Critical Care for Patients With Cancer

Over the last 20 years, cancer treatment has changed with the introduction of new and intensified treatment protocols and improved supportive care. ¹ Survival in patients with cancer requiring intensive care unit (ICU) admission was long considered dismal, and the concept of futility was used to support either denial of ICU admission or early treatment limitation decisions for critically ill patients with cancer. ² However, recent studies showed improved survival rates after ICU admission in patients with solid tumors^1,3 or hematological malignancies.^4,5 Part of this improvement is probably ascribable to better selection of patients with cancer for ICU admission. Many of these patients require admission to ICU for acute concurrent illness, postoperative care or complications associated with cancer or the cancer therapy. ⁶ Malignancies are becoming increasingly common, especially as the population ages, and patients with cancer are likely to represent an increasing proportion of ICU populations. ⁷ Advances in oncological and supportive care have led to improved prognosis and extension of survival time in patients with cancer. The decision to admit a patient with cancer to the ICU is complex. ³ It recommended that the validity of criteria used for patient selection should be assessed regularly over time. ² The ICU admission should not be denied only on the basis of a patient having a malignancy. At the present time, ICU management of selected critically ill patients with cancer is not futile.

The National Institute Cancer located in Mexico City has an oncological ICU with 6 beds. Data on the characteristic and organization of our ICU had been previously reported. ¹ During the biennium 2008-2009, 573 patients with cancer were admitted to the ICU. The mean age was 51 ± 16.36 years and 58.6% were women. The length of stay in the ICU was 2 days (interquartile range; 1-5). The 71.6% were surgical patients. The mortality rate was 15.9% (Figure 1). Patients with hemato-oncological cancer had higher ICU mortality rate than subgroup of critically ill patients with solid tumors (39.5% versus 11.9%). The mortality rate for patients with cancer in our ICU is lower than that previously reported. ⁷

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Figure 1.

Mortality during the biennium 2008-2009, Intensive Care Unit, The National Cancer Institute, Mexico City, Mexico.

The course of organ dysfunction over first days of life-sustaining treatment before admission to ICU could be useful for physicians who treat critically ill cancer patients to detect patients who should be admitted to ICU to try to avoid the progression to multiple organ dysfunction. On the other hand, admission to the ICU should be offered to patients with newly diagnosed cancer and acute life-threatening cancer related events. ⁸ When uncertainty or disagreement exists about the criteria for ICU admission, a trial of ICU management should be offered to ensure that no patients are deprived of a chance for recovering from their acute complication. After 3 days of full life-support management, a reduction in the number of organ failures indicates that additional life-sustaining treatment could be continued. ⁸ Treatment-limitation decisions should not be taken before day 5. ⁹ The critical care of patients with cancer contribute and support to continue the fight against cancer.