Predictors and Consequences of Refusing Recommended Radiation for Locally Advanced Inoperable Non-Small Cell Lung Cancer.

Purpose/objective(s) Definitive chemoradiation is standard-of-care treatment for locally advanced inoperable non-small cell lung cancer (NSCLC). However, some patients refuse radiation therapy (RT) and this information is captured in the National Cancer Database (NCDB). We sought to examine factors associated with patient refusal of RT recommended for clinical stage III NSCLC and to evaluate subsequent outcomes compared to standard treatment. Materials/methods The NCDB (2004-2015) was queried for clinical stage III NSCLC patients who were recommended definitive chemoradiation. We then selected cases in which RT was given or was recommended but refused "by the patient, patient's family member or guardian." We excluded patients with: unknown treatment modality/sequence, those who did not undergo RT for unknown reasons, and those initially not recommended RT. Survival of patients who received RT vs. those who refused RT was compared using log rank test in Kaplan Meier curves. Univariate and multivariate Cox regression were performed to identify predictors of refusal of RT and relationships between each covariate and survival. Results We identified 147,314 patients recommended RT for clinical stage III NSCLC. 141,668 patients underwent definitive treatment with RT and 5,646 (3.8%) refused the recommended RT. On multivariate analysis, older age, female sex, lack of insurance or Medicare/Medicaid insurance, lower income, and higher comorbidity score all significantly predicted refusal of RT. 11.5% (n = 649) of the patients who refused RT were treated with chemotherapy alone. Median survival was significantly worse for patients who refused RT versus those who received RT (5.7 months vs 14.7 months, P Conclusion While the vast majority of locally advanced NSCLC patients are amenable to proceeding with standard treatment, refusal of RT when recommended comes at the cost of inferior survival in this unadjusted cohort from a large hospital-based national database. Sociodemographic factors appear to be associated with refusal of standard of care treatment. These should be further explored to eliminate disparities in the treatment of inoperable but potentially curable NSCLC.