Factors Associated With Refusal of Surgery for PDAC and Its Impact: An NCDB Analysis

Background/Aim: Pancreatic ductal adenocarcinoma (PDAC) has poor survival despite advances in multidisciplinary care. While many patients do not undergo resection due to advanced disease or comorbidity, a small fraction refuse surgery despite recommendations. This study evaluated the association between surgical refusal and overall survival (OS) and identified factors associated with refusal of surgery. Patients and Methods: We performed a retrospective cohort study using the National Cancer Database (NCDB), 2004-2019. Sociodemographic (age, sex, race/ethnicity, income, insurance, distance, rurality, facility type) and clinical variables (stage, grade, treatment) were analyzed. Associations with refusal were assessed using chi-square/Wilcoxon tests. OS was estimated using the Kaplan–Meier test with log-rank testing and evaluated using Cox proportional hazards models. Results: The cohort included 108,978 patients with PDAC (mean age 69.3 years; 50.9% women). Stage I disease comprised 25.8% of the overall cohort. Among patients recommended for surgery, 24.8% underwent resection and 2.2% refused. Refusal was associated with older age (mean 77.5 years), female sex (58.6%), and early stage at diagnosis (stage I: 46.8% among refusers), as well as lower income, rural residence, treatment at comprehensive cancer centers, closer proximity to the treatment center, Medicare insurance, and absence of prior chemotherapy (all p<0.001). Patients who underwent surgery had longer median survival than those who refused (64 vs. 57.1 months), with higher 1-year and 5-year OS (98% and 48% vs. 93% and 40%; log-rank p<0.0001). Conclusion: Refusal of surgery among patients with PDAC is uncommon but is associated with worse OS. Older age, female sex, lower socioeconomic status, rural residence, and early-stage diagnosis were associated with refusal. These factors serve as targetable interventions for decreasing surgery refusal rates.