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Annals of Surgical Oncology
Published in: Annals of Surgical Oncology 1/2019

01-01-2019 | Pancreatic Tumors

Correlates of Refusal of Surgery in the Treatment of Non-metastatic Pancreatic Adenocarcinoma

Authors: Alex Coffman, MD, Anna Torgeson, MD, Shane Lloyd, MD

Published in: Annals of Surgical Oncology | Issue 1/2019

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Abstract

Background

Surgical resection is the most important therapeutic intervention for eligible patients with pancreatic cancer; however, a majority of patients never receive surgery for a variety of reasons, including patient refusal. Utilizing the National Cancer Database, we investigated the associated sociodemographic and clinical factors for those patients who refused surgery, and the impact of this decision on overall survival (OS).

Methods and Materials

We analyzed adult patients with non-metastatic adenocarcinoma of the pancreas diagnosed from 2004 to 2013. Univariate and multivariate logistic regression modeling was used to identify factors predictive of refusing surgery, and Kaplan–Meier and log-rank analysis was performed to investigate the effect on OS.

Results

A total of 48,902 patients were identified: 47,107 received surgery (96.3%) and 1795 were offered surgery but refused (3.7%). Factors associated with refusing surgery include both sociodemographic factors [age > 50 years, female sex, Black race, non-private insurance, treatment at a non-academic institution or non-metro facility, Carlson Comorbidity Index of 2 + (p ≤ 0.01)], and clinical factors [advanced clinical T (tumor) category and tumor size > 20 cm (p ≤ 0.01)]. Patients who refused surgery and received no treatment at all experienced a median survival of 5.1 months, while those who refused surgery but received chemoradiotherapy experienced a median survival of 11.2 months. As an index for comparison, those who received surgery had a median survival of 20.5 months.

Conclusion

Refusing surgery is an understudied phenomenon associated with several sociodemographic and clinical factors. The expected prognosis for patients who refuse surgery is presented.
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Literature
1.
2.
Li D, Xie K, Wolff R, Abbruzzese JL. Pancreatic cancer. Lancet Lond Engl. 2004;363(9414):1049–1057.CrossRef
3.
Oettle H, Post S, Neuhaus P, et al. Adjuvant chemotherapy with gemcitabine vs observation in patients undergoing curative-intent resection of pancreatic cancer: a randomized controlled trial. JAMA. 2007;297(3):267–277.CrossRefPubMed
4.
Neoptolemos JP, Stocken DD, Bassi C, et al. Adjuvant chemotherapy with fluorouracil plus folinic acid vs gemcitabine following pancreatic cancer resection: a randomized controlled trial. JAMA. 2010;304(10):1073–1081.CrossRefPubMed
5.
Regine WF, Winter KA, Abrams RA, et al. Fluorouracil vs gemcitabine chemotherapy before and after fluorouracil-based chemoradiation following resection of pancreatic adenocarcinoma: a randomized controlled trial. JAMA. 2008;299(9):1019–1026.CrossRefPubMed
6.
Neoptolemos JP, Palmer DH, Ghaneh P, et al. Comparison of adjuvant gemcitabine and capecitabine with gemcitabine monotherapy in patients with resected pancreatic cancer (ESPAC-4): a multicentre, open-label, randomised, phase 3 trial. The Lancet. 2017;389(10073):1011–1024.CrossRef
7.
StatBite. U.S. pancreatic cancer rates. J Natl Cancer Inst. 2010;102(24):1822.CrossRef
8.
Bilimoria KY, Bentrem DJ, Ko CY, Stewart AK, Winchester DP, Talamonti MS. National failure to operate on early stage pancreatic cancer. Ann Surg. 2007;246(2):173–180.CrossRefPubMedPubMedCentral
9.
10.
Lieberman MD, Kilburn H, Lindsey M, Brennan MF. Relation of perioperative deaths to hospital volume among patients undergoing pancreatic resection for malignancy. Ann Surg. 1995;222(5):638–645.CrossRefPubMedPubMedCentral
11.
Ho V, Heslin MJ. Effect of hospital volume and experience on in-hospital mortality for pancreaticoduodenectomy. Ann Surg. 2003;237(4):509–514.PubMedPubMedCentral
12.
Rosemurgy AS, Bloomston M, Serafini FM, Coon B, Murr MM, Carey LC. Frequency with which surgeons undertake pancreaticoduodenectomy determines length of stay, hospital charges, and in-hospital mortality. J Gastrointest Surg. 2001;5(1):21–26.CrossRefPubMed
13.
Maldonado G, Greenland S. Simulation study of confounder-selection strategies. Am J Epidemiol. 1993;138(11):923–936.CrossRefPubMed
14.
Budtz-Jørgensen E, Keiding N, Grandjean P, Weihe P. Confounder selection in environmental epidemiology: assessment of health effects of prenatal mercury exposure. Ann Epidemiol. 2007;17(1):27–35.CrossRefPubMed
15.
16.
Chamberlain RS, Gupta C, Paragi P. In Defense of the Whipple: An Argument for Aggressive Surgical Management of Pancreatic Cancer. The Oncologist. 2009;14(6):586–590.CrossRefPubMed
17.
18.
McLeod RS, Taylor BR, O’Connor BI, et al. Quality of life, nutritional status, and gastrointestinal hormone profile following the Whipple procedure. Am J Surg. 1995;169(1):179–185.CrossRefPubMed
19.
Varadhachary GR, Tamm EP, Abbruzzese JL, Xiong HQ, Crane CH, Wang H, et al. Borderline resectable pancreatic cancer: definitions, management, and role of preoperative therapy. Ann Surg Oncol 2006;13:1035–1046.CrossRefPubMed
20.
Krishnan S, Rana V, Janjan NA, et al. Induction chemotherapy selects patients with locally advanced, unresectable pancreatic cancer for optimal benefit from consolidative chemoradiation therapy. Cancer. 2007;110(1):47–55.CrossRefPubMed
21.
Ferrone CR, Marchegiani G, Hong TS, et al. Radiological and surgical implications of neoadjuvant treatment with FOLFIRINOX for locally advanced and borderline resectable pancreatic cancer. Ann Surg. 2015;261(1):12–17.CrossRefPubMedPubMedCentral
22.
23.
Verhoef MJ, Rose MS, White M, Balneaves LG. Declining conventional cancer treatment and using complementary and alternative medicine: a problem or a challenge? Curr Oncol Tor Ont. 2008;15 Suppl 2: S101–S106.
24.
Goldberg RJ. Systematic Understanding of Cancer Patients Who Refuse Treatment. Psychother Psychosom. 1983;39(3):180–189.CrossRefPubMed
25.
Aizer AA, Chen M-H, Parekh A, et al. Refusal of curative radiation therapy and surgery among patients with cancer. Int J Radiat Oncol Biol Phys. 2014;89(4):756–764.CrossRefPubMed
26.
Gaitanidis A, Alevizakos M, Tsalikidis C, Tsaroucha A, Simopoulos C, Pitiakoudis M. Refusal of Cancer-Directed Surgery by Breast Cancer Patients: Risk Factors and Survival Outcomes. Clin Breast Cancer. 2018;18(4):e469–e476.CrossRefPubMed
27.
Liu C-Y, Chen WT-L, Kung P-T, et al. Characteristics, survival, and related factors of newly diagnosed colorectal cancer patients refusing cancer treatments under a universal health insurance program. BMC Cancer. 2014;14:446.CrossRefPubMedPubMedCentral
28.
Cykert S, Dilworth-Anderson P, Monroe MH, et al. Factors associated with decisions to undergo surgery among patients with newly diagnosed early-stage lung cancer. JAMA. 2010;303(23):2368–2376.CrossRefPubMedPubMedCentral
29.
Lathan CS, Neville BA, Earle CC. The effect of race on invasive staging and surgery in non-small-cell lung cancer. J Clin Oncol. 2006;24(3):413–418.CrossRefPubMed
30.
Massa ST, Osazuwa-Peters N, Franco J, Ward GW, Walker RJ. Survival after refusal of surgical treatment for locally advanced laryngeal cancer. Oral Oncol. 2017;71:34–40.CrossRefPubMed
31.
Shah A, Chao KSC, Ostbye T, et al. Trends in racial disparities in pancreatic cancer surgery. J Gastrointest Surg. 2013;17(11):1897–1906.CrossRefPubMed
32.
Balogh EP, Ganz PA, Murphy SB, Nass SJ, Ferrell BR, Stovall E. Patient-centered cancer treatment planning: improving the quality of oncology care. Summary of an Institute of Medicine workshop. The Oncologist. 2011;16(12):1800–1805.CrossRefPubMedPubMedCentral
Metadata
Title
Correlates of Refusal of Surgery in the Treatment of Non-metastatic Pancreatic Adenocarcinoma
Authors
Alex Coffman, MD
Anna Torgeson, MD
Shane Lloyd, MD
Publication date
01-01-2019
Publisher
Springer International Publishing
Published in
Annals of Surgical Oncology / Issue 1/2019
Print ISSN: 1068-9265
Electronic ISSN: 1534-4681
DOI
https://doi.org/10.1245/s10434-018-6708-y

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