Determinants of Patient Refusal of Postoperative Radiation Therapy in Sinonasal Squamous Cell Carcinoma

Objectives: Although adjuvant radiotherapy may be indicated in patients with sinonasal squamous cell carcinoma (SNSCC) following primary surgery, some patients may choose to forgo recommended postoperative radiation (PORT). Data regarding the effect of PORT refusal on overall survival and which patient factors are associated with PORT refusal remain limited for this neoplasm. This study aimed to elucidate factors associated with patient refusal of recommended PORT in SNSCC and whether refusal is associated with overall survival.

Methods: We performed a retrospective analysis of patients with SNSCC treated with primary surgery from the National Cancer Database diagnosed between 2004 and 2016. A multivariable logistic regression model was created using backward selection to determine the association between clinical or demographic covariates and likelihood of PORT refusal. Unadjusted Kaplan–Meier estimates, log-rank tests, and a multivariable Cox proportional hazard model were used to assess overall survival.

Results: A total of 2,231 patients were included in the final analysis, of which 1,456 (65.3%) were male and 73 (3.3%) refused recommended PORT. A majority of patients were white (1,910, 85.6%) and were treated at academic centers (1,194, 53.5%). On multivariable analysis, patients older than 74 years were more likely to refuse PORT than those younger than 54 (OR: 3.43, CI: 1.84–6.62). Additionally, black patients had increased odds of refusing PORT compared with white patients (OR: 2.88, CI: 1.41–5.52). When compared with residence in a metro county, residence in an urban county was associated with increased odds of refusing PORT (OR: 2.39, CI: 1.34–4.11). Patients with pathologic T4 tumors had decreased odds of refusing PORT compared with those with T1 tumors (OR: 0.27, CI: 0.11–0.63). Median survival among the entire cohort, those who received recommended PORT, and those who refused PORT were 83.0 months (CI: 74.6–97.1), 83.0 months (CI: 74.9–98.2), and 63.6 months (CI: 37.3–101.4), respectively. There was no statistically significant difference in survival between those who received or refused PORT (p = 0.165) on univariate analysis. Following Cox proportional hazards modeling, age, race, insurance status, income, and margin status were independently associated with overall survival. However, refusal of PORT was not associated with overall survival (HR: 0.99, CI: 0.69–1.42).

Conclusion: PORT refusal in patients with SNSCC is rare and was found to be associated with several patient factors. However, the decision to forgo PORT is not independently associated with overall survival in this cohort. Further study is required to determine the clinical implications of these findings as the treatment decisions are complex and likely involve factors not accounted for in this analysis.

Fig. 1 Factors associated with refusal of recommended PORT following multivariable logistic regression.

Fig. 2 Kaplan–Meier curves for patients who received recommended PORT and for patients who refused PORT.

Publication History

Article published online:
12 February 2021