High-Quality Critical
Care for Patients
with Cancer
The Nine-I
Network
Bekele Afessa Research Day
Critical Care Specialists of Cancer Patients:
Our Challenges for the Future.
Marcio Soares
D’Or Institute for Research and Education
BRICNet – Brazilian Research in Intensive Care Network
Paris, 2017
High-Quality Critical
Care for Patients
with Cancer
The Nine-I
Network
Bekele Afessa Research Day
Providing High-Quality ICU Care
for Critically Ill Patients With Cancer:
Our Challenges for the Future.
Marcio Soares
D’Or Institute for Research and Education
BRICNet – Brazilian Research in Intensive Care Network
Paris, 2017
High-Quality Critical Care for Patients with Cancer
Conflicts of Interest:
Founder and R&D Director at Epimed Solutions
Financial Support:
Research grants from FAPERJ and CNPq;
departmental funds from IDOR
High-Quality Critical Care for Patients with Cancer
What we have learned in the last 25 yrs...
Carlon GC. Crit Care Med 1989
High-Quality Critical Care for Patients with Cancer
Research in ICU Cancer Patients
Pubmed: 6,263 articles
1970
2017
High-Quality Critical Care for Patients with Cancer
Outline of Presentation
 Where are we now?
 What are the driving pressures changing the way we
care for ICU patients with cancer?
 Where do we go from here?
High-Quality Critical Care for Patients with Cancer
What we have learned in the last 25 yrs...
 Survival in admitted patients may have improved in the
last 15 yrs
Darmon & Azoulay. CoCC 2009
High-Quality Critical Care for Patients with Cancer
Better outcomes than commonly perceived
in different scenarios…
• Acute respiratory failure + need of MV
Azoulay et al. CCM 2001; Soares et al. CCM 2005; Azevedo et al. Chest 2014
•
Acute kidney injury
Benoit et al, NDT 2005; Soares et al. JCO 2006; Darmon ICM 2007; Maccariello et al. NDT 2011
•
Chemotherapy - recent use / use in ICU
Darmon et al. CCM 2005; Benoit et al, ICM 2006; Vandjick et al. ICM 2008
•
Prolonged ICU admission
Soares et al. Chest 2008
•
Neutropenia
Souza-Dantas et al. Ann Oncol 2011; Legrand et al. CCM 2012
•
Autollogous BMT
Khassavneh et al. Chest 2002
High-Quality Critical Care for Patients with Cancer
Outcomes vary largely among different
clinical profiles
Good PS
Poor PS
• 449 patients with lung cancer
• 22 ICUs
• 6 Countries in EU and LatAm
LUCCA Study. Soares et al. Ann Oncol 2014
High-Quality Critical Care for Patients with Cancer
What we have learned in the last 25 yrs...
 Survival in admitted patients improved in the last 15 yrs
 Delays in ICU referral and admission are associated with
increased mortality
Benoit, Soares & Azoulay. ICM 2014; Azoulay et al. Blood 2015;Azoulay et al. Unpublished
High-Quality Critical Care for Patients with Cancer
The higher the time to intervention,
the higher the mortality
Song et al. ICM 2012
High-Quality Critical Care for Patients with Cancer
What we have learned in the last 25 yrs...
 Survival in admitted patients improved in the last 15 yrs
 Delays in ICU referral and admission are associated with increased mortality
 Prognostic uncertainty and inaccuracy in triage
decisions are the rule
Benoit, Soares & Azoulay. ICM 2014; Azoulay et al. Blood 2015;Azoulay et al. Unpublished
SAPS 3
High-Quality Critical Care for Patients with Cancer
APACHE II
Severity scores are unrealiable for individual decision-making
High-Quality Critical Care for Patients with Cancer
Intensivists are usually overpessimistic
regarding short- and long-term outcomes
Hemato-oncologists are overoptimistic
regarding short- and long-term outcomes
High-Quality Critical Care for Patients with Cancer
Mortality by survival time according to ICU admission decision.
Refused “too-well” for benefit
Admitted to the ICU
Refused “too-sick” for benefit
Thiéry G et al. J Clin Oncol 2005
High-Quality Critical Care for Patients with Cancer
What we have learned in the last 25 yrs...
 Survival in admitted patients improved in the last 15 yrs
 Delays in ICU referral and admission are associated with increased mortality
 Prognostic uncertainty and inaccuracy in triage decisions are the rule
 Broadening ICU admission and new admission policies
and goals of care have been introduced
Benoit, Soares & Azoulay. ICM 2014; Azoulay et al. Blood 2015;Azoulay et al. Unpublished
High-Quality Critical Care for Patients with Cancer
All cancer patients for whom ICU
admission was requested
• Bedridden / Poor PS
• Palliative care only
• Other intermediate
situations
• Newly diagnosed
disease
• First-line treatment
• Refusal ICU admission
• Potentially reversible
acute complication
• ICU admission not
recommended
• Comfort / palliative care
• Consider ICU trial if
patient / family are willing
to
• Proceed ICU admission
• Full code management
Adapted from Lecuyer L et al. Crit Care Med 2007
High-Quality Critical Care for Patients with Cancer
Different ICU Admission Policies for Cancer Patients
Terminal ICU
Admission?
Non-ICU care
In ICU?
Palliative ICU
Admission?
?
Prophylactic ICU
Admission?
Early ICU
Admission?
HEROIC
ICU ADMISSION
EXCEPTIONAL
ICU ADMISSION
ICU TRIAL
FUL CODE ICU MANAGEMENT
Azoulay E, Soares M, Darmon M, et al. Managing Critically Ill Cancer
Patients: Another Medical Success Story? Ann Intensive Care 2011
High-Quality Critical Care for Patients with Cancer
What we have learned in the last 25 yrs...
 Survival in admitted patients improved in the last 15 yrs
 Delays in ICU referral and admission are associated with increased mortality
 Prognostic uncertainty and inaccuracy in triage decisions are the rule
 Broadening ICU admission and new admission policies and goals of care
have been introduced
 Our abilities to diagnose, prevent and manage acute
complications and organ dysfunctions improved
Benoit, Soares & Azoulay. ICM 2014; Azoulay et al. Blood 2015;Azoulay et al. Unpublished
High-Quality Critical Care for Patients with Cancer
Our abilities to diagnose, prevent and manage
acute complications and organ dysfunctions
improved

Prevention and management AKI, ATLS
 Safe de-escalation ATBs in neutropenic patients
 Cautious use of non-invasive ventilation strategies in
ARF
 FO-BAL is not a rule for all patients with ARF and
pulmonar infltrates
 Urgent chemotherapy in the ICU
 ...
Benoit, Soares & Azoulay. ICM 2014; Azoulay et al. Blood 2015;Azoulay et al. Unpublished
High-Quality Critical Care for Patients with Cancer
What we have learned in the last 25 yrs...
Just Say No!
Carlon GC. CCM 1989
Consider Saying Yes...
Groeger J. CCM 2003
Critical care is essential to the
supportive care in patients with cancer
2016
High-Quality Critical Care for Patients with Cancer
What we have learned in the last 25 yrs...
 Up to 1/5 patients admitted to ICUs have cancer
• SOAP – Cancer (Taccone et al. Crit Care 2009)
15%
• Brazil Multicenter study (Soares et al. CCM 2010) 20%
• ICON – Vincent (Vincent et al. L Resp Med 2014
14%
• ORCHESTRA (Soares et al. ICM 2015)
17%
Critical care is essential in the supportive care
of cancer patients!
High-Quality Critical Care for Patients with Cancer
Research in ICU Cancer Patients
Pubmed: 6,263 articles
1970
 Most of the studies focused on outcomes, triage
procedures and management of different clinical
conditions and complications.
2017
High-Quality Critical Care for Patients with Cancer
Outline of Presentation
 Where are we now?
 What are the driving pressures changing the way we
care for ICU patients with cancer?
 Where do we go from here?
High-Quality Critical Care for Patients with Cancer
CA Cancer Journal 2017
High-Quality Critical Care for Patients with Cancer
CA Cancer Journal 2017
High-Quality Critical Care for Patients with Cancer
High-Quality Critical Care for Patients with Cancer
CA Cancer Journal 2017
High-Quality Critical Care for Patients with Cancer
There are many
more people living
with cancer, ever in
advanced stages of
the disease
CA Cancer Journal 2017
High-Quality Critical Care for Patients with Cancer
Lancet 2015
High-Quality Critical Care for Patients with Cancer
Kato et al. Lung Cancer 2017
Kushnir & Wolf. Cardiology 2017
High-Quality Critical Care for Patients with Cancer
What we have learned in the last 25 yrs...
 Up to 1/5 patients admitted to ICUs have cancer
• SOAP – Cancer (Taccone et al. Crit Care 2009)
15%
• Brazil Multicenter study (Soares et al. CCM 2010) 20%
• ICON – Vincent (Vincent et al. L Resp Med 2014
14%
• ORCHESTRA (Soares et al. ICM 2015)
17%
Critical care is essential in the supportive care
of cancer patients!
High-Quality Critical Care for Patients with Cancer
Shi et al. JCO 2013
High-Quality Critical Care for Patients with Cancer
Shi et al. JCO 2013
Soares & Salluh, JCO 2014
High-Quality Critical Care for Patients with Cancer
High-Quality Critical Care for Patients with Cancer
High-Quality Critical Care for Patients with Cancer
The healthcare system is changing fast...
High-Quality Critical Care for Patients with Cancer
The healthcare system is changing fast...
•
•
•
•
•
•
•
Safe
Effective
Patient centered
Efficient
Timely
Equitable
Affordable
Better care for individuals, Better health for populations, Lower per capita costs
High-Quality Critical Care for Patients with Cancer
The healthcare system is changing fast...
High-Quality Critical Care for Patients with Cancer
The healthcare system is changing fast...
High-Quality Critical Care for Patients with Cancer
Ong et al. JAMA Oncol 2017
Goldstein. JAMA Oncol 2016
Alvarnas. JAMA Oncol 2015
High-Quality Critical Care for Patients with Cancer
The way our patients expect we care for
them as well...
High-Quality Critical Care for Patients with Cancer
ICM 2007
High-Quality Critical Care for Patients with Cancer
The way our patients expect we care for
them as well...
High-Quality Critical Care for Patients with Cancer
High-Quality Critical Care for Patients with Cancer
And also the way care providers expect
High-Quality Critical Care for Patients with Cancer
And also the way care providers expect
High-Quality Critical Care for Patients with Cancer
The Fourth Aim
High-Quality Critical Care for Patients with Cancer
Outline of Presentation
 Where are we now?
 What are the driving pressures changing the way we
care for ICU patients with cancer?
 Where do we go from here?
High-Quality Critical Care for Patients with Cancer
Management of critically ill patients with cancer is
very complex and multifaceted
• Provision of high-quality and patient-centered
care
• Avoidance of inappropriate care
• Offering of anticancer treatments in ICU
• Management of oncologic and non-oncologic
complications
• Provision of early ICU / Palliative care
• Reduce conflicts
Soares & Salluh. CCM 2011; Azoulay et al. AIC 2011;
High-Quality Critical Care for Patients with Cancer
Management of critically ill patients with cancer is
very complex and multifaceted
• Provision of high-quality and patient-centered
care
• Avoidance of inappropriate care
• Offering of anticancer treatments in ICU
• Management of oncologic and non-oncologic
complications
• Provision of early ICU / Palliative care
• Reduce conflicts
Soares & Salluh. CCM 2011; Azoulay et al. AIC 2011;
High-Quality Critical Care for Patients with Cancer
Key targets for improving quality and efficiency of
patients’ care
 Multiprofessional collaborative work
 Specific skills that can be learned and taught
 Moving toward systemic gains in clinical
efficiency
High-Quality Critical Care for Patients with Cancer
ORCHESTRA Study
9,946 cancer patients admitted to 70 ICUs during 2013.
ORCHESTRA Study. JCO 2016
High-Quality Critical Care for Patients with Cancer
Multivariate Multilevel Models - Hospital Mortality
(adjusted for admission diag. comorbidities, functional status, MV on Day1, SOFA)
Type of hospital
General
1.00
Referral cancer center
1.21 (0.89-1.63)
Training programs in critical care
1.37 (1.04-1.80)
Clinical pharmacist in the ICU
0.67 (0.49-0.90)
Daily meetings between oncologists and intensivists for
care planning in all patients
0.68 (0.52-0.91)
Clinical protocols (n)
0.92 (0.86-0.98)
High-Quality Critical Care for Patients with Cancer
Subgroup Analyses
High-Quality Critical Care for Patients with Cancer
Variables Associated with High Efficiency
(adjusted ORs)
Daily meetings between oncologists and intensivists
4.70 (1.15-19.22)
Clinical Protocols (n)
1.52 (1.11-2.07)
ORCHESTRA Study. JCO 2016
High-Quality Critical Care for Patients with Cancer
Admission Volume Effect on Hospital Mortality
(adjusted for patients and ICU characteristics)
All patients (n=9946)
0.992 (0.979-1.004)
High-Quality Critical Care for Patients with Cancer
Admission Volume Effect on Hospital Mortality
(adjusted for patients and ICU characteristics)
All patients (n=9946)
0.992 (0.979-1.004)
Surgical patients (n=4929)
0.980 (0.959-1.001)
Medical patients (n=5017)
0.997 (0.985-1.009)
Solid tumors (n=8956)
0.990 (0.977-1.003)
Hematological malignancies (n=990)
1.002 (0.976-1.029)
Patients stratified according to the SAPS 3 tertiles
1st tertile (<40 points) (n=3334))
0.992 (0.977-1.005)
2nd tertile (40-55 points) (n=3458)
0.993 (0.979-1.008)
3rd tertile (>55 points) (n=3154)
0.988 (0.966-1.010)
High-Quality Critical Care for Patients with Cancer
Specialized and general
hospitals can achieve
comparable clinical
outcomes and efficiency
ORCHESTRA Study. JCO 2016
High-Quality Critical Care for Patients with Cancer
Update training programs to meet the current
needs
 Patient-family centered care
 Improve interactions with oncologists
 Diagnose and manage oncology-related
complications
Identification of specific skills that can be
learned and taught is urgently needed
High-Quality Critical Care for Patients with Cancer
High-Quality Critical Care for Patients with Cancer
Moving toward systemic gains in efficiency
Three Systems of Improved Care Delivery
High-Quality Critical Care for Patients with Cancer
Key targets for improving quality and efficiency of
patients’ care
 Multiprofessional collaborative work
 Specific skills that can be learned and taught
 Moving toward systemic gains in clinical
efficiency