Refusal of Recommended Chemotherapy for Ovarian Cancer: Risk Factors and Outcomes; a National Cancer Data Base Study

Objective: To identify risk factors associated with refusal of recommended chemotherapy and its impact on patients with epithelial ovarian cancer (EOC). Methods: We identified patients in the National Cancer Data Base diagnosed with EOC from January 1998 to December 2011. Patients who refused chemotherapy were identified and compared with those who received recommended, multiagent chemotherapy. Univariate and multivariable analyses were performed using chi-square test with Bonferroni correction, binary logistic regression, logrank test, and Cox proportional hazards modeling. The threshold for statistical significance was set at a P value of less than 0.05. Results: From a cohort of 147,713 eligible patients, 2,707 refused chemotherapy. These patients were compared with 92,212 patients who received recommended multiagent chemotherapy. Older age, more medical comorbidities, not having insurance, and later year of diagnosis were directly and significantly associated with chemotherapy refusal when analyzed using multivariable logistic regression. In addition, lower-than-expected facility adherence to NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Ovarian Cancer, treatment at low-volume center, lower grade, and higher stage were all significantly and independently associated with chemotherapy refusal. Median overall survival of patients who received multiagent chemotherapy was significantly longer than that of those who refused chemotherapy (43 vs 4.8 months; P<.0005). After controlling for known patient, facility, and disease prognostic factors, chemotherapy refusal is significantly associated with increased risk of death. Conclusions: Refusal of recommended chemotherapy carries significant risk of early death from ovarian cancer. Our data demonstrate that the decision to refuse chemotherapy is multifactorial and, in addition to unalterable factors (eg, stage/grade, age), involves factors that can be changed, including facility type and payor. Efforts at addressing these discrepancies in care can improve compliance with chemotherapy recommendations in the NCCN Guidelines for Ovarian Cancer and outcomes.

Target Audience

This activity has been designed to meet the educational needs of physicians and nurses involved in the management of patients with cancer.

Learning Objectives

Upon completion of this activity, participants will be able to:

  • Identify risk factors associated with refusal of recommended chemotherapy in patients with ovarian cancer
  • Describe the impact on patient outcomes related to refusal of recommended chemotherapy in patients with ovarian cancer
Additional information
Supporters: 

No commercial support was received for this article.

Course summary
Available credit: 
  • 1.00 AMA PRA Category 1 Credit™
  • 1.00 ANCC contact hours
  • 1.00 Participation
Course opens: 
05/12/2016
Course expires: 
05/12/2017
Cost:
$0.00

Disclosure of Relevant Financial Relationships

All faculty and activity planners participating in NCCN continuing education activities are expected to disclose any relevant financial relationships with a commercial interest as defined by the ACCME’s, ANCC’s, and ACPE’s Standards for Commercial Support. All faculty presentations have been reviewed for adherence to the ACCME’s Criterion 7: The provider develops activities/educational interventions independent of commercial interests (SCS 1, 2, and 6) by experts on the topics. Full disclosure of faculty relationships will be made prior to the activity.

The authors have disclosed that they have no financial interests, arrangements, affiliations, or commercial interests with the manufacturers of any products discussed in this article or their competitors. Dr. Tergas is the recipient of a fellowship (NCI R25 CA094061-11) from the National Cancer Institute.

EDITOR:
Kerrin M. Green, MA, Assistant Managing Editor, JNCCN—Journal of the National Comprehensive Cancer Network
Ms. Green has disclosed that she has no relevant financial relationships.

CE AUTHORS:
Deborah J. Moonan, RN, BSN, Director, Continuing Education, hasdisclosed that she has no relevant financial relationships.

Kristina M. Gregory, RN, MSN, OCN, Vice President, Clinical Information Operations, has disclosed that she has no relevant financial relationships.

Rashmi Kumar, PhD, Senior Manager, Clinical Content, has disclosed that she has no relevant financial relationships.

Miranda Hughes, PhD, Oncology Scientist/Senior Medical Writer, has disclosed that she has no relevant financial relationships.

The ACCME/ANCC/ACPE defines “conflict of interest” as when an individual has an opportunity to affect CE content about products or services of a commercial interest with which he/she has a financial relationship.

ACCME, ACPE, and ANCC focuses on financial relationships with commercial interests in the 12-month period preceding the time that the individual is being asked to assume a role controlling content of the CE activity. ACCME, ACPE, and ANCC have not set a minimal dollar amount for relationships to be significant. Inherent in any amount is the incentive to maintain or increase the value of the relationship. The ACCME, ACPE, and ANCC defines “’relevant’ financial relationships” as financial relationships in any amount occurring within the past 12 months that create a conflict of interest.

All faculty for this continuing education activity are competent in the subject matter and qualified by experience, training, and/or preparation to the tasks and methods of delivery.

Physicians
The National Comprehensive Cancer Network (NCCN) is accredited by the ACCME to provide continuing medical education for physicians.

NCCN designates this journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Nurses
NCCN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center`s Commission on Accreditation.

NCCN designates the education activity for a maximum of 1.0 contact hour. Accreditation as a provider refers to recognition of educational activities only; accredited status does not imply endorsement by NCCN or ANCC of any commercial products discussed/displayed in conjunction with the educational activity. Kristina M. Gregory, RN, MSN, OCN, is our nurse planner for this educational activity.

All clinicians completing this activity will be issued a certificate of participation.

Release date: May 12, 2016
Expiration date: May 12, 2017

Available Credit

  • 1.00 AMA PRA Category 1 Credit™
  • 1.00 ANCC contact hours
  • 1.00 Participation

Accreditation Period

Course opens: 
05/12/2016
Course expires: 
05/12/2017

Price

Cost:
$0.00
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Required Hardware/software

To access this activity, users will need:

  • A device with an Internet connection
  • Adobe Reader or other PDF reader software for article and certificate viewing/printing