1. 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

2. 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

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

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

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

6. 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?

7. 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

8. 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

9. 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

10. 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 Unpublished

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

12. 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

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

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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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 %
ORCHESTRA (Soares et al. ICM 2015) %
Critical care is essential in the supportive care of cancer patients!

23. 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.

24. 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?

25. CA Cancer Journal 2017

26. CA Cancer Journal 2017

28. CA Cancer Journal 2017

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

30. Lancet 2015

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

32. 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 %
ORCHESTRA (Soares et al. ICM 2015) %
Demand for ICU care is expected to increase substantially
Critical care is essential in the supportive care of cancer patients!

33. Shi et al. JCO 2013

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

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

37. The healthcare system is changing fast...

38. 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

39. The healthcare system is changing fast...

40. The healthcare system is changing fast...

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

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

43. ICM 2007

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

46. And also the way care providers expect

47. And also the way care providers expect

48. The Fourth Aim

49. 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?

50. 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;

51. 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;

52. 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

53. 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

54. Multivariate Multilevel Models - Hospital Mortality
(adjusted for admission diag. comorbidities, functional status, MV on Day1, SOFA)
Type of hospital
General
Referral cancer center ( )
Training programs in critical care ( )
Clinical pharmacist in the ICU ( )
Daily meetings between oncologists and intensivists for care planning in all patients ( )
Clinical protocols (n) ( )

55. Subgroup Analyses

56. Variables Associated with High Efficiency
(adjusted ORs)
Daily meetings between oncologists and intensivists
4.70 ( )
Clinical Protocols (n) ( )
ORCHESTRA Study. JCO 2016

57. Admission Volume Effect on Hospital Mortality
(adjusted for patients and ICU characteristics)
All patients (n=9946) ( )

58. Admission Volume Effect on Hospital Mortality
(adjusted for patients and ICU characteristics)
All patients (n=9946) ( )
Surgical patients (n=4929) ( )
Medical patients (n=5017) ( )
Solid tumors (n=8956) ( )
Hematological malignancies (n=990) ( )
Patients stratified according to the SAPS 3 tertiles
1st tertile (<40 points) (n=3334)) ( )
2nd tertile (40-55 points) (n=3458) ( )
3rd tertile (>55 points) (n=3154) ( )

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

60. 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

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

63. 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