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Cancer patients admitted in the intensive care unit: Characteristics and outcomes
Pacientes con cáncer ingresados en la unidad de cuidados intensivos: características y resultados
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Petra Ziehera, Márcia Eliane Giuliatob, Luana Turraa, Mariane Carolina de Almeidab, Sara Fernanda Hilgertb, Antuani Rafael Baptistellab,
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a Universidade do Oeste de Santa Catarina, Brazil
b Programa de Pós-Graduação em Biociências e Saúde da Universidade do Oeste de Santa Catarina, Brazil
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Table 1. Profile of patients admitted to the intensive care unit (ICU) in the study period (n=183).
Table 2. Clinical characteristics of oncology and non-oncology patients admitted to the intensive care unit (ICU) (n=183).
Table 3. Clinical characteristics of oncology and non-oncology patients admitted to the intensive care unit (ICU) (n=183).
Table 4. Intensive care unit (ICU) outcome of surgical and clinical oncology patients (n=183).
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Abstract
Objective

The aim of this study was to identify the profile of cancer patients admitted in the intensive care unit (ICU) and compares the outcomes with non-cancer patients hospitalized in the same period.

Design

This is a cross-sectional study.

Setting

Data were collected from medical records at Hospital Universitário Santa Terezinha, Joaçaba-SC, Brazil.

Patients

Admitted at ICU from April to November 2018.

Interventions

NA.

Main variables of interest

ICU outcomes.

Results

Of the 183 patients, 92 were cancer patients and 91 were non-cancer patients. There was a predominance of females for cancer and males for non-caner group, mostly elderly. Most hospitalizations of cancer patients were postoperative (49.4%). The cause of hospitalization of non-cancer patients was pneumonia, followed by traumatic brain injury, postoperative period, polytrauma, and septicemia. On the Sequential Organ Failure Assessment (SOFA) scale, cancer patients scored an average of 7.8 (±4.2) and on the Acute Physiology and Chronic Health Disease Classification System (APACHE II) 13.3 points (±8.6), whereas non-cancer scored 7.6 (±3.55) and 20.9 points (±7.2), respectively. Non-cancer patients used more invasive mechanical ventilation and vasoactive drugs.

Conclusion

Cancer patients received less sedation and used less mechanical ventilation than non-cancer patients. In addition, cancer patients had a lower APACHE II score, denoting a less severe condition. Most surgical cancer patients demonstrate to benefit from intensive care, but it is still necessary to create more specific criteria for ICU admission.

Keywords:
Intensive care
Cancer
Outcomes
Resumen
Objetivo

El objetivo de este estudio fue identificar el perfil de los pacientes con cáncer ingresados en la unidad de cuidados intensivos (UCI) y comparar los resultados con los pacientes no oncológicos hospitalizados en el mismo período.

Diseño

Se trata de un estudio transversal.

Ámbito

Los datos se recogieron de las historias clínicas.

Pacientes

Ingresados en la UCI de abril a noviembre del año 2018 en el Hospital Universitário Santa Terezinha, Joaçaba-SC, Brasil.

Intervenciones

NA.

Variables de interés principales

Resultados de la UCI.

Resultados

De los 183 pacientes, 92 eran pacientes con cáncer y 91 eran pacientes sin cáncer. Hubo predominio del sexo femenino para el cáncer y del sexo masculino para el grupo sin cáncer, en su mayoría ancianos. La mayoría de las hospitalizaciones de pacientes oncológicos fueron postoperatorias (49,4%). La causa de hospitalización de los pacientes no oncológicos fue la neumonía, seguida del traumatismo craneoencefálico, el postoperatorio, el politraumatismo y la septicemia. En la escala Sequential Organ Failure Assessment (SOFA), los pacientes oncológicos obtuvieron una puntuación media de 7,8 (±4,2) y en el Acute Physiology and Chronic Health Disease Classification System (APACHE II) 13,3 puntos (±8,6), mientras que los no oncológicos obtuvieron una puntuación de 7,6 (±3,55) y 20,9 puntos (±7,2), respectivamente. Los pacientes sin cáncer utilizaron ventilación mecánica más invasiva y fármacos vasoactivos.

Conclusión

Los pacientes con cáncer recibieron menos sedación y usaron menos ventilación mecánica que los pacientes sin cáncer. Además, los pacientes con cáncer tenían una puntuación APACHE II más baja, lo que indica una condición menos grave. La mayoría de los pacientes oncológicos quirúrgicos demuestran beneficiarse de los cuidados intensivos, pero aún es necesario crear criterios más específicos para el ingreso en la UCI.

Palabras clave:
Cuidados intensivos
Cáncer
Resultados
Texto completo
Introduction

The epidemiological transition, with the aging of the population, could lead to important changes in the profile of patients admitted to intensive care. Brazilian statistics indicate that the elderly population will increase from 10.5 to 15% in 2025.1 Aging causes an increased vulnerability to diseases, including cancer. Its incidence increases with age, possibly because the advancing years accumulate risk factors for various types of neoplasms, associated with a lower effectiveness of cellular repair mechanisms.2

To face the public health problem caused by the increase in the incidence of cancer, many actions have been developed in the field of prevention, some with great efficiency and visibility, such as the reduction of smoking, early detection campaigns and vaccines, such as hepatitis B and, more recently, HPV. The World Health Organization estimates that effective prevention measures could reduce the incidence of new cases of cancer by up to 40%.3,4

With regard to treatment, 80% of patients require a surgical procedure at some point in the course of the disease, and probably needing chemotherapy and/or radiotherapy.3 The use of the intensive care unit has been frequently used for the hospitalization of cancer patients, both clinical and in the immediate postoperative period. However, during this process, these patients may be exposed to factors that can trigger complications, such as: hospital infections, immobility, pressure ulcers and oral alterations,5 even the most serious ones like sepsis and septic shock.6

There are still a large number of ICU admissions of cancer patients with no clinical perspectives, with a poor prognosis, in palliative care or with an indication for it, who evolve with clinical worsening within this unit, impacting high mortality rates, high cost with therapies, procedures and length of stay.7–9

Given the above and that cancer patients may need intensive care, it is necessary to know this group of patients and investigate the perspectives of such patients with ICU admission.10,11 In this study, we sought to identify the profile of oncological patients hospitalized in an ICU, comparing it to the profile and outcomes of non-oncological patients who required ICU admission during the study period.

Methods

Cross-sectional study, with patients admitted to the ICU of the Hospital Universitário Santa Terezinha (HUST), from April to November 2018.

Data collection was carried out by consulting the medical records and completing the data collection instrument prepared by the authors. Clinical data and outcomes of cancer and non-cancer patients admitted at ICU during the study period were collected. The Microsoft Excel 2010 software was used for data tabulation and the statistical analysis was performed using the IBM SPSS Statistics (version 22.0). To analyze the categorical variables, Fisher's exact test was used for 2×2 tables and the univariate analysis of Pearson's Chi-square for the others. To compare means, Student's T test for independent samples was used. The statistical significance value adopted was p<0.05. The present study strictly followed the precepts contained in Resolution n. 466/2012 of the National Research Ethics Committee, starting only after approval by the UNOESC/HUST Research Ethics Committee (n° 1,984,980).

Results

During the study period, 183 patients were included, with a mean age of 62.4±15.9 years for cancer and 61.4±22.2 years for non-cancer patients. Among cancer patients, 52.2% (n=48) were female, while in non-cancer patients, 48.4% (n=44). The mean Body Mass Index (BMI) for cancer was 24.1±4.7kg/m2 and 26.1±4.7kg/m2 for non-cancer patients. The APACHE II score at ICU admission an average of 13.3±8.6 for cancer patients and 20.9±7.3 for non-cancer patients, that means, a potential higher mortality risk for non-cancer patients in ICU (Table 1).

Table 1.

Profile of patients admitted to the intensive care unit (ICU) in the study period (n=183).

  Cancer patients  Non-cancer patients  p 
  92 (50.2%)  91 (49.7%)   
Sex n (%)
Female  48 (52.2)  44 (48.4)  0.658
Male  44 (47.8)  47 (51.6) 
Previous comorbidity n (%)
Yes  47 (51.1)  49 (53.8)  0.768
No  45 (48.9)  42 (46.2) 
Age (years) (mean±SD)  62.4±15.9  61.4±22.2  0.729 
BMI (kg/m2) (mean±SD)  24.1±4.7  26.1±4.7  0.115 
SOFA score (mean±SD)  7.8±4.2  7.6±3.5  0.826 
APACHE II score (mean±SD)  13.3±8.6  20.9±7.3  0.101 
Cause of Hospitalization n (%)
Pneumonia    11 (12%)   
Traumatic brain injury    9 (9.9%)   
Postoperative    9 (9.9%)   
Treatment n (%)
Oncological surgery  44 (49.4%)     
Chemotherapy+surgery  23 (25.8%)     
Surgery+chemotherapy+radiotherapy  8 (9%)     
Surgery+radiotherapy  3 (3.4%)     

Regarding the treatment of cancer patients, cancer surgery was performed in 49.4% of patients, followed by chemotherapy plus surgery in 25.8%, chemotherapy alone 12.4%, cancer surgery plus chemotherapy and radiotherapy 9% and radiotherapy with surgery 3.4%. The main causes of hospitalization of non-cancer patients were pneumonia in 12%, Traumatic Brain Injury (TBI) in 9.9%, and postoperative care in 9.9% (Table 1).

Comparing the interventions received during ICU stay, we observed that 35.2% of the non-cancer patients used vasoactive drugs versus 22.8 of cancer patients (p=0.074), and 68.1% of non-cancer patients were sedated, compared to 46.7 of the cancer patients (p=0.004). The oxygen was used in 38% of the cancer patients and in 29.7% of the non-cancer patients (p=0.275), while non-cancer patients used more IMV (75.8% vs 52.1%; p=0.01). The diagnosis of sepsis was found in 7.6% of the cancer patients and in 22% of the non-cancer patients (p=0.007). ICU discharge was observed in 68.5 of cancer patients and 62.6 of non-cancer patients (p=0.439) (Table 2).

Table 2.

Clinical characteristics of oncology and non-oncology patients admitted to the intensive care unit (ICU) (n=183).

  Cancer patients  Non-cancer patients  p 
  92 (50.2%)  91 (49.7%)   
Vasoactive drug use – n (%)
Yes  21 (22.8)  32 (35.2)  0.074
No  71 (53.3)  59 (64.8) 
Sedation – n (%)
Yes  43 (46.7)  62 (68.1)  0.004
No  49 (53.3)  29 (31.9) 
Oxygen therapy – n (%)
Yes  35 (38.0)  27 (29.7)  0.275
No  57 (62.0)  64 (70.3) 
Invasive mechanical ventilation – n (%)
Yes  47 (51.1)  69 (75.8)  0.001
No  45 (48.9)  22 (24.2) 
Sepsis – n (%)
Yes  7 (7.6)  20 (22.0)  0.007
No  85 (92.4)  71 (78.0) 
ICU outcome– n (%)
Discharge  63 (68.5)  57 (62.6)  0.439
Death  29 (31.5)  34 (37.4) 

The mean of the sedation's duration was 7.5±5.5 days for cancer patients and 5.6±5.0 days for non-cancer (p=0.074), and mean duration of the IMV use was 8.5±7.5 days for cancer and 9.6±10.7 days for non-cancer patients (p=0.570). The length of stay in the ICU was on average 9.3±9.6 days for non-cancer and 6.8±7.3 days for cancer patients (p=0.046) (Table 3).

Table 3.

Clinical characteristics of oncology and non-oncology patients admitted to the intensive care unit (ICU) (n=183).

  Cancer patients  Non-cancer patients  p 
  92 (50.2%)  91 (49.7%)   
Time of sedation (days) (mean±SD)  7.5±5.6  5.6±5.0  0.074 
Duration of mechanical ventilation (days) (mean±SD)  8.5±7.5  9.6±10.7  0.570 
ICU stay (days) (mean±SD)  6.8±7.4  9.3±9.7  0.046 

When we separated the cancer patients between surgical and non-surgical patients, was observed an important difference in the ICU mortality rate. The mortality rate for surgical patients was 19.7%, while for non-surgical patients was 71.4% (p=0.000) (Table 4).

Table 4.

Intensive care unit (ICU) outcome of surgical and clinical oncology patients (n=183).

  Surgical patients  Clinical patients  p 
  66 (75.9%)  21 (24.1%)   
ICU outcome – n (%)
Discharge  53 (80.3)  6 (28.6)  0.000 
Death  13 (19.7)  15 (71.4)   
Discussion

In this cohort of patients, admitted in the ICU of a hospital that is a regional reference in cancer treatment, we do not find any difference related to age, sex and BMI, between cancer and non-cancer patients. According to estimates carried out by INCA12 the incidence rates of new cancer cases is higher in men (324,580cases/year) than in women (310,300cases/year),12 as well as other studies where male prevalence was also obtained.13 In non-cancer patients, we observed a higher prevalence of males, which is reinforced by other studies that indicate that in many countries, men are more commonly admitted to the ICU and are more likely to receive more aggressive support than women.14

Both cancer and non-cancer patients were elderly, that is, over 60 years old. This public's demand for care in critical units tends to happen because population aging is growing every year, especially in developing countries. Several studies identified the same age profile of patients admitted to the ICU.13,15,16 The elderly population uses hospital services more intensively than other age groups, implying higher costs, duration of treatment and slower recovery.1

In non-cancer patients was observed a high rate of IMV use. Although risk factors associated with the use of IMV in the studied patients were not analyzed, it is known that the population most frequently in need of ventilatory support is the same represented in the study, that is, male and over 60 years old, which reproduces what is usually seen in other general services.17,18 Although the high APACHE II score at admission in non-cancer patients, and the risk of complications observed in cancer patients, the mean of IVM duration was 8.5±7.5 days for cancer and 9.6±10.7 days for non-cancer patients, much less than the 21 days or more to characterize the prolonged mechanical ventilation.19

According to the 2nd Brazilian Consensus of ICUs, the average length of stay is 1–6 days, but non-cancer patients had an average ICU stay of 9.3 days, which is considered risk factors for complications, as there are several invasive procedures performed, which often leads to a hospital infection, such as sepsis, urinary tract infection, pressure ulcer, further worsening the patient's condition.20 Cancer patients had an average of 6.8 days of ICU stay, significantly less than non-cancer patients.

Sedation was more common in non-cancer patients, probably associated with the disease severity (higher APACHE II), and the need for ventilatory support. Although sedation is used to reduce anxiety and promote amnesia in patients undergoing mechanical ventilation, as well as to facilitate the care provided by professionals, excessive use is associated with increased duration of mechanical ventilation, longer ICU stay, and increased rates of delirium and mortality.21 The use of vasoactive drugs were also more frequent in non-cancer patients, what is expected, due the high rate of sepsis in this group, in addition to the more severe disease, use of IMV and sedation.22

Despite non-cancer patients were more sedated, needed more IMV, had a higher rate of sepsis, and stayed for more time in ICU, the mortality rate was similar to cancer patients, as previous shown in other studies.7,12 On the other hand, when we analyzed the mortality in cancer patients, comparing the surgical with the clinical patients, we observed an important difference (19.7% of mortality for surgical and 71.4% for clinical patients). This is also expected, because postoperative patients have a lower chance of complications, and they were not hospitalized due to clinical intercurrences, exactly the opposite of clinical oncological patients, who are admitted at ICU due clinical complications.

This study has some limitations, as the size of the sample, the single center characteristic, and the short time of data collection.

Conclusion

In this study, we found that cancer patients admitted in the ICU, most postoperative patients, were less sedated, needed less IMV, had a lower rate of sepsis, and stayed for less time in ICU, compared to non-cancer patients, despite the mortality rate between them was similar.

While most postoperative cancer patients demonstrate to benefit from intensive care, clinical cancer patients presented a poor prognosis, what suggest that is still necessary to create more specific admission criteria for cancer patients, taking into account the particularities of the disease and their previous clinical status.

Contribution of the authors

PZ: conceived and designed the analysis; collected the data; contributed data and analysis tools; wrote the paper. MEG: performed the analysis; wrote the paper. LT: conceived and designed the analysis; collected the data. MCA: conceived and designed the analysis; collected the data. SFH: wrote the paper; review the manuscript. ARB: conceived and designed the analysis; contributed data and analysis tools; performed the analysis; wrote the paper.

Funding

No funding was received in this project.

Conflict of interest

Petra Zieher: No conflict to declare.

Márcia Eliane Giuliato: No conflict to declare.

Luana Turra: No conflict to declare.

Mariane Carolina de Almeida: No conflict to declare.

Sara Fernanda Hilgert: No conflict to declare.

Antuani Rafael Baptistella: No conflict to declare.

Acknowledgements

Authors would like to thank the team of the ICU of the Hospital Universitário Santa Terezinha.

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