Introduction

Racial disparities in prostate cancer treatment and outcomes are a persistent public health problem. Communication between physician and patient about the clinical implications of prostate cancer and the trade-offs between different primary treatment options remains critical to prostate cancer management. To evaluate the communication about treatment options for prostate cancer, we assessed variation in the refusal of primary therapy among men diagnosed with prostate cancer from a national database.

Methods

Using the National Cancer Database (NCDB), we identified all men diagnosed with localized prostate cancer from 2004 to 2013. The primary outcome was patient refusal of surgical or radiation therapy, annotated in the NCDB when recommended treatment was not performed with documentation of patient refusal. Multivariable logistic regression analysis was performed to determine clinical factors associated with patient refusal of primary therapy after meeting with a radiation oncologist or urologist. We also examined the association of all-cause mortality with refusal of therapy using Cox proportional hazards regression.

Results

During the study interval, we identified 1,153,871 men diagnosed with localized prostate cancer. The median age was 65 years old. The most common primary therapies were surgery (55%) and radiation therapy (37%). Overall, 21,893 men refused any primary therapy (2.1%), which occurred in 2.0% of patients offered surgery and 2.5% of patients offered radiation. On multivariable analysis, African American (AA) men were more likely to refuse primary therapy compared to white men diagnosed with localized prostate cancer (OR:1.3; 95% CI 1.2-1.3). Similar findings were seen among patients with low income compared to high income (OR: 1.2; 95% CI 1.16-1.23). Refusal of primary therapy was also associated with higher all-cause mortality (HR: 1.2; 95% CI: 1.2-1.3) after adjusting for clinical stage, Gleason score, and treatment.

Conclusions

Although this occurs infrequently, AA men diagnosed with localized prostate cancer are more likely to refuse primary therapy, which is also associated with worse survival. Increased attention to improving patient communication about the severity of prostate cancer and risks and benefits of treatment is needed.

Funding

none