Advancing Education, Research, and Quality of Care for the Head and Neck oncology patient.
Background: Postoperative radiotherapy (PORT) is recommended for advanced-stage oral cavity cancer (OCC). Patients may choose to forgo recommended PORT for various reasons. This study aimed to elucidate factors associated with patient refusal of recommended PORT in OCC, specifically within early-onset (EO-OCC, aged = 50 years) and late-onset (LO-OCC, aged 50 years) patient populations.
Methods: We conducted a retrospective cohort study of patients diagnosed with OCC treated with primary surgery from the National Cancer Database (NCDB) between January 2004 and December 2021. We primarily assessed the odds of refusing PORT based on demographic and socioeconomic factors. A subset analysis was performed for EO-OCC and LO-OCC cases. Multivariate logistic regression analysis was performed across the two groups to assess factors associated with PORT refusal.
Results: A total of 47,073 patients were included in the final analysis, with 3,483 (7.4%) opting out of recommended PORT, while 43,590 patients (92.6%) received recommended PORT. The mean age was 64 years old (SD 12 years). Most patients were male (62%), non-Hispanic white (78%), Medicare users (43%), did not have comorbid conditions (75%), lived in metro areas (83%) and within 50 miles from their care facility (83%). In the LO-OCC group, females (OR = 1.2, 95%CI: 1.11 – 0.30, p=<0.001) were more likely to refuse PORT than males. Black (OR = 0.72, 95% CI: 0.608 – 0.851, p=<0.001) and Hispanic (OR = 0.65, 95% CI: 0.518 - 0.808, p=<0.001) patients were less likely to refuse radiation compared to non-Hispanic white (NHW) patients; however, these associations were not significant in the EO-OCC group. Distance to the treatment center greater than 50 miles was associated with higher odds of PORT refusal in both LO-OCC (OR = 1.27, 95% CI: 1.14–1.42, p < 0.001) and EO-OCC (OR = 1.62, 95% CI: 1.12–2.30, p = 0.008). Within the EO-OCC group, a significant increase in refusal was seen only with the highest comorbidity score (OR = 2.23, 95% CI: 0.97–4.50). Among all subsites, tongue cancer had the highest overall refusal rate (4.71%) and was independently associated with higher refusal odds in both EO-OCC (OR = 1.72, 95% CI: 1.24–2.41, p = 0.001) and LO-OCC (OR = 1.16, 95% CI: 1.05–1.27, p = 0.002), with a more substantial effect in EO-OCC. Non-Hispanic white female patients with tongue cancer had higher odds of refusing PORT compared to all other patients (OR = 1.25, 95% CI: 1.14–1.97, p < 0.001).
Conclusion: Our study demonstrates that specific demographic and socioeconomic factors significantly influence the decision to refuse recommended PORT in OCC patients, with distinct differences between EO-OCC and LO-OCC cases. Longer distance to the treatment center, higher comorbidity index, and tongue subsite are significant determinants of PORT refusal in the EO-OCC group. While factors like sex, race/ethnicity, insurance type, education, and income levels significantly influence PORT refusal in LO-OCC patients, they are not independent predictors in EO-OCC cases. These findings underscore the need for a targeted multidisciplinary approach to improve treatment adherence in these populations.