Survival Outcomes and Disparities in Surgery Refusal for Papillary Thyroid Cancer

Abstract

Background/aim: Surgery is the cornerstone of treatment for papillary thyroid cancer (PTC), yet some patients refuse surgery, which may impact their survival outcomes. Understanding factors associated with surgery refusal could inform interventions to improve acceptance of recommended care.

Patients and methods: This retrospective cohort study evaluated the impact of surgery refusal on overall survival (OS) and identified associated demographic and clinical factors using data on patients with PTC from the National Cancer Database from 2004 to 2019. OS was analyzed using the Kaplan-Meier method, with survival curves compared using the log-rank test. Patient characteristics were analyzed using Pearson Chi-square tests or Wilcoxon Rank Sum tests.

Results: Of the 201,051 patients with PTC who were advised to undergo surgery, 200,656 (99.8%) underwent surgery, while 395 (0.2%) refused. Patients who refused surgery were older (mean age 55.2 years vs. 48.7 years), more often male (27.8% vs. 22.8%), and represented higher proportions of Black, Asian, Hispanic, lower-income, uninsured, and non-privately insured patients (p<0.001). OS rates were significantly lower in patients who refused surgery, with one-year and five-year survival rates of 87% and 34%, respectively, compared to 96% and 56% for those who underwent surgery.

Conclusion: Surgery refusal in patients with PTC was associated with poorer OS outcomes and was more frequent among older adults, socioeconomically disadvantaged populations, and racial and ethnic minorities. Interventions addressing patient concerns and barriers to surgery are critical to improving treatment acceptance and survival among these groups.

Keywords: Thyroid cancer; cancer disparities; cancer survival; papillary thyroid cancer (PTC); refusal; thyroid surgery; thyroidectomy.