Racial Disparities among Asian American, Native Hawaiian, and Other Pacific Islander Patients with Cancer Who Refuse Recommended Radiation Therapy or Surgery

Abstract

Despite radiation therapy (RT) and surgery being the curative treatments, prior work demonstrated that the aggregated Asian American (AA) and Native Hawaiian and Other Pacific Islanders (NHPI) population refuse RT and surgery at a higher rates than other races. Given that AA and NHPI are distinct groups, data disaggregation is necessary to understand racial and ethnic disparities for treatment refusal. We aimed to (1) compare RT and surgery refusal rates between AA and NHPI populations, (2) assess RT and surgery refusal on overall mortality, and (3) determine predictors of refusing RT and surgery using the United States (U.S.) National Cancer Database. Adjusted odds ratios (aOR) and 95% confidence intervals (95%CI) for treatment refusal were calculated using logistic regression. Adjusted hazard ratios (aHR) were calculated for overall survival using Cox proportional hazard models among propensity score-matched groups. The overall rate of RT refusal was 4.8% and surgery refusal was 0.8%. Compared to East AA patients, NHPI patients had the highest risk of both RT refusal (aOR = 1.38, 95%CI = 1.21-1.61) and surgery refusal (aOR = 1.28, 95%CI = 1.00-1.61). RT refusal significantly predicted higher mortality (aHR = 1.17, 95%CI = 1.08-1.27), whereas surgery refusal did not. Predictors of RT and surgery refusal were older patient age, high comorbidity index, and cancer diagnosis between 2011-2017. The results show heterogenous treatment refusal patterns among AA and NHPI populations, suggesting areas for targeted intervention.

Keywords: Asian Americans; Native Hawaiian and Other Pacific Islanders; cancer disparities; radiotherapy refusal; surgery refusal.

Figure 1

Study flowchart of patients included in this study. Patients were included for complete survival, complete follow-up, complete staging data, biopsy confirmed diagnosis, age ≥18 years, and recommended for RT or surgery as an initial treatment. Patient race included AA and NHPI. AA was stratified by East AA, South AA, and Southeast AA. The analyses were divided into patients who were recommended for RT and those who were recommended for surgery. Abbreviations: AA = Asian American; NHPI = Native Hawaiian and other Pacific Islander; RT = Radiation Therapy; AIAN = American Indian/Alaska Native.

Figure 2

The proportions of RT and surgery refusal rates among Southeast AA, South AA, NHPI, and East AA patients. Abbreviations: NHPI = Native Hawaiian and other Pacific Islander; RT = Radiation Therapy; AA = Asian American.