eP242 - Drivers and Outcomes Related to Refusal of Surgery in Non-Metastatic Rectal Adenocarcinoma

Purpose/Background: Surgical resection is a mainstay of treatment for non-metastatic rectal adenocarcinoma. An increasing number of patients elect non-operative management, although the reasons why some patients decline surgery are not entirely clear. This study aims to elucidate factors related to declining surgery. We hypothesize that patients who refuse surgical resection experience poorer survival and that certain diagnosis-specific, demographic, and socioeconomic factors are associated with patient refusal.Methods/Interventions: Patients with clinical stage I-III rectal adenocarcinoma patients were identified in the National Cancer Database (NCDB) 2004-2020. A subgroup of patients with clinical stage I rectal adenocarcinoma without additional comorbidities, for whom guidelines recommend surgery alone, were also analyzed. Patients categorized as declining surgery were those for whom surgery was recommended as part or all of their treatment plan. Univariate and multivariate logistic regressions identified disease-specific (e.g., stage, year of diagnosis), demographic (e.g., age, sex, race), and socioeconomic factors (e.g., insurance type, median income quartile, surrounding population density) significantly associated with refusal of surgical resection. Multivariate Cox regressions compared survival among those who declined surgery and those who proceeded with surgery. This analysis did not account for the role of chemotherapy or radiation therapy as clinical response and subsequent surgical recommendations could not be accurately determined.Results/Outcomes: Among the 202,156 identified patients with stage I-III rectal adenocarcinoma, 5,754 (2.8%) refused surgery. Median age for the cohort was 63 years [IQR 53-83] and 75 years [IQR 63-84] for those who declined surgery (p < 0.001). Among the subgroup of 27,940 patients with stage I disease and no additional comorbid burden, 486 (1.7%) refused surgery. Factors significantly associated with refusal of surgery were older age, race (Black and Asian American/Pacific Islander), Charlson-Deyo score 3+, insurance type (uninsured and Medicaid/other government support), and non-urban metropolitan setting. Higher clinical stage was associated with increased likelihood of declining surgery, as was a more recent year of diagnosis (Table 1). Of the 486 otherwise healthy patients with stage I disease, age, insurance type, income, and year of diagnosis significantly predicted refusal of surgery. Mortality was higher in all patients (HR 2.23, 95% CI 2.12-2.34) and in the subset of stage I patients (HR 3.03, 95% CI 2.66-3.46) who declined surgery. Survival at 5 years was 72% for those who underwent surgery and 32% for those who did not. For stage I and otherwise healthy patients, 5-year survival was 81% for those who underwent surgery and 35% for those who declined surgery (Figure 1).Conclusion/

Discussion: Declining surgery for rectal cancer is associated with increased mortality. Decisions to refuse surgery are at least partly driven by demographic and socioeconomic factors. Further examination of the underlying reasons for declining surgery is necessary to promote shared decision-making while providing optimal care."Table 1Multivariate logistic regression to predict refusal for surgery, presented as odds ratios with 95% confidence intervals. Asterisks reflect statistical significance.
Figure 1Kaplan-Meier curve demonstrating five-year survival for patients who underwent surgery and those who refused among all-comers (A) and among the subgroup with stage 1 rectal adenocarcinoma and no comorbidities (B)."