Correspondence

Patients are treated in the ICU because they are at risk of dying without such care. The ICU may seem to be a good place for patients to stay for their entire admission because of the high level of care; however, ICU care involves a number of risks, particularly the risk of acquiring new infections, and it is quite expensive to provide constant attention to patients who are improving.6 Patients with hematooncologic illness consume more critical care resources and have a longer ICU stay than patients with nononcologic illnesses.7 Many hospitals in low-income countries do not have an ICU, and critically ill patients are treated in the general wards.8 There is a large variation in ICU bed rates across North America and Western Europe. The United States and Canada were found to have the highest number of ICU beds, with 20 and 13.5 beds per population of 100,000, respectively.9 Mexico does not have an accurate record of the number of ICU beds, although it is estimated that there are approximately 1,984 ICU beds with mechanical ventilators.10 According to data reported by The Instituto Nacional de Estadística y Geografía in 2010, the population of Mexico is approximately 112.5 million11; thus, the estimated number of ICU beds in Mexico is 1.76 ICU beds per population of 100,000, similar to that of the United Kingdom (3.5 adult ICU beds per population of 100,000) and less than in France (9.3 adult ICU beds per population of 100,000). The goals of many ICU interventions are to stabilize and support patients, rather than to cure or improve an underlying condition.12 The prioritization model (eg, highest priority with greatest potential benefit) is most often used by critical care physicians.13 Recently, our group reported 20% and 70.1% ICU mortality rates for patients with HMs who had two or fewer organ system dysfunctions and three or more system dysfunctions, respectively (P ⬍ .001).14 Delayed ICU admission is associated with increased mortality in patients with cancer.15 In our institution, critically ill patients with HMs and a SOFA score of ⱖ 10 points during the first 24 hours after ICU admission have an in-hospital mortality rate greater than 80%.14 We therefore suggest admission to the ICU for three or fewer organ dysfunctions or a SOFA score of ⬍ 10 points.14,16 However, the distribution and use of critical care resources must be determined for policy decisions regarding critical care services for critically ill patients with HMs.

˜ amendys-Silva Silvio A. N Instituto Nacional de Cancerología; and Instituto Nacional de Ciencias Me´dicas y Nutricio´n Salvador Zubira´n, Mexico City, Mexico

Francisco J. García-Guille´n and Angel Herrera-Go´mez

AUTHOR’S DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

The author(s) indicated no potential conflicts of interest. REFERENCES 1. Azoulay E, Mokart D, Pe`ne F, et al: Outcomes of critically ill patients with hematologic malignancies: Prospective multicenter data from France and Belgium—A Groupe de Recherche Respiratoire en Re´animation OncoHe´matologique study. J Clin Oncol 31:2810-2818, 2013 2. Shelton BK: Admission criteria and prognostication in patients with cancer admitted to the intensive care unit. Crit Care Clin 26:1-20, 2010 3. Fullerton JN, Perkins GD: Who to admit to intensive care? Clin Med 11:601-604, 2011 4. Chang L, Horng CF, Huang YC, et al: Prognostic accuracy of Acute Physiology and Chronic Health Evaluation II scores in critically ill cancer patients. Am J Crit Care 15:47-53, 2006 5. Kopterides P, Liberopoulos P, Ilias I, et al: General prognostic scores in outcome prediction for cancer patients admitted to the intensive care unit. Am J Crit Care 20:56-66, 2011 6. American Thoracic Society: What is the purpose of an intensive care unit? New York, NY, American Thoracic Society. http://www.thoracic.org/clinical/ critical-care/patient-information/ccprimer-general-information.php 7. Merz TM, Scha¨r P, Bu¨hlmann M, et al: Resource use and outcome in critically ill patients with hematological malignancy: A retrospective cohort study. Crit Care 12:R75, 2008 8. Baker T: Critical care in low-income countries. Trop Med Int Health 14:143-148, 2009 9. Wunsch H, Angus DC, Harrison DA, et al: Variation in critical care services across North America and Western Europe. Crit Care Med 36:27872793, e1-e9, 2008 10. Volkow P, Bautista E, de la Rosa M, et al: The response of the intensive care units during the influenza A H1N1 pandemic: The experience in Chiapas, Mexico [in Spanish]. Salud Publica Mex 53:345-353, 2011 11. Instituto Nacional de Estadística y Geografía: Censo de Poblacio´n y Vivienda 2010. http://www3.inegi.org.mx/sistemas/mexicocifras/default.aspx? src⫽487 12. [No authors listed]: Understanding costs and cost-effectiveness in critical care: Report from the second American Thoracic Society workshop on outcomes research. Am J Respir Crit Care Med 165:540-550, 2002 13. Task Force of the American College of Critical Care Medicine, Society of Critical Care Medicine: Guidelines for intensive care unit admission, discharge and triage: Task Force of the American College of Critical Care Medicine, Society of Critical Care Medicine. Crit Care Med 27:633-638, 1999 14. N˜amendys-Silva SA, Gonza´lez-Herrera MO, García-Guille´n FJ, et al: Outcome of critically ill patients with hematological malignancies. Ann Hematol 92:699-705, 2013 15. Mokart D, Lambert J, Schnell D, et al: Delayed intensive care unit admission is associated with increased mortality in patients with cancer with acute respiratory failure. Leuk Lymphoma 54:1724-1729, 2013 16. N˜amendys-Silva SA, Gonza´lez-Herrera MO, Texcocano-Becerra J, et al: Clinical characteristics and outcomes of critically ill cancer patients with septic shock. QJM 104:505-511, 2011

DOI: 10.1200/JCO.2013.52.1401; published online ahead of print at www.jco.org on March 10, 2014

Instituto Nacional de Cancerología, Mexico City, Mexico

■ ■ ■

˜ amendys-Silva et al Reply to S.A. N ˜ amendys-Silva et al1 with interest. We have read the letter from N Although use of the severity score for triage purposes is a compelling idea, we disagree with the authors with regard to its feasibility. First, ˜ amendys-Silva et al cite positive studies that suggest the severity N score to be discriminant in predicting outcome. However, several studies2-4 have indicated that the usual severity scores, including the Acute Physiology and Chronic Health Evaluation score, were neither discriminant nor well calibrated in critically ill patients with cancer. We believe that these studies should be taken into consideration. 1170

© 2014 by American Society of Clinical Oncology

Additionally, the inability of these scores to predict individual outcomes because of their lack of calibration was demonstrated two decades ago.5,6 In keeping with these findings, and although we agree that reliance on physician predictions of outcome remains imperfect,7,8 we would strongly discourage outdated triage practices that are based on severity scores. We fully agree that the prioritization of admission policy might be in order in low income countries. However, this can only be performed according to objective criteria. We believe that if intensive care unit admission of patients with cancer is limited, it is first necessary to carefully assess the outcomes of these patients. Our study provides convincing evidence that the prognosis of these patients is no longer JOURNAL OF CLINICAL ONCOLOGY

Information downloaded from jco.ascopubs.org and provided by at J S GERICKE LIBRARY on October 4, 2014 from Copyright © 2014 American Society of Clinical Oncology. All rights reserved. 146.232.129.75

Correspondence

associated with the poor outcome to which the authors refer.8 In addition, a whole field of research could be devoted to understanding the reluctance of critical care physicians to admit patients with cancer on the basis of their estimated prognosis, when this reluctance is not demonstrated with respect to patients who have experienced cardiac arrest (a population with low survival and poor functional outcome).9 Last, although it may sound logical to limit intensive care unit admission to reduce health care costs, literature shows us that this strategy merely increases costs as well as patient suffering.10

with a “C” were compensated. For a detailed description of the disclosure categories, or for more information about ASCO’s conflict of interest policy, please refer to the Author Disclosure Declaration and the Disclosures of Potential Conflicts of Interest section in Information for Contributors. Employment or Leadership Position: None Consultant or Advisory Role: None Stock Ownership: None Honoraria: Elie Azoulay, Pfizer, Gilead, MSD Pharmaceuticals Research Funding: Elie Azoulay, Pfizer Expert Testimony: None Patents, Royalties, and Licenses: None Other Remuneration: None REFERENCES

Elie Azoulay Hoˆpital Saint-Louis, Paris, France

Djamel Mokart Paoli-Calmettes Institute, Marseilles, France

Virginie Lemiale Hoˆpital Saint-Louis, Paris, France

Fre´de´ric Pe`ne Cochin Hospital, Paris, France

Franc¸ois Vincent Avicenne Hospital, Paris, France

Michael Darmon North Hospital, Saint-Etienne, France

ACKNOWLEDGMENT

Written on behalf of the Groupe de Recherche Respiratoire en Re´animation Onco-He´matologique. AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

Although all authors completed the disclosure declaration, the following author(s) and/or an author’s immediate family member(s) indicated a financial or other interest that is relevant to the subject matter under consideration in this article. Certain relationships marked with a “U” are those for which no compensation was received; those relationships marked

1. N˜amendys-Silva SA, García-Guille´n FJ, Herrera-Go´mez A: Opening the doors of the intensive care unit to patients with hematologic malignancies. J Clin Oncol 32:1169-1170, 2014 2. Lamia B, Hellot MF, Girault C, et al: Changes in severity and organ failure scores as prognostic factors in onco-hematological malignancy patients admitted to the ICU. Intensive Care Med 32:1560-1568, 2006 3. Lecuyer L, Chevret S, Thiery G, et al: The ICU trial: A new admission policy for cancer patients requiring mechanical ventilation. Crit Care Med 35:808-814, 2007 4. Soares M, Fontes F, Dantas J, et al: Performance of six severity-of-illness scores in cancer patients requiring admission to the intensive care unit: A prospective observational study. Crit Care 8:R194 –R203, 2004 5. Rogers J, Fuller HD: Use of daily Acute Physiology and Chronic Health Evaluation (APACHE) II scores to predict individual patient survival rate. Crit Care Med 22:1402-1405, 1994 6. Lemeshow S, Klar J, Teres D: Outcome prediction for individual intensive care patients: Useful, misused, or abused? Intensive Care Med 21:770-776, 1995 7. 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 8. Azoulay E, Mokart D, Pe`ne F, et al: Outcomes of critically ill patients with hematologic malignancies: Prospective multicenter data from France and Belgium— A Groupe de Recherche Respiratoire en Re´animation Onco-He´matologique study. J Clin Oncol 31:2810-2818, 2013 9. Young GB: Clinical practice: Neurologic prognosis after cardiac arrest. N Engl J Med 361:605-611, 2009 10. Luce JM, Rubenfeld GD: Can health care costs be reduced by limiting intensive care at the end of life? Am J Respir Crit Care Med 165:750-754, 2002

DOI: 10.1200/JCO.2013.53.4248; published online ahead of print at www.jco.org on March 10, 2014 ■ ■ ■

www.jco.org

© 2014 by American Society of Clinical Oncology

Information downloaded from jco.ascopubs.org and provided by at J S GERICKE LIBRARY on October 4, 2014 from Copyright © 2014 American Society of Clinical Oncology. All rights reserved. 146.232.129.75

1171

Reply to S.A. NAMENDYS-Silva et al.

Reply to S.A. NAMENDYS-Silva et al. - PDF Download Free
50KB Sizes 3 Downloads 3 Views