Critical Care Specialists of Cancer Patients: 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

Providing High-Quality ICU Care 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

Conflicts of Interest: Founder and R&D Director at Epimed Solutions Financial Support: Research grants from FAPERJ and CNPq; departmental funds from IDOR

What we have learned in the last 25 yrs... Carlon GC. Crit Care Med 1989

Research in ICU Cancer Patients Pubmed: 6,263 articles 1970 2017

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?

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

Better outcomes than commonly perceived in different scenarios… Acute respiratory failure + need of MV Acute kidney injury Chemotherapy - recent use / use in ICU Prolonged ICU admission Neutropenia Autollogous BMT Azoulay et al. CCM 2001; Soares et al. CCM 2005; Azevedo et al. Chest 2014 Benoit et al, NDT 2005; Soares et al. JCO 2006; Darmon ICM 2007; Maccariello et al. NDT 2011 Darmon et al. CCM 2005; Benoit et al, ICM 2006; Vandjick et al. ICM 2008 Soares et al. Chest 2008 Souza-Dantas et al. Ann Oncol 2011; Legrand et al. CCM 2012 Khassavneh et al. Chest 2002

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

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 Unpublished

The higher the time to intervention, the higher the mortality Song et al. ICM 2012

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

Severity scores are unrealiable for individual decision-making SAPS 3 APACHE II Severity scores are unrealiable for individual decision-making

Intensivists are usually overpessimistic regarding short- and long-term outcomes Hemato-oncologists are overoptimistic regarding short- and long-term outcomes

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

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

All cancer patients for whom ICU admission was requested Bedridden / Poor PS Palliative care only Refusal ICU admission Other intermediate situations Newly diagnosed disease First-line treatment 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

Different ICU Admission Policies for Cancer Patients Azoulay E, Soares M, Darmon M, et al. Managing Critically Ill Cancer Patients: Another Medical Success Story? Ann Intensive Care 2011

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

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

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

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!

Research in ICU Cancer Patients Pubmed: 6,263 articles 1970 2017 Most of the studies focused on outcomes, triage procedures and management of different clinical conditions and complications.

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?

CA Cancer Journal 2017

CA Cancer Journal 2017

CA Cancer Journal 2017

There are many more people living with cancer, ever in advanced stages of the disease CA Cancer Journal 2017

Lancet 2015

Kato et al. Lung Cancer 2017 Kushnir & Wolf. Cardiology 2017

Demand for ICU care is expected to increase substantially 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% Demand for ICU care is expected to increase substantially Critical care is essential in the supportive care of cancer patients!

Shi et al. JCO 2013

Shi et al. JCO 2013 Soares & Salluh, JCO 2014

Critical care management and use of ICU resources are uniformly out of all those agendas

The healthcare system is changing fast...

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

The healthcare system is changing fast...

The healthcare system is changing fast...

Ong et al. JAMA Oncol 2017 Goldstein. JAMA Oncol 2016 Alvarnas. JAMA Oncol 2015

The way our patients expect we care for them as well...

ICM 2007

The way our patients expect we care for them as well...

And also the way care providers expect

And also the way care providers expect

The Fourth Aim

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?

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;

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 How to bridge the gap between specialized and general hospitals to meet the need for an increasing demand for ICU care ? Soares & Salluh. CCM 2011; Azoulay et al. AIC 2011;

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

9,946 cancer patients admitted to 70 ICUs during 2013. ORCHESTRA Study 9,946 cancer patients admitted to 70 ICUs during 2013. ORCHESTRA Study. JCO 2016

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)

Subgroup Analyses

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

Admission Volume Effect on Hospital Mortality (adjusted for patients and ICU characteristics) All patients (n=9946) 0.992 (0.979-1.004)

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)

Specialized and general hospitals can achieve comparable clinical outcomes and efficiency ORCHESTRA Study. JCO 2016

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

Three Systems of Improved Care Delivery Moving toward systemic gains in efficiency Three Systems of Improved Care Delivery

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