Factors Associated With Refusal of Surgery for PDAC and Its Impact: An NCDB Analysis.

BACKGROUND/AIM: Pancreatic ductal adenocarcinoma (PDAC) has poor survival despite advances in multidisciplinary care. While many patients do not undergo resection due to advanced disease or comorbidity, a small fraction refuse surgery despite recommendations. This study evaluated the association between surgical refusal and overall survival (OS) and identified factors associated with refusal of surgery.

PATIENTS AND

METHODS

We performed a retrospective cohort study using the National Cancer Database (NCDB), 2004-2019. Sociodemographic (age, sex, race/ethnicity, income, insurance, distance, rurality, facility type) and clinical variables (stage, grade, treatment) were analyzed. Associations with refusal were assessed using chi-square/Wilcoxon tests. OS was estimated using the Kaplan-Meier test with log-rank testing and evaluated using Cox proportional hazards models.

RESULTS

The cohort included 108,978 patients with PDAC (mean age 69.3 years; 50.9% women). Stage I disease comprised 25.8% of the overall cohort. Among patients recommended for surgery, 24.8% underwent resection and 2.2% refused. Refusal was associated with older age (mean 77.5 years), female sex (58.6%), and early stage at diagnosis (stage I: 46.8% among refusers), as well as lower income, rural residence, treatment at comprehensive cancer centers, closer proximity to the treatment center, Medicare insurance, and absence of prior chemotherapy (all p<0.001). Patients who underwent surgery had longer median survival than those who refused (64 vs. 57.1 months), with higher 1-year and 5-year OS (98% and 48% vs. 93% and 40%; log-rank p<0.0001).

CONCLUSION

Refusal of surgery among patients with PDAC is uncommon but is associated with worse OS. Older age, female sex, lower socioeconomic status, rural residence, and early-stage diagnosis were associated with refusal. These factors serve as targetable interventions for decreasing surgery refusal rates.