Navigating Choices: Determinants and Outcomes of Surgery Refusal in Thyroid Cancer Patients Using SEER Data
Abstract
:Simple Summary
Abstract
1. Introduction
2. Materials and Methods
2.1. Data Source
2.2. Study Population and Variables
2.3. Primary Outcomes
2.4. Statistical Analysis
3. Results
3.1. Characteristics of the Study Population
3.2. Determinants of Surgical Refusal in Cancer Patients
3.3. Disease Outcomes
3.4. Overall Survival Analysis
3.5. Disease-Specific Survival Analysis
3.6. Impact of Delayed Surgery on Recurrence and Survival
4. Discussion
5. Conclusions
Supplementary Materials
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
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Characteristics | Levels | Total Patients (n = 176,472) | Surgery Performed (n = 176,002) | Patient Refused (n = 470) | p-Value |
---|---|---|---|---|---|
Total number | 176,472 | 176,002 (99.7) | 470 (0.3) | ||
Age (years) | Median (IQR) | 49.0 (38–60) | 49.0 (38–60) | 59.0 (44–74) | <0.001 |
<55 years | 110,252 (62.5) | 110,055 (62.5) | 197 (41.9) | <0.001 | |
≥55 years | 66,220 (37.5) | 65,947 (37.5) | 273 (58.1) | ||
Gender | Female | 134,960 (76.5) | 134,637 (76.5) | 323 (68.7) | <0.001 |
Male | 41,512 (23.5) | 41,365 (23.5) | 147 (31.3) | ||
Race | White | 143,085 (82.1) | 142,752 (82.1) | 333 (72.1) | <0.001 |
Black | 11,063 (6.3) | 11,031 (6.3) | 32 (6.9) | ||
API | 18,998 (10.9) | 18,908 (10.9) | 90 (19.5) | ||
AI/AN | 1168 (0.7) | 1161 (0.7) | 7 (1.5) | ||
Ethnicity | Not Hispanic/Latino | 147,128 (83.4) | 146,740 (83.4) | 388 (82.6) | 0.68 |
Hispanic/Latino | 29,344 (16.6) | 29,262 (16.6) | 82 (17.4) | ||
Marital status | Married/domestic partner | 108,619 (64.8) | 108,410 (64.9) | 209 (48.9) | <0.001 |
Single | 36,539 (21.8) | 36,431 (21.8) | 108 (25.3) | ||
Separated/divorced | 13,900 (8.3) | 13,858 (8.3) | 42 (9.8) | ||
Widowed | 8485 (5.1) | 8417 (5.0) | 68 (15.9) | ||
Metropolitan | Metropolitan > 1 M pop | 106,097 (60.2) | 105,788 (60.2) | 309 (66.2) | 0.11 |
Metropolitan > 250 K–1 M | 39,729 (22.5) | 39,643 (22.5) | 86 (18.4) | ||
Metropolitan of <250 K | 13,149 (7.5) | 13,118 (7.5) | 31 (6.6) | ||
Nonmetropolitan adj to a Metropolitan | 9925 (5.6) | 9903 (5.6) | 22 (4.7) | ||
Nonmetropolitan not adj to Metropolitan | 7370 (4.2) | 7351 (4.2) | 19 (4.1) | ||
Household annual income | USD 75,000+ | 60,727 (34.4) | 60,547 (34.4) | 180 (38.3) | 0.33 |
USD 70,000–USD 74,999 | 16,114 (9.1) | 16,069 (9.1) | 45 (9.6) | ||
USD 65,000–USD 69,999 | 27,760 (15.7) | 27,681 (15.7) | 79 (16.8) | ||
USD 60,000–USD 64,999 | 28,092 (15.9) | 28,016 (15.9) | 76 (16.2) | ||
USD 55,000–USD 59,999 | 11,380 (6.4) | 11,360 (6.5) | 20 (4.3) | ||
USD 50,000–USD 54,999 | 13,498 (7.6) | 13,466 (7.7) | 32 (6.8) | ||
USD 45,000–USD 49,999 | 7801 (4.4) | 7783 (4.4) | 18 (3.8) | ||
USD 40,000–USD 44,999 | 5760 (3.3) | 5748 (3.3) | 12 (2.6) | ||
USD 35,000–USD 39,999 | 3163 (1.8) | 3158 (1.8) | 5 (1.1) | ||
<USD 35,000 | 2163 (1.2) | 2160 (1.2) | 3 (0.6) |
Characteristics | Levels | Total (n = 176,472) | Surgery Performed (n = 176,002) | Patient Refused (n = 470) | p-Value |
---|---|---|---|---|---|
Previous malignancies | No | 155,637 (88.2) | 155,264 (88.2) | 373 (79.4) | <0.001 |
Yes | 20,830 (11.8) | 20,733 (11.8) | 97 (20.6) | ||
Histological Type | Papillary | 166,311 (94.2) | 165,867 (94.2) | 444 (94.5) | 0.91 |
Follicular | 10,161 (5.8) | 10,135 (5.8) | 26 (5.5) | ||
T staging | T1 | 90,418 (59.8) | 90,309 (59.8) | 109 (48.9) | <0.001 |
T2 | 26,415 (17.5) | 26,358 (17.5) | 57 (25.6) | ||
T3 | 29,482 (19.5) | 29,455 (19.5) | 27 (12.1) | ||
T4 | 4859 (3.2) | 4829 (3.2) | 30 (13.5) | ||
N staging | N0 | 128,380 (76.3) | 128,105 (76.3) | 275 (72.4) | 0.08 |
N1 | 39,855 (23.7) | 39,750 (23.7) | 105 (27.6) | ||
M staging | M0 | 174,068 (98.8) | 173,641 (98.8) | 427 (91.2) | <0.001 |
M1 | 2161 (1.2) | 2120 (1.2) | 41 (8.8) | ||
Extension | Localized | 112,842 (64.5) | 112,594 (64.5) | 248 (62.6) | <0.001 |
Regional | 57,949 (33.1) | 57,863 (33.1) | 86 (21.7) | ||
Distant | 4273 (2.4) | 4211 (2.4) | 62 (15.7) |
Determinant of Surgical Refusal | Odds Ratio | Lower Limit | Upper Limit | p-Value |
---|---|---|---|---|
Age: ≥55 vs. <55 years old | 1.570 | 1.122 | 2.197 | 0.009 |
Sex: Male vs. Female | 1.679 | 1.215 | 2.320 | 0.002 |
Race: White vs. Black | 1.770 | 1.069 | 2.929 | 0.026 |
Race: White vs. API | 2.754 | 1.931 | 3.928 | <0.001 |
Race: White vs. AI/AN | 1.119 | 0.155 | 8.096 | 0.91 |
Single vs. Married | 1.899 | 1.321 | 2.729 | 0.001 |
Separated/divorced vs. Married | 1.309 | 0.741 | 2.314 | 0.35 |
Widowed vs. Married | 4.268 | 2.782 | 6.547 | <0.001 |
Residency: Urban vs. Rural | 1.271 | 0.714 | 2.264 | 0.42 |
Income ≥USD 75,000 vs. <USD 75,000 | 1.038 | 0.761 | 1.417 | 0.81 |
Prior primary malignancy vs. None | 1.169 | 0.787 | 1.735 | 0.43 |
Histopathology: Follicular vs. Papillary | 0.316 | 0.128 | 0.785 | 0.013 |
T staging: T3/4 vs. T1/2 | 1.728 | 1.204 | 2.478 | 0.003 |
N staging: N1 vs. N0 | 0.782 | 0.538 | 1.137 | 0.19 |
M staging: M1 vs. M0 | 6.402 | 3.717 | 11.026 | <0.001 |
Characteristics | Levels | Total (n = 176,472) | Surgery Performed (n = 176,002) | Patient Refused (n = 470) | p-Value |
---|---|---|---|---|---|
Management | |||||
Radiotherapy | RAI | 76,331 (43.3) | 76,327 (43.4) | 4 (0.9) | <0.001 |
Beam radiation | 1863 (1.1) | 1845 (1.0) | 18 (3.8) | ||
Radioactive implants | 1278 (0.7) | 1278 (0.7) | 0 (0.0) | ||
Unspecified radiotherapy | 981 (0.6) | 981 (0.6) | 1 (0.0) | ||
Time to treatment | <1 month | 111,162 (63.5) | 111,109 (63.5) | 53 (60.2) | <0.001 |
1–3 months | 57,943 (33.1) | 57,924 (33.1) | 19 (21.6) | ||
4–6 months | 4562 (2.6) | 4552 (2.6) | 10 (11.4) | ||
≥6 months | 1429 (0.8) | 1423 (0.8) | 6 (6.8) | ||
Clinical outcomes | |||||
Second primary malignancy | Positive | 13,597 (8.7) | 13,568 (8.7) | 29 (7.8) | 0.72 |
Survival status | Died | 15,568 (8.8) | 15,418 (8.8) | 150 (31.9) | <0.001 |
Risk Factors for Mortality | Frequency | HR (Univariable) | HR (Multivariable) |
---|---|---|---|
Age: ≥55 vs. <55 years old | 69,710 (38.2) | 7.74 (7.46–8.02, p < 0.001) | 6.20 (5.96–6.45, p < 0.001) |
Sex: Male vs. Female | 43,599 (23.9) | 2.22 (2.16–2.29, p < 0.001) | 1.55 (1.50–1.60, p < 0.001) |
Ethnicity: Hispanic/Latino vs. None | 30,509 (16.7) | 0.78 (0.74–0.82, p < 0.001) | 0.95 (0.91–1.00, p = 0.07) |
Household income: >USD 75,000 vs. <USD 75,000 | 62,906 (34.4) | 0.79 (0.77–0.82, p < 0.001) | 0.84 (0.81–0.87, p < 0.001) |
Residency: Urban vs. Rural | 164,605 (90.2) | 0.71 (0.68–0.75, p < 0.001) | 0.79 (0.75–0.82, p < 0.001) |
Histopathology: Papillary vs. Follicular | 10,662 (5.8) | 1.63 (1.55–1.71, p < 0.001) | 1.31 (1.24–1.38, p < 0.001) |
Prior primary malignancy vs. None | 22,555 (12.4) | 3.98 (3.85–4.10, p < 0.001) | 2.27 (2.19–2.35, p < 0.001) |
Surgery: Patient refused vs. Operated | 470 (0.3) | 5.98 (5.09–7.02, p < 0.001) | 3.48 (2.52–4.82, p < 0.001) |
Extension: Regional vs. Localized | 58,810 (32.8) | 1.28 (1.24–1.32, p < 0.001) | 1.39 (1.34–1.44, p < 0.001) |
Extension: Distant vs. Localized | 5102 (2.8) | 6.80 (6.48–7.13, p < 0.001) | 4.75 (4.48–5.03, p < 0.001) |
Delayed treatment: ≥4 vs. <4 months | 6096 (3.5) | 1.64 (1.52–1.78, p < 0.001) | 1.26 (1.16–1.36, p < 0.001) |
Risk Factors for Disease-Specific Mortality | Frequency | HR (Univariable) | HR (Multivariable) |
---|---|---|---|
Age: ≥55 vs. <55 years old | 56,586 (34.5) | 9.11 (8.36–9.92, p < 0.001) | 8.43 (7.71–9.22, p < 0.001) |
Sex: Male vs. Female | 36,915 (22.5) | 2.72 (2.53–2.91, p < 0.001) | 1.61 (1.50–1.73, p < 0.001) |
Ethnicity: Hispanic/Latino vs. None | 28,060 (17.1) | 1.11 (1.01–1.22, p = 0.028) | 1.21 (1.10–1.33, p < 0.001) |
Household income: >USD 75,000 vs. <USD 75,000 | 56,955 (34.8) | 0.85 (0.79–0.91, p < 0.001) | 0.91 (0.85–0.99, p = 0.024) |
Residency: Urban vs. Rural | 148,123 (90.5) | 0.76 (0.69–0.85, p < 0.001) | 0.80 (0.71–0.89, p < 0.001) |
Histopathology: Papillary vs. Follicular | 9156 (5.6) | 2.31 (2.08–2.56, p < 0.001) | 1.58 (1.42–1.76, p < 0.001) |
Prior primary malignancy vs. None | 16,955 (10.3) | 2.63 (2.42–2.87, p < 0.001) | 1.50 (1.37–1.63, p < 0.001) |
Surgery: Patient refused vs. Operated | 470 (0.3) | 17.3 (9.55–31.4, p < 0.001) | 3.52 (1.93–6.42, p < 0.001) |
Extension: Regional vs. Localized | 53,950 (33.2) | 4.07 (3.73–4.44, p < 0.001) | 4.44 (4.07–4.85, p < 0.001) |
Extension: Distant vs. Localized | 3715 (2.3) | 39.9 (36.3–43.9, p < 0.001) | 33.8 (30.7–37.4, p < 0.001) |
Delayed treatment: ≥4 vs. <4 months | 5483 (3.4) | 1.52 (1.28–1.81, p < 0.001) | 0.96 (0.80–1.14, p = 0.64) |
Cause of Death | Early Surgery (n = 140,149) | Delayed Surgery (n = 5257) | HR (95% CI) | p-Value |
---|---|---|---|---|
Alive | 130,253 | 4760 | Reference | |
Death | 9896 | 497 | 1.37 (1.25–1.51) | <0.001 |
Thyroid cancer | 2062 | 97 | 1.28 (1.05–1.58) | 0.016 |
Nonthyroid cancer | 7834 | 400 | 1.39 (1.25–1.55) | <0.001 |
Other malignancies | 2670 | 185 | 1.89 (1.62–2.21) | <0.001 |
Diseases of Heart | 1511 | 60 | 1.08 (0.83–1.4) | 0.53 |
Cerebrovascular Diseases | 373 | 15 | 1.1 (0.65–1.84) | 0.71 |
Pneumonia and Influenza | 140 | 13 | 2.54 (1.43–4.48) | 0.001 |
Accidents and Adverse Effects | 329 | 12 | 0.99 (0.56–1.77) | 0.007 |
Diabetes Mellitus | 218 | 10 | 1.25 (0.66–2.36) | 0.7 |
Septicemia | 109 | 9 | 2.25 (1.14–4.46) | 0.018 |
Chronic Obstructive Pulmonary Disease | 299 | 8 | 0.73 (0.36–1.47) | 0.38 |
Alzheimer’s (ICD-9 and 10 only) | 178 | 7 | 1.07 (0.51–2.29) | 0.84 |
Hypertension without Heart Disease | 93 | 7 | 2.05 (0.95–4.44) | 0.06 |
Nephritis, Nephrotic Syndrome, and Nephrosis | 188 | 5 | 0.73 (0.29–1.76) | 0.48 |
Suicide and Self-Inflicted Injury | 90 | 3 | 0.91 (0.28–2.88) | 0.87 |
Chronic Liver Disease and Cirrhosis | 72 | 2 | 0.76 (0.18–3.09) | 0.7 |
Other Infectious and Parasitic Diseases, including HIV | 75 | 2 | 0.79 (0.18–2.97) | 0.66 |
Study Characteristics | Data Source | Study Population | Sample Size | Outcomes | ||||
---|---|---|---|---|---|---|---|---|
Author, Year (Ref.) | Country | Total | Surgery | No Surgery | Cancer-Directed Surgery Cohort | No Surgery Cohort | ||
Wu, 2023 [16] | USA | Institutional (2000–2021) | ATC | 97 | 44 | 53 | Higher OS | Lower OS |
Chaves, 2022 [17] | USA | SEER (1999–2018) | Medicare beneficiaries, PTC | 8170 | 8170 | - | Surgery (<90 days): high OS, DSS Surgery (>180 days): lower OS, DSS | |
Sahli, 2021 [18] | USA | SEER | MTC (Exclude lobectomy) | 1367 | 1301 | 66 | Lower disease-specific mortality | Higher disease-specific mortality |
Zhou, 2020 [19] | CHN | SEER (1973–2015) | >85 years old, PTC | 1196 | 871 | 325 | Higher OS | Lower OS |
Van Gerwen, 2020 [1] | USA | SEER (1988–2015) | Localized and regional, PTC | 45,136 | 44,990 | 146 | Higher DSS time | Lower DSS times * |
Maniakas, 2020 [20] | USA | Tertiary Care Center (2000–2019) | ATC | 479 | 55 | 424 | 1-year survival; 94% | 1-year survival; 52% |
Corrigan, 2019 [21] | USA | Institutional (1990–2015) | ATC | 28 | 19 | 9 | Higher OS | Lower OS |
Megwalu, 2017 [6] | USA | SEER (1988–2009) | >65 years old, PTC | 2323 | - | - | 5-year survival rate; 91% | 5-year survival rate; 23% |
Pierie, 2002 [22] | USA | Tertiary Care Center (1969–1999) | ATC | 67 | 44 | 23 | Higher 6-month, 1- and 3-year survival rates | Lower 6-month, 1 and 3-year survival rates |
Study Characteristics | Data Source | Study Population | Sample Size | Outcomes | ||||
---|---|---|---|---|---|---|---|---|
Author, Year (Ref.) | Country | Total | Surgery | No Surgery | Cancer-Directed Surgery Cohort | No Surgery Cohort | ||
Chen, 2023 [23] | China | Institutional (2010–2019) | Localized and advanced Prostate cancer | 19,729 | 6339 | 13,390 | Reduced rates of cancer-specific and overall mortality | Increased rates of cancer-specific and overall mortality |
Birkenbeuel, 2022 [4] | USA | NCDB (2004–2015) | Pituitary macroadenoma | 34,226 | 33,946 | 280 | Increased OS | Reduced OS * |
Sun, 2022 [9] | China | SEER (2010–2015) | Stage IV gastric cancer | 6284, matched 864 | 432 | 432 | Prolonged median survival time | Reduced median survival time |
Silva, 2021 [24] | Brazil | Hospital Haroldo Juaçaba (2000–2014) | Oral Squamous Cell Carcinoma | 934 | - | - | Higher OS | Lower OS |
Coffman, 2021 [3] | USA | NCDB (2004–2015) | Rectal adenocarcinoma | 55,704 | 54,266 | 1438 | Median survival time 84.4 months | Median survival time 48.5 months * |
Delisle, 2020 [8] | USA | SEER (2004–2015) | Colorectal | 153,698 | 152,731 | 983 | Lower disease-specific mortality | Higher disease-specific mortality |
Coffman, 2019 [25] | USA | NCDB (2004–2013) | Nonmetastatic pancreatic adenocarcinoma | 48,902 | 47,107 | 1795 | Higher median survival times | Lower median survival times * |
May 2017 [26] | Canada | Tom Baker Cancer Center (not provided) | Stage IIIC or IV serous ovarian carcinoma | 303 | 142 | 161 | 5-year survival; 39% | 5-year survival; 27% |
Wang, 2010 [7] | USA | SEER (not provided) | Hepatocellular carcinoma | 4373 | 4231 | 142 | Lower mortality risk | 2.5-fold increased mortality risk * |
Verkooijen, 2005 [27] | Switzerland | Geneva Cancer Database (1975–2000) | <80 years old, nonmetastatic | 5339 | 5269 | 70 | Lower mortality risk | 2.1-fold increased mortality risk * |
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Hussein, M.H.; Toraih, E.A.; Ohiomah, I.E.; Siddeeque, N.; Comeaux, M.; Landau, M.B.; Anker, A.; Jishu, J.A.; Fawzy, M.S.; Kandil, E. Navigating Choices: Determinants and Outcomes of Surgery Refusal in Thyroid Cancer Patients Using SEER Data. Cancers 2023, 15, 3699. https://doi.org/10.3390/cancers15143699
Hussein MH, Toraih EA, Ohiomah IE, Siddeeque N, Comeaux M, Landau MB, Anker A, Jishu JA, Fawzy MS, Kandil E. Navigating Choices: Determinants and Outcomes of Surgery Refusal in Thyroid Cancer Patients Using SEER Data. Cancers. 2023; 15(14):3699. https://doi.org/10.3390/cancers15143699
Chicago/Turabian StyleHussein, Mohammad H., Eman A. Toraih, Ifidon E. Ohiomah, Nabeela Siddeeque, Marie Comeaux, Madeleine B. Landau, Allison Anker, Jessan A. Jishu, Manal S. Fawzy, and Emad Kandil. 2023. "Navigating Choices: Determinants and Outcomes of Surgery Refusal in Thyroid Cancer Patients Using SEER Data" Cancers 15, no. 14: 3699. https://doi.org/10.3390/cancers15143699
APA StyleHussein, M. H., Toraih, E. A., Ohiomah, I. E., Siddeeque, N., Comeaux, M., Landau, M. B., Anker, A., Jishu, J. A., Fawzy, M. S., & Kandil, E. (2023). Navigating Choices: Determinants and Outcomes of Surgery Refusal in Thyroid Cancer Patients Using SEER Data. Cancers, 15(14), 3699. https://doi.org/10.3390/cancers15143699