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Cuidados Intensivos no Paciente com Câncer

O Paciente com Câncer na UTI

Márcio SoaresPPGO - Instituto Nacional de Câncer, Rio de Janeiro

D’Or Institute for Research and EducationBRICNet – Brazilian Research in Intensive Care Network

Bolsista CNPq e FAPERJ

Rio de Janeiro, 2013

Internaçãona UTI


• APACHE III (Knaus et al. Chest 1991) 10%

• SAPS 3 (Metnitz et al. ICM 2005) 11%

Prevalence of Patients with Cancer in ICUs

• SOAP – Cancer (Taccone et al. Crit Care 2009) 15%

• Brazil Multicenter study (Soares et al. CCM 2010) 20%


• Postoperative monitoring / care

• Monitoring of patients receiving treatmentswith potential severe complications

Reasons for ICU Admission

with potential severe complications

• Acute life-threatening complications

• Cancer- or treatment-related acutecomplications


Survival curves for patients with cancer on

a 20-year period-based

Brenner. Lancet 2002

Internaçãona UTI

Eficiência do Tratamento


• Outcomes considered poor a priori

• Inequities among patients with different

Controversies Regarding ICU Admission of Cancer Patients

• Inequities among patients with different diseases, but similar prognoses

• Intra-team conflicts


1988

4 artigos Pubmed: 1691 artigos

Termos: (cancer OR malignancy OR malignancies) AND (intensive care unit OR mechanical ventilation OR critical care)


• Estudo prospectivo de coorte

• UTI: 10 leitos (clínica e cirúrgica)

Projeto de Pesquisa - INCA

• UTI: 10 leitos (clínica e cirúrgica)

• Seguimento até alta hospitalar e sobrevida em 6m

• 2000 – 2007: 3.163 pacientes


• Avaliação do Prognóstico

• Triagem e Critérios de Internação na UTI

Tópicos da Apresentação


• Disfunções Orgânicas Específicas

• Oportunidades para Pesquisa

• Impacto global na UTI


Prognosis

Acute Disease Related

Characteristics

Patient’s Characteristics

Prognosis

Patient’s management

and ICU organization

Chance


Outcome EvaluationSubjective

� Clinical judgement


Outcome EvaluationSubjective

� Clinical judgement

Objective

Identification of Prognostic FactorsIdentification of Prognostic Factors

Scoring SystemsScoring Systems


Study Hospital mortality

Before 1995

Hauser et al (1982) 40 (55%)

Schuster e Marion (1983) 77 (61%)

Lloyd-Thomas et al (1988) 60 (78%)

Yau et al (1991) 92 (77%)

Schapira et al (1993) 150 (44%)

n = 419 patients

Mortality = 64%

Survival in Cancer Patients Admitted to ICU

Soares & Salluh. Indian J Crit Care 2006


Study Hospital mortality

Before 1995

Hauser et al (1982) 40 (55%)

Schuster e Marion (1983) 77 (61%)

Lloyd-Thomas et al (1988) 60 (78%)

Yau et al (1991) 92 (77%)

Schapira et al (1993) 150 (44%)

After 1995

Groeger et al. (1998) 1483 (42%)

n = 419 patients

Mortality = 64%

Survival in Cancer Patients Admitted to ICU

Kress et al. (1999) 348 (41%)

Azoulay et al. (2000) 120 (59%)

Sculier et al. (2000) 261 (33%)

Nelson et al. (2001) 100 (56%)

Kroschinsky et al. (2002) 104 (45%)

Massion et al. (2002) 84 (61%)

Maschmeyer et al. (2003) 189 (53%)

Benoit et al. (2003) [41] 124 (54%)

Schellongowsky et al. (2004) 242 (44%)

Berghmans et al. (2004) 247 (34%)

Soares et al. (2005) 772 (47%)

n = 3302 patients

Mortality = 43%

Soares & Salluh. Indian J Crit Care 2006


Better outcomes than commonly perceived in different scenarios…• Acute respiratory failure + need of MV

• Acute kidney injury

Azoulay et al. CCM 2001; Soares et al. CCM 2005

Benoit et al, NDT 2005; Soares et al. JCO 2006; Darmon ICM 2007

• Chemotherapy - recent use / use in ICU

• Prolonged ICU admission

• Neutropenia

Darmon et al. CCM 2005; Benoit et al, ICM 2006; Vandjick et al. ICM 2008

Soares et al. Chest 2008

Souza-Dantas et al. Ann Oncol 2011; Legrand et al. CCM, In press


� Severity of acute disease and organ failures

� Poor performance status

� Severity of comorbidities

Allogenic BMT (*** GVHD)

Main Prognostic Factors

� Allogenic BMT (*** GVHD)

� NIV failure

� Lack of specific diagnosis (*** in case of ARF)

Groeger et al. JCO 1998; Kress et al. AJRCCM 1999; Staudinger et al, CCM 2000; Larche et al. ICM 2003; Benoit et al CCM 2003; Azoulay et al Medicine 2004; Soares et al. CCM 2005; Soares et al. ICM 2005; Lamia et al. ICM 2006; Soares et al. CCM 2006; Soares et al. JCO 2006; Soares

et al. Chest 2007; Vandjick et al. ICM 2008; Leigne et al. CCM 2008; Soares et al. Chest 2008


NO LONGER associated with short-term survival

� Type of malignancy

� Short-term neutropenia

� Recent chemotherapy

Prognostic Factors


� Autollogous BMT

Larché et al. ICM 2003; Benoit et al. CCM 2003; Azoulay et al. Medicine 2004; Soares et al. CCM 2005; Azoulay & Schlemmer. ICM 2006; Khassavneh et al. 2002; Azoulay et al. CCM 2008; Vandjick et al. ICM 2008; Soares et al. Crit Care Clin 2010 Depuydt et al. JCC 2010


NO LONGER associated with short-term survival

� Type of malignancy

� Short-term neutropenia


Prognostic Factors


� Autollogous BMT

Larché et al. ICM 2003; Benoit et al. CCM 2003; Azoulay et al. Medicine 2004; Soares et al. CCM 2005; Azoulay & Schlemmer. ICM 2006; Khassavneh et al. 2002; Azoulay et al. CCM 2008; Vandjick et al. ICM 2008; Soares et al. Crit Care Clin 2010 Depuydt et al. JCC 2010

� Age –moderate impact on the outcomes; selected

older patients with cancer can benefit from intensive

care.


Soares et al. CCM 2010


Mortality Rates

44

30

37

54

30

40

50

60

Mortality rate (%)

Soares et al. Crit Care Med, 2010

21

6

23

11

0

10

20

30

All Sched Surg Emerg Surg Medical

Mortality rate (%)

ICU Hospital


Soares et al. Crit Care Med 2010


Souza-Dantas VC, Salluh JI, Soares M. Impact of neutropenia on the outcomes of critically ill

patients with cancer: a matched ase-control study. Ann Oncol. 2011 Sep;22(9):2094-100.


2101801501209060300

Sobrevida

1,0

,8

,6

,4

,2

0,0

5

4

3

2

1

0

2101801501209060300

Sobrevida

1,0

,8

,6

,4

,2

0,0

PS

4

3

2

1

0

2101801501209060300

Sobrevida

1,0

,8

,6

,4

,2

0,0

Stg

Active - Prog

Active - ND

Control

Effect of Each Single Characteristic on the Patients’ Survival Organ Failures Performance Status Cancer Phase

Tempo (dias)

2101801501209060300

Tempo (dias)

2101801501209060300

Tempo (dias)

2101801501209060300

Tempo (dias)

2101801501209060300

Sobrevida

1,0

,8

,6

,4

,2

0,0

Comorb

Grave

Moderada

Leve

Nenhuma

Tempo (dias)

2101801501209060300

Sobrevida

1,0

,8

,6

,4

,2

0,0

Grupo

Hem HG

Hem LG

Sol MTX

Sol Loc

Comorbidities Type of cancer

INCA

n = 962

Soares et al. Crit Care Med 2006


Effect of Combined Characteristics on the Patients’ Survival

Soares et al. Crit Care Med 2006 Soares et al. J Clin Oncol 2006


� Characterization of patients in terms of

severity-of-disease in clinical studies

� Assistance in ICU perfomance evaluation

Potential Use of Scoring Systems

� Assistance in ICU perfomance evaluation

� Benchmarking

� Scores SHOULD NOT BE USED on an individual

basis


Soares et al. ICM 2010


Triage Procedures for ICU Admission

• Patient characteristics

• Published evidence

• Personal experience

Identify patients with a potential benefit from

intensive care!

SCCM Ethics Committee JAMA 1994; SCCM Guidelines CCM 1999; Thiery et al. JCO 2005

• Personal experience

• Hospital guidelines

• Patients preferences and values


YES !

Should I admit “more” cancer

patients to my ICU ?

YES !


• Improvements in survival rates

• Disease-specific factors play a minor role on short-term mortality

Reasons for a Broad ICU Admission Policy

on short-term mortality

• Severity-of-illness scores inaccurate

• Advances in the management of ICU patients with cancer


• Close collaboration among intensivists and oncologists improves outcomes

• Case-volume affects patients outcomes

The more we see, The more we know…

• Offering of anticancer treatments in ICU

• Management of oncologic and non-oncologic complications

• Provision of early ICU care

• Family-patient centered care

Soares & Salluh. CCM 2012; Zuber et al. CCM 2012; Legrand et al. CCM 2012; Soares & Lisboa. CCM 2012; Darmon et al. CCM 2005; Benoit ICM 2006


Anticancer treatments in ICU

20-y old man with a high-grade NHL and obstructive ARF

ICU admission After chemotherapy


However…

Thiery et al. JCO 2005

• Triage procedures are inaccurate!


Refused “too-well” for benefit

Mortality by survival time according to ICU admission decision.

Thiéry G et al. J Clin Oncol 2005

Refused “too-sick” for benefit

Admiited to the ICU


And…

•Physicians from the same institution vary •Physicians from the same institution vary significantly in their treatment decisions.

Barnato et al. Crit Care Med 2008


All cancer patients for whom ICU admission was requested

• Newly diagnosed • Newly diagnosed disease

• First-line treatment

• Potentially reversible acute complication

• Proceed ICU admission

• Full code management

Adapted from Lecuyer L et al. Crit Care Med 2007



• Bedridden / Poor PS • Newly diagnosed • Bedridden / Poor PS

• Palliative care only

• Refusal ICU admission

• ICU admission not recommended

• Comfort / palliative care

• Newly diagnosed disease








• Bedridden / Poor PS • All other intermediate • Newly diagnosed • Bedridden / Poor PS

• Palliative care only

• Refusal ICU admission

• ICU admission not recommended

• Comfort / palliative care

• All other intermediate situations

• Consider ICU trial if patient / family are willing to

• Newly diagnosed disease







The ICU trial consists of full-code treatment for

first days (e.g. 3 to 7 days) followed by a

reappraisal of the appropriate level of care.reappraisal of the appropriate level of care.


• Avoid forgoing ICU admission for patients with potential benefit

• Reduce conflicts (intra-team and team-family)

Benefits of Broader ICU Triage Policies


HEROIC

ICU ADMISSION

?Prophylactic ICU

Admission?

Early ICU

Admission?

Palliative ICU

Admission?

Terminal ICU

Admission?

Non-ICU care

In ICU?

EXCEPTIONAL

Should we be even more liberal ???

Azoulay E, Soares M, Darmon M, et al. Managing Critically Ill Cancer Patients: Another Medical Success Story? Ann Intensive Care 2011

FUL CODE ICU MANAGEMENT

ICU TRIAL

EXCEPTIONAL

ICU ADMISSION


• Uso indiscriminado de VNI

Soares et al. J Crit Care 2009

• Taxas de falha > 50%

• Falha de VNI com intubação subsequente >>> mortalidade


Soares et al. Crit Care Clin 2010

Soares et al. Crit Care Clin 2010


Soares et al. J Clin Oncol 2006



Recovering of Renal Function



ASSESS approach: a 5-step framework for a comprehensive

evaluation in studies on ICU cancer patients

• Triage for ICU Admission

• Code Status

• ICU Support and patient’s Evolution

• Survival

• Picture of Survivors

Soares & Azoulay. Intensive Care Med 2009

Clinical Features and Outcomes of

Lung Cancer Patients Admitted to

ICUs in Latin America and Europe

Preliminary Results

Steering Committee:

• Márcio Soares• Élie Azoulay • Jorge Salluh• Jean-François Timsit

Funded by: CNPq, FAPERJ, INCA, IDOR

Study Flowchart

498 admissions to the participating ICUs

Excluded:• 46 readmissions

Participants:• 6 Countries

•Argentina• Brasil• Chile

452 patients eligible for the study

• Chile• France• UK• Uruguay

• 22 Hospitals


CTI – HC1 INCA

Assistência

FormaçãoProdução

científica

Gestão de

Informações


• Conhecimento da epidemiologia local => contextualização do seu serviço

• Acompanhamento dos indicadores

Impacto na Gestão e Processos de Cuidado

• Substanciar as discussões com gestores hospitalares, clientes e fontes pagadoras

• Contribuir para melhorar a “eficiência clínica”


< 2000 – Especialização (01 vaga / ano)

2001 – Especialização (02 vagas / ano)

2005 – PRM / MEC (02 vagas / ano)

2008 – IC-PIBIC (01 vaga / ano)

2009 – PG Stricto Sensu


< 2000 – Especialização (01 vaga / ano)

2001 – Especialização (02 vagas / ano)

2005 – PRM / MEC (02 vagas / ano)

2008 – IC-PIBIC (01 vaga / ano)

2009 – PG Stricto Sensu

Todos envolvidos com a coleta de

informações e estudos científicos !


CTI INCA: 2004 – 2012

• >90 artigos científicos (70% Medline)

• > 120 resumos em congressos

• 18 capítulos de livros• 18 capítulos de livros

• Formação de redes de pesquisa

• Condução de estudos multicêntricos


Coloborações

• Élie Azoulay – Hosp. Saint Louis, França

• Dominique Benoit – Univ. Ghent, Bélgica

• Michael Darmon – Hosp. St. Ettiene, França

• Bekele Afessa – Mayo Clinic, EUA• Bekele Afessa – Mayo Clinic, EUA

• Steve Pastores – MSKCC, EUA

• Ulysses Silva – Hcancer Barretos - SP

• Pedro Caruso – Hosp. A. C. Camargo - SP

• Luciano Azevedo – Hosp. Sírio Libanês - SP

• André Torelly – Sta. Casa PoA - RS


Conclusions

• Up to 1/5 of ICU admissions was in patients with cancer.

• Diverse studies confirmed the improved survival rates for patients with cancer requiring ICU observed over the last years.

• Mortality was mostly dependent on the severity of organ failures, performance status and need for mechanical ventilation, rather than cancer-related characteristics.

• The general reluctance to admit patients with malignancies to the ICU is unjustified.


• Admitting a patient with cancer to the ICU require a

thorough evaluation of the diverse clinical variables and

expectancies from patients and their families.

Conclusions

• Care for these patients is complex and require close

collaboration between intensivists and oncologists

• A better understanding of such parameters may be

helpful to avoid forgoing intensive care to patients who

can potentially benefit from it.

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