This is the first report describing the short- and long-term outcome of critically ill patients with women's cancer. It shows that women with breast or gynaecological cancer admitted to ICU had an ICU mortality of 31.4% similar to that of other patient cohorts routinely admitted to the ICU.21,22
However, six-month mortality was high at 68%.
It is important to acknowledge some limitations of our study. Firstly, we do not have any data on patients who were referred but not admitted to the ICU, including patients who had sepsis but were well enough to remain on the oncology ward and patients in whom the prognosis was considered futile and end-of-life care was initiated on the ward. In principle, we have a low threshold to admit cancer patients, especially in the light of the lack of reliable physiological scores. We are also conscious of the study by Thiéry et al
which showed that the 30-day survival of cancer patients who were considered ‘too sick’ for ICU admission was 26%. More worryingly, 30-day survival of the patients considered ‘too well’ for ICU admission was only 78.7%. Secondly, our sample size was too small for an in-depth analysis and significant differences between survivors and non-survivors cannot be excluded. Therefore, any non-significant results need to be interpreted with caution. Thirdly, we cannot exclude possible selection biases that may have occurred as a result of our ICU admission/discharge policy. Finally, we did not record performance status or quality of life of patients after discharge from the ICU.
To our best knowledge, there are no data in the literature available for direct comparison. Pène et al.23
recently published an ICU mortality rate of 58.8% among 148 cancer patients with septic shock in the ICU. Patients with urogenital malignancies were included but the authors did not report the mortality rates of individual types of cancers separately.
The decision to admit patients with advanced malignancy to ICU often raises controversy ranging from concern about the inappropriate use of scarce resources to the right to effective care for everybody. However, it is well known that the task of assessing risk and predicting outcome of critically ill cancer patients is difficult, mainly because traditional physiological scores do not perform well in this patient group.24
Analysis of 86 patients with haematological malignancies did not identify any absolute predictors of mortality.25
In fact, the data suggested that sequential changes in the SOFA score during the stay in the ICU (i.e. after admission) were helpful in the decision-making about the continuation or discontinuation of treatment. Reports also suggest that cancer-specific characteristics, including long-term prognosis, have minimal effect on short-term prognosis during an acute critical illness. Whether metastases in patients with solid tumours have an impact during a critical illness remains unclear. We found no difference between ICU survivors and non-survivors in the proportion of patients with metastatic disease.
Consistent with our previous analysis and studies in the literature, we confirmed that the number of failed organ systems is an important risk factor for mortality in cancer patients admitted to ICU.3,9,12
Although neutropenia is often associated with an increased risk of sepsis and is generally considered to be a poor prognostic indicator, we found that the presence of neutropenia on admission to ICU or during stay in ICU was not associated with an increased mortality. Presumably, the use of haematopoietic growth factors and timely management of infectious complications have contributed to this improvement.
Six-month mortality was high confirming that ICU care does not modify the cancer-related prognosis.26
Without data to compare with, we are unable to say whether such high six-month mortality is usual for a cohort in whom the majority suffered from metastatic disease, or whether it is related to the way patients are managed in our institution. However, a high six-month mortality of almost 70% raises the question whether admission to ICU was justified and appropriate. In this context, several factors need to be considered, including patient's preferences and availability of alternative management strategies. Previous studies have also attempted to analyse the cost–benefit ratio of ICU utilization for patients with cancer. Although it is possible to calculate the health-care costs consumed by an individual patient, it is difficult to estimate the value and quality of life per period of survival. Clearly, more research is necessary to improve our understanding of the factors which determine the prognosis of critically ill cancer patients as well as patients’ quality of life, performance status and medical and psychological needs after discharge from ICU so that patients and clinicians can be advised appropriately.
In conclusion, we report acceptable short-term outcomes in women with breast or gynaecological cancer admitted to the ICU. In our opinion, the decision to admit critically ill patients with women's cancer to the ICU should be based on the probability of surviving the acute illness rather than the underlying malignancy per se. Thus, invasive therapy should not be withheld, especially in cases of sepsis/septic shock. Nevertheless, frequent reappraisal of the benefits of intensive care is necessary, in close partnership with the patient, the patient's family and the oncology team. Our high six-month mortality emphasizes the need for more research into management and quality of life of cancer patients after discharge from ICU.