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.

Introduction

Limited data are available regarding the relationship of premortem clinical diagnoses and postmortem autopsy findings in cancer patients who die in an oncologic intensive care unit (ICU). The purposes of this study were to compare the premortem clinical and postmortem diagnoses of cancer patients who died in the ICU and to analyze any discrepancies between them.

Methods

This is a retrospective review of medical records and autopsy reports of all cancer patients who died in a medical-surgical ICU and had an autopsy performed between 1 January 1999 and 30 September 2005 at a tertiary care cancer center. Premortem clinical diagnoses were compared with the postmortem findings. Major missed diagnoses were identified and classified, according to the Goldman criteria, into class I and class II discrepancies.

Results

Of 658 deaths in the ICU during the study period, 86 (13%) autopsies were performed. Of the 86 patients, 22 (26%) had 25 major missed diagnoses, 12 (54%) patients had class I discrepancies, 7 (32%) had class II discrepancies, and 3 (14%) had both class I and class II discrepancies. Class I discrepancies were due to opportunistic infections (67%) and cardiac complications (33%), whereas class II discrepancies were due to cardiopulmonary complications (70%) and opportunistic infections (30%).

Conclusion

There was a discrepancy rate of 26% between premortem clinical diagnoses and postmortem findings in cancer patients who died in a medical-surgical ICU at a tertiary care cancer center. Our findings underscore the need for enhanced surveillance, monitoring, and treatment of infections and cardiopulmonary disorders in critically ill cancer patients.