Refusal of cancer-directed surgery in male breast cancer

Abstract

Supplemental Digital Content is available in the text Abstract It has been reported that some male breast cancer patients may refuse the recommended surgery, but the incidence rate in the United States is not clear. The purpose of this study was to identify the incidence, trends, risk factors, and eventual survival outcomes associated with the rejection of such cancer-directed surgery. We collected data on 5860 patients with male breast cancer (MBC) from the Surveillance, Epidemiology, and End Results database, including 50 patients refusing surgery as recommended. Kaplan–Meier survival analysis and Cox proportional hazard regression were used to identify the effects of refusing surgery on cancer-specific survival (CSS) and overall survival (OS). The association between acceptance or rejection of surgery and mortality were estimated by nested Cox proportional hazards regression models with adjustment for age, race, clinical characteristics, and radiation. Of the 5860 patients identified, 50 (0.9%) refused surgery. Old age (≥65: hazard ratio [HR]: 3.056, 95% confidence interval [CI]: 1.738–5.374, P\u200a<\u200a.0001), higher AJCC stage (III: HR: 3.283, 95% CI: 2.134–5.050, P\u200a<\u200a.0001, IV: HR: 14.237, 95% CI: 8.367–24.226, P\u200a<\u200a.0001), progesterone receptor status (negative: HR: 1.633, 95% CI: 1.007–2.648, P\u200a=\u200a.047) were considered risk factors. Compared with the surgery group, the refusal group was associated with a poorer prognosis in both OS and CSS (χ2\u200a=\u200a94.81, P\u200a<\u200a.001, χ2\u200a=\u200a140.4, P\u200a<\u200a.001). Moreover, significant differences were also observed in OS and CSS among 1:3 matched groups (P\u200a=\u200a.0002, P\u200a<\u200a.001). Compared with the patients undergoing surgery, the patients who refused the cancer-directed surgery had poor prognosis in the total survival period, particularly in stage II and III. The survival benefit for undergoing surgery remained even after adjustment, which indicates the importance of surgical treatment before an advanced stage for male breast cancer patients.