Determinants of 1-year survival in critically ill acute leukemia patients: a GRRR-OH study

Impact of critical illness on continuation of anticancer treatment and prognosis of patients with aggressive hematological malignancies

BACKGROUND

Maintaining the dose-intensity of cancer treatment is an important prognostic factor of aggressive hematological malignancies. The objective of this study was to assess the long-term outcomes of intensive care unit (ICU) survivors with acute myeloid leukemia (AML) or aggressive B-cell non-Hodgkin lymphoma (B-NHL) with emphasis on the resumption of the intended optimal regimen of cancer treatment.

PATIENTS AND METHODS

We conducted a retrospective (2013-2021) single-center observational study where we included patients with AML and B-NHL discharged alive from the ICU after an unplanned admission. The primary endpoint was the change in the intended optimal cancer treatment following ICU discharge. Secondary endpoints were 1-year progression-free survival and overall survival rates. Determinants associated with modifications in cancer treatment were assessed through multivariate logistic regression.

RESULTS

Over the study period, 366 patients with AML or B-NHL were admitted to the ICU, of whom 170 survivors with AML (n = 92) and B-NHL (n = 78) formed the cohort of interest. The hematological malignancy was recently diagnosed in 68% of patients. The admission Sequential Organ Failure Assessment (SOFA) score was 5 (interquartile range 4-8). During the ICU stay, 30 patients (17.6%) required invasive mechanical ventilation, 29 (17.0%) vasopressor support, and 16 (9.4%) renal replacement therapy. The one-year survival rate following ICU discharge was 59.5%. Further modifications in hematologic treatment regimens were required in 72 patients (42%). In multivariate analysis, age > 65 years (odds ratio (OR) 3.54 [95%-confidence interval 1.67-7.50], p < 0.001), ICU-discharge hyperbilirubinemia > 20 µmol/L (OR 3.01 [1.10-8.15], p = 0.031), and therapeutic limitations (OR 16.5 [1.83-149.7], p = 0.012) were independently associated with modifications in cancer treatment. Post-ICU modifications of cancer treatment had significant impact on in-hospital, 1-year overall survival and progression-free survival.

CONCLUSION

The intended cancer treatment could be resumed in 58% of ICU survivors with aggressive hematological malignancies. At the time of ICU discharge, advanced age, persistent liver dysfunction and decisions to limit further life-support therapies were independent determinants of cancer treatment modifications. These modifications were associated with worsened one-year outcomes.

Characteristics and outcomes of patients with acute myeloid leukemia admitted to intensive care unit with acute respiratory failure: a post-hoc analysis of a prospective multicenter study

BACKGROUND

Acute respiratory failure (ARF) is the leading cause of intensive care unit (ICU) admission in patients with Acute Myeloid Leukemia (AML) and data on prognostic factors affecting short-term outcome are needed.

METHODS

This is a post-hoc analysis of a multicenter, international prospective cohort study on immunocompromised patients with ARF admitted to ICU. We evaluated hospital mortality and associated risk factors in patients with AML and ARF; secondly, we aimed to define specific subgroups within our study population through a cluster analysis.

RESULTS

Overall, 201 of 1611 immunocompromised patients with ARF had AML and were included in the analysis. Hospital mortality was 46.8%. Variables independently associated with mortality were ECOG performance status ≥ 2 (OR = 2.79, p = 0.04), cough (OR = 2.94, p = 0.034), use of vasopressors (OR = 2.79, p = 0.044), leukemia-specific pulmonary involvement [namely leukostasis, pulmonary infiltration by blasts or acute lysis pneumopathy (OR = 4.76, p = 0.011)] and liver SOFA score (OR = 1.85, p = 0.014). Focal alveolar chest X-ray pattern was associated with survival (OR = 0.13, p = 0.001). We identified 3 clusters, that we named on the basis of the most frequently clinical, biological and radiological features found in each cluster: a "leukemic cluster", with high-risk AML patients with isolated, milder ARF; a "pulmonary cluster", consisting of symptomatic, highly oxygen-requiring, severe ARF with diffuse radiological findings in heavily immunocompromised patients; a clinical "inflammatory cluster", including patients with multi-organ failures in addition to ARF. When included in the multivariate analysis, cluster 2 and 3 were independently associated with hospital mortality.

CONCLUSIONS

Among AML patients with ARF, factors associated with a worse outcome are related to patient's background (performance status, leukemic pulmonary involvement), symptoms, radiological findings, the need for vasopressors and the liver SOFA score. We identified three specific ARF syndromes in AML patients, which showed a prognostic significance and could guide clinicians to optimize management strategies.

[Invasive mechanical ventilation in patients with solid tumor or hematological malignancy]

Invasive mechanical ventilation in onco-hematology patients has become relatively routine, and is now part and parcel of their care pathway. Nevertheless, specific complications and subsequent therapeutic possibilities require discussion. To a greater extent than with regard to other patient populations, cooperation between specialist and ICU physician is mandatory, the objective being to more comprehensively assess a therapeutic project before or during the period of invasive mechanical ventilation. After an overview of recent results concerning ventilated patients in intensive care, this review aims to describe the specific complications and factors associated with mortality in this population.

Outcomes of Sepsis and Septic Shock in Cancer Patients: Focus on Lactate

The number of oncological patients (OP) admitted to intensive care units (ICU) for sepsis/septic shock has dramatically increased in recent years. The definition of septic shock has been modified, adding hyperlactatemia as a severity biomarker for mortality. However, it remains poorly reported in septic OP. We performed a retrospective analysis from a prospective database of sepsis/septic shock patients admitted to our ICU between September 2017 and September 2019 and followed until day 90. We identified 251 patients and 31.9% had active oncological comorbidity, mainly solid tumor (81.3%). Septic shock criteria were met for 112 (44.6%). Hyperlactatemia was observed in 136 (54.2%) patients and this was associated with a lower survival rate. Overall 90-day mortality was 15.1%. In OP vs. non-OP, hyperlactatemia was more frequent (65% vs. 49.1%, p = 0.013) and associated with lower survival (65.4% vs. 85.7%, p = 0.046). In OP, poor performance status was also associated with lower survival (HR 7.029 [1.998-24.731], p = 0.002) In an adjusted analysis, cancer was associated with lower 90-day survival (HR 2.690 [1.402-5.160], p = 0.003). In conclusion, septic OP remains a high mortality risk group in whom lactate levels and performance status could help with better risk stratification.

Understanding and Managing Sepsis in Patients With Cancer in the Era of Antimicrobial Resistance

Sepsis is a frequent complication in immunosuppressed cancer patients and hematopoietic stem cell transplant recipients that is associated with high morbidity and mortality rates. The worldwide emergence of antimicrobial resistance is of special concern in this population because any delay in starting adequate empirical antibiotic therapy can lead to poor outcomes. In this review, we aim to address: (1) the mechanisms involved in the development of sepsis and septic shock in these patients; (2) the risk factors associated with a worse prognosis; (3) the impact of adequate initial empirical antibiotic therapy given the current era of widespread antimicrobial resistance; and (4) the optimal management of sepsis, including adequate and early source control of infection, optimized antibiotic use based on the pharmacokinetic and pharmacodynamics changes in these patients, and the role of the new available antibiotics.

Acute respiratory failure in immunosuppressed patients admitted to ICU

INTRODUCTION

The number of hospitalized immunosuppressed adults is a growing and often develop severe complications that require admission to an Intensive Care Unit (ICU). The main cause of admission is acute respiratory failure (ARF). The goal of the study was to determine if ARF represents an independent risk factor for hospital mortality and in particular, we sought to ascertain if any risk factors were independently and identifiably associated with a bad outcome.

METHODS

We perform a retrospective study of a prospectively collected data from patients admitted to an ICU. Adult patients with known immunosuppressive condition admitted to ICU were included.

RESULTS

A total of 248 patients were included. Of 248 patients, 117 (47.2%) had a diagnosis of ARF at the time of ICU admission. Patients with ARF had a significantly higher in-hospital mortality (53.4% vs. 28.2% p = 0.001). Factors independently associated with hospital mortality were diagnosis of ARF at ICU admission, the presence of septic shock, use of continuous renal replacement therapy and failure of high-flow nasal canula(HFNC)/non-invasive (NIV) respiratory therapies.

CONCLUSION

We identified ARF on admission and failure of HFNC/NIV to be independently associated with increased hospital mortality in immunosuppressed patients.

Sepsis and Cancer: An Interplay of Friends and Foes

Sepsis and cancer share a number of pathophysiological features, and both result from the inability of the host's immune system to cope with the initial insult (tissue invasion by pathogens and malignant cell transformation, respectively). The common coexistence of both disorders and the profound related alterations in immune homeostasis raise the question of their mutual impact on each other's course. This translational review aims to discuss the interactions between cancer and sepsis supported by clinical data and the translation to experimental models. The dramatic improvement in cancer has come at a cost of increased risks of life-threatening infectious complications. Investigating the long-term outcomes of sepsis survivors has revealed an unexpected susceptibility to cancer long after discharge from the ICU. Nonetheless, it is noteworthy that an acute septic episode may harbor antitumoral properties under particular circumstances. Relevant double-hit animal models have provided clues to whether and how bacterial sepsis may impact malignant tumor growth. In sequential sepsis-then-cancer models, postseptic mice exhibited accelerated tumor growth. When using reverse cancer-then-sepsis models, bacterial sepsis applied to mice with cancer conversely resulted in inhibition or even regression of tumor growth. Experimental models thus highlight dual effects of sepsis on tumor growth, mostly depending on the sequence of insults, and allow deciphering the immune mechanisms and their relation with microorganisms.

One-year survival of patients with high-grade glioma discharged alive from the intensive care unit

Introduction

Only limited data are available regarding the long-term prognosis of patients with high-grade glioma discharged alive from the intensive care unit. We sought to quantify 1-year mortality and evaluate the association between mortality and (1) functional status, and (2) management of anticancer therapy in patients with high-grade glioma discharged alive from the intensive care unit.

Patients and methods

Retrospective observational cohort study of patients with high-grade glioma admitted to two intensive care units between January 2009 and June 2018. Functional status was assessed by the Karnofsky Performance Status. Anticancer therapy after discharge was classified as (1) continued (unchanged), (2) modified (changed or stopped), or (3) initiated (for newly diagnosed disease).

Results

Ninety-one high-grade glioma patients (73% of whom had glioblastoma) were included and 78 (86%) of these patients were discharged alive from the intensive care unit. Anticancer therapy was continued, modified, and initiated in 41%, 42%, and 17% of patients, respectively. Corticosteroid therapy at the time of ICU admission [odds ratio (OR) 0.07] and cancer progression (OR 0.09) was independently associated with continuation of anticancer therapy. The mortality rate 1 year after ICU admission was 73%. On multivariate analysis, continuation of anticancer therapy (OR 0.18) and Karnofsky performance status on admission (OR 0.90) were independently associated with lower 1-year mortality.

Conclusion

The presence of high-grade glioma is not sufficient to justify refusal of intensive care unit admission. Performance status and continuation of anticancer therapy are associated with higher survival after intensive care unit discharge.

Previous presentation

Preliminary results were presented at the most recent congress of the French Intensive Care Society, Paris, 2019.

Electronic supplementary material

The online version of this article (10.1007/s00415-020-10191-0) contains supplementary material, which is available to authorized users.

Impact of a computer-assisted decision support system (CDSS) on nutrition management in critically ill hematology patients: the NUTCHOCO study (nutritional care in hematology oncologic patients and critical outcome)

BACKGROUND

Mortality of critically ill hematology (HM) patients has improved over time. Thus, those patients require an extensive diagnostic workup and the optimal use of available treatments. There are no data regarding nutrition strategy for critically ill HM patients, while nutritional support is crucial for both HM and critically ill patients. We hypothesized that the implementation of a computer-assisted decision support system (CDSS), designed to supervise a nutritional intervention by a multidisciplinary team, would be able to increase guidelines adherence and outcomes.

RESULTS

In this before/after study, 275 critically ill hematology patients admitted to the ICU over 5-year period were included. Energy and protein intakes were delivered using standard protocol in the 147 patients (53%) of the 'before group' and using a CDSS in order to reach every day predefined caloric and protein targets accordingly to the catabolic or anabolic status in the 128 patients (47%) of the 'after group.' Using a Poisson regression, we showed that the use of CDSS allowed to reach a relative increase in the rate of days in compliance with caloric (1.57; 95% confidence interval (CI), [1.17-2.10], p = 0.0025) and protein targets (3.86 [2.21-6.73], p < 0.0001) in the 'after group' by more than 50% as compared with the 'before group.' Interestingly, compliance rates were low and only reached 30% after intervention. Hospital mortality, ICU-acquired infection, and hospital, and ICU length of stay were similar in the two groups of patients. Importantly, exploratory analysis showed that hospital mortality was lower in the 'after group' for neutropenic and severely ill patients.

CONCLUSION

For critically ill hematology patients, the use of a nutritional CDSS allowed to increase the days in compliance with caloric and protein targets as compared with no CDSS use. In this context, overall hospital mortality was not affected.

The experience of medical communication in adults with acute leukemia: Impact of age and attachment security

BACKGROUND

Health care providers' (HCPs) communication with cancer patients provides both information and support. Younger patient age and greater difficulty accepting support (attachment security) have been linked to poorer communication experiences with HCPs. The present secondary data analysis examined the impact of age group and attachment security on perceived communication problems with HCPs in adults with acute leukemia (AL).

METHODS

The sample included 95 younger (age < 40 years) and 225 older (age ≥ 40 years) patients with newly diagnosed or recently relapsed AL. We assessed avoidant and anxious attachment security (reluctance to accept support and fear of its unavailability, respectively) with the modified 16-item Experiences in Close Relationships Scale. The impact of age group and attachment security on perceived communication problems, measured with the Cancer Rehabilitation Evaluation System-Medical Interaction Subscale, was assessed based on the presence and extent of communication problems.

RESULTS

Younger patients (OR = 1.79-1.82, P = .030) and those with greater avoidant (OR = 1.44, P = .001) or anxious attachment (OR = 1.38, P = .009) were more likely to report communication problems. A similar relationship was found between age (β's = -.17-.19, P = .015-.025), avoidant (β = .29, P = .013), or anxious attachment (β = .17, P = .031), and the extent of communication problems. A significant age-group × avoidant-attachment interaction (β = -.31, P = .008) suggested that more avoidant attachment was associated with more perceived communication problems in the younger but not in the older group.

CONCLUSIONS

Younger patients with AL, especially those more reluctant to seek or accept support, perceive more communication problems with their HCPs than older patients. Greater attention by HCPs to their communication with younger patients is needed.

In-hospital and day-120 survival of critically ill solid cancer patients after discharge of the intensive care units: results of a retrospective multicenter study-A Groupe de recherche respiratoire en réanimation en Onco-Hématologie (Grrr-OH) study

Objectives

To assess outcomes at hospital discharge and day-120 after intensive care unit (ICU) discharge among patients with solid cancer admitted to ICU and to identify characteristics associated with in-hospital and day-120 after ICU discharge mortalities.

Design

International, multicenter, retrospective study.

Setting

Five ICUs in France and Brazil, two located in cancer centers, two in university affiliated and one in general hospitals.

Patients

Consecutive patients aged > 18 years, with underlying solid cancers (known before admission to the ICU or diagnosed during the stay in the ICU), admitted to the participating ICUs and discharged alive from the ICU from January 2006 to December 2011 were included in this study. Patients admitted after scheduled surgery or to secure procedure were excluded. Variables of interest were in-hospital and day-120 post-ICU mortality among patients discharged alive from the ICU.

Interventions

None.

Measurements and results

A total of 1053 patients aged 63 years (54–71) (median [IQR]) were included. Most of the patients were of the male gender (66.8%). The in-ICU, in-hospital, and four-month post-ICU discharge mortalities were, respectively, 41.3, 60.7, and 65.8%. Among patients discharged alive from the ICU, in multivariate analysis, factors associated with four months post-ICU discharge mortality were type of cancer (OR from 0.25 to 0.52 when compared to lung cancers), systemic extension of the disease (OR 2.54; 95% CI 1.87–3.45), need for invasive mechanical ventilation (OR 2.54; 95% CI 1.80–3.59), for vasopressors (OR 2.35; 95% CI 1.66–3.29), or renal replacement therapy (OR 1.54; 95% CI 0.99–2.38). A predictive score, “Oncoscore,” was built performing fairly in predicting 4 months post-ICU discharge outcome (AUC 0.74; 95% CI 0.71–0.77).

Conclusion

Despite the high day-120 mortality following the ICU discharge, our study reports a meaningful medium-term survival rate after the ICU discharge of solid cancer patients. Of utmost importance, the “Oncoscore” must be validated in prospective studies and cannot be used, in its form without external validation, for individual decision making. Prospective studies to answer questions not provided by this study are needed, including only patients with solid cancers admitted in the ICU for medical reasons or after emergency surgery.

Electronic supplementary material

The online version of this article (10.1186/s13613-018-0386-6) contains supplementary material, which is available to authorized users.