Risk of treatment refusal in male patients with advanced-stage cancers.
Authors: Akpoviroro Ogheneyoma , Sauers Nathan Kyle , Akpoviroro Oghenetejiro Princess , Ahmed Sameer , Castagne Myriam , Rodrigues Elga , Humayun Sara , Uwandu Queeneth , Bolden Brian , Mirza Wasique 
Published: June 2023

e18690

Background: A previous study conducted revealed that males with advanced cancer(CA) were 1.6 times more likely to refuse treatment(TX) than females. Based on this study, we sought to determine factors associated with TX refusal in males. Methods: Retrospective review. Inclusion criteria: male, 18-75 years, stage IV CA, between 01/01/2010-12/31/2015, refused any CA TX(refusal group(RG)). A randomly selected group of stage IV males who accepted TX in the same timeframe was used for comparison(acceptance group(AG)). Geisinger Health System’s data was used. Results: RG had 307 males; AG had 298. Mean age of RG was 62.9 (standard deviation(SD)7.9) and 59.2 (SD9.8) in AG; p < 0.001. Lung CA was the most prevalent CA in both groups: 29.9% in AG and 34.9% in RG. Median interval-to-mortality was 42 days in RG (IQR 101.5), and 387 days in AG (IQR 686.5) p < 0.001. Median Charlson Comorbidity Index(CCI) was greater in AG (9, IQR 6) than RG (median 5, IQR 5.5). BMI, PHQ score, median household income, mean number of years educated and tobacco use history were not associated with TX decisions. While 38.3% of AG had government-funded insurance(GFI), 67.1% of RG had GFI; p < 0.001, OR 3.3, 95% CI 2.3-4.6. The prevalence of alcohol use disorder in RG was 9.8% compared with 3.4% in AG; p = 0.001, OR 3.1, 95% CI 1.5-6.5. RG had a greater prevalence of pre-cancer use of: antidepressants (28.3%) vs AG (14.4%)(p < 0.001, OR 2.3, 95% CI 1.6-3.5), antipsychotics (20.8%) vs 11.1% in AG(p = 0.001, OR 2.1, 95% CI 1.3-3.3), benzodiazepines (24.1%) vs 16.8% in AG(p = 0.03, OR 1.6, 95% CI 1.1-2.4), non-benzodiazepine anxiolytics (26.7%) vs 19.8% in AG(p = 0.04, OR 1.5, 95% CI 1.0-2.2), mood stabilizers(15.6%) vs 7% in AG(p < 0.001; OR 2.4; 95% CI 1.4-4.2). After cancer diagnosis(dx), the use of psychiatric medications becomes more prevalent in the AG. RG had a lower prevalence of post-cancer use of: antipsychotics(42.0%) vs 61.4% in AG (p < 0.001, OR 0.5, 95% CI 0.3-0.6), benzodiazepines (51.5%) vs in 76.5% AG(p < 0.001, OR 0.3, 95% CI 0.2-0.5), non-benzodiazepine anxiolytics(37.8%) vs 78.2% in AG(p < 0.001, OR 0.2, 95% CI 0.1-0.2); mood stabilizers(16.6%) vs 28.2% in AG(p < 0.001, OR 0.5, 95% CI 0.3-0.8). A married status was more prevalent in AG(58.4%) than RG(47.2%)(p = 0.005, OR 0.6, 95% CI 0.5-0.9). Only 19.2% and 20.1% in RG and AG, respectively, were referred to palliative medicine. Conclusions: TX refusal in males with advanced CA is associated with older age, GFI and a lower comorbid burden. Survival in males who accepted TX was 9 times longer. Males with private insurance were 3 times more likely to accept TX. TX of psychiatric disorders was more prevalent in the refusal group prior to CA dx but becomes more prevalent in the acceptance group after CA dx; this may indicate an increased prevalence of psychiatric disease in males who refused TX before CA dx, and a potential lack of psychiatric disease TX after CA dx. Married males were 1.6 times more likely to accept TX than single males.