Special article
Intensive care in cancer patients in the age of immunotherapy and molecular therapies: Commitment of the SEOM-SEMICYUC
Cuidados intensivos en pacientes con cáncer en la era de la inmunoterapia y las terapias moleculares: el compromiso de la SEOM-SEMICYUC
A. Carmona-Bayonasa, F. Gordob, C. Beatoc, J. Castaño Pérezd, P. Jiménez-Fonsecae, J. Virizuela Echaburuc, J. Garnacho-Monterof,
Autor para correspondencia
a Hematology and Medical Oncology Department, Hospital Universitario Morales Meseguer, Instituto Murciano de Investigación Biosanitaria (IMIB), UMU, Murcia, Spain
b Servicio de Medicina Intensiva, Hospital Universitario del Henares (Coslada-Madrid), Grupo de investigación en patología crítica, Facultad de Ciencias de la Salud, Universidad Francisco de Vitoria, Pozuelo de Alarcón, Madrid, Spain
c Medical Oncology Department, Hospital Universitario Virgen de la Macarena, Sevilla, Spain
d Intensive Care Department, Virgen de las Nieves University Hospital, Granada, Spain
e Medical Oncology Department, Hospital Universitario Central de Asturias, Oviedo, Spain
f Intensive Care Clinical Unit, Hospital Universitario Virgen Macarena, Sevilla, Spain
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"apellidos" => "Jiménez-Fonseca" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] ] ] 5 => array:3 [ "nombre" => "J." "apellidos" => "Virizuela Echaburu" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 6 => array:4 [ "nombre" => "J." "apellidos" => "Garnacho-Montero" "email" => array:1 [ 0 => "jgarnachom@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">f</span>" "identificador" => "aff0030" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:6 [ 0 => array:3 [ "entidad" => "Hematology and Medical Oncology Department, Hospital Universitario Morales Meseguer, Instituto Murciano de Investigación Biosanitaria (IMIB), UMU, Murcia, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Medicina Intensiva, Hospital Universitario del Henares (Coslada-Madrid), Grupo de investigación en patología crítica, Facultad de Ciencias de la Salud, Universidad Francisco de Vitoria, Pozuelo de Alarcón, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Medical Oncology Department, Hospital Universitario Virgen de la Macarena, Sevilla, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Intensive Care Department, Virgen de las Nieves University Hospital, Granada, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Medical Oncology Department, Hospital Universitario Central de Asturias, Oviedo, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Intensive Care Clinical Unit, Hospital Universitario Virgen Macarena, Sevilla, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Cuidados intensivos en pacientes con cáncer en la era de la inmunoterapia y las terapias moleculares: el compromiso de la SEOM-SEMICYUC" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1246 "Ancho" => 1367 "Tamanyo" => 75099 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The virtuous circle of multidisciplinary cancer treatment.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Cancer patients, even those who respond to treatment and become long-term survivors, are exposed to numerous potential risks, including the most obvious one: progression of their cancer. To name just a few of these dangers, respiratory failure is estimated to affect between 10 and 50%<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">1</span></a>; febrile neutropenia in 5–50%, with severe complications or acute organ failure in some 25%<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">2</span></a>; thromboembolic disease develops in 20% and is associated with hemodynamic instability in a high percentage of cases.<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">3</span></a> Putting end-of-life palliative care aside, many of these patients with severe complications, such as sepsis, respiratory failure, severe toxicities, etc. are cared for on Oncology wards.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Recently, several observational registries have estimated a cumulative incidence of Intensive Care Unit (ICU) admissions of cancer patients of approximately 5–7%, although this figure varies considerably depending on tumor type and other variables.<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">4–6</span></a> To translate this into absolute terms, we must bear in mind that cancer is a leading cause of morbi-mortality worldwide, with approximately 14 million new cases per year.<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">7,8</span></a> The trend is growing and population estimates point toward a rising number of new cases in the coming two decades to reach 22 million diagnoses every year. Therefore, more and more cancer patients are expected to be eligible for ICU admission.<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">9</span></a> At present, roughly 15% of all ICU admissions are oncological patients and, according to the SEER (Surveillance, Epidemiology, and End Results) data, a yearly increase of 6.6% was recorded between 1993 and 2002.<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">10</span></a> Although part of that can be attributed to the epidemiological patterns of cancer,<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">11</span></a> as oncological treatments become more and more efficacious and patient prognosis improves, the need for critical care is likely to intensify.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Improved prognosis for oncological patients</span><p id="par0015" class="elsevierStylePara elsevierViewall">Cancer patients have typically been regarded as highly vulnerable. Nevertheless, for the last 15 years, population registries have consistently reported improved survival.<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">12,13</span></a> Beyond the contribution of early diagnosis and palliative and supportive care, this prolonged survival is due to a new generation of targeted cancer treatments.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Since the Food and Drug Administration (FDA) approved the use of the first targeted drug, trastuzumab in September 1998,<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">14</span></a> tens of molecules have been integrated into our therapeutic arsenal.<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">15</span></a> For instance, imatinib now enables more than 50% of patients with gastrointestinal stromal tumors (GIST), previously deemed rapidly fatal, to survive for more than 5 years.<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">16</span></a> The first CTLA-4-blocking antibody for the treatment of melanoma, ipilimumab, was approved in 2011. Since then, new immuno-oncology strategies have revolutionized the treatment of various neoplasms, including pre-treated individuals, previously considered refractory to any therapy. Thus, the KEYNOTE-010 trial has recently proven that pembrolizumab (anti-PD1 antibody) could achieve long-term survival rates of 21–25% in previously treated lung cancer patients, in comparison with the anecdotal survival of those who receive conventional chemotherapy.<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">17</span></a> In melanoma, ipilimumab, anti-PD1 antibodies, and anti-MEK or anti-BRAF drugs yield 12-month survival rates of some 75%, which is very uncommon with chemotherapy alone.<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">18</span></a> In another common tumor, colorectal cancer, median survival has gone from 6 to more than 30 months in recent years,<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">19</span></a> with the possibility of cure following metastasectomy and combined treatments.<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">20</span></a> Essentially, all prevalent tumors have attained similar improvements in survival. Furthermore, the research agenda into new targets is vast and other novelties include poly(ADP-ribose) polymerase (PARP) inhibitors, cyclin-dependent kinases 4 and 6 (CDK4/6) inhibitors, antiangiogenics, or multi-targeted tyrosine kinase inhibitors, among others.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The benefit of these strategies surpasses that of the intrinsic effect of the drugs. The availability of effective therapies comprises a stimulus that opens the way to progress on other levels, including more ambitious indications and surgical techniques for primary tumors and metastases, individualized treatments, and better diagnostic processes and outcome evaluation.</p><p id="par0030" class="elsevierStylePara elsevierViewall">This is a virtuous circle, seen as a feedback process in which a beneficial event sets off a chain of favorable outcomes that spreads to other levels, stimulating efforts of other specialists, which, in turn, results in more cancer patients benefitting from therapies and coming back to amplify the original positive effects (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Novel drugs not only lead to greater expectations, but also new challenges and toxicities.<a class="elsevierStyleCrossRefs" href="#bib0370"><span class="elsevierStyleSup">15,21</span></a> In the previous decade, a generation of oncologists had learned that some of the most intense and aggressive antineoplastic strategies (e.g., taxanes for adjuvant use in breast cancer) were theoretically efficacious, but would only truly be applicable when they could properly prevent and treat the most severe complications and toxicities.<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">22,23</span></a> Today, it is crucial that these lessons from the past not be squandered; instead, we must endeavor to apply them in the new emerging scenario.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Cause for ICU admission of oncological patients</span><p id="par0040" class="elsevierStylePara elsevierViewall">More and more of these patients are being admitted to the ICU to manage infectious or non-infectious complications associated with the disease itself, treatment side effects, or for an ailment unrelated to their cancer requiring ICU care. Shock, respiratory failure, neurological impairment, and acute kidney failure are the leading causes of ICU admissions of cancer patients.<a class="elsevierStyleCrossRefs" href="#bib0415"><span class="elsevierStyleSup">24,25</span></a> Moreover, approximately 30% of all oncological patients (including those with hematologic cancers) who are admitted to the ICU present neutropenia,<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">26</span></a> traditionally believed to associate extremely high mortality that advised against their admission to the ICU, given its futility. Moreover, another growing plethora of reasons for admission is currently accepted, such as the management of specific syndromes (e.g., tumor lysis, airway obstruction, severe hydroelectrolyte imbalance, immune-mediated adverse effects, or desensitization to cytostatics).</p><p id="par0045" class="elsevierStylePara elsevierViewall">Admission is currently deemed reasonable for patients with non-small-cell lung cancer with epidermal growth factor receptor (EGFR) or anaplastic lymphoma kinase (ALK) mutations who debut with respiratory failure and require mechanical ventilation (MV). In these conditions, tyrosine kinase inhibitors (TKI), such as erlotinib or crizotinib, are correlated with rapid tumor response and dramatic recovery.<a class="elsevierStyleCrossRefs" href="#bib0430"><span class="elsevierStyleSup">27,28</span></a> Urgent chemotherapy has even been administered together with intensive support treatments that include MV. The need for chemotherapy for patients with recently diagnosed an advanced tumor should not contraindicate ICU admission; in fact, it may well be feasible in selected cases.<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">29</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Improved prognosis for oncological patients admitted to ICU</span><p id="par0050" class="elsevierStylePara elsevierViewall">Advances in early diagnosis and the development of new treatments have significantly prolonged survival in cancer patients in the ICU runs by intensivists. This is due to a series of incremental insights into the physiopathology of the diseases, particularly, multiorgan failure, and breakthroughs in diagnostics and treatment (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Progress includes better diagnostic techniques (e.g., diagnosis of respiratory distress), stratification scales, sepsis and febrile neutropenia algorithms, the development of antifungals, or non-invasive MV.<a class="elsevierStyleCrossRefs" href="#bib0445"><span class="elsevierStyleSup">30–33</span></a> The outcome of all this is that, one by one, results have also begun to improve for subgroups with specific complications, confirming general trends.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">In contrast, it has not been easy to demonstrate a general increase in survival in time series of patients with cancer admitted in ICUs.<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">34</span></a> There is rarely a direct answer to this type of question, since both complications and patients are diverse and we still lack data from the post-immunotherapy era and long-term outcomes, enriched with accurate descriptions of the oncological context.<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">34</span></a> Most of the survival data published in these conditions still lack all the contextualized information from an oncological perspective that we would like, so as to have a clear idea of what is indeed going on.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Nevertheless, series in the 1990s reported extremely high intrahospital mortality rates in this population, especially in individuals with neutropenic sepsis, bone marrow transplant, or ventilatory failure. In recent decades, we have witnessed an important fall in mortality among cancer patients admitted into these units, from 80% (all but universal when MV was needed) to 40% (∼60% when MV is required) at present.<a class="elsevierStyleCrossRefs" href="#bib0470"><span class="elsevierStyleSup">35–40</span></a> One meta-analysis that pooled 38 studies of cancer patients necessitating admission to ICU examined a total of 6054 patients (2097 neutropenic). During the study period (2005–2015), mortality declined by 11%.<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">26</span></a> Interestingly, the crude mortality rate for neutropenic vs. non-neutropenic patients rose by 10%. However, after adjusting for confounding variables, neutropenia did not significantly impact mortality. In fact, it is currently thought that cancer patients benefit from ICU admission just as much as individuals with other underlying medical conditions, such as cirrhosis of the liver or chronic heart failure.<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">40</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">On the other hand, MV was previously considered to be futile, but given the improved survival rate achieved in the last decade thanks to positive pressure ventilation (PPV),<a class="elsevierStyleCrossRefs" href="#bib0500"><span class="elsevierStyleSup">41,42</span></a> current thought is that invasive or non-invasive PPV should be used in cancer patients with acute respiratory failure receiving curative or palliative treatment, with good functional status, and consistent with patients’ wishes, since hospital survival is 60% when it is implemented. A recent study conducted in England, Wales, and Northern Ireland of more than 90,000 patients with solid tumors admitted to intensive care between 1997 and 2013 revealed greater survival between 2009 and 2013 as opposed to the previous period and a mortality rate of only 26%.<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">43</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Early treatment of the critical cancer patient</span><p id="par0070" class="elsevierStylePara elsevierViewall">Early admission of critical oncological patients improves their prognosis and has been identified as an independent factor associated with higher survival rates.<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">44,45</span></a> We know that many of the techniques applied in the ICU achieve better outcomes when initiated early and that delaying treatments entails a worse prognosis for all patients.<a class="elsevierStyleCrossRefs" href="#bib0525"><span class="elsevierStyleSup">46,47</span></a> This is evident in the case of sepsis that cancer patients often develop, as well as in cases of acute respiratory failure that benefit from early ventilatory support.<a class="elsevierStyleCrossRefs" href="#bib0490"><span class="elsevierStyleSup">39,48</span></a> Early administration of non-invasive respiratory support (non-invasive MV or high-flow nasal oxygen) has proven to be efficacious in these patients in preventing the need for invasive MV and lower mortality in cancer patients with respiratory failure.<a class="elsevierStyleCrossRefs" href="#bib0540"><span class="elsevierStyleSup">49,50</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Shared decision-making for cancer patient admission to intensive care</span><p id="par0075" class="elsevierStylePara elsevierViewall">We are currently seeing a paradigm shift as regards treatment approach and admission of patients with active oncological disease to ICU<a class="elsevierStyleCrossRefs" href="#bib0505"><span class="elsevierStyleSup">42,51</span></a> owing to different circumstances, such as a change in prognosis for cancer in recent years even after being admitted to an ICU,<a class="elsevierStyleCrossRefs" href="#bib0555"><span class="elsevierStyleSup">52,53</span></a> improved quality of life after receiving treatment, and the evolution of monitoring systems and treatment in Intensive Care, enabling less invasive and aggressive support, adapting treatment to the patient, as well as possibly to a change in thinking about treatment objectives in caring for critical patients.<a class="elsevierStyleCrossRef" href="#bib0565"><span class="elsevierStyleSup">54</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">In 2011, an international consensus was published on ICU admission criteria in patients with cancer.<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">42</span></a> The consensus established different groups of possible alternatives and treatment steps, ranging from admission for the use of all treatment measures available to different treatment options to suit each patient's true aims, including alternatives for treatments that can potentially cause immediate complications and alternatives for palliative treatment.</p><p id="par0085" class="elsevierStylePara elsevierViewall">In general, we can state that at present, admission of this group of patients to the ICU would be justified in four circumstances:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">(1)</span><p id="par0090" class="elsevierStylePara elsevierViewall">The reason for ICU admission must be reversible, regardless of the cancer.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">(2)</span><p id="par0095" class="elsevierStylePara elsevierViewall">The prognosis for the cancer itself justifies applying potentially aggressive treatments, given the expectation of being able to maintain adequate subsequent quality of life.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">(3)</span><p id="par0100" class="elsevierStylePara elsevierViewall">The patient, or their legal representatives when necessary, does not refuse treatment in the ICU.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">(4)</span><p id="par0105" class="elsevierStylePara elsevierViewall">The patient has good quality of life prior to the complication, with feasible cancer treatment options and reasonable expectation for survival.</p></li></ul></p><p id="par0110" class="elsevierStylePara elsevierViewall">Be that as it may, we believe that at present, these patients can clearly benefit from the existence of a closer relationship between Oncology and Intensive Care Medicine. This would entail setting up top quality, structured consultations between both services. The prognosis for each patient must be adequately and accurately established, planning ahead (together with the patient and their family) for possible complications, creating plans for future treatment, and contemplating early admission or adequate treatment for organ dysfunction, as well as palliative treatment plans. The ICU trial admission policy, with rapid transition to Palliative Care if evolution is unfavorable, is a particularly appropriate admission model for some patients with advanced cancer.<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">55</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Progress undoubtedly implies new responsibilities for all professionals involved in treating cancer; however, they also call for important organizational repercussions for each center's daily activity. Additionally, in terms of pharmacoeconomics, the only way to amortize the huge investments of resources in anti-cancer treatments is through proper, efficient, and rational decision-making that also factors in support for toxicities and complications.</p><p id="par0120" class="elsevierStylePara elsevierViewall">One possibility that has grown in recent years is multi-professional, inter-specialty collaboration in managing these individuals in the initial stages on regular wards, with follow-up by means of systems that alert of both clinical and analytical decline, allowing us to get a jump on complications.<a class="elsevierStyleCrossRefs" href="#bib0545"><span class="elsevierStyleSup">50,56</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">We must all be aware of the fact that we, as professionals as well as all parties concerned, have cognitive biases that will definitely affect decision-making. Being cognizant of the impact of irrational decision-making on such a vulnerable group of patients is the only way to find a truly better alternative in each case. Therefore and insofar as possible, decisions should be protocolized ahead of time, by means of practicable algorithms accepted by all the hospital teams; goals should be discussed ahead of time with the patients whenever possible, taking into account the families’ wishes and values in other situations of uncertainty.</p><p id="par0130" class="elsevierStylePara elsevierViewall">Given that intensive care physicians do not participate in the patient's overall treatment strategy, they will only be aware of the tip of the iceberg; i.e., a specific critical condition. In contrast, the oncologist, lacking sufficient objective elements, confronts a highly subjective decision. Thus, a 15% discrepancy has been reported between oncologists/hematologists as regards the suitability of transferring a patient to the ICU.<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">25</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Furthermore, the general trend is to look for strategies to lessen the negative impact of ICU admission in this vulnerable population, thereby enabling more patients to benefit from this kind of care. These efforts include open ICU policies, preventive ICU admissions, and the use of critical treatments in controlled conditions outside of the ICU.<a class="elsevierStyleCrossRefs" href="#bib0505"><span class="elsevierStyleSup">42,55</span></a> Management is probably clear for the long-term survivor, complications from adjuvant treatment, or sustained response to immunotherapy over time. However, it is less obvious how these strategies should be individually transmitted to other cases (e.g., unevaluated response) and will probably continue to be open to debate.</p><p id="par0140" class="elsevierStylePara elsevierViewall">A new clinical research agenda has therefore been opened that aspires to gain greater insight into the conditions that lead to full recovery and continuation of anti-neoplastic therapy, subjective endpoints, such as health-related quality of life or symptomatic control, the application of shared decision-making models, and admission policies, in light of new options, as well as investigating the effect of new care modalities and critical management outside of the ICU in a contextualized manner.<a class="elsevierStyleCrossRef" href="#bib0580"><span class="elsevierStyleSup">57</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">The role of the oncologist when the patient is admitted to the ICU</span><p id="par0145" class="elsevierStylePara elsevierViewall">In the age of immunotherapy, determining who is eligible for full code admission (decision to administer all advanced life support techniques if necessary, including cardiopulmonary resuscitation maneuvers and MV), ICU trial (full code for 3–4 days followed by reevaluation of the level of support going forward), or non-admission to ICU can be extremely complex, given the uncertainty surrounding the patient's possibility of becoming a long-term survivor. The oncologist's fundamental role is to contribute their prior knowledge about the patient, prognostic factors, and possibilities for recovery.<a class="elsevierStyleCrossRefs" href="#bib0520"><span class="elsevierStyleSup">45,58</span></a> Cancer is not a single clinical and molecular reality. At present, the mere label of cancer does not suffice and calls for greater knowledge about its molecular alterations, stage, available treatment options, etc. However, it is worth mentioning that recent developments in treating cancer not only fail to ameliorate uncertainty, but instead, actually increase it, given the impossibility of knowing ahead of time which patient is most likely to become a long-term survivor.<a class="elsevierStyleCrossRef" href="#bib0590"><span class="elsevierStyleSup">59</span></a> Once the patient has been admitted to the ICU, the oncologist's role must be to aid in the prevention, diagnosis, and management of specific complications (e.g., drug-induced toxicity, neutropenia, etc.). During follow-up, the oncologist must collaborate with the intensive care physician in decision-making (e.g., initiation of aggressive support measures, transition to Palliative Care, etc.).</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">SEOM-SEMICYUC collaboration</span><p id="par0150" class="elsevierStylePara elsevierViewall">The time has come to revisit the ICU admission policy of some of these patients to optimize their support treatment. As a result of these reflections between professionals of both societies, in June 2017 the first SEOM-SEMICYUC Framework Collaboration Agreement was signed, with the aim of improving the quality of care of cancer patients with critical complications. This agreement is in line with recent work and consensus with institutions around the world.<a class="elsevierStyleCrossRef" href="#bib0580"><span class="elsevierStyleSup">57</span></a> Among the most salient aspects of this agreement are to:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">1.</span><p id="par0155" class="elsevierStylePara elsevierViewall">Contribute to improving care for cancer patients with critical complications for whom intensification of support treatment is indicated.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">2.</span><p id="par0160" class="elsevierStylePara elsevierViewall">Aid in shared decision-making between Oncology and Intensive Care Medicine, by jointly drafting Evidence-Based Clinical Practice Guidelines, setting forth the main indications for ICU admission and treatment of cancer patients, addressing their differences and special characteristics with respect to other patients.</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">3.</span><p id="par0165" class="elsevierStylePara elsevierViewall">Contribute to standardizing care for these patients, reducing unjustified variability, subjectivity, and bias in decision-making.</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">4.</span><p id="par0170" class="elsevierStylePara elsevierViewall">Generate channels of communication to boost information exchange and dialog between both specialties, with the aim of delving deeper into the scientific and ethical aspects of decision-making.</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">5.</span><p id="par0175" class="elsevierStylePara elsevierViewall">Contribute to creating working groups dedicated to specific treatment aspects (infections in immunodepressed individuals, non-invasive MV in cancer patients, etc.).</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">6.</span><p id="par0180" class="elsevierStylePara elsevierViewall">Develop joint clinical registries and clinical or basic research projects that enable us to better understand prognostic factors of critical oncological patients and generating evidence of the best diagnostic and therapeutic approaches.</p></li></ul></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conclusion</span><p id="par0185" class="elsevierStylePara elsevierViewall">Oncological patients’ survival has improved markedly in recent years, coinciding with a decrease in intrahospital mortality among these individuals. With this comes the need for both oncologists and intensive care physicians to change their thinking once and for all about ICU admission for selected patients. Quality consultation among professionals must be fostered to decide on the best attitude to adopt in each case without bias. All patients with possibilities of being cured should be routinely admitted to the ICU (e.g., adjuvant or neoadjuvant therapies). Likewise, patients with chemosensitive tumors, mutations predictive of response with targeted therapies, possibilities of long-term tumor control with immunotherapy, and other specific situations should be deemed eligible for ICU admission, in a concerted manner, on the basis of their distinct characteristics.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conflict of interest</span><p id="par0190" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interests.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:15 [ 0 => array:3 [ "identificador" => "xres1063747" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1011896" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1063746" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1011897" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Improved prognosis for oncological patients" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Cause for ICU admission of oncological patients" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Improved prognosis for oncological patients admitted to ICU" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Early treatment of the critical cancer patient" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Shared decision-making for cancer patient admission to intensive care" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "The role of the oncologist when the patient is admitted to the ICU" ] 11 => array:2 [ "identificador" => "sec0040" "titulo" => "SEOM-SEMICYUC collaboration" ] 12 => array:2 [ "identificador" => "sec0045" "titulo" => "Conclusion" ] 13 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflict of interest" ] 14 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-01-15" "fechaAceptado" => "2018-01-20" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1011896" "palabras" => array:6 [ 0 => "SEOM" 1 => "SEMICYUC" 2 => "Cancer" 3 => "ICU" 4 => "Shock" 5 => "Respiratory failure" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1011897" "palabras" => array:6 [ 0 => "SEOM" 1 => "SEMICYUC" 2 => "Cáncer" 3 => "UCI" 4 => "<span class="elsevierStyleItalic">Shock</span>" 5 => "Insuficiencia respiratoria" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Cancer patients are a vulnerable group exposed to numerous and serious risks beyond cancer itself. In recent years, the prognosis of these individuals has improved substantially thanks to several advances such as immunotherapy, targeted molecular therapies, surgical techniques, or developments in support treatment. This coincides with the prolonged survival of oncological patients admitted to the ICU due to critical complications, and under the supervision of intensivists. The time has therefore come to revisit the intensive care support of these patients, which poses new professional as well as organizational challenges. An agreement was signed in 2017 between the SEOM and SEMICYUC with the aim of improving the quality of care of cancer patients with critical complications. The initiative seeks to aid in decision-making, standardize criteria, decrease subjectivity, generate channels of communication, and delve deeper into the ethical and scientific aspects of these situations. This document sets forth the most important reasons that have led us to undertake this initiative.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Los pacientes con cáncer constituyen un colectivo vulnerable expuesto a numerosos riesgos graves, más allá del cáncer en sí. En los últimos años, el pronóstico de estos individuos ha mejorado sustancialmente gracias a varios avances, como la inmunoterapia, las terapias moleculares específicas, las técnicas quirúrgicas o el desarrollo de los tratamientos de soporte. Esto se traduce en un aumento de la supervivencia de los pacientes oncológicos hospitalizados en la UCI y que son llevados por intensivistas. Por lo tanto, ha llegado el momento de revisar el apoyo de cuidados intensivos para estos pacientes, lo que plantea nuevos desafíos profesionales y de organización. En este marco, en 2017 se firmó un acuerdo entre la SEOM y la SEMICYUC con el objetivo de mejorar la calidad de la atención de pacientes oncológicos con complicaciones críticas. Esta iniciativa busca ayudar en la toma de decisiones, estandarizar criterios, disminuir la subjetividad, generar canales de comunicación y profundizar en los aspectos éticos y científicos de estas situaciones. Este documento establece las razones más importantes que nos han llevado a emprender esta iniciativa.</p></span>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1246 "Ancho" => 1367 "Tamanyo" => 75099 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The virtuous circle of multidisciplinary cancer treatment.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2153 "Ancho" => 2083 "Tamanyo" => 302317 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Summary of progress in intensive management of cancer patients.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:59 [ 0 => array:3 [ "identificador" => "bib0300" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Acute respiratory distress syndrome in patients with malignancies" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "E. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 11 | 14 | 25 |
| 2024 Octubre | 180 | 117 | 297 |
| 2024 Septiembre | 178 | 66 | 244 |
| 2024 Agosto | 177 | 87 | 264 |
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| 2024 Febrero | 160 | 68 | 228 |
| 2024 Enero | 186 | 67 | 253 |
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| 2023 Noviembre | 245 | 69 | 314 |
| 2023 Octubre | 215 | 66 | 281 |
| 2023 Septiembre | 438 | 72 | 510 |
| 2023 Agosto | 104 | 35 | 139 |
| 2023 Julio | 125 | 57 | 182 |
| 2023 Junio | 127 | 59 | 186 |
| 2023 Mayo | 187 | 69 | 256 |
| 2023 Abril | 133 | 37 | 170 |
| 2023 Marzo | 205 | 100 | 305 |
| 2023 Febrero | 181 | 68 | 249 |
| 2023 Enero | 105 | 60 | 165 |
| 2022 Diciembre | 181 | 54 | 235 |
| 2022 Noviembre | 164 | 90 | 254 |
| 2022 Octubre | 140 | 61 | 201 |
| 2022 Septiembre | 132 | 68 | 200 |
| 2022 Agosto | 99 | 86 | 185 |
| 2022 Julio | 84 | 83 | 167 |
| 2022 Junio | 86 | 62 | 148 |
| 2022 Mayo | 111 | 67 | 178 |
| 2022 Abril | 90 | 71 | 161 |
| 2022 Marzo | 155 | 97 | 252 |
| 2022 Febrero | 90 | 75 | 165 |
| 2022 Enero | 121 | 75 | 196 |
| 2021 Diciembre | 108 | 78 | 186 |
| 2021 Noviembre | 85 | 87 | 172 |
| 2021 Octubre | 121 | 106 | 227 |
| 2021 Septiembre | 104 | 64 | 168 |
| 2021 Agosto | 91 | 50 | 141 |
| 2021 Julio | 78 | 54 | 132 |
| 2021 Junio | 84 | 63 | 147 |
| 2021 Mayo | 133 | 74 | 207 |
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| 2021 Marzo | 172 | 58 | 230 |
| 2021 Febrero | 372 | 46 | 418 |
| 2021 Enero | 134 | 44 | 178 |
| 2020 Diciembre | 128 | 43 | 171 |
| 2020 Noviembre | 122 | 36 | 158 |
| 2020 Octubre | 86 | 42 | 128 |
| 2020 Septiembre | 100 | 50 | 150 |
| 2020 Agosto | 63 | 24 | 87 |
| 2020 Julio | 72 | 32 | 104 |
| 2020 Junio | 80 | 44 | 124 |
| 2020 Mayo | 80 | 24 | 104 |
| 2020 Abril | 134 | 35 | 169 |
| 2020 Marzo | 153 | 26 | 179 |
| 2020 Febrero | 271 | 75 | 346 |
| 2020 Enero | 209 | 67 | 276 |
| 2019 Diciembre | 183 | 49 | 232 |
| 2019 Noviembre | 283 | 73 | 356 |
| 2019 Octubre | 187 | 53 | 240 |
| 2019 Septiembre | 103 | 69 | 172 |
| 2019 Agosto | 74 | 57 | 131 |
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| 2019 Junio | 55 | 36 | 91 |
| 2019 Mayo | 112 | 66 | 178 |
| 2019 Abril | 62 | 45 | 107 |
| 2019 Marzo | 60 | 65 | 125 |
| 2019 Febrero | 73 | 47 | 120 |
| 2019 Enero | 84 | 68 | 152 |
| 2018 Diciembre | 137 | 96 | 233 |
| 2018 Noviembre | 48 | 31 | 79 |
| 2018 Octubre | 3 | 6 | 9 |
| 2018 Septiembre | 7 | 6 | 13 |
| 2018 Agosto | 8 | 4 | 12 |
| 2018 Julio | 7 | 2 | 9 |
| 2018 Junio | 0 | 2 | 2 |
| 2018 Mayo | 0 | 4 | 4 |
| 2018 Abril | 0 | 16 | 16 |
| 2018 Marzo | 0 | 15 | 15 |
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