Factors associated with the refusal of surgery and the associated impact on survival in patients with rectal cancer using the National Cancer Database.

BACKGROUND: Surgical resection is an integral component of the curative-intent treatment for most patients with non-metastatic rectal cancer. However, some patients refuse surgery for a number of reasons. Utilizing the National Cancer Database (NCDB), we investigated the sociodemographic and clinical factors associated with patients who were coded as having been offered but refused surgery, and the factors affecting overall survival (OS) in these patients. METHODS: Adult patients with adenocarcinoma of the rectum (excluding T1N0M0 and M1 disease) diagnosed from 2004 to 2015 were analyzed in this retrospective cohort study. Logistic regression was performed to identify factors associated with refusal of surgery. OS of patients refusing surgery was compared using Kaplan-Meier estimate, log-rank test, propensity score matching, and proportional hazards regression. RESULTS: A total of 55,704 patients were identified: 54,266 received definitive surgery (97.4%) and 1,438 refused (2.6%). Of patients refusing surgery, 135 (9.4%) were stage I, 709 (49.3%) were stage II, and 594 (41.3%) were stage III. Patients were more likely to refuse surgery as the study period progressed (P<0.01). Factors associated with refusal of surgery on multivariate analysis include: age ≥70 years, Black race, non-private insurance, and tumor size greater than 2 cm (all values P≤0.01). The 5-year OS was 61.6% for the surgery cohort and 35.7% for the refusal cohort. In the propensity matched groups, median survival was 84.2 months in patients who received definitive surgery compared to 43.7 months in patients who refused surgery. As an index for comparison, patients who refused surgery but received both radiotherapy and chemotherapy had a median survival of 48.5 months. Among patients that refused surgery, those that received radiotherapy alone, chemotherapy alone, or radiotherapy and chemotherapy (compared to no treatment) experienced a survival benefit (all values P≤0.01). CONCLUSIONS: In patients with non-metastatic adenocarcinoma of the rectum reported in the NCDB, age, race, and insurance status were associated with refusal of surgery. Refusal of surgery was more common in the later years of the study. Survival is poor in patients who refused surgical resection.

Early-Stage Non-Small Cell Lung Cancer Stereotactic Body Radiation Therapy (SBRT) Outcomes in an Equal Access Military Setting.

Introduction Lung stereotactic body radiation therapy (SBRT) is a first-line treatment for early-stage lung cancer in non-surgical candidates or those who refuse surgery. We compared our institutional outcomes from a unique patient population with decreased barriers to care with a recently published prospective series. Materials and methods  We retrospectively reviewed all patients who received definitive lung SBRT at the Walter Reed National Military Medical Center from 2015 to 2020. All patients underwent a positron emission tomography-computed tomography (PET-CT) and all were presented at a multidisciplinary tumor board. Patients were treated on a Trubeam linear accelerator (LINAC)-based system with daily cone-beam CT. The results were qualitatively compared to outcomes from prospective studies including RTOG 0236 and RTOG 0618. Results A total of 105 patients with 114 lesions were included. Median age was 77 years and 54.7% had ≥ 40-pack year smoking history. 36.8% did not have pathologic confirmation. With a median follow-up of 24 months, three-year local control (LC), disease-free survival (DFS) and overall survival (OS) rates were 92.4%, 81.0%, and 80.0%, respectively. Rates of Grade 1 and 2 toxicity were 21.9% and 6.7% and no patients experienced Grade ≥ 3 toxicity. Conclusions In our military setting with universal coverage and routine multidisciplinary care, lung SBRT provides outcomes comparable to prospective studies conducted at high-volume academic centers. More than one-third of patients were treated empirically without pathologic confirmation of disease, demonstrating a difference between clinical trials and community practice. Further investigation is warranted to integrate multidisciplinary management and achieve equal access to care to bridge existing health disparities in the community setting.

The variable impact of positive lymph nodes in cervical cancer: Implications of the new FIGO staging system.

OBJECTIVE: The 2018 International Federation of Gynecology and Obstetrics (FIGO) staging system for cervical cancer changed from a clinical system to a clinical/pathologic/radiologic system with stages IIIC1 and IIIC2 indicating positive pelvic and para-aortic lymph nodes, respectively. We evaluated the National Cancer Database (NCDB) for the impact on survival of lymph node metastases (LNM). METHODS: The NCDB from 2004 to 2015 was queried for patients with cervical cancer, yielding 115,819 patients. Patients with FIGO IVB (22,569), non-adeno/squamous cell histologies (5,909), unknown nodal status (60,695), or unknown survival time (9,473) were excluded. Survival was compared using Cox proportional hazard model based on nodal status. Univariate (UVA) and multivariate analyses (MVA) were done for the overall cohort, followed by UVA by individual stage. RESULTS: In 17,173 eligible patients, LNM negatively affected survival (UVA IIIC1 Hazard Ratio [HR] 2.0, p < 0.001, IIIC2 HR 3.9, p < 0.001, MVA IIIC1 HR 1.36, p < 0.001, IIIC2 HR 2.14, p < 0.001). In T1B, the effect of IIIC2 was most pronounced (HR 5.38, p < 0.001 versus HR 1.5 p = 0.001 for IIIC1 disease). In T3, the effect of LNM was markedly less: (HR 1.7, p < 0.001 for IIIC2 versus HR 1.2 p = 0.02 for IIIC1). Within T1B, there was no difference in survival for IIIC1 for the smaller T stages (IB1-2). CONCLUSION: In this study, LNM negatively affects prognosis in cervical cancer. The impact on survival varies by T stage with the greatest effect seen in stage T1B with IIIC2 disease.