Which Patients With Cancer Best Survive the ICU?

Because cancer is a complex disease, admitting a patient with cancer to the intensive care unit (ICU) can be challenging triage. Often the reason for the admission is acute complications related to the cancer or its treatment. Understanding how those complications might affect the patient’s outcome is critical to planning care, gauging use of ICU resources, and counseling patients and their families.

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Although some studies have identified important determinants of mortality, the existing literature is “scarce,” say researchers who studied outcomes in ICU patients with cancer. They analyzed data from 2 cohort studies of 1,737 patients with solid tumors and 291 with hematologic malignancies. Of those, 456 (23%) had cancer-related complications at ICU admission, most frequently chemotherapy and radiation therapy toxicity, venous thromboembolism (VTE), and respiratory failure by tumor.

Patients with complications tended to have worse performance status scores and active disease. They also were more likely to have more severe organ dysfunctions, greater need for invasive support, and infection at ICU admission.

Complications occurred more often in patients with metastatic solid tumors, particularly patients with lung and breast cancer (although less common in patients with gastrointestinal [GI] tumors), and in patients with more aggressive hematologic malignancies, especially acute leukemia and aggressive non-Hodgkin lymphoma.

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Their study had several major findings, the researchers say. First, 1 in 4 patients with cancer admitted to the ICU has acute complications related to the underlying cancer or treatment adverse effects. However, although there were many cancer-related complications with varying degrees of prognostic impact and despite high mortality rates, outcomes in these patients were “better than perceived a priori,” the researchers say.

A high Sequential Organ Failure Assessment score on the first day of ICU stay, worse performance status, and need for mechanical ventilation were independent predictors of mortality, and all in accord with current literature. However, among the individual cancer-related complications studied, only vena cava syndrome, GI involvement, and respiratory failure were independently associated with in-hospital mortality. A “substantial” mortality rate (73%) among patients with GI involvement emphasizes the importance of discussing the appropriateness of ICU admission in these patients, the researchers caution. Although VTE was one of the most common complications, it was not a major determinant of outcome.

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Another important point, the researchers note, was the high frequency of chemotherapy/radiation therapy-induced toxicity. Treatment-related neutropenia is not a good predictor of outcome, they say, since research has found it is not a relevant predictor of mortality.

Source:

Torres VBL, Vassalo J, Silva UVA, et al. PLoS One. 2016;11(10): e0164537.
doi: 10.1371/journal.pone.0164537.