Outcomes of elderly patients with stage IIIB–IV non-small cell lung cancer admitted to the intensive care unit

doi:10.1016/j.lungcan.2012.05.103

Lung Cancer

Volume 77, Issue 3, September 2012, Pages 600-604

https://doi.org/10.1016/j.lungcan.2012.05.103 Get rights and content

Abstract

Background

Although the prognosis of elderly patients with stage IIIB and IV non-small cell lung cancer (NSCLC) is poor, it remains a common cause of cancer related admissions to the intensive care unit (ICU). The objective was to evaluate short and long-term outcomes of a population-based sample of elderly patients with advanced NSCLC who require ICU care.

Methods

Using combined data from the Surveillance, Epidemiology and End Results registry and Medicare files, we identified 1134 patients >65 years of age with stage IIIB and IV NSCLC admitted to an ICU with a diagnosis of respiratory, cardiac, or neurologic complications, renal failure, or sepsis. We assessed rates and predictors of death during hospitalization. The Kaplan–Meier method was used to estimate mortality rates at 90 days and 1 year post hospital discharge.

Results

In-hospital mortality was 33% (95% CI: 30–36%). The 90-day and 1-year mortality rate was 71% and 90%, respectively. Patients with an admitting diagnosis of sepsis had the highest rate of in-hospital mortality (59%). Of those who were alive at discharge, 52% were transferred to a skilled nursing facility, 6% to hospice, and 42% returned home.

Conclusion

We found that one-third of elderly patients with advanced NSCLC admitted to the ICU do not survive hospitalization. Among survivors, most patients required continued institutionalization with a very low likelihood of surviving >1 year from discharge. This data should help patients, families, and health care providers of elderly patients with advanced NSCLC make decisions regarding ICU utilization.

Introduction

Lung cancer is predominately a disease of the elderly and is also the leading cause of cancer-related mortality in both men and women in the United States (US). When lung cancer is diagnosed at an early stage, treatment with surgical resection is potentially curative. Unfortunately, >50% of patients with non small cell lung cancer (NSCLC) are diagnosed at an advanced stage which is not amenable to resection [1]. Although there have been recent advances in therapy, the overall 5-year survival for these patients remains <5% [2] with the majority of patients dying within two years of diagnosis [3]. Despite this poor prognosis, lung cancer is the third most common solid tumor in critically ill patients [4] and accounts for about 16% of all cancer admissions to the intensive care unit (ICU) [5].

The prognosis and long-term outcomes of lung cancer patients admitted to the ICU remains unclear. Older studies have shown that lung cancer patients have a high in-hospital mortality (75–95%) when admitted to the ICU [6], [7], [8]. However, more recent studies have reported considerably more favorable outcomes [9], [10], [11], [12]. Most of these studies however, were conducted in tertiary referral centers, included patients with early and advanced stage, and were not focused on the elderly. ICU use in elderly patients with advanced NSCLC appears to be increasing [13]. As such, there is an increasing need for outcomes data in order for elderly patients, families, and physicians to make informed decisions about ICU admissions.

In this study, we used data from the Surveillance, Epidemiology and End Results (SEER) registry linked to Medicare files, a nationally representative, population-based source of cancer data to assess the short and long-term outcomes of elderly patients with stage IIIB and IV NSCLC admitted to the ICU.

Section snippets

Methods

Study patients were identified from the SEER-Medicare registry [14]. The SEER program collects data on all incident cancer cases in selected areas of the US, covering approximately 26% of the US population [15]. For patient's ≥ 65 years of age, SEER data has been linked to inpatient, outpatient, and physician Medicare claims. Using Medicare inpatient files we selected all patients > 65 years of age with a primary diagnosis of stage IIIB and IV NSCLC diagnosed between 1992 and 2005 with at least one

Statistical analysis

Differences in the baseline characteristics between patients who survived and did not survive to hospital discharge were assessed using the Chi-square test. The probability of in-hospital mortality as well as mortality rates among patients with respiratory, cardiac, or neurological conditions, sepsis, and renal failure are reported with 95% confidence intervals based on the binomial distribution. We used the Kaplan–Meier method to estimate mortality rates at 90 days and 1 year after hospital

Results

A total of 1134 patients with stage IIIB and IV were identified from the SEER-Medicare registry. Overall, 376 (33%, 95% CI: 30–36%) patients died during the hospitalization. Of the patients surviving hospitalization, 307 (42%) were discharged home, 384 (52%) to a skilled nursing facility and 48 (6%) to hospice. Only 143 (19%) of patients received some form of lung cancer directed treatment (chemotherapy and/or RT) after hospital discharge. Baseline characteristics of study patients are shown in

Discussion

Despite the poor long-term outcomes of patients with advanced stage NSCLC and the uncertain benefit of the use of critical care resources in this patient population, ICU admissions remain common. Using population-based data we found that in-hospital mortality of elderly patients admitted to the ICU with advanced NSCLC is approximately 33%, but varies according to the underlying admission diagnosis. However, the long-term prognosis remains very poor and less than half of surviving patients

Funding

This work was supported in part by a Research Supplement to Promote Diversity in Health-Related Research Program Award Number [R01CA131348] from the National Cancer Institute.

Conflict of interest

Dr. Wisnivesky is a member of the research board of EHE International, has received lecture fees from Novartis Pharmaceutical, consulting honorarium from UBC, and a research grant from GlaxoSmithKline. The remaining authors have no relevant relationships to disclose.

Acknowledgements

This study used the linked SEER-Medicare database. The interpretation and reporting of these data are the sole responsibility of the authors. The authors acknowledge the efforts of the Applied Research Program, NCI; the Office of Research, Development and Information, CMS; Information Management Services (IMS), Inc.; and the Surveillance, Epidemiology, and End Results (SEER) Program tumor registries in the creation of the SEER-Medicare database.

References (30)

P. Yang et al.
Clinical features of 5628 primary lung cancer patients: experience at Mayo Clinic from 1997 to 2003
Chest
(2005)
J.P. Griffin et al.
End-of-life care in patients with lung cancer
Chest
(2003)
Y.C. Lin et al.
Outcome of lung cancer patients with acute respiratory failure requiring mechanical ventilation
Respir Med
(2004)
C.A. Reichner et al.
Outcome and code status of lung cancer patients admitted to the medical ICU
Chest
(2006)
G. Sharma et al.
Trends in end-of-life ICU use among older adults with advanced lung cancer
Chest
(2008)
C.N. Klabunde et al.
Development of a comorbidity index using physician claims data
J Clin Epidemiol
(2000)
C.N. Klabunde et al.
A refined comorbidity measurement algorithm for claims-based studies of breast, prostate, colorectal, and lung cancer patients
Ann Epidemiol
(2007)
M. Soares et al.
Prognosis of lung cancer patients with life-threatening complications
Chest
(2007)
P.A. Bunn et al.
Systemic treatment for advanced (stage IIIb/IV) non-small cell lung cancer: more treatment options; more things to consider Conclusion
Oncologist
(2008)

J.P. Kress et al.

Outcomes of critically ill cancer patients in a university hospital setting

Am J Respir Crit Care Med

(1999)

M.S. Ewer et al.

Outcome of lung cancer patients requiring mechanical ventilation for pulmonary failure

JAMA

(1986)

S. Boussat et al.

Predictive factors of death in primary lung cancer patients on admission to the intensive care unit

Intensive Care Med

(2000)

S. Roques et al.

Six-month prognosis of patients with lung cancer admitted to the intensive care unit

Intensive Care Med

(2009)

C. Christodoulou et al.

Performance status (PS): a simple predictor of short-term outcome of cancer patients with solid tumors admitted to the intensive care unit (ICU)

Anticancer Res

(2007)

Cited by (42)

Chemotherapy for Non-Small Cell Lung Cancer in the Intensive Care Unit
2021, Cancer Treatment and Research Communications
patients with non-small-cell lung cancer (NSCLC) admitted to the intensive care unit have poor prognosis. There is limited data on cytotoxic chemotherapy in this setting. The standard of care for these patients is usually best supportive care.
60-year-old previously healthy female was admitted to the ICU with newly diagnosed mucinous adenocarcinoma of the lung. She received cisplatin and pemetrexed while intubated and mechanically ventilated. She was extubated a week later and discharged home after achieving an excellent radiographic and clinical response.
in select patients with NSCLC admitted to the ICU due to complications from their malignancy, a trial of cytotoxic chemotherapy may be reasonable. To our knowledge, this is the first case of mucinous NSCLC treated in the ICU.
Understanding irresponsible use of intensive care unit resources in the USA
2019, The Lancet Respiratory Medicine
Citation Excerpt :
Institutional triage practices and policies, physicians' triaging behaviours, or family members' preferences, however, might nonetheless lead to the admission of such patients to ICUs. Patients with serious illnesses and poor functional status before an ICU admission have high in-hospital mortality, and survivors have very high rates of morbidity and mortality within a year.26,27 Nonetheless, ICU use at the end of life has been rising in the USA since at least 2000,28,29 and it is notably higher compared with the UK.
Use of intensive care unit (ICU) resources in the USA far outpaces that of other countries. This increased use is not accompanied by superior clinical outcomes and is at times discordant with patient desires. This Series paper seeks to identify major drivers of ICU resource use in the USA, and to offer steps towards better aligning ICU resource use with clinical needs and patient preferences. After considering several factors, such as organisational, ethical, and economic factors, we suggest that there are four intersecting drivers of irresponsible use of ICU resources in the USA: first, excess ICU bed capacity and a scarcity of data to understand which patients that truly benefit from ICU compared with ward care; second, clinicians misinterpreting the goals and means of patient autonomy; third, an extreme fear of rationing by the general public; and fourth, fee-for-service driven use of advanced medical technologies and procedures that beget ICU expansion.
Depression and Health Care Utilization at End of Life Among Older Adults With Advanced Non–Small-Cell Lung Cancer
2018, Journal of Pain and Symptom Management
Citation Excerpt :
The presence of depression negatively affects quality of life for patients with lung cancer5 and decreases survival among those with advanced disease.6 Patients with cancer and depression have longer hospital stays and more readmissions7 compared to cancer patients without depression,8,9 High intensity end-of-life (EOL) care, such as hospitalization, emergency department (ED) visits, and chemotherapy use, is associated with poorer quality of life for cancer patients10 and their surviving caregivers,11 does not confer a survival benefit,12,13 and is often discordant with the preferences of most cancer patients who would prefer to die at home or without high-intensity interventions.14,15 While hospice is a reasonable recommendation for patients with advanced cancer16 as an alternative to high-intensity healthcare, study findings have been mixed regarding the association between psychological distress and hospice enrollment.17,18
Limited data exist regarding how depression diagnosed at different times relative to a cancer diagnosis may affect healthcare utilization at end of life (EOL).
To assess the relationship between depression and health care utilization at EOL among older adults (ages >=67) diagnosed with advanced non-small cell lung cancer (NSCLC) from 2009 to 2011.
Using the SEER-Medicare database, we fit multivariable logistic regression models to explore the association of depression with duration of hospice stay plus high-intensity care, for example inpatient admissions, in-hospital death, emergency department visits, and chemotherapy at EOL. We used a regression model to evaluate hospice enrollment, accounting for the competing risk of death.
Among 13,827 subjects, pre-cancer depression was associated with hospice enrollment (sub-hazard ratio 1.19, 95% confidence interval [CI] 1.11–1.28), 90 + hospice days (adjusted odds ratio [aOR] 1.29, 95% CI 1.06–1.58), and lower odds of most utilization; we found no association with EOL chemotherapy. Diagnosis-time depression was associated with hospice enrollment (SHR 1.16, 95% CI 1.05–1.29) but not high-intensity utilization. Post-diagnosis depression was associated with lower hospice enrollment (SHR 0.80, 95% CI 0.74–0.85) and higher odds of ICU admission (aOR 1.18, 95% CI 1.01–1.37).
EOL healthcare utilization varied by timing of depression diagnosis. Those with pre-cancer depression had lower odds of high-intensity healthcare, were more likely to utilize hospice, and have longer hospice stays. Regular depression screening and treatment may help patients optimize decision-making for EOL care. Additionally, hospice providers may need additional resources to attend to mental health needs in this population.
Critical Care Prognosis and Outcomes in Patients with Cancer
2017, Clinics in Chest Medicine
Treatment of Lung Cancer Patients With Actionable Mutations in the Intensive Care Unit
2016, Clinical Lung Cancer
Citation Excerpt :
Advanced-stage lung cancer patients have high mortality in the intensive care unit (ICU) setting.7-11 Acute respiratory failure, advanced-stage cancer, and poor performance status (PS) have all been associated with significant mortality in lung cancer patients admitted to the ICU.7-11 Although data from different studies have varied, the overall reported mortality in the ICU setting has been in the range of 40% to 55%,7,8 and in those patients who develop acute respiratory failure requiring mechanical ventilation, the mortality increases substantially to ≥ 70%.7-10
Patients with advanced-stage non–small-cell lung cancer (NSCLC) have high mortality rates in the intensive care unit (ICU). Although the benefit of chemotherapy for hematologic malignancies in the ICU has previously been explored, few data exist regarding the use of targeted therapy for NSCLC in such settings. The primary objective of the present study was to report our experience with the use of targeted therapy in patients with NSCLC in the ICU.
We performed a single-institution, retrospective medical record review. The eligibility criteria included patients with NSCLC with targetable mutations who had received tyrosine kinase inhibitors (TKIs) in the ICU. Cases were identified by queries of our institution's information warehouse database and pharmacy dispensary records from 2010 to 2015.
All 9 patients who had received TKIs in the ICU had acute respiratory failure. Three patients were successfully extubated after initiating TKI therapy, although 1 required later tracheostomy. TKI therapy stabilized another patient's refractory disseminated intravascular coagulation. The remaining 5 patients showed no measurable clinical improvement and were transitioned to comfort care. The overall ICU mortality rate was 56%.
Patients with metastatic NSCLC requiring mechanical ventilation have high mortality rates. Cytotoxic chemotherapy is generally contraindicated for poor performance status patients. However, targeted TKI therapy should be considered, given its proven efficacy and few systemic side effects. We recommend the empiric use of targeted therapy for NSCLC patients with suspected and/or known actionable mutations presenting with multifactorial respiratory failure to the ICU, with aggressive determination of the mutation status if not known.
Prognosis of lung cancer patients followed in the intensive care unit: A cross-sectional study
2023, Tuberkuloz ve Toraks

View all citing articles on Scopus

View full text

Outcomes of elderly patients with stage IIIB–IV non-small cell lung cancer admitted to the intensive care unit

Abstract

Background

Methods

Results

Conclusion

Introduction

Section snippets

Methods

Statistical analysis

Results

Discussion

Funding

Conflict of interest

Acknowledgements

Chest

Chest

Respir Med

Chest

Chest

J Clin Epidemiol

Ann Epidemiol

Chest

Systemic treatment for advanced (stage IIIb/IV) non-small cell lung cancer: more treatment options; more things to consider Conclusion

Oncologist

Outcomes of critically ill cancer patients in a university hospital setting

Am J Respir Crit Care Med

Outcome of lung cancer patients requiring mechanical ventilation for pulmonary failure

JAMA

Predictive factors of death in primary lung cancer patients on admission to the intensive care unit

Intensive Care Med

Six-month prognosis of patients with lung cancer admitted to the intensive care unit

Intensive Care Med

Performance status (PS): a simple predictor of short-term outcome of cancer patients with solid tumors admitted to the intensive care unit (ICU)

Anticancer Res