Health Services Research

PV QA 3 - Poster Viewing Q&A 3

TU_36_2948 - Factors Predicting for Patient Refusal of Definitive Treatment in Non-Metastatic Head and Neck Cancer

Tuesday, October 23
1:00 PM - 2:30 PM
Location: Innovation Hub, Exhibit Hall 3

Factors Predicting for Patient Refusal of Definitive Treatment in Non-Metastatic Head and Neck Cancer
A. Amini1, R. Li1, A. Shinde1, R. Nelson2, S. Sampath1, N. L. Vora1, R. Kang3, T. Gernon3, E. Maghami3, A. Hurria4, E. Massarelli4, and S. M. Glaser1; 1Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA, 2Division of Biostatistics, City of Hope National Medical Center, Duarte, CA, 3Department of Otolaryngology, City of Hope National Medical Center, Duarte, CA, 4Department of Medical Oncology, City of Hope National Medical Center, Duarte, CA

Purpose/Objective(s): Definitive therapy for patients with non-metastatic head and neck squamous cell carcinoma (HNSCC) consists of either surgery followed by adjuvant therapy if indicated or organ-preservation with definitive radiation therapy (RT) with or without chemotherapy. This study assesses the survival impact of patients refusing to undergo definitive therapy and evaluates for factors associated with refusal of therapy.

Materials/Methods: The National Cancer Database was queried for patients ≥ 18 years with non-metastatic HNSCC (nasopharynx, oral cavity, oropharynx, larynx, hypopharynx) treated from 2004-2015. Patients were stratified based on recommendation for definitive RT or surgery and the refusal of both. Cases coded as palliation were excluded. Two categories were selected: definitive treatment performed and definitive treatment recommended but refused by patient. Logistic regression was used to assess variables associated with refusal of definitive treatment. Variables included: age, race, insurance, facility type, region of country, distance to facility, residence, income, education level, comorbidity score, year of diagnosis, primary disease site, and AJCC overall stage.

Results: 277,196 patients were included; 273,089 (98.5%) received definitive treatment, 4,107 (1.5%) were recommended definitive treatment but refused. Median survival was 84.9 months and 23.5 months respectively (Log-rank p<0.001). When comparing those who refused definitive therapy to those who received it using multiple logistic regression, patients ≥ 65 years (odds ratio [OR], 1.40; 95% confidence interval [CI], 1.28-1.54; p<0.001), females (OR 1.12; 1.04-1.20; p=0.002), African Americans (OR 1.22; 1.10-1.37; p<0.001), Other/Hispanic race (OR 1.44; 1.31-1.57; p<0.001), those with higher Charlson comorbidity scores ≥ 1 (ORs 1.23-1.50; p<0.001), patients with Medicare (OR 1.33; 1.21-1.46; p<0.001) or Medicaid/other government insurance (OR 1.26; 1.13-1.41; p<0.001), and uninsured (OR 2.12; 1.86-2.42; p<0.001) were more likely to refuse therapy. Individuals presenting at comprehensive community, academic, and integrated network cancer programs were less likely to refuse treatment when compared to community cancer programs as were patients with higher income and those with higher stage. Refusal of therapy was not associated with primary tumor site.

Conclusion: Refusal of definitive therapy with either surgery or RT in non-metastatic HNSCC is more common in elderly, non-Caucasian races, those with government-based insurance or who are uninsured, patients from low income communities, and those with higher comorbidity scores. Refusal of treatment leads to a severe detriment in median survival and appears most apparent in patients who lack social and financial support to undergo curative treatment.

Author Disclosure: A. Amini: None. R. Li: None. A. Shinde: None. S. Sampath: None. R. Kang: None. E. Massarelli: None. S.M. Glaser: None.

Arya Amini, MD

City of Hope National Medical Center

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