Cancer Causes & Control

, Volume 30, Issue 12, pp 1389–1397 | Cite as

Disparities in surgery for early-stage cancer: the impact of refusal

  • Joseph Rapp
  • Stephanie Tuminello
  • Naomi Alpert
  • Raja M. Flores
  • Emanuela TaioliEmail author
Original Paper



For early-stage cancer surgery is often curative, yet refusal of recommended surgical interventions may be contributing to disparities in patient treatment. This study aims to assess predictors of early-stage cancers surgery refusal, and the impact on survival.


Patients recommended surgery with primary stage I and II lung, prostate, breast, and colon cancers, diagnosed between 2007–2014, were identified in the Surveillance, Epidemiology and End Results database (n = 498,927). Surgery refusal was reported for 5,757 (1.2%) patients. Associations between sociodemographic variables and surgery refusal by cancer type were assessed in adjusted multivariable logistic regression models. The impact of refusal on survival was investigated using adjusted Cox-Proportional Hazard regression in a propensity score-matched cohort.


Increasing age (p < 0.0001 for all four cancer types), non-Hispanic Black race/ethnicity (ORadjBREAST 2.00, 95% CI 1.68–2.39; ORadjCOLON 3.04, 95% CI 2.17–4.26; ORadjLUNG 2.19, 95% CI 1.77–2.71; ORadjPROSTATE 2.02, 95% CI 1.86–2.20; vs non-Hispanic White), insurance status (uninsured: ORadjBREAST 2.75, 95% CI 1.89–3.99; ORadjPROSTATE 2.10, 95% CI 1.72–2.56; vs insured), marital status (ORadjBREAST 2.16, 95% CI 1.85–2.51; ORadjCOLON 1.56, 95% CI 1.16–2.10; ORadjLUNG 2.11, 95% CI 1.80–2.47; ORadjPROSTATE 1.94, 95% CI 1.81–2.09), and stage (ORadjBREAST 1.94, 95% CI 1.70–2.22; ORadjCOLON 0.13, 95% CI 0.09–0.18; ORadjLUNG 0.71, 95% CI 0.52–0.96) were all associated with refusal; patients refusing surgery were at increased risk of death compared to patients who underwent surgery.


More vulnerable patients are at higher risk of refusing recommended surgery, and this decision negatively impacts their survival.


Cancer surgery Early-stage Surgery Refusal Survival 


Supplementary material

10552_2019_1240_MOESM1_ESM.pdf (194 kb)
Supplementary file1 (PDF 193 kb)


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Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Joseph Rapp
    • 1
  • Stephanie Tuminello
    • 1
  • Naomi Alpert
    • 1
  • Raja M. Flores
    • 2
  • Emanuela Taioli
    • 1
    • 2
    • 3
    • 4
    Email author
  1. 1.Institute for Translational Epidemiology and Department of Population Health Science and PolicyIcahn School of Medicine at Mount SinaiNew YorkUSA
  2. 2.Department of Thoracic SurgeryIcahn School of Medicine at Mount SinaiNew YorkUSA
  3. 3.Tisch Cancer InstituteIcahn School of Medicine at Mount SinaiNew YorkUSA
  4. 4.Icahn School of Medicine at Mount SinaiNew YorkUSA

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