Refusal of Local Therapy in Esophageal Cancer and Impact on Overall Survival

Objective. The aim of this study was to understand factors associated with refusal of local therapy in esophageal cancer and compare the overall survival (OS) of patients who refuse therapies with those who undergo recommended treatment. Methods. National Cancer Database data for patients with non-metastatic esophageal cancer from 2006 to 2013 were pooled. T1N0M0 tumors were excluded. Pearson's Chi-square test and multivariate logistic regression analyses were used to assess demographic, clinical, and treatment factors. After propensity-score matching with inverse probability of treatment weighting, OS was compared between patients who refused therapies and those who underwent recommended therapy, using Kaplan-Meier analyses and doubly robust estimation with multivariate Cox proportional hazards modeling. Results. In total, 37,618 patients were recommended radiation therapy (RT) and/or esophagectomy; we found 1403 (3.7%) refused local therapies. Specifically, 890 of 18,942 (4.6%) patients refused surgery and 667 of 31,937 (2.1%) refused RT. Older patients, females, those with unknown lymphovascular space invasion, and those uninsured or on Medicare were more likely to refuse. Those with squamous cell carcinoma, N1 disease, higher incomes, living farther from care, and those who received chemotherapy were less likely to refuse. Five-year OS was decreased in patients who refused (18.1% vs. 27.6%). The survival decrement was present in adenocarcinoma but not squamous cell carcinoma. In patients who received surgery or >= 50.4 Gy RT, there was no OS decrement to refusing the other therapy. Conclusions. We identified characteristics that correlate with refusal of local therapy. Refusal of therapy was associated with decreased OS. Patients who received either surgery or >= 50.4 Gy RT had no survival decrement from refusing the opposite modality.