Refusal of Cancer-Directed Surgery by Breast Cancer Patients: Risk Factors and Survival Outcomes

It has been reported that some patients with breast cancer may refuse cancer-directed surgery, but the incidence in the United States is not currently known. The purpose of this study was to identify the incidence, trends, risk factors, and eventual survival outcomes associated with refusal of recommended breast cancer-directed surgery.A retrospective review of the Surveillance Epidemiology and End Results (SEER) database between 2004 and 2013 was performed. Patients who underwent cancer-directed surgery were compared with patients in whom cancer-directed surgery was refused, even though it was recommended.Of 531,700 patients identified, 3389 (0.64%) refused surgery. An increasing trend was observed from 2004 to 2013 (P = .009). Older age (50-69: odds ratio [OR] 4.96; 95% confidence interval, 1.23-19.96; P = .024, ≥ 70 years: OR 17.27; 95% CI, 4.29-69.54; P .001), ethnicity (P .001), marital status (single: OR 2.28; 95% CI, 1.98-2.62; P .001, separated/divorced/widowed: OR 2.26; 95% CI, 2.01-2.53; P .001), higher stage (II: OR 2.05; 95% CI, 1.83-2.3; P .001, III: OR 2.2; 95% CI, 1.87-2.6; P .001, IV: OR 13.3; 95% CI, 11.67-15.16; P .001), and lack of medical insurance (OR 2.11; 95% CI, 1.59-2.8; P .001) were identified as risk factors associated with refusal of surgery. Survival analysis showed a 2.42 higher risk of mortality in these patients.There has been an increasing rate of patients refusing recommended surgery, which significantly affects survival. Age, ethnicity, marital status, disease stage, and lack of insurance are associated with higher risk of refusal of surgery.