VOLUME
32
䡠
NUMBER
13
䡠
MAY
1
2014
JOURNAL OF CLINICAL ONCOLOGY
C O R R E S P O N D E N C E
Providing High-Quality and Affordable Intensive Care to Patients With Cancer: The Forgotten Brick in the Steep Wall of Costs Throughout the Cancer Care Continuum TO THE EDITOR: The article by Shih et al1 summarized the activities of the workshop entitled “Delivering Affordable Cancer Care in the 21st Century” led by the National Cancer Policy Forum of the Institute of Medicine. We congratulate the authors for such work that, as remarked by themselves, describes the challenges posed by the increasing costs of cancer care as being exemplary of those facing the health care system as whole, driven significantly by an aging population. Many concerns regarding the implications of the overuse and/or inappropriate use of screening and therapeutic strategies (in particular, the new therapies and technologies) for the costs of cancer care were raised by the authors. In addition, there is urgent need for improvements in supportive care for these patients. In this sense, the growing demand for intensive care represents another critical and forgotten facet of a complex problem. Intensive care–related costs in the United States (estimated at $82 billion in 2005) account for 13% of hospital expenditures and approximately 1% of the gross domestic product.2 Although many targets to improve the provision of supportive care for patients with cancer were addressed, the discussion was restricted to palliative care. Nonetheless, intensive care units (ICUs) are essential for the supportive care of patients with cancer; up to one in five patients admitted to ICUs have cancer.3 It is well known that survival of critically ill patients with cancer has improved significantly in recent years, even in the case of respiratory failure or severe infection.3 In contrast, many patients with cancer are still inappropriately admitted to the ICU at the end of life.4 However, because triage procedures are inaccurate even in specialized centers,5 the broadening of ICU admission policies has been recommended by experts worldwide.3
For all these reasons, the provision of intensive care to an increasing number of patients with cancer deserves to be included in any future agenda of care planning for these patients. Along this lines, future investigations should address the roles of fast-track postoperative care, planned recovery tracks, dehospitalization programs, rehabilitation, and hospice-based care for patients with cancer who survive ICU stays. Meanwhile, close collaboration between oncologists and intensivists coupled with the need to document patient preferences for aggressive therapies and end-of-life issues at the time of ICU admission are essential to avoid either depriving patients who may benefit from life-sustaining treatments or, conversely, inappropriately prolonging the end of life. Integrating palliative and intensive care is paramount to achieving high-quality and affordable supportive care that will meet the needs of patients, family members, care providers, and society.
Ma´rcio Soares and Jorge I.F. Salluh Instituto Nacional de Caˆncer; D’Or Institute for Research and Education, Rio de Janeiro, Brazil
AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST
The author(s) indicated no potential conflicts of interest. REFERENCES 1. Shih YC, Ganz PA, Aberle D, et al: Delivering high-quality and affordable care throughout the cancer care continuum. J Clin Oncol 31:4151-4157, 2013 2. Halpern NA, Pastores SM: Critical care medicine in the United States 2000-2005: An analysis of bed numbers, occupancy rates, payer mix, and costs. Crit Care Med 38:65-71, 2010 3. Azoulay E, Soares M, Darmon M, et al: Intensive care of the cancer patient: Recent achievements and remaining challenges. Ann Intensive Care 1:5, 2011 4. Ho TH, Barbera L, Saskin R, et al: Trends in the aggressiveness of end-of-life cancer care in the universal health care system of Ontario, Canada. J Clin Oncol 29:1587-1591, 2011 5. Thie´ry G, Azoulay E, Darmon M, et al: Outcome of cancer patients considered for intensive care unit admission: A hospital-wide prospective study. J Clin Oncol 23:4406-4413, 2005
DOI: 10.1200/JCO.2013.54.6614; published online ahead of print at www.jco.org on March 31, 2014
■ ■ ■
Reply to M. Soares et al Soares and Sullah1 address the use of care in intensive care units (ICUs) as an important element in the care continuum of the patient with cancer. They reiterate the broad concerns about overuse of intensive care near the end of life. They suggest that far more clarity is required with respect to patients’ wishes for the use of aggressive care at this juncture in their illness, while concurrently emphasizing the lifesaving contribution of this resource and implying its importance to improving survival. We neither disagree with their statement nor with the suggestion that ICU care is a critically important contributor to lifesaving treatment for the properly selected patient with cancer. The crucial question is when is the use of the ICU and, to broaden the scope 1384
© 2014 by American Society of Clinical Oncology
of the discussion, intensive cancer-directed care, likely to reverse the course of an acute complication that will still result in maintenance of good health for a significant period of time after the intensive therapeutic or critical care intervention? Developing and implementing broadly accepted criteria to address overuse of the ICU in the patient with advanced cancer who has little hope for long-term survival is an important and daunting task. Numerous factors govern the use of intensive treatments near life’s end. Common to many is poor communication between patients and physicians about the true state of illness and prospects for meaningful recovery or cure.2,3 Patients and their families often do not fully understand the gravity of the patient’s illness and the limited likelihood that the patient will return to a semblance of good health, even Journal of Clinical Oncology, Vol 32, No 13 (May 1), 2014: pp 1384-1385
Information downloaded from jco.ascopubs.org and provided by at Northeastern University on October 4, 2014 from Copyright © 2014 American Society of Clinical Oncology. All rights reserved. 155.33.16.124
32
䡠
NUMBER
13
䡠
MAY
1
2014
JOURNAL OF CLINICAL ONCOLOGY
C O R R E S P O N D E N C E
Providing High-Quality and Affordable Intensive Care to Patients With Cancer: The Forgotten Brick in the Steep Wall of Costs Throughout the Cancer Care Continuum TO THE EDITOR: The article by Shih et al1 summarized the activities of the workshop entitled “Delivering Affordable Cancer Care in the 21st Century” led by the National Cancer Policy Forum of the Institute of Medicine. We congratulate the authors for such work that, as remarked by themselves, describes the challenges posed by the increasing costs of cancer care as being exemplary of those facing the health care system as whole, driven significantly by an aging population. Many concerns regarding the implications of the overuse and/or inappropriate use of screening and therapeutic strategies (in particular, the new therapies and technologies) for the costs of cancer care were raised by the authors. In addition, there is urgent need for improvements in supportive care for these patients. In this sense, the growing demand for intensive care represents another critical and forgotten facet of a complex problem. Intensive care–related costs in the United States (estimated at $82 billion in 2005) account for 13% of hospital expenditures and approximately 1% of the gross domestic product.2 Although many targets to improve the provision of supportive care for patients with cancer were addressed, the discussion was restricted to palliative care. Nonetheless, intensive care units (ICUs) are essential for the supportive care of patients with cancer; up to one in five patients admitted to ICUs have cancer.3 It is well known that survival of critically ill patients with cancer has improved significantly in recent years, even in the case of respiratory failure or severe infection.3 In contrast, many patients with cancer are still inappropriately admitted to the ICU at the end of life.4 However, because triage procedures are inaccurate even in specialized centers,5 the broadening of ICU admission policies has been recommended by experts worldwide.3
For all these reasons, the provision of intensive care to an increasing number of patients with cancer deserves to be included in any future agenda of care planning for these patients. Along this lines, future investigations should address the roles of fast-track postoperative care, planned recovery tracks, dehospitalization programs, rehabilitation, and hospice-based care for patients with cancer who survive ICU stays. Meanwhile, close collaboration between oncologists and intensivists coupled with the need to document patient preferences for aggressive therapies and end-of-life issues at the time of ICU admission are essential to avoid either depriving patients who may benefit from life-sustaining treatments or, conversely, inappropriately prolonging the end of life. Integrating palliative and intensive care is paramount to achieving high-quality and affordable supportive care that will meet the needs of patients, family members, care providers, and society.
Ma´rcio Soares and Jorge I.F. Salluh Instituto Nacional de Caˆncer; D’Or Institute for Research and Education, Rio de Janeiro, Brazil
AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST
The author(s) indicated no potential conflicts of interest. REFERENCES 1. Shih YC, Ganz PA, Aberle D, et al: Delivering high-quality and affordable care throughout the cancer care continuum. J Clin Oncol 31:4151-4157, 2013 2. Halpern NA, Pastores SM: Critical care medicine in the United States 2000-2005: An analysis of bed numbers, occupancy rates, payer mix, and costs. Crit Care Med 38:65-71, 2010 3. Azoulay E, Soares M, Darmon M, et al: Intensive care of the cancer patient: Recent achievements and remaining challenges. Ann Intensive Care 1:5, 2011 4. Ho TH, Barbera L, Saskin R, et al: Trends in the aggressiveness of end-of-life cancer care in the universal health care system of Ontario, Canada. J Clin Oncol 29:1587-1591, 2011 5. Thie´ry G, Azoulay E, Darmon M, et al: Outcome of cancer patients considered for intensive care unit admission: A hospital-wide prospective study. J Clin Oncol 23:4406-4413, 2005
DOI: 10.1200/JCO.2013.54.6614; published online ahead of print at www.jco.org on March 31, 2014
■ ■ ■
Reply to M. Soares et al Soares and Sullah1 address the use of care in intensive care units (ICUs) as an important element in the care continuum of the patient with cancer. They reiterate the broad concerns about overuse of intensive care near the end of life. They suggest that far more clarity is required with respect to patients’ wishes for the use of aggressive care at this juncture in their illness, while concurrently emphasizing the lifesaving contribution of this resource and implying its importance to improving survival. We neither disagree with their statement nor with the suggestion that ICU care is a critically important contributor to lifesaving treatment for the properly selected patient with cancer. The crucial question is when is the use of the ICU and, to broaden the scope 1384
© 2014 by American Society of Clinical Oncology
of the discussion, intensive cancer-directed care, likely to reverse the course of an acute complication that will still result in maintenance of good health for a significant period of time after the intensive therapeutic or critical care intervention? Developing and implementing broadly accepted criteria to address overuse of the ICU in the patient with advanced cancer who has little hope for long-term survival is an important and daunting task. Numerous factors govern the use of intensive treatments near life’s end. Common to many is poor communication between patients and physicians about the true state of illness and prospects for meaningful recovery or cure.2,3 Patients and their families often do not fully understand the gravity of the patient’s illness and the limited likelihood that the patient will return to a semblance of good health, even Journal of Clinical Oncology, Vol 32, No 13 (May 1), 2014: pp 1384-1385
Information downloaded from jco.ascopubs.org and provided by at Northeastern University on October 4, 2014 from Copyright © 2014 American Society of Clinical Oncology. All rights reserved. 155.33.16.124
