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:

Conclusions:

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.

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?