Cancer represents a global public health problem, and in developed countries it is projected to soon become the leading cause of death [1]. Advances in oncology have led to many patients, although not completely cured, living longer; thus, the number of people living with this condition will increase ass well as the number of oncology patients who will need to be admitted to the intensive care unit (ICU). Despite advances, cancer is still seen as a "fatal disease" and, in some regions, the admission of patients with cancer to the ICU is still limited or questioned, although many patients can be managed as chronically ill, and sometimes even cured. In fact, many nonmalignant diseases have a prognosis equally or more unfavorable than certain severe types of cancer [2]. The unique characteristics of critically ill patients with cancer underscore the need for dedicated approaches and areas of expertise for this population.
Since the 1950s, critical care has evolved considerably. Technological innovations, such as organic support systems (mechanical ventilation, dialysis, and extracorporeal membrane oxygenation), now make it possible to replace vital functions temporarily, complementing advances in the understanding of the pathophysiology of critical illness. Historically, oncology patients, especially those with solid tumors, were restricted access to the ICU. Intensivists were often hesitant to admit them due to limited knowledge about prognosis and treatment options in this population. Studies in intensive care show that a diagnosis of cancer increases the likelihood of refusal of admission to the ICU or limiting aggressive treatment almost sixfold [3]. However, recent advances in cancer therapies and intensive care have improved expectations for these patients.
Today, survival rates are on the rise thanks to early diagnosis and more specific and effective treatments with fewer adverse effects. This evolution is largely due to "precision medicine", which has enabled the development of anticancer treatments that offer a wide range of therapeutic options to oncologists [4]. Between 5% and 10% of oncology patients develop life-threatening conditions requiring admission to the ICU [5, 6, 7]. A study conducted in France showed that the percentage of admissions to the ICU for oncology patients ranged from 0.7% to 12%, with higher rates in cases of esophageal cancer, acute leukemias, and allogeneic bone marrow transplantation [8, 9]. Currently, oncologic patients account for 13.5% to 21.5% of all admissions to the ICU [10, 11]. At the end of the 20th century, survival rates for critically ill patients with cancer ranged from 20% to 30%; today, these rates have reached 50% to 60% [12, 13]. In our specialized oncology unit, survival is approximately 70%, thus approaching that of critical patients without cancer. This suggests that cancer itself is no longer a universal contraindication for admission to the ICU. This decision should be based on factors such as type and stage of cancer, response to previous treatments, functional and nutritional status, as well as patient and family preferences.
A review made in our unit revealed that patients with a higher ECOG (Eastern Cooperative Oncology Group Functional Status) score (limited functionality) had higher mortality rates, regardless of cancer type. Although many complications presented by critical oncology patients are common in patients without cancer, this population has specific characteristics, such as leukostasis, superior vena cava syndrome, and paraneoplastic autoimmune phenomena, among others. These patients benefit from joint management between oncologists, hematologists, oncologic surgeons, palliative care specialists, and intensivists, with vital support from experts in nutrition and physiotherapy [14]. Currently, some hospitals have implemented rapid response teams, composed of critical care physicians and/or nurses who assist the oncologist in identifying patients who would benefit from early transfer to ICU or more intensive room management. This approach has demonstrated a positive impact on mortality, as it allows intervention before irreversible organ failure [15, 16]. The integration of palliative care in the ICU is another key aspect, as it reduces the use of aggressive treatments in the end-of-life phase and improves the experience of patients and their families, thus facilitating the transition from curative intent to limiting therapeutic effort [17, 18].
As a conclusion, the rapid development of critical care medicine and oncology allows intensive care for oncology patients continue to evolve; therefore, the demand for intensive care in this population will increase. Comprehensive care of critically ill patients with cancer requires close collaboration between specialists in oncohematology, palliative care, and intensive care. This collaboration should start at hospitalization, allowing the prevention of irreversible organ failure and avoiding aggressive measures in patients with an unfavorable prognosis. The decision to admit patients to the ICU should be based on a set of criteria and should be taken as a team, in order to offer quality intensive care adapted to the needs and personal preferences of each patient.
2. Tanvetyanon T, Leighton JC. Life-sustaining treatments in patients who died of chronic congestive heart failure compared with metastatic cancer. Crit Care Med. 2003; 31:60-4.
T Tanvetyanon JC Leighton Life-sustaining treatments in patients who died of chronic congestive heart failure compared with metastatic cancerCrit Care Med2003316064
3. O'Brien JM, Aberegg SK, Ali NA, Diette GB, Lemeshow S. Results from the National Sepsis Practice Survey: Predictions about mortality and morbidity and recommendations for limitation of care orders [serial online]. Crit Care. 2009;13: R96.
JM O'Brien SK Aberegg NA Ali GB Diette S Lemeshow Results from the National Sepsis Practice Survey: Predictions about mortality and morbidity and recommendations for limitation of care orders [serial online]Crit Care200913R96R96
4. Schwaederle M, Zhao M, Lee JJ, Eggermont AM, Schilsky RL, Mendelsohn J, et al. Impact of precision medicine in diverse cancers: A meta-analysis of phase II clinical trials. J Clin Oncol. 2015; 33:3817-25.
M Schwaederle M Zhao JJ Lee AM Eggermont RL Schilsky J Mendelsohn Impact of precision medicine in diverse cancers: A meta-analysis of phase II clinical trialsJ Clin Oncol20153338173825
5. Azoulay E, Thiery G, Chevret S, Moreau D, Darmon M, Bergeron A, et al. The prognosis of acute respiratory failure in critically ill cancer patients. Medicine (Baltimore). 2004; 83:360-70.
E Azoulay G Thiery S Chevret D Moreau M Darmon A Bergeron The prognosis of acute respiratory failure in critically ill cancer patientsMedicineBaltimore200483360370
6. Puxty K, McLoone P, Quasim T, Sloan B, Kinsella J, Morrison DS. Risk of critical illness among patients with solid cancers: A population-based observational study. JAMA Oncol. 2015;1:1078-85.
K Puxty P McLoone T Quasim B Sloan J Kinsella DS Morrison Risk of critical illness among patients with solid cancers: A population-based observational studyJAMA Oncol2015110781085
7. Gordon AC, Oakervee HE, Kaya B, Mason N, Sizer B, Chopra R, et al. Incidence and outcome of critical illness amongst hospitalised patients with haematological malignancy: A prospective observational study of ward and intensive care unit based care. Anaesthesia. 2005; 60:340-47.
AC Gordon HE Oakervee B Kaya N Mason B Sizer R Chopra Incidence and outcome of critical illness amongst hospitalised patients with haematological malignancy: A prospective observational study of ward and intensive care unit based careAnaesthesia200560340347
8. Bos MM, Verburg IW, Dumaij I, de Keizer NF, de Jonge E, de Vos R, et al. Intensive care admission of cancer patients: a comparative analysis. Cancer Med. 2015;4:966-76.
MM Bos IW Verburg I Dumaij NF de Keizer E de Jonge R de Vos Intensive care admission of cancer patients: a comparative analysisCancer Med20154966976
9. Benz R, Schanz U, Maggiorini M, Seebach JD, Stussi G. Risk factors for ICU admission and ICU survival after allogeneic hematopoietic SCT. Bone Marrow Transplant. 2014;49:62-65.
R Benz U Schanz M Maggiorini JD Seebach G Stussi Risk factors for ICU admission and ICU survival after allogeneic hematopoietic SCTBone Marrow Transplant2014496265
10. Taccone FS, Artigas AA, Sprung CL, Moreno R, Sakr Y, Vincent JL. Characteristics and outcomes of cancer patients in European ICUs [serial online]. Crit Care. 2009;13:R15.
FS Taccone AA Artigas CL Sprung R Moreno Y Sakr JL Vincent Characteristics and outcomes of cancer patients in European ICUs [serial online]Crit Care200913R15R15
11. 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.
M Soares P Caruso E Silva JM Teles SM Lobo G Friedman Characteristics and outcomes of patients with cancer requiring admission to intensive care units: A prospective multicenter studyCrit Care Med201038915
12. Pene F, Percheron S, Lemiale V, Viallon V, Claessens YE, Marqué S, et al. Temporal changes in management and outcome of septic shock in patients with malignancies in the intensive care unit. Crit Care Med. 2008;36:690-96.
F Pene S Percheron V Lemiale V Viallon YE Claessens S Marqué Temporal changes in management and outcome of septic shock in patients with malignancies in the intensive care unitCrit Care Med200836690696
14. Kim MM, Barnato AE, Angus DC, Fleisher LF, Kahn JM. The effect of multidisciplinary care teams on intensive care unit mortality. Arch Intern Med. 2010; 170:369-76.
MM Kim AE Barnato DC Angus LF Fleisher JM Kahn The effect of multidisciplinary care teams on intensive care unit mortalityArch Intern Med2010170369376
15. Parmar A, Richardson H, McKinlay D, Gibney RT, Bagshaw SM. Medical emergency team involvement in patients hospitalized with acute myeloid leukemia. Leuk Lymphoma. 2013; 54:2236-42.
A Parmar H Richardson D McKinlay RT Gibney SM Bagshaw Medical emergency team involvement in patients hospitalized with acute myeloid leukemiaLeuk Lymphoma20135422362242
17. Greer JA, Jackson VA, Meier DE, Temel JS. Early integration of palliative care services with standard oncology care for patients with advanced cancer. CA Cancer J Clin. 2013; 63:349-63.
JA Greer VA Jackson DE Meier JS Temel Early integration of palliative care services with standard oncology care for patients with advanced cancerCA Cancer J Clin201363349363
18. Jang RW, Krzyzanowska MK, Zimmermann C, Taback N, Alibhai SM. Palliative care and the aggressiveness of end-of-life care in patients with advanced pancreatic cancer. J Natl Cancer Inst. 2015;107(1):dju424.
RW Jang MK Krzyzanowska C Zimmermann N Taback SM Alibhai Palliative care and the aggressiveness of end-of-life care in patients with advanced pancreatic cancerJ Natl Cancer Inst20151071dju424dju424
How to cite: Roosemberg Ordóñez F. Critical Care for Cancer Patients: A Global Challenge and a Need for Interdisciplinary Collaboration. Oncología (Ecuador). 2024;34(3): 89-91. https://doi.org/10.33821/767
El cáncer representa un problema de salud pública a nivel global, y en países desarrollados se proyecta que pronto será la principal causa de muerte [1]. Los avances en oncología han llevado a que muchos pacientes, aunque no se curen por completo, vivan más tiempo; así, el número de personas que viven con esta condición aumentará, lo cual a su vez incrementará la cantidad de pacientes oncológicos que necesitarán atención en unidades de cuidados intensivos (UCI). A pesar de los avances, el cáncer sigue siendo visto como una "enfermedad fatal" y, en algunas regiones, el ingreso de pacientes oncológicos a la UCI es aún limitado o cuestionado, aunque muchos pueden ser manejados como enfermos crónicos y en ocasiones pueden ser curados. De hecho, muchas enfermedades no malignas presentan un pronóstico igual o más desfavorable que ciertos tipos graves de cáncer [2]. Las características únicas de los pacientes críticos con cáncer subrayan la necesidad de enfoques y áreas de especialización dedicados a esta población.
Desde los años cincuenta, el campo de los cuidados críticos ha evolucionado considerablemente. Las innovaciones tecnológicas, como los sistemas de soporte orgánico (ventilación mecánica, diálisis y oxigenación por membrana extracorpórea), ahora permiten reemplazar funciones vitales temporalmente, y complementan los avances en la comprensión de la fisiopatología de la enfermedad crítica. Históricamente, a los pacientes oncológicos, especialmente con tumores sólidos, se les ha restringido el acceso a UCI. Los intensivistas a menudo dudan en admitir a estos pacientes debido a un conocimiento limitado sobre el pronóstico y las opciones de tratamiento en esta población. Estudios en cuidados intensivos muestran que un diagnóstico de cáncer aumenta casi seis veces la probabilidad de rechazo de ingreso a UCI o de limitar el tratamiento agresivo [3]. Sin embargo, los avances recientes en terapias contra el cáncer y en cuidados intensivos han mejorado las expectativas de estos pacientes.
Hoy en día, los índices de supervivencia están en ascenso gracias a un diagnóstico temprano, tratamientos más específicos y efectivos con menores efectos adversos. Esta evolución se debe en gran parte a la "medicina de precisión", que ha permitido el desarrollo de tratamientos anticancerígenos que ofrecen una amplia gama de opciones terapéuticas a los oncólogos [4]. Entre el 5 y el 10 % de los pacientes oncológicos desarrollan condiciones que ponen en riesgo su vida y requieren ingreso a UCI [5-7]. Un estudio en Francia mostró que el porcentaje de ingresos a UCI en pacientes oncológicos varía entre el 0,7 y el 12 %, con mayores tasas en casos de cáncer de esófago, leucemias agudas y trasplantes alogénicos de médula ósea [8,9]. Actualmente, los pacientes oncológicos representan entre el 13,5 y el 21,5 % de todos los ingresos a UCI [10,11]. A finales del siglo XX, las tasas de supervivencia para pacientes oncológicos críticamente enfermos variaban entre un 20 y un 30 %; hoy, estas tasas han alcanzado entre el 50 y el 60 % [12,13]. En nuestra unidad especializada de oncología, la supervivencia es de aproximadamente el 70 %, lo que se acerca a la de pacientes críticos sin cáncer y sugiere que el cáncer en sí mismo ya no es una contraindicación universal para el ingreso a UCI. Esta decisión debe basarse en factores como el tipo y estadio del cáncer, la respuesta a tratamientos previos, el estado funcional y nutricional, así como en las preferencias del paciente y su familia.
Una revisión en nuestra unidad reveló que los pacientes con una puntuación más alta del Estado Funcional del Eastern Cooperative Oncology Group (ECOG) (funcionalidad limitada) tenían mayores tasas de mortalidad, independientemente del tipo de cáncer. Aunque muchas complicaciones que presentan los pacientes oncológicos críticos son comunes en pacientes sin cáncer, esta población tiene características específicas, como leucostasis, síndrome de vena cava superior y fenómenos autoinmunes paraneoplásicos, entre otras. Estos pacientes se benefician de un manejo conjunto entre oncólogos, hematólogos, cirujanos oncológicos, especialistas en cuidados paliativos e intensivistas, con el apoyo vital de expertos en nutrición y fisioterapia [14]. Actualmente, algunos hospitales han implementado equipos de respuesta rápida, compuestos por médicos o enfermeras de cuidados críticos que asisten al oncólogo en la identificación de pacientes que se beneficiarían de un traslado temprano a UCI o de un manejo más intensivo en sala. Este enfoque ha demostrado un impacto positivo en la disminución de la mortalidad, ya que permite la intervención antes de la falla orgánica irreversible [15,16]. La integración de cuidados paliativos en la UCI es otro aspecto clave, ya que reduce el uso de tratamientos agresivos en la fase final de la vida y mejora la experiencia de los pacientes y sus familias; esto facilita la transición de una intención curativa a la limitación del esfuerzo terapéutico [17,18].
Como conclusión, cabe señalar que, ante el rápido desarrollo de la medicina crítica y la oncología, la atención intensiva para pacientes oncológicos continuará evolucionando, y con ello la demanda de cuidados intensivos en esta población aumentará. La atención integral de los pacientes críticos con cáncer requiere una estrecha colaboración entre especialistas en oncohematología, cuidados paliativos y cuidados intensivos. Esta colaboración debería iniciarse desde la hospitalización, con el fin de prevenir fallos orgánicos irreversibles y evitar medidas agresivas en pacientes con pronóstico desfavorable. La decisión de ingreso a UCI debe basarse en un conjunto de criterios y tomarse en equipo, para ofrecer una atención intensiva de calidad adaptada a las necesidades y preferencias personales de cada paciente.