Has survival increased in cancer patients admitted to the ICU? Yes

Abstract

Intensive care unit (ICU) admission of patients with cancer has long been controversial. Studies performed in the early 1990s demonstrated high mortality rates in cancer patients admitted to the ICU, especially among those with respiratory failure requiring mechanical ventilation, neutropenic sepsis, and in hematopoietic stem cell transplant (HSCT) recipients [1, 2]. Additionally, a lack of cost-effectiveness was noted and some authors argued that denial of ICU admission could avoid futile care and unwarranted aggressive therapy in dying patients [3, 4].Over the past decade, however, studies that report prognosis and predictive factors for mortality in critically ill cancer patients have shown different results [5][6][7][8][9][10]. Although mortality remains high when compared to the general population of critically ill patients, these studies have demonstrated meaningful ICU and hospital survival rates and some of them improved survival over time [5][6][7][8]. Unadjusted ICU and hospital mortality rates have been found to decrease progressively [9]. However, these findings were mainly reported by single center cohort studies and usually involved a small number of patients [9]. A recent, prospective multicenter study of 1,011 critically ill patients with hematological malignancies [5] reported encouraging hospital, 90-day, and 1-year survival rates of 60.7, 52.5, and 43.3 %, respectively compared with the poor outcomes reported 15-20 years ago [1, 2, 5, 9]. Similarly, although hospital mortality remained high in those patients requiring mechanical ventilation (60.5 %), this mortality rate is significantly lower than the over 90 % mortality rates in mechanically ventilated cancer patients that were earlier reported [1, 2, 5]. Recent studies have also confirmed that complete or partial remission of the underlying disease, lack of comorbidities, and good performance status are associated with increased risk of survival whereas some of the usual prognostic factors such as neutropenia failed to be associated with adverse outcomes [5, 6, 10].Improved survival has also been demonstrated in subgroups of critically ill cancer patients including those with neutropenic sepsis [7], myeloma patients [10], and to a lesser extent in HSCT recipients [11]. Similarly, the outcome of cancer patients admitted to the ICU with severe sepsis or septic shock [6], acute respiratory distress syndrome (ARDS) [8], or those requiring mechanical Intensive Care Med (2014) 40:1570-1572

Critically ill allogeneic hematopoietic stem cell transplantation patients in the intensive care unit: reappraisal of actual prognosis

“…8,9 Recent data support the use of ICU resources in these patients, with dramatically decreased mortality rates and long-term benefits. [10][11][12] Whether these trends are confirmed in allo-HSTC patients is more controversial. 13,14 Considering all recent advances in HSCT techniques and ICU management, the reappraisal of actual prognosis became crucial to identify patients who are most likely to benefit from ICU support.…”

Has survival increased in cancer patients admitted to the ICU? We are not sure

“…By defending the pro viewpoint, Mokart et al [1] may be right in claiming that survival in cancer patients in general and more particularly in those with hematological malignancies has increased over the past decade. As recently reported in a prospective study including more than 1,000 hematological patients admitted to 18 ICUs from a French-Belgian network [2], overall mortality was 50 %, but more important were mortality rates in the sickest subgroups: 60 % in the case of either one vital organ failure (need for ventilation, vasopressor, or dialysis) or two vital organ failures if reversible within 7 days.…”

“…Mokart et al [1] ascribe recent survival benefits mainly to earlier and better supportive care provided to a more selected patient population with less comorbidities and a better performance status. It is true that ICU admission within 24 h of hospital referral has been associated with improved outcome [11].…”

“…Interestingly, both Mokart et al [1] and Pène et al [8] highlight that we need to learn how to make appropriate triage decisions taking into account the burden of aggressive intensive care, expected short-term outcomes, cancer outcomes, and long-term outcomes. This requires, however, much more than pure medical skills or scientific knowledge.…”

Focus on immunocompromised patients

“…In a systematic review of patients with solid tumors, 35 studies (25,339 patients) reported ICU and hospital mortality rates of 31.2 and 38.2 %, respectively [12]. These studies confirm the impact of performance status and mechanical ventilation on mortality, but also the lack of prognostic value of variables depicting the characteristics of the malignancy [13][14][15]. Clinical consequences of these findings are of paramount importance.…”