Impact of Surgery Refusal on Overall Survival in Merkel Cell Carcinoma

BACKGROUND/AIM: The mainstay of treatment for Merkel cell carcinoma (MCC) is surgery; however, some individuals refuse this treatment modality, which may influence their survival outcomes. Interventions to increase acceptance of suggested care could be informed by an understanding of the factors linked to surgery refusal. PATIENTS AND METHODS: This retrospective study used data on patients with MCC from the National Cancer Database from 2004 to 2019 to assess the effect of surgical refusal on overall survival (OS) and identify related clinical and demographic characteristics. The Kaplan-Meier method was used to examine OS, and the log-rank test was used to compare survival curves. Wilcoxon Rank Sum or Pearson Chi-square tests were used to examine patient characteristics. RESULTS: Of the 9,901 patients with MCC who were advised to undergo surgery, 9,863 (99.6%) underwent surgery, while 38 (0.4%) refused. Patients who refused surgery were older (mean age 74.3 years vs. 82.6 years), in a later stage of disease (54% of the cohort in stage I MCC vs. 47.4% of patients who refused surgery), more often received care at a community cancer facility (7.4% of cohort vs. 23.7% among those patients who refused), and more often had prior chemotherapy (16.7% in the cohort vs. 23.7% who refused surgery) (p<0.001). OS rates were lower in patients who refused surgery, with one-year and five-year survival rates of 97% and 50%, respectively, compared to 98% and 54% for those who underwent surgery. CONCLUSION: Surgery refusal in patients with MCC was related to poorer OS outcomes and was more common among older individuals, those treated at community cancer centers, and those with late-stage cancer. Interventions that address patient concerns and obstacles to surgery are crucial for increasing surgery acceptance and survival in these populations.