{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,22]],"date-time":"2026-06-22T15:47:40Z","timestamp":1782143260627,"version":"3.54.5"},"reference-count":22,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2026,6,22]],"date-time":"2026-06-22T00:00:00Z","timestamp":1782086400000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2026,6,22]],"date-time":"2026-06-22T00:00:00Z","timestamp":1782086400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"name":"National Hospital"}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["J Gastrointest Canc"],"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Purpose<\/jats:title>\n                    <jats:p>To investigate the risk factors, reasons, and survival outcomes associated with refusal of surgery for colorectal liver metastases (CRLM). Surgery is the only curative treatment for CRLM, however, some patients refuse. The risk factors and reasons for refusal remain uninvestigated in patients with CRLM.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>Patients with resectable and operable CRLM referred for treatment at Copenhagen University Hospital (2013\u20132023), were identified through the Danish Liver Cancer Group registry. Those who refused surgery were matched 1:4 by WHO performance status with patients who accepted surgery. Data were retrieved from medical records. Risk factors were evaluated using Conditional Logistic Regression. Reasons for refusal were described by frequencies. Survival was analyzed using the Kaplan-Meier estimator and Cox Regression.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Among 2,727 patients referred for treatment, 1,478 were resectable and operable. Twenty-one patients (1.4%) refused surgery. Lower BMI and longer time since the primary tumor diagnosis increased the odds of refusing surgery by 15% per kg\/m\n                      <jats:sup>2<\/jats:sup>\n                      (95% CI 0.76\u20130.99) and 3% per month (95% CI 1.01\u20131.06), respectively. Reasons for refusal included declining further surgery, logistical priorities, preference for chemotherapy and self-assessed unfitness. Patients who refused surgery had significantly lower overall survival (\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.003) and higher mortality risk (HR: 1.87; 95% CI: 1.02\u20133.43).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>This study is the first to identify risk factors and reasons for refusal of surgery in CRLM. The findings provide insight into motivational and prognostic considerations that may support shared decision-making. Further research across cancer types is needed to optimize patient care.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1007\/s12029-026-01503-0","type":"journal-article","created":{"date-parts":[[2026,6,22]],"date-time":"2026-06-22T14:55:25Z","timestamp":1782140125000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Understanding Surgery Refusal in Patients with Colorectal Liver Metastases"],"prefix":"10.1007","volume":"57","author":[{"given":"Laerke Wolf","family":"Andreasen","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lucas Alexander","family":"Kn\u00f8fler","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Delal","family":"Akdag","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sophie Bull","family":"Nordkild","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hans-Christian","family":"Pommergaard","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,6,22]]},"reference":[{"issue":"3","key":"1503_CR1","doi-asserted-by":"publisher","first-page":"209","DOI":"10.3322\/caac.21660","volume":"71","author":"H Sung","year":"2021","unstructured":"Sung H, Ferlay J, Siegel RL, et al. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin. 2021;71(3):209\u201349. https:\/\/doi.org\/10.3322\/caac.21660.","journal-title":"CA Cancer J Clin"},{"key":"1503_CR2","doi-asserted-by":"publisher","unstructured":"Zhou H, Liu Z, Wang Y, et al. Colorectal liver metastasis: molecular mechanism and interventional therapy. Signal Transduct Target Ther. 2022;7(1). https:\/\/doi.org\/10.1038\/s41392-022-00922-2.","DOI":"10.1038\/s41392-022-00922-2"},{"key":"1503_CR3","doi-asserted-by":"publisher","first-page":"w20390","DOI":"10.4414\/smw.2021.20390","volume":"151","author":"DL Birrer","year":"2021","unstructured":"Birrer DL, Tschuor C, Reiner C, et al. Multimodal treatment strategies for colorectal liver metastases. Swiss Med Wkly. 2021;151:w20390. https:\/\/doi.org\/10.4414\/smw.2021.20390.","journal-title":"Swiss Med Wkly"},{"key":"1503_CR4","doi-asserted-by":"publisher","unstructured":"Engstrand J, Nilsson H, Str\u00f6mberg C, Jonas E, Freedman J. Colorectal cancer liver metastases - a population-based study on incidence, management and survival. BMC Cancer. 2018;18(1). https:\/\/doi.org\/10.1186\/s12885-017-3925-x.","DOI":"10.1186\/s12885-017-3925-x"},{"key":"1503_CR5","doi-asserted-by":"publisher","unstructured":"Wagner JS, Adson MA, Adson MH, Ilstrup DM, Van Heerden JA. The Natural History of Hepatic Metastases from Colorectal Cancer A Comparison with Resective Treatment.; 1984. https:\/\/doi.org\/10.1097\/00000658-198405000-00002","DOI":"10.1097\/00000658-198405000-00002"},{"issue":"6","key":"1503_CR6","doi-asserted-by":"publisher","first-page":"456","DOI":"10.1053\/j.seminoncol.2023.01.002","volume":"49","author":"Y Moodley","year":"2022","unstructured":"Moodley Y, Govender K, van Wyk J, et al. Predictors of treatment refusal in patients with colorectal cancer: A systematic review. Semin Oncol. 2022;49(6):456\u201364. https:\/\/doi.org\/10.1053\/j.seminoncol.2023.01.002.","journal-title":"Semin Oncol"},{"issue":"8","key":"1503_CR7","doi-asserted-by":"publisher","first-page":"1306","DOI":"10.1002\/jso.25917","volume":"121","author":"PW Lu","year":"2020","unstructured":"Lu PW, Fields AC, Yoo J, et al. Sociodemographic predictors of surgery refusal in patients with stage I-III colon cancer. J Surg Oncol. 2020;121(8):1306\u201313. https:\/\/doi.org\/10.1002\/jso.25917.","journal-title":"J Surg Oncol"},{"issue":"2","key":"1503_CR8","doi-asserted-by":"publisher","first-page":"276","DOI":"10.1097\/01.sla.0000171305.31703.84","volume":"242","author":"HM Verkooijen","year":"2005","unstructured":"Verkooijen HM, Fioretta GM, Rapiti E, et al. Patients\u2019 refusal of surgery strongly impairs breast cancer survival. Ann Surg. 2005;242(2):276\u201380. https:\/\/doi.org\/10.1097\/01.sla.0000171305.31703.84.","journal-title":"Ann Surg"},{"key":"1503_CR9","doi-asserted-by":"crossref","unstructured":"Gail M, Williams R, Byar DP, Brown C. How many controls? Vol 29. Pergamon Press; 1976.","DOI":"10.1016\/0021-9681(76)90073-4"},{"issue":"2","key":"1503_CR10","doi-asserted-by":"publisher","first-page":"144","DOI":"10.1200\/JCO.2015.61.6441","volume":"34","author":"LA Renfro","year":"2016","unstructured":"Renfro LA, Loupakis F, Adams RA, et al. Body Mass Index Is Prognostic in Metastatic Colorectal Cancer: Pooled Analysis of Patients From First-Line Clinical Trials in the ARCAD Database. J Clin Oncol. 2016;34(2):144\u201350. https:\/\/doi.org\/10.1200\/JCO.2015.61.6441.","journal-title":"J Clin Oncol"},{"issue":"4","key":"1503_CR11","doi-asserted-by":"publisher","first-page":"1482","DOI":"10.21037\/jgo-20-437","volume":"12","author":"AR Coffman","year":"2021","unstructured":"Coffman AR, Tao R, Cohan JN, et al. Factors associated with the refusal of surgery and the associated impact on survival in patients with rectal cancer using the National Cancer Database. J Gastrointest Oncol. 2021;12(4):1482\u201397. https:\/\/doi.org\/10.21037\/jgo-20-437.","journal-title":"J Gastrointest Oncol"},{"issue":"1","key":"1503_CR12","doi-asserted-by":"publisher","first-page":"39","DOI":"10.1016\/j.amjsurg.2020.06.020","volume":"221","author":"IG Alty","year":"2021","unstructured":"Alty IG, Dee EC, Cusack JC, et al. Refusal of surgery for colon cancer: Sociodemographic disparities and survival implications among US patients with resectable disease. Am J Surg. 2021;221(1):39\u201345. https:\/\/doi.org\/10.1016\/j.amjsurg.2020.06.020.","journal-title":"Am J Surg"},{"issue":"6","key":"1503_CR13","doi-asserted-by":"publisher","first-page":"1605","DOI":"10.1016\/j.amjsurg.2020.04.022","volume":"220","author":"C Kaltenmeier","year":"2020","unstructured":"Kaltenmeier C, Malik J, Yazdani H, et al. Refusal of cancer-directed treatment by colon cancer patients: Risk factors and survival outcomes. Am J Surg. 2020;220(6):1605\u201312. https:\/\/doi.org\/10.1016\/j.amjsurg.2020.04.022.","journal-title":"Am J Surg"},{"issue":"4","key":"1503_CR14","doi-asserted-by":"publisher","first-page":"12","DOI":"10.1016\/j.sopen.2020.07.001","volume":"2","author":"M Delisle","year":"2020","unstructured":"Delisle M, Singh S, Howard J, Panda N, Weppler AM, Wang Y. Refusal of colorectal cancer surgery in the United States: Predictors and associated cancer- specific mortality in a Surveillance, Epidemiology, and End Results (SEER) cohort. Surg Open Sci. 2020;2(4):12\u20138. https:\/\/doi.org\/10.1016\/j.sopen.2020.07.001.","journal-title":"Surg Open Sci"},{"key":"1503_CR15","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1155\/2010\/381795","volume":"2010","author":"J Wang","year":"2010","unstructured":"Wang J, Wang FW. Refusal of Cancer-Directed Surgery Strongly Impairs Survival of Patients with Localized Hepatocellular Carcinoma. Int J Surg Oncol. 2010;2010:1\u20138. https:\/\/doi.org\/10.1155\/2010\/381795.","journal-title":"Int J Surg Oncol"},{"issue":"4","key":"1503_CR16","doi-asserted-by":"publisher","first-page":"e469","DOI":"10.1016\/j.clbc.2017.07.010","volume":"18","author":"A Gaitanidis","year":"2018","unstructured":"Gaitanidis A, Alevizakos M, Tsalikidis C, Tsaroucha A, Simopoulos C, Pitiakoudis M. Refusal of Cancer-Directed Surgery by Breast Cancer Patients: Risk Factors and Survival Outcomes. Clin Breast Cancer. 2018;18(4):e469\u201376. https:\/\/doi.org\/10.1016\/j.clbc.2017.07.010.","journal-title":"Clin Breast Cancer"},{"issue":"6","key":"1503_CR17","doi-asserted-by":"publisher","first-page":"990","DOI":"10.1002\/jso.25873","volume":"121","author":"AC Fields","year":"2020","unstructured":"Fields AC, Lu PW, Yoo J, et al. Treatment of stage I-III rectal cancer: Who is refusing surgery? J Surg Oncol. 2020;121(6):990\u20131000. https:\/\/doi.org\/10.1002\/jso.25873.","journal-title":"J Surg Oncol"},{"issue":"4","key":"1503_CR18","doi-asserted-by":"publisher","first-page":"756","DOI":"10.1016\/j.ijrobp.2014.03.024","volume":"89","author":"AA Aizer","year":"2014","unstructured":"Aizer AA, Chen MH, Parekh A, et al. Refusal of curative radiation therapy and surgery among patients with cancer. Int J Radiat Oncol Biol Phys. 2014;89(4):756\u201364. https:\/\/doi.org\/10.1016\/j.ijrobp.2014.03.024.","journal-title":"Int J Radiat Oncol Biol Phys"},{"key":"1503_CR19","doi-asserted-by":"publisher","unstructured":"Hu X, Ye H, Yan W, Sun Y. Factors Associated With Patient\u2019s Refusal of Recommended Cancer Surgery: Based on Surveillance, Epidemiology, and End Results. Front Public Health. 2022;9. https:\/\/doi.org\/10.3389\/fpubh.2021.785602.","DOI":"10.3389\/fpubh.2021.785602"},{"issue":"6","key":"1503_CR20","doi-asserted-by":"publisher","first-page":"1368","DOI":"10.1002\/lary.27116","volume":"129","author":"MM Crippen","year":"2019","unstructured":"Crippen MM, Elias ML, Weisberger JS, et al. Refusal of Cancer-Directed Surgery in Head and Neck Squamous Cell Carcinoma Patients. Laryngoscope. 2019;129(6):1368\u201373. https:\/\/doi.org\/10.1002\/lary.27116.","journal-title":"Laryngoscope"},{"key":"1503_CR21","doi-asserted-by":"publisher","unstructured":"Tang Y, Gao Y, Zhang R, et al. A population-based propensity score matching analysis of risk factors and the impact on survival associated with refusal of cancer-directed surgery in patients with prostate cancer. Sci Rep. 2024;14(1). https:\/\/doi.org\/10.1038\/s41598-024-60180-w.","DOI":"10.1038\/s41598-024-60180-w"},{"issue":"7","key":"1503_CR22","doi-asserted-by":"publisher","first-page":"890","DOI":"10.1080\/00365521.2019.1641215","volume":"54","author":"P Even Storli","year":"2019","unstructured":"Even Storli P, Johnsen G, Juel IS, et al. Impact of increased resection rates and a liver parenchyma sparing strategy on long-term survival after surgery for colorectal liver metastases. A population-based study. Scand J Gastroenterol. 2019;54(7):890\u20138. Epub 2019 Jul 18. PMID: 31318299.","journal-title":"Scand J Gastroenterol"}],"container-title":["Journal of Gastrointestinal Cancer"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s12029-026-01503-0.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1007\/s12029-026-01503-0","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s12029-026-01503-0.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,6,22]],"date-time":"2026-06-22T14:55:32Z","timestamp":1782140132000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/10.1007\/s12029-026-01503-0"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,6,22]]},"references-count":22,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2026,12]]}},"alternative-id":["1503"],"URL":"https:\/\/doi.org\/10.1007\/s12029-026-01503-0","relation":{},"ISSN":["1941-6636"],"issn-type":[{"value":"1941-6636","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,6,22]]},"assertion":[{"value":"11 January 2026","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"24 May 2026","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"22 June 2026","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"The authors declare no competing interests.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing Interests"}},{"value":"The authors declare no competing interests.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Conflict of Interest"}},{"value":"The study was conducted in accordance with the principles of the Declaration of Helsinki. According to Danish legislation, retrospective studies based on existing data do not require approval from a national research ethics committee or informed consent from participants. Approval for data access, use, and storage was obtained from the Capital Region of Denmark through the Team for Journal Data, Center for Health (approval numbers: R-23057752; P-2024-15920).","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethical Approval"}}],"article-number":"140"}}