I recently saw a new patient with advanced cancer in the intensive care unit (ICU). She had been treated with multiple lines of therapy at other cancer centers. While she already had an oncologist, I was called in to help the ICU team with any oncologic issues. There were no acute cancer problems to solve, but I noted the patient was “full code.” I thought that clarifying code status might be helpful. In our discussion, it seemed that (at least from the patient’s perspective) no one had deeply dived into this topic. I quoted cardiopulmonary resuscitation (CPR) statistics in cancer, and after a long discussion, she changed her code status to “do not resuscitate, do not intubate (DNR/I).” That was the right decision.
Later, I self-analyzed that discussion and realized I was reciting information from my fellowship training. I did not know the primary data supporting what I said. As I researched the literature, it turns out that I was indeed accurate. I did what any physician would do these days -- I Googled the question. I found a good reference, but then used my enriched “micro-crowd sourcing” to ask for any references from a friend and palliative-care expert. He shared some PDF files, including a meta-analysis, which I will discuss below. My conclusions are distilled down to this:
1) The chance of survival after CPR for advanced cancer patients is low (~ 5-8%)
2) Survival may be increasing over time. We need data on survivor quality of life (QOL).
3) Poor Px Fx (%survival): ICU (<=2%), Heme/BMT (1.5%) or anticipated code (0%)
4) Informed (via 3 min video) patients are 3.5 times more likely to choose DNR/I
2001: MDACC (n=243) Inpatients with Cancer
In 2001, a group at MD Anderson Cancer Center published “Characteristics of Cardiac Arrest in Cancer Patients as a Predictor of Survival after Cardiopulmonary Resuscitation.” (Ewer et al. Cancer 2001;92:1905–12). From 1993-1997, cases for 243 inpatients who experienced cardiac arrest and received CPR were reviewed, and their course observed until hospital discharge or death. 16/73 patients (22%) who had sudden, unanticipated cardiac arrests survived to be discharged from the hospital. 0/171 of patients who experienced an anticipated cardiac arrest survived (P < 0.001). They analyzed by subgroup (Table 2 from study, below) and used logistic regression (Table 3 from study, below). They also suggested an algorithm for anticipated codes that might “avoid painful and costly interventions that are futile with the present techniques of cardiopulmonary resuscitation.”
2006: Meta-analysis (N=1707)
In 2006, Reisfield and colleagues at the University of Florida Health Science Center published “Survival in cancer patients undergoing in-hospital cardiopulmonary resuscitation: a meta-analysis” (Resuscitation 2006 Nov;71(2):152-60). In their meta-analysis, they found 42 studies from 1966-2005, including 1707 adult cancer patients undergoing in-hospital CPR. The overall survival to discharge was: all adult cancer patients (6.2%), localized disease (9.5%), metastatic (5.6%). When analyzed for data since 1990, this gap seemed to decrease, with survival: localized disease (9.1%) and metastatic (7.8%). Survival for patients on general floors was 10.1% and was 2.2% for the ICU. The authors concluded that improved outcomes more recently may be due to more selective use of CPR in advanced cancer patients.
2012/2013: Better Information = Better Decisions
Dr. Volandes and colleagues published online (2012) and in print (2013) on a “Randomized Controlled Trial of a Video Decision Support Tool for Cardiopulmonary Resuscitation Decision Making in Advanced Cancer” (J Clin Oncol 2013 vol. 31(3):380-386; JCO podcast-Thomas Smith). In 150 patients with advanced cancer they randomized patients to: 1) a verbal narrative (control) describing CPR and the chance of CPR success versus 2) a 3 minute video (experimental intervention). The video showed a patient on a ventilator and CPR on a simulated patient. Most patients were comfortable watching the video, had better CPR knowledge compared with the control group, and were more likely to choose DNR/I (see Table below, unadjusted odds ratio, 3.5; 95% CI, 1.7 to 7.2; P < 0.001).
These studies suggested to me that patients with advanced cancer rarely survive in-hospital CPR. Often those who do survive have a poor quality of life and short survival after (I haven’t seen those data explicitly depicted). We are likely getting better at selecting patients for CPR, but not in a systematic fashion. Patients who are anticipated to have a code should not receive CPR. We now have randomized data showing that a short, non-threatening intervention such as a short video can improve patient knowledge and potentially avoid costly futile interventions. I would love to see a downloadable video available (e.g., iTunes or JCO online appendix) to use for all cancer patient admissions that is viewable on a computer or tablet (e.g., iPad) to help facilitate these discussions and appropriate decision making.
What are your thoughts and experiences with CPR in patients with advanced cancer?