Intensive care of the cancer patient: recent achievements and remaining challenges

Abstract

A few decades have passed since intensive care unit (ICU) beds have been available for critically ill patients with cancer. Although the initial reports showed dismal prognosis, recent data suggest that an increased number of patients with solid and hematological malignancies benefit from intensive care support, with dramatically decreased mortality rates. Advances in the management of the underlying malignancies and support of organ dysfunctions have led to survival gains in patients with life-threatening complications from the malignancy itself, as well as infectious and toxic adverse effects related to the oncological treatments. In this review, we will appraise the prognostic factors and discuss the overall perspective related to the management of critically ill patients with cancer. The prognostic significance of certain factors has changed over time. For example, neutropenia or autologous bone marrow transplantation (BMT) have less adverse prognostic implications than two decades ago. Similarly, because hematologists and oncologists select patients for ICU admission based on the characteristics of the malignancy, the underlying malignancy rarely influences short-term survival after ICU admission. Since the recent data do not clearly support the benefit of ICU support to unselected critically ill allogeneic BMT recipients, more outcome research is needed in this subgroup. Because of the overall increased survival that has been reported in critically ill patients with cancer, we outline an easy-to-use and evidence-based ICU admission triage criteria that may help avoid depriving life support to patients with cancer who can benefit. Lastly, we propose a research agenda to address unanswered questions.

Figure 1

Trends of mortality in critically ill cancer patients during the past two decades. Unadjusted hospital mortality rates in critically ill cancer patients by year of study publication (clear gray). Unadjusted ICU mortality rates in bone marrow transplant recipients by year of study publication (dark gray)

Figure 2

Alternative to ICU refusal in cancer patients proposed for ICU admission.

Figure 3

Code status in cancer patients receiving mechanical ventilation. Good life expectancy refers to a malignancy where complete remission and long term survival are possible outcomes. Poor life expectancy refers to a malignancy where median life expectancy is below one year.