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Socioeconomic factors, not race or ethnicity, linked to treatment refusal for advanced lung cancer

Issue: May 25, 2018

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Narjust Duma

CHICAGO — Socioeconomic factors influenced whether patients with stage IV non-small cell lung cancer refused cancer treatment, according to study results presented at American Association for Cancer Research Annual Meeting.

However, contrary to prior research — much of which was conducted in breast cancer — race and ethnicity did not appear to influence treatment refusal among this group.

“Previous single-center institution studies reported minorities were more likely to refuse systemic therapy. This could be related to language barriers, cultural beliefs or perceptions of health,” researcher Narjust Duma, MD, hematology/medical oncology fellow at Mayo Clinic in Rochester, Minnesota, told HemOnc Today. “In our study, we observed that minorities were less likely to refuse treatment in the setting of stage IV non-small cell lung cancer.”

The use of novel therapies and better supportive care have significantly prolonged survival for patients with stage IV NSCLC.

“We wanted to see if these novel agents or treatment combinations were affecting the rates of treatment refusal,” Duma said.

Duma and colleagues used the National Cancer Data Base to identify all incident cases of stage IV NSCLC from 2004 to 2014. Researchers used multivariable logistic regression models to determine the factors associated with treatment refusal among these patients.

Researchers excluded patients who received cancer treatment outside of the reporting facility, as well as those who died prior to receiving treatment.

The analysis included 341,993 patients. Overall, 5.4% of patients refused radiation therapy and 10.3% refused chemotherapy despite provider recommendations.

During the entire period analyzed, the proportion of patients who refused radiation increased (4.2% to 7.3%; P < .001), as did the proportion of patients who refused chemotherapy (7.9% vs. 15%; P < .001).

“We were surprised to observe the rate of treatment refusal has increased over time — opposite of our original hypothesis — and that insurance status, income and treating facility (academic vs. community) were factors associated with treatment refusal in our population of interest,” Duma said.

Multivariable analysis showed men were less likely than women to refuse radiation (OR = 0.82; 95% CI, 0.76-0.83) or chemotherapy (OR = 0.84; 95% CI, 0.81-0.86).

Duma and colleagues identified several factors identified with radiation therapy refusal. They included Medicaid as primary insurance (OR = 1.95; 95% CI, 1.76-2.15), Medicare as primary insurance (OR = 1.25; 95% CI, 1.17-1.34), or Charlson Comorbidity Index of 2 or higher (OR = 1.97; 95% CI, 1.85-2.1). Patients treated at an academic center appeared less likely to refuse radiation (OR = 0.57; 95% CI, 0.53-0.62).

Factors associated with chemotherapy refusal included uninsured status (OR = 2.45; 95% CI, 2.26-2.66), Medicaid as primary insurance (OR = 2.17; 95% Ci, 2.03-2.32) and high comorbidity index (OR = 1.76; 95% CI, 1.68-1.84).

Patients who received care at an academic center (OR = 0.76; 95% CI, 0.72-0.8) and those who lived in high-income neighborhoods (OR = 0.76; 95% Ci, 0.71-0.81) appeared less likely to refuse chemotherapy. Residence in a rural county and distance from a patient’s residence to treating facility did not affect treatment refusal.

Contrary to findings from prior studies, non-Hispanic blacks (OR = 0.86; 95% CI, 0.82-0.91) and Hispanics (OR = 0.78; 95% CI, 0.72-0.89) appeared less likely than non-Hispanic whites to refuse chemotherapy.

“Factors like insurance status, comorbidities and access to care can be associated with treatment refusal [among] patients with stage IV non-small lung cancer,” Duma told HemOnc Today. “Conversations about all factors involved in treatment decisions — from fear of adverse events to the financial toxicity associated with these regimens — should take place at several phases of patients’ cancer journeys. Further studies — prospective studies, ideally — are necessary to determine the role of race/ethnicity, as well as other psychosocial factors, in treatment decisions.” – by Mark Leiser

Reference:

Duma N, et al. Abstract 4230. Presented at: American Association for Cancer Research Annual Meeting; April 14-18, 2018; Chicago.

Disclosures: The researchers report no relevant financial disclosures.