|Year : 2019 | Volume
| Issue : 3 | Page : 99-103
The characteristics and outcomes of oncology patients in intensive care unit in a tertiary care hospital in Saudi Arabia
Hani M S Lababidi1, Abrar Alajlani2, Abdullah Alasmari3, Wajed Alshammeri4, Wejdan Khalid Suwayyid2, Ahmed A Bahnassy5
1 Department of Critical Care, King Fahad Medical City, Riyadh, Saudi Arabia
2 Medical School, AlMaarefa University, Riyadh, Saudi Arabia
3 Medical School, Imam Muhammad Ibn Saud Islamic University, Riyadh, Saudi Arabia
4 Medical School, Riyadh ELM University, Riyadh, Saudi Arabia
5 Faculty of Medicine, King Fahad Medical City, Riyadh, Saudi Arabia
|Date of Submission||09-Aug-2019|
|Date of Decision||04-Sep-2019|
|Date of Acceptance||08-Sep-2019|
|Date of Web Publication||30-Oct-2019|
Hani M S Lababidi
Department Critical Care, King Fahad Medical City, Riyadh 11525
Source of Support: None, Conflict of Interest: None
Background: Many cancer patients need admission to intensive care unit (ICU). It is important to identify patients who will benefit most from ICU care. Objective: The current study aimed to identify the clinical features associated with outcomes and factors predicting ICU mortality of cancer patients at a tertiary care hospital in Riyadh, Saudi Arabia. Materials and Methods: This was a single-center, retrospective study of all adult patients with either hematological or solid cancer admitted to ICU between January 2017 and June 2018 at King Fahad Medical City, Riyadh, Saudi Arabia. Collected data included: patients' demographics, type of cancer, diagnosis, stage of disease, number of organs failure, reason for ICU admission, severity scores (Acute Physiology and Chronic Health Evaluation [APACHE] II, and Sepsis-related Organ Failure Assessment [SOFA] score), code status, interventions in the ICU, and outcomes. Results: A total of 108 cancer patients were admitted 128 times to ICU during the specified study period. Overall, mortality rate was 57% with standardized mortality rate according to the APACHE II of 0.75. Associative mortality included: vasopressor agents odds ratio (OR) = 3.44, cardiopulmonary resuscitation (CPR) before ICU admission OR = 3.35, presence of sepsis OR = 2.64, and need for invasive ventilatory support OR = 2.16. A total of 46 patients (43%) had hematological malignancies, whereas 62 (57%) had solid organ malignancies. Septic shock ranked first (44%) as the main reason for ICU admission. The mortality rate among hematological and solid organ cancer patients were 52% and 61%, respectively. The code status was do not resuscitate (DNR) in 55 patients (51%), 22% of the DNR patients were survivors. Twelve patients (22%) were DNR before ICU admission, whereas 43 (78%) were made DNR during their ICU stay. Most of ICU mortalities for both groups occurred within the first 20 days of ICU admission. Conclusion: Cancer patients admitted to ICU has high mortality rates; however, this does not preclude aggressive treatment for some. Factors associated with mortality include vasopressors, CPR, sepsis, and mechanical ventilation. Change of code status to DNR during ICU stay is common.
Keywords: Hematologic cancer, intensive care unit, mortality, solid organ cancer
|How to cite this article:|
S Lababidi HM, Alajlani A, Alasmari A, Alshammeri W, Suwayyid WK, Bahnassy AA. The characteristics and outcomes of oncology patients in intensive care unit in a tertiary care hospital in Saudi Arabia. Saudi Crit Care J 2019;3:99-103
|How to cite this URL:|
S Lababidi HM, Alajlani A, Alasmari A, Alshammeri W, Suwayyid WK, Bahnassy AA. The characteristics and outcomes of oncology patients in intensive care unit in a tertiary care hospital in Saudi Arabia. Saudi Crit Care J [serial online] 2019 [cited 2023 Mar 24];3:99-103. Available from: https://www.sccj-sa.org/text.asp?2019/3/3/99/270096
| Introduction|| |
It is estimated that there are 18.1 million new cancer cases and about 9.6 million deaths from cancer in 2018 worldwide. In Saudi Arabia, it is estimated that there will be 151,719 new cancer cases in the year 2025 and about 30,718 cancer deaths are expected for the same year. The number of patients living with cancer is increasing due to advances in malignancies treatment. Historically, patients with advanced malignancies have been considered poor candidates for intensive care unit (ICU) admission due to perceived poor prognosis and outcomes. However, with the rapid development of new treatment for cancer patients, survival and prognosis have been continually improving, especially with solid malignancies., Since cancer-related complications are common, and such novel treatments often have unique toxicity, many patients may need admission to the ICU for managing underlying pathophysiological disorders such as respiratory failure, postoperative complications, and sepsis. Because of this, requirements for ICU services access and use will continue to increase. It is important to identify patients who will benefit best from these interventions. Several prognostic factors including the need for vasopressors and invasive mechanical ventilation have been proposed;, however, their use in clinical practice is limited because of their lack of external validation and limited predictive power in the context of new treatments. Although, earlier admission to the ICU has been shown to have a positive impact on survival.
The ICU mortality rate in cancer patients is variable and can range between 30% and 77%.,,, This wide range of mortality rates is due to the multiple factors that may affect outcome in these patients, such as malignancy type, cause of admission, presence of metastasis, number of organ failures, and therapies before ICU admission.,
Domestic data about the outcome of cancer patients in ICU from Saudi Arabia are scarce.,,, The current study aims to describe the characteristics and to identify clinical features associated with outcomes and factors predicting ICU mortality of cancer patients at a tertiary care hospital in Riyadh, Saudi Arabia.
| Materials And Methods|| |
This is a single-center, retrospective, cohort study conducted at King Fahad Medical City, a tertiary hospital in Riyadh, Saudi Arabia. All adult patients with hematological or solid organ cancer admitted to ICU between January 1, 2017, and June 1, 2018 are recruited in the study. Patients on experimental medications are excluded from the study. Data are collected from patients' files using a standardized form. The collected data include demographics (age and gender), type of cancer, diagnosis, stage of the disease, number of organs failure, reason for ICU admission, and outcomes. The collected clinical outcomes include ICU mortality, length of stay, mechanical ventilation, vasopressors, and the management of infection. Validated ICU prognostic scores including the Acute Physiology and Chronic Health Evaluation (APACHE) II, and Sepsis-related Organ Failure Assessment (SOFA) are determined using laboratory and clinical values on ICU admission.
Data are analyzed using the Statistical Package for the Social Studies (SPSS 22; IBM Corp., New York, NY, USA). The study population is characterized using standard descriptive statistics. Continuous variables are expressed as a mean ± standard deviation, and categorical variables are expressed as percentages. The t-test is used for continuous variables, and Chi-square test is used for categorical variables. A value of P < 0.05 is considered statistically significant. Kaplan–Meier survival analysis is performed using GraphPad Prism 7 (GraphPad Software, San Diego, CA, USA).
| Results|| |
A total of 108 cancer patients were admitted 128 times to the ICU during the specified study period, more than half of them 55 (51%) were females, whereas 53 (49%) were males. The median age was 54.5 ± 16.9 years (17–96 years). The overall mortality rate was 57% with standardized mortality rate (SMR) according to the APACHE II of 0.75. The general characteristics of the study population are presented in [Table 1]. Assessment of the associative factors and mortality revealed an odds ratio (OR) for the use of vasopressor agents of 3.44 (confidence interval [CI] = 1.51–7.86, 95%), cardiopulmonary resuscitation (CPR) before ICU admission OR = 3.35 (CI = 1.03–10.89, 95%), presence of sepsis OR = 2.64 (CI = 1.2–5.78, 95%), and need for invasive ventilatory support OR = 2.16 (CI = 0.95–4.72, 95%). A total of 46 patients (43%) were diagnosed with hematological malignancies, whereas 62 (57%) had solid organ malignancies. From those with hematological cancer, 28% had leukemia and 72% had lymphoma. The site of solid organ cancer included: breast cancer 38%, colon cancer 34%, lung cancer 13%, rectal cancer 9%, and thyroid cancer 6%. Around 14 patients (13%) have been admitted more than once. Septic shock ranked first (44%) as the main reasons for ICU admission [Figure 1].
|Figure 1: Reason of admission of oncology patients to intensive care unit|
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The characteristics and outcomes of hematological cancer patients admitted to ICU are shown in [Table 2]. The overall ICU mortality rate among hematological cancer patients was 52%, with SMR of 0.68. The code status was do not resuscitate (DNR) in 20 patients (44%); 15% of the DNR patients were survivors. Eight patients (40%) were DNR before ICU admission, whereas 12 (60%) were made DNR during their ICU stay. Adjusted mortality rate by excluding DNR patients was 15.2%. On admission to the ICU, nonsurvivors had a higher number of organ failure (2.46 vs. 1.1, P = 0.001). The majority (73%) of hematological cancer survivors was males, whereas for nonsurvivors group, females represented 54%.
|Table 2: The characteristics of hematological cancer patients admitted to the intensive care unit|
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The characteristics and outcome of patients with solid organ malignancies in ICU are shown in [Table 3]. The overall ICU mortality rate was 61%, whereas the SMR was 0.80. The code status was DNR in 35 patients (57%), 20% of the DNR patients were survivors. Four patients (11%) were DNR before ICU admission, whereas 31 (89%) were made DNR during their ICU stay. Adjusted mortality rate by excluding DNR patients was 16%. Nonsurvivors had higher APACHE II score than survivors (30 vs. 21, P = 0.0003), higher need for inotropic support (50% vs. 12.5%, P = 0.003). There were no statistical differences in prevalence of metastases between survivors and nonsurvivors (71% vs. 90%, P = 0.056), or multiple ICU admissions (33% vs. 24%, P = 0.441).
|Table 3: The characteristics of solid organ cancer patients admitted to intensive care unit|
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The Kaplan–Meier curve for survival and comparison between hematological and solid organ malignancies is presented in [Figure 2]. Most of the mortalities for both groups occurred within the first 20 days of ICU admission.
|Figure 2: Kaplan–Meier curve for intensive care unit survival for patients with hematological and solid organ malignancies|
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| Discussion|| |
Our retrospective study revealed overall mortality rate of 57% among all cancer patients admitted to ICU, 52% among hematological malignancies and 61% with solid organ malignancies. Al-Dorzi et al. reported hospital mortality rate of 71% in 190 patients with hematologic malignancies admitted to ICU over a 6-year period at a tertiary care hospital in Riyadh, Saudi Arabia. The direct comparisons of our results with other similar studies are difficult owing to the significant variations in ICU admission criteria and patient population. In a large series of 39,734 patients from England, Wales, and Northern Ireland, hospital mortality was 26.4% among solid tumor patients, and 53.6% with hematological malignancies. On the other hand, a study from Brazil reported ICU mortality rate of 21%, including solid and hematological tumors, a percentage far lower than other reported rates worldwide.
There are many factors that affect the outcome of cancer patients in ICU. These include acuity of illness, type of cancer, presence of metastasis, comorbidities, CPR before ICU admission, vasopressors, mechanical ventilation, dialysis, chemo/radiation therapy-induced toxicity, venous thromboembolism, and respiratory failure. Acuity scores in ICU such as the APACHE II and SOFA scores are independent predictors of hospital mortality. Our study population were quite sick as evidenced by high APACHE II and SOFA scores. There were significant differences in both APACHE II and SOFA scores in all categories of cancer patients in this study. Factors that are independently associated with higher mortality in cancer patients admitted to ICU include emergency department admission, sepsis, invasive mechanical ventilation, and chemotherapy-induced adverse events., In addition to these factors, the study revealed that vasopressors need and CPR before ICU admission were predictors of mortality as well.
Septic shock ranked first as the main reason for Oncology patients to be admitted to ICU. The third international consensus definition for sepsis and septic shock (Sepsis-3) defined septic shock as “life-threatening organ dysfunction caused by a dysregulated host response to infection” and clinically identified by a “vasopressor requirement to maintain a mean arterial pressure of 65 mm Hg or greater and serum lactate level >2 mmol/L (>18 mg/dL) in the absence of hypovolemia.” Similar findings have been reported in cancer patients in European ICUs.
The code status of cancer patients commonly changes during their ICU stay., Only 22% of our cancer patients were DNR on admission to ICU, whereas 78% had their code status changed to DNR during their stay in the ICU. It is rather common for such patients to undergo rigorous repeated evaluation during their ICU stay to determine risk and benefits of intensive and invasive treatment in ICU. Every effort should be made to discuss code status as early as possible in patients with cancer. In fact, early palliative care can reduce significantly ICU admission for patients with advanced cancer.
The current study has some limitations. This is a single-center study with relatively small sample size. Our outcome was ICU mortality only without hospital mortality or quality of care after ICU discharge. Clearly, more research is needed to understand the impact of prognostic factors on the decision to admit to ICU or to alter the code status.
| Conclusion|| |
Cancer patients admitted to ICU has a poor prognosis; however, this does not preclude aggressive treatment for some. Factors associated with mortality include vasopressors, CPR, sepsis, and mechanical ventilation. Current ICU scoring system, namely APACHE II and SOFA are valuable tools to determine prognosis among these patients. Change of code status to DNR during ICU stay is common and is subject to repetitive evaluation by the treating team.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2018;68:394-424.
Alattas MT. Cancer control priorities and challenges in Saudi Arabia: A Preliminary projection of cancer burden. Gulf J Oncolog 2019;1:22-30.
Jemal A, Ward EM, Johnson CJ, Cronin KA, Ma J, Ryerson B, et al.
Annual report to the nation on the status of cancer, 1975-2014, featuring survival. J Natl Cancer Inst 2017;109:1-22.
Topalian SL, Hodi FS, Brahmer JR, Gettinger SN, Smith DC, McDermott DF, et al.
Five-year survival and correlates among patients with advanced melanoma, renal cell carcinoma, or non-small cell lung cancer treated with nivolumab. JAMA Oncol 2019: e192187.
Fisher R, Dangoisse C, Crichton S, Whiteley C, Camporota L, Beale R, et al.
Short-term and medium-term survival of critically ill patients with solid tumours admitted to the intensive care unit: A retrospective analysis. BMJ Open 2016;6:e011363.
Torres VB, Vassalo J, Silva UV, Caruso P, Torelly AP, Silva E, et al.
Outcomes in critically ill patients with cancer-related complications. PLoS One 2016;11:e0164537.
Schellongowski P, Sperr WR, Wohlfarth P, Knoebl P, Rabitsch W, Watzke HH, et al.
Critically ill patients with cancer: Chances and limitations of intensive care medicine-a narrative review. ESMO Open 2016;1:e000018.
Afessa B, Azoulay E. Critical care of the hematopoietic stem cell transplant recipient. Crit Care Clin 2010;26:133-50.
Azoulay E, Moreau D, Alberti C, Leleu G, Adrie C, Barboteu M, et al.
Predictors of short-term mortality in critically ill patients with solid malignancies. Intensive Care Med 2000;26:1817-23.
Azoulay E, Mokart D, Pène F, Lambert J, Kouatchet A, Mayaux J, et al.
Outcomes of critically ill patients with hematologic malignancies: Prospective multicenter data from france and belgium – A groupe de recherche respiratoire en réanimation onco-hématologique study. J Clin Oncol 2013;31:2810-8.
Taccone FS, Artigas AA, Sprung CL, Moreno R, Sakr Y, Vincent JL. Characteristics and outcomes of cancer patients in European ICUs. Crit Care 2009;13:R15.
Anisoglou S, Asteriou C, Barbetakis N, Kakolyris S, Anastasiadou G, Pnevmatikos I. Outcome of lung cancer patients admitted to the intensive care unit with acute respiratory failure. Hippokratia 2013;17:60-3.
Müller AM, Gazzana MB, Silva DR. Outcomes for patients with lung cancer admitted to intensive care units. Rev Bras Ter Intensiva 2013;25:12-6.
Ostermann M, Raimundo M, Williams A, Whiteley C, Beale R. Retrospective analysis of outcome of women with breast or gynaecological cancer in the intensive care unit. JRSM Short Rep 2013;4:2.
Aygencel G, Turkoglu M, Turkoz Sucak G, Benekli M. Prognostic factors in critically ill cancer patients admitted to the intensive care unit. J Crit Care 2014;29:618-26.
Kostakou E, Rovina N, Kyriakopoulou M, Koulouris NG, Koutsoukou A. Critically ill cancer patient in intensive care unit: Issues that arise. J Crit Care 2014;29:817-22.
Al-Dorzi HM, Al Orainni H, Al Eid F, Tlayjeh H, Itani A, Al Hejazi A, et al.
Characteristics and predictors of mortality of patients with hematologic malignancies requiring invasive mechanical ventilation. Ann Thorac Med 2017;12:259-65.
] [Full text]
Aldawood AS. Prognosis and resuscitation status of critically ill patients with lung cancer admitted to the intensive care unit. Anaesth Intensive Care 2010;38:920-3.
Bahammam AS, Basha SJ, Masood MI, Shaik SA. Outcome of patients with hematological malignancies admitted to the intensive care unit with life-threatening complications. Saudi Med J 2005;26:246-50.
Al Maani MA, Al SAied G. Adult cancer patients admitted to the critical care unit in Saudi Arabia. Saudi Crit Care J 2019;3:52-3.
Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: A severity of disease classification system. Crit Care Med 1985;13:818-29.
Vincent JL, Moreno R, Takala J, Willatts S, De Mendonça A, Bruining H, et al.
The SOFA (Sepsis-related organ failure assessment) score to describe organ dysfunction/failure. On behalf of the working group on sepsis-related problems of the European society of intensive care medicine. Intensive Care Med 1996;22:707-10.
Ostermann M, Ferrando-Vivas P, Gore C, Power S, Harrison D. Characteristics and outcome of cancer patients admitted to the ICU in England, Wales, and Northern Ireland and national trends between 1997 and 2013. Crit Care Med 2017;45:1668-76.
Soares M, Caruso P, Silva E, Teles JM, Lobo SM, Friedman G, et al.
Characteristics and outcomes of patients with cancer requiring admission to intensive care units: A prospective multicenter study. Crit Care Med 2010;38:9-15.
Tan AC, Jacques SK, Oatley M, Guminski AD. Characteristics and outcomes of oncology unit patients requiring admission to an Australian intensive care unit. Intern Med J 2019;49:734-9.
Martos-Benítez FD, Soto-García A, Gutiérrez-Noyola A. Clinical characteristics and outcomes of cancer patients requiring intensive care unit admission: A prospective study. J Cancer Res Clin Oncol 2018;144:717-23.
Bos MM, Verburg IW, Dumaij I, Stouthard J, Nortier JW, Richel D, et al.
Intensive care admission of cancer patients: A comparative analysis. Cancer Med 2015;4:966-76.
Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, et al.
The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA 2016;315:801-10.
Ahmed T, Koch AL, Isom S, Klepin HD, Bishop JM, Ellis LR, et al.
Outcomes and changes in code status of patients with acute myeloid leukemia undergoing induction chemotherapy who were transferred to the intensive care unit. Leuk Res 2017;62:51-5.
Cardenas-Turanzas M, Gaeta S, Ashoori A, Price KJ, Nates JL. Demographic and clinical determinants of having do not resuscitate orders in the intensive care unit of a comprehensive cancer center. J Palliat Med 2011;14:45-50.
Biskup E, Cai F, Vetter M, Marsch S. Oncological patients in the intensive care unit: Prognosis, decision-making, therapies and end-of-life care. Swiss Med Wkly 2017;147:w14481.
Romano AM, Gade KE, Nielsen G, Havard R, Harrison JH Jr., Barclay J, et al.
Early palliative care reduces end-of-life intensive care unit (ICU) use but not ICU course in patients with advanced cancer. Oncologist 2017;22:318-23.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]
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