What Happens After Declining Recommended Surgery? Analysis of Early-Stage Non-Small Cell Lung Cancer.

Background: Surgery provides curative-intent treatment for early-stage non-small cell lung cancer (NSCLC). Some patients decline recommend lung cancer resection and have worse overall survival (OS). The details of what treatment or palliative care is received among those who decline recommend surgery have not been described. We aimed to identify factors associated with declining all treatment among patients who decline recommended surgery for NSCLC. Methods: The National Cancer Database was utilized to identify stage I and II patients with NSCLC age ≤70 years diagnosed from 2004-2020. Patients were assigned to 2 cohorts: declined recommended surgery but received alternative treatment (alternative treatment cohort) and declined recommended surgery and declined all other treatment modalities (no treatment cohort). Cox regression analysis was performed to identify variables independently associated with OS. Results: A total of 67,454 adult patients met inclusion criteria. Among patients who did not receive surgery (n = 923), 70.6% of patients received no treatment (n = 652). Patients who declined surgery were more likely of Black race. Compared with alternative treatment, patients who received no treatment were more likely to have stage I cancer and nongovernment insurance. Multivariable Cox regression demonstrated that residence in areas with higher income and receiving alternative treatment were associated with improved OS; while increased comorbidities was associated with worse OS. Conclusions: Most patients who decline recommended surgery receive no treatment, and declining all treatment for early-stage NSCLC is associated with worse OS. Targeted interventions to mitigate socioeconomic barriers for lung cancer treatment are necessary.