番茄社区

SAN DIEGO -- Which groups of people in the U.S. are more likely to put themselves at higher risk of death by refusing treatment for non-small cell lung cancer (NSCLC)? The answer varies by treatment modality, a new study finds, but one trend is consistent: Poorer people are more likely to just say no.

Still, the variable findings mean that "there's no single magic bullet" that will lower treatment-refusal rates across the nation, said the lead author of the study presented here at the annual meeting of the American Thoracic Society, Alex Arto Balekian, MD, of the Keck School of Medicine at the University of Southern California in Los Angeles.

"There are going to be local factors about why patients have this hurdle," he told 番茄社区. "We need to be diligent at looking at who in our local areas is not getting guideline-compliant care."

For the , Balekian and colleagues examined the American College of Surgeons' National Cancer Database and focused on whether patients underwent recommended treatment for clinical stage 1A (surgical resection), pathologic stages II-IV (chemotherapy), and pathologic stages IIIA-B (radiation) disease.

According to the American Society of Clinical Oncology, for stage 1A NSCLC is about 49%, but dips to about 14% and about 5% for stages IIIA and IIIB, respectively.

Many patients tracked by the database underwent treatment, while others were not offered treatment for reasons such as being too ill. Balekian noted that 3% of patients declined recommended surgery, 11% declined recommended chemotherapy, and 6-7% declined recommended radiation.

Among more than 166,000 patients diagnosed at clinical stage 1A, several groups were statistically significantly more likely to decline surgery compared with white patients: blacks (adjusted OR 1.94), East Asian (AOR 1.35), Pacific Islanders (AOR 1.72), and Native Americans (AOR 2.01). In addition, patients without insurance (AOR 2.60) and on Medicaid (AOR 2.24) were more likely to refuse surgery than those on Medicare.

Among nearly 159,000 patients with pathologic stages II-IV lung cancer who were eligible for chemotherapy, those without insurance (AOR 2.39) or on Medicaid (AOR 1.66) were more likely to refuse treatment compared with those on Medicare. Hispanics were also less likely to refuse treatment than were non-Hispanics (AOR 0.88).

And among nearly 58,000 patients with pathologic stages IIIA-B lung cancer and eligible for radiation, women were more likely than men to decline treatment (AOR 1.15), as were East Asians versus whites (AOR 1.73) and those without insurance (AOR 2.42) or on Medicaid (AOR 1.31) versus Medicare.

Overall, "the patterns in which this is occurring are highly variable and not consistent," Balekian said.

The fate of the patients who refused treatment is not clear, but he said the treatment guidelines are well supported.

Why might patients in these different groups be especially resistant to various types of treatment? The findings don't provide an answer, he said, noting, though, that he believes the findings reveal more of a class disparity than a race disparity.

It's possible that poorer patients may face more obstacles in accessing treatment, he said, perhaps because they can't take time off from work. Or they may not be able to use public transit to get to treatments, since radiation, for example, can require 3-4 days of treatment for 5 weeks.

Moving forward, he said, clinicians should be sure to ask patients individually -- "for example, a black patient in Philadelphia may have different reasons for declining surgery than a black patient in South Central Los Angeles."

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