Patient Refusal of Provider-Recommended Locoregional Treatment for Prostate Cancer: Sociodemographic Factors

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In a study reported in JCO Oncology Practice, Dee et al found that the rate of refusal of provider-recommended locoregional treatment for localized prostate adenocarcinoma has increased over time, with Black and Asian men with intermediate- or higher-risk disease being more likely to refuse such treatment vs White men.

The study involved data from the National Cancer Database on men diagnosed with TxN0M0 prostate cancer between 2004 and 2015 who either received or refused locoregional treatment, including radiotherapy and surgery, despite provider recommendations.

Key Findings

Among 887,839 men included in the analysis (median age = 64 years, median follow-up = 6.14 years), 2,487 (0.28%) refused locoregional treatment. Patients with intermediate- or high-risk disease (n = 651,345) were less likely to refuse locoregional treatment vs those with low-risk disease (0.20% vs 0.49%, adjusted odds ratio [OR] = 0.34, P < .001).

Among all patients, Black patients were more likely to refuse locoregional treatment vs White patients (0.42% vs 0.25%, adjusted OR = 1.46, P < .001). Among men with intermediate- or high-risk disease, Black patients (0.35%; adjusted OR = 1.75, P < .001) and Asian patients (0.29%; adjusted OR = 1.47, P = .027) were more likely to refuse locoregional treatment vs White patients (0.17%; P < .001 for interaction of race and risk group).

Factors significantly associated with greater likelihood of refusal of locoregional treatment overall (as shown) and when stratified by risk group included:

  • Later year of diagnosis (0.36% for 2010–2015 vs 0.21% for 2004–2009, adjusted OR = 1.81, P < .001)
  • No insurance or Medicaid vs private insurance (0.81% vs 0.26%, adjusted OR = 2.82, P < .001)
  • Age > 80 vs ≤ 50 years (0.83% vs 0.19%, adjusted OR = 7.22, P < .001)
  • Lower county-wide mean household income (0.21% for > $63,000 U.S. dollars vs 0.37% for < $38,000, adjusted OR = 0.74, P < .001)
  • Undergoing treatment at a community cancer program (0.54%) vs academic or research program facility (0.32%; adjusted OR = 0.74, P < .001).

Among men with intermediate- or high-risk disease, locoregional treatment refusal was associated with significantly poorer 5-year overall survival (80.1% vs 91.5%, hazard ratio = 1.65, P < .001).

The investigators concluded, “Locoregional treatment refusal has increased over time; racial disparities were greater in higher-risk disease. Refusal despite provider recommendation highlights populations that may benefit from efforts to assess and reduce barriers to care.”

Vinayak Muralidhar, MD, MSc, of the Department of Radiation Oncology, Brigham and Women’s Hospital, is the corresponding author for the JCO Oncology Practice article.

Disclosure: The study was supported by a grant from the National Cancer Institute. For full disclosures of the study authors, visit

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