy, which substantially increased their hazard ratio for mortality (4). Factors contributing to refusal include fear of adverse effects, insufficient understanding of the procedure’s benefits, and logistical challenges related to insurance coverage and personal circumstances (5). Additionally, racial and ethnic disparities have been identified, with evidence suggesting that Black and Asian/Pacific Islander individuals are more likely to refuse surgery than Whites (5, 6). Effective communication between healthcare providers and patients is essential; a lack of clear communication can heighten distrust, fear, and uncertainty, thus influencing patients to reject medical recommendations (7).
This study aimed to assess the impact of surgical refusal on overall survival in melanoma patients and to identify the demographic and clinical factors associated with such refusals. A deeper understanding of these disparities can guide the development of strategies that address patient concerns, reduce barriers to care, and promote surgical treatment utilization, ultimately improving patient outcomes. By tackling the root causes of surgery refusal, healthcare providers can create targeted interventions to enhance acceptance and adherence to surgical recommendations, thus optimizing survival rates for patients with melanoma.
Patients and Methods
Design. This retrospective cohort study utilized data from the National Cancer Database (NCDB) for 2024. The NCDB is a comprehensive, facility-based clinical surveillance registry established through a partnership between the American Cancer Society and the American College of Surgeons’ Commission on Cancer, encompassing approximately 70% of new cancer cases in the United States and derived from over 1,500 accredited facilities (8). Institutional Review Board approval was not required as the NCDB data is de-identified.
Study population. The NCDB was queried to identify patients diagnosed with melanoma. Sociodemographic variables included age at diagnosis, race, ethnicity, sex, patient distance to the treatment facility, income, insurance status by primary insurance carrier at diagnosis, treatment facility type, and urban-rural classification. Patient distance to the treatment facility was measured as the mileage from each patient’s zip code to the reporting hospital. Income was defined by the median household income for each patient’s zip code based on the American Community Survey, adjusted for inflation. Treatment facility type classification followed the Commission on Cancer’s standards, based on program structure, services provided, and caseload. Classification of rural, urban, or metro areas was determined using rural-urban continuum codes from the United States Department of Agriculture Economic Research Service, derived from each patient’s county. Clinical characteristics considered included treatment type, stage, and grade, with staging determined according to the American Joint Committee on Cancer’s 8th edition guidelines.
Statistical analysis. Descriptive statistics were employed to summarize the sociodemographic and clinical characteristics of the patients. Associations between categorical variables and surgery refusal were evaluated using Pearson Chi-square tests, presented as frequencies and relative frequencies. The Wilcoxon Rank Sum test analyzed continuous variables, provided as medians, means, and standard deviations. Overall survival (OS) was defined as the interval from cancer diagnosis to death. Factors impacting OS were assessed using both univariable and multivariable Cox proportional hazards models, with hazard ratios (HR), 95% confidence intervals (CI), and p-values reported. The Kaplan–Meier (KM) method was used to analyze OS, and survival curves were compared via the log-rank test. Numbers at risk were included in the KM curves. Statistical analyses were conducted using SAS version 9.4 (SAS Institute Inc., Cary, NC, USA).
Results
Patient characteristics. The study encompassed a total of 1,048,575 patients with melanoma identified in the NCDB for 2024. The patient demographics are detailed in Table I. The mean age of the cohort was 62.1 years, with 57.7% of patients identified as male. In terms of race, 60.6% were White, 0.3% Black, 38.8% Asian, and 0.1% Native American. Notably, 95.0% of patients underwent surgery, while a small subset (0.1%) refused surgical intervention. Patients who refused surgery had a higher mean age of 75.8 years compared to the overall mean (p<0.001). Male patients accounted for 57.3% of those undergoing surgery but rose to 58.5% among those who refused (p<0.001).
Cox proportional hazards model for overall survival.
Factors associated with surgery refusal. Analysis revealed that surgery refusal was more prevalent in older and frail patients, with refusal patients presenting a mean age of 75.8 years, significantly higher than those who accepted surgery. Racial disparities were evident, as Black and Hispanic patients represented higher proportions among those refusing surgery (3.3% and 2.8%, respectively, compared to 0.5% and 1.4% in the overall cohort, p<0.001). Socioeconomic and geographic factors also played a role; patients with lower income levels and those from rural areas were more likely to refuse surgery. An uninsured status was linked to higher refusal rates, with uninsured patients constituting 3.4% of refusals compared to 1.9% of the overall cohort (p<0.001). Clinical factors related to surgery refusal included severe comorbidities, influencing decisions against surgery in frail patients.
Overall survival. The analysis of overall survival rates highlighted significant discrepancies between patients based on surgical intervention. The overall 1-year and 5-year survival rates were 96% and 59%, respectively, as shown in Figure 1. Patients who underwent surgery demonstrated a 5-year survival rate of 59%, with a median survival of 72.2 months. Conversely, those who refused surgery exhibited a substantially lower 5-year survival rate of 46% and a median survival of 53.6 months. The log-rank test affirmed statistically significant differences in overall survival between surgical and non-surgical groups (p<0.001), as depicted in Table II.
Kaplan–Meier curves for overall survival stratified by surgery status and reason. Unadjusted Kaplan–Meier estimates of overall survival in melanoma patients, stratified by surgery status and the documented reason for not receiving surgery. The y-axis represents the overall survival rate, and the x-axis represents time at risk in months. Curves represent the following groups: patients who had surgery (solid line), patients who refused surgery (dashed line), reason for no surgery unknown (dotted line), surgery not performed due to co-morbidities or frailty (dash-dot line), and surgery not part of planned treatment (long dash line). p-Value was calculated using Log-rank test.
Overall survival stratified by surgery status and reason.
Discussion
This study analyzed the effects of surgery refusal on overall survival (OS) among patients diagnosed with melanoma, while also identifying the demographic and clinical attributes influencing such refusals. The results showed that individuals who declined surgery had notably lower one-year and five-year OS rates, as well as shorter median survival times when compared to those who accepted surgical treatment. Key factors associated with surgery refusal included advanced age, male sex, specific racial and ethnic backgrounds, lower income levels, and uninsured or publicly funded insurance plans.
The mean age of patients who declined surgery was 75.8 years, significantly higher than the overall study population’s mean age of 62.1 years, as shown in Table III.
Baseline patient characteristics stratified by surgery status and reason.
Such findings are in line with earlier research highlighting that older individuals are more likely to decline surgical interventions, often due to concerns regarding potential risks and postoperative complications (1). Additionally, older adults typically experience higher rates of comorbidities that can complicate surgical results and increase anxiety regarding surgical procedures (2). Similar patterns have been reported in colon cancer studies showing that older patients are more likely to refuse surgery (7). To tackle these worries, enhancing communication and providing comprehensive pre-surgical counseling may lead to improved acceptance of surgery and better outcomes for this population.
Sex differences in surgical refusal were also evident, with males being more likely to decline surgery than females, as shown in Table III. This observation is consistent with broader trends in healthcare utilization, where men generally engage less with healthcare services than women (8). Research indicates that women utilize more healthcare resources, influenced in part by higher medical expenses for various services, despite equivalent hospitalization rates (8). Furthermore, there were marked racial disparities, with Black, Asian, and Hispanic patients exhibiting increased rates of surgery refusal. This aligns with findings from studies on other cancer types, reflecting complex barriers related to cultural, socioeconomic, and systemic factors (9). Issues with affordability, financial burden, and disparities in insurance coverage significantly affect healthcare access and participation among different populations (9). Implementing initiatives to improve culturally sensitive care and patient education could help address these disparities and support informed decision-making regarding surgical options.
Economic factors played a significant role in surgery refusal, with low-income individuals and those without private insurance declining surgery at higher rates, as shown in Table III.
In the U.S., financial obstacles to healthcare access are more severe than in many other affluent nations, particularly affecting low-income and uninsured groups, thereby exacerbating disparities in surgical acceptance (10). Patients without insurance face greater challenges in affording necessary healthcare services and are more likely to postpone or skip treatments because of costs (10). To alleviate these economic barriers, it is essential to establish programs aimed at enhancing care affordability and expanding insurance access. Initiatives like patient navigation programs have proven effective in assisting individuals through the complexities of the healthcare system, potentially increasing their acceptance of recommended care (11). Addressing financial and structural barriers through comprehensive policy reforms can significantly improve access to vital surgical interventions for marginalized groups.
The association between surgery refusal and poorer survival outcomes emphasizes the life-saving potential of surgical treatment for melanoma. The decreased OS rates among those who refuse surgery highlight the pressing need to understand and mitigate the factors that lead to surgical hesitance. Educational efforts aimed at explaining the survival benefits of surgical interventions, alongside effective support systems, are crucial to enhancing treatment acceptance and improving patient outcomes.
This study contributes valuable insights into the patterns and consequences of surgery refusal in patients with melanoma using the NCDB’s extensive data. However, certain limitations should be noted, such as the absence of specific information regarding recurrence, cause of death, or individual reasons for surgery refusal, which restrict deeper evaluation of these factors. The retrospective design may also limit the study’s ability to capture the evolution of treatment practices and shifting patient perceptions regarding surgical options for melanoma.
Future studies should aim to explore the intricate reasons behind surgery refusal in melanoma patients. Incorporating patient navigators and decision aids could empower individuals with the necessary knowledge to make informed treatment decisions. By utilizing comprehensive databases like the NCDB, subsequent research can further clarify surgical decision-making processes in melanoma and help formulate strategies to enhance patient care effectively.
Footnotes
Authors’ Contributions
RP was responsible for writing the original draft. RP and EMG were responsible for conceptualization, methodology, investigation, and visualization. EMG was responsible for validation, formal analysis, resources, data curation, supervision, and funding acquisition. RP, BPS, SRR, SHR, RS, JCB, KBS, GK, PBJ, FM, EPE, KP, SB, SS, HKM, and EMG were responsible for reviewing and editing.
Conflicts of Interest
The Authors declare no conflicts of interest in relation to this study.
Funding
This work was supported by Roswell Park Cancer Institute and National Cancer Institute (NCI) grant P30CA016056.
- Received January 27, 2025.
- Revision received February 8, 2025.
- Accepted February 14, 2025.
- Copyright © 2025 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.
This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY-NC-ND) 4.0 international license (https://creativecommons.org/licenses/by-nc-nd/4.0).
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