Cohort studyindependent cross-checkabstract checked I-SRC-107 standard review
Refusing breast-cancer surgery
Refusal of Cancer-Directed Surgery by Breast Cancer Patients: Risk Factors and Survival Outcomes.
Overview
Gaitanidis A et al.. Clin Breast Cancer 2018 · PMID 28784267 · DOI 10.1016/j.clbc.2017.07.010
Patients who refused recommended surgery had a 2.4 times higher risk of death; the groups also differed in other ways.
Does the study support the specific claim? No · Methodological quality: low
Plain-language summary
Study explained simply
- What did the researchers want to find out?
Study surgery refusal
- How was the study done?
Registry cohort
- How many people, animals or samples were studied?
531,700 patients
- What was actually found?
Refusal rare but linked to higher mortality
- How large was the observed effect?
2.42 times higher mortality risk
- What do the results mean in everyday life?
Refusing surgery is risky
- What are the study's limitations?
Observational, confounded
- What does it say about Elawady's specific claim?
Contradicts distrust of tumour surgery
- Do the results apply to Germany and Europe?
Direction applicable
- What can explicitly not be concluded from this study?
Exact causal effect
Scientific in-depth review
1. Full reference
- Authors
- Gaitanidis A et al.
- Journal
- Clin Breast Cancer
- Year
- 2018
- Identifier
- PMID 28784267 DOI 10.1016/j.clbc.2017.07.010
- Verification
- verified – PubMed efetch 2026-10-26; Crossref works record checked
- Retracted
- no
- Corrections
- none
- Extent checked
- abstract only
- Conflicts of interest and funding
Not stated in abstract.
2. Research question
How often do breast-cancer patients refuse recommended surgery, and how does refusal relate to survival?
3. Study design and population
- Study design
- Cohort study – Retrospective registry cohort (SEER)
- Population
US breast-cancer patients in SEER
- Country
USA
- Period
2004-2013
- Sample size
531,700 patients; 3389 refused surgery
- Inclusion and exclusion criteria
Surgery recommended
4. Methods and endpoints
- Exposure / intervention
Refusal of recommended cancer-directed surgery
- Comparator
Patients who had surgery
- Endpoints
Mortality
- Statistical methods
Logistic regression for predictors; survival analysis
5. Actual results
- Results
0.64% refused surgery, increasing over time; refusal associated with older age, being unmarried, higher stage and no insurance. Survival analysis showed a 2.42 higher risk of mortality in patients who refused surgery.
- Absolute risks
Not reported in abstract.
- Authors' conclusion
Refusal of recommended surgery is increasing and significantly affects survival.
6. Strengths
- Very large population registry
7. Weaknesses
- Observational; refusers differ (age, stage, insurance)
- Hazard ratio given without CI in abstract
- Abstract only
8. Risk of bias
- Orienting tool
- ROBINS-E
- Type of assessment
- simplified assessment (abstract only)
- Full formal assessment
- no
- Overall risk of bias
- high
- Rationale
Strong confounding by age, stage and comorbidity likely; direction consistent with other studies (I-CHM-04).
9. Assessment of the statistical interpretation
The 2.42-fold mortality figure cannot be checked (no CI in abstract) and is confounded; it indicates direction rather than exact size (stats/C-SRC-45_insema_refusal.py).
10. Relevance to the specific claim
Addresses the safety-critical consequence of distrust of cancer surgeons: refusing surgery is associated with higher death rates.
11. Independent contrary findings
Confounding could inflate the estimate.
12. Transferability to Germany and Europe
US data; direction transferable.
13. Overall methodological judgement
Supportive observational evidence for the safety note.
| Multidimensional assessment | |
|---|---|
| Authenticity of the source | verified |
| Methodological quality | low |
| Risk of bias | high |
| Precision of results | not applicable |
| Directness | direct |
| Reproducibility | partly replicated |
| Consistency with the overall evidence | consistent |
| Regional transferability | high |
| Adequacy of the interpretation (by the archive) | not applicable |
14. Open questions
15. Linked fact checks
- Surgical oncologists do not understand what tumours are: they remove the tumour and 'clean out' the lymph nodes, which he regards as wrong. – Studies contradicting or limiting the claim