Has survival increased in cancer patients admitted to the ICU? We are not sure
We are committed to providing a balanced answer on the reality of improved survival in critically ill patients with cancer. By defending the pro viewpoint, Mokart et al.  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 , 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. Congruently to this finding, mortality rates in severe sepsis and septic shock (the most common complications in this population [3, 4, 5, 6]) were 34 and 46 %, respectively, approaching the figures in the non-cancer population. More recently, a large multicenter study using data from the Dutch National Intensive Care Evaluation (NICE) database published in this journal indicated that 60-day mortality in patients with hematological malignancies was similar to that in solid cancer patients and also in patients with other more classical severe comorbidities such as chronic heart failure, liver cirrhosis, and chronic pulmonary obstructive disease (COPD) . In other words, triage decisions solely based on the type of underlying comorbidity is becoming obsolete. By defending the con viewpoint, Pène et al.  somewhat attenuates this optimism by focusing on the fact that current survival rates are still based on studies performed in heterogeneous populations coming from different centers with different experiences and cultures. Therefore, it seems naïve to recommend broad ICU admission policies or full code status for any patient with cancer and acute organ dysfunction. Strikingly, Pène et al. also shrewdly claim that for the same reasons, routine denial of cancer patients carrying one or several poor prognostic factors would be inappropriate as none of those are specific enough to predict non-beneficial care. At the end of the day, the question remains how we can move forward at the bedside to integrate these results into a genuine decision-making process so as to maintain or even improve long-term outcome in these patients without only prolonging the dying process? Indeed, the reality of physical and emotional suffering of critically ill cancer patients  and their relatives  cannot remain unrecognized.
Mokart et al.  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 . The complex relationship between time to ICU admission and mortality has been recently investigated in a study published in this journal . Herein, when medical intervention occurred within 1.6 h of the first physiological derangement, mortality was about 30 %, increasing to 55 and 80 % when medical intervention occurred between 1.6 and 4.7 h, and later than 4.7 h, respectively. These findings may be even more relevant in the case of acute respiratory failure or septic shock where mortality varies between 34 and 50 % in highly skilled centers [2, 3, 4, 5, 6, 13] and 66 and 68 % in general ICUs [14, 15].
Interestingly, both Mokart et al.  and Pène et al.  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.
From scientific evidence to the bedside: 10 most relevant things intensivists should keep in mind during triage decisions in cancer patients
1. In cancer patients admitted to the ICU, characteristics of the malignancy are no longer associated with short-term mortality
2. Classic predictors of mortality (i.e., neutropenia, autologous BMT, physiologic scores) are not relevant anymore
3. Current mortality in specialized centers is 60 % in the case of one organ failure (need for ventilation, vasopressor, or dialysis) or two organ failures if reversible in less than 7 days
4. Current mortality of severe sepsis and septic shock in highly skilled centers is 30–40 % in the case of non-pulmonary origin and 50–60 % in the case of pulmonary origin in contrast to more than 65 % overall in general ICUs
5. Delays in ICU referral and admission are associated with increased mortality
6. Intensivists are usually overpessimistic regarding short- and long-term outcomes
7. Hemato-oncologists are overoptimistic regarding short- and long-term outcomes
8. Postponing EOL decisions increases the physical and emotional burden of patients and relatives
9. Triage and EOL decisions are an inherent part of an intensivist’s duties
10. Prognostic uncertainty is the rule, but we can improve outcome prediction by sharing decisions with all stakeholders inside and outside the team and by taking decisions more closely in tune with our senses and emotions
DB received a senior clinical investigator grant from the Research Foundation of Flanders, Belgium (1800513N).
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