CPR in Advanced Cancer

CPR in Advanced Cancer

Michael A. Thompson, FASCO, MD, PhD

Mar 01, 2013

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?


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Christopher O. Ruud, MD

Mar, 02 2013 9:11 AM

Excellent Review of a common problem Chris Ruud MD

Michael A. Thompson, FASCO, MD, PhD

Mar, 02 2013 10:33 AM

Dr. Ruud -

Thank you for the comment.
While my post is not an extensive academic review, hopefully it is helpful.
It would be great if others point out articles (w/links) that we should all know about as a community and other innovative ways to improve care such as the Volandes RCT.


Nathan A. Pennell, MD, PhD

Mar, 02 2013 1:43 PM

Very helpful! I too tend to quote patients and fellows numbers I remember vaguely from fellowship, and this is a topic where the data really can help educate the patient and hopefully guide him/her to the correct decision about DNR status.

Nicholas J. Petrelli, MD, FASCO

May, 01 2013 11:26 AM

Mike, we looked at our own data in a NCI selected( NCCCP) large community cancer center which is below  and reflects what is published in the literature . We need to do a better job of educating our patients and their  families.The days of pushing until God intervenes are gone ! 
 Delaware Medical Journal Vol .84,No.4.pp117-121,2012.
Results: There were a total of 94 cancer patients and 60 non-cancer patients. The cancer patients were subdivided into those with solid tumors (63 patients) versus those with hematological malignancy (31 patients). The solid tumor group was further divided into localized (23 patients) and metastatic (40 patients) disease. The cancer patients were also divided by age, those 65 and older (37 patients) and those less than 65 years of age (57 patients). The non-cancer group was similarly divided into 65 and older (38 patients) and younger than 65 (22 patients). In total 16 percent of all cancer patients were alive at day 30 compared to 23 percent of non-cancer patients (p = 0.167). With respect to solid vs. hematologic tumors, both had a survival rate of 16 percent at 30 days. When comparing age differences, the younger non-cancer patients had better outcomes (27 percent survival rate) compared with younger oncology patients (18 percent). There was not a significant difference in survival between the older patients in either group. Conclusion: Overall the rate of survival of cancer patients in a community hospital after undergoing CPR is similar to what is described in the recent literature. The prognosis remains poor for cancer patients undergoing CPR. Therefore, clinicians should and are now mandated by law (in certain states) to engage in honest discussions using data concerning end of life care and expectations.
Nick Petrelli

Michael A. Thompson, FASCO, MD, PhD

May, 01 2013 11:49 AM

Nick -

Thank you for your comments and the reference.
Have other NCCCP sites provided this data?
It would be interesting, but I suspect very similar.

I agree that is time to improve education about this very important issue.
Thanks again.


Nicholas J. Petrelli, MD, FASCO

May, 01 2013 11:55 AM

Mike I am not aware of any other NCCCP sites that have evaluated this . Nick

James M. Sinclair, MD

May, 03 2013 7:41 PM

I appreciate the comments and data but thought I would bring up a dilemna many of us face in dealing with fear of death. I have had patients and or families say when told chances of surviving a code are 1% that they believe they are in that 1%. I think each of us at one time or another consider ourselves and or our loved ones to be extraordinary making statistics about someone else. On the other hand I think most of us don't need to quote statistics each time we are at the bedside of a moribund patient. I find the less I say sometimes the more likely the patient and family will recognize the reality of the situation. For me not speaking is one of the most difficult interventions I can offer. I call it active presence and I look forward to it when I ear the end of life.

Susan Hendrickson

Jan, 23 2015 7:10 PM

As a cancer patient, I appreciate this post. I was asked today to make a decsion about DNR and needed more information. Your post came up on a google search. With such a low rate of recovery/survival I now know I will change my advance directive to decline CPR. It is a very hard decision. Also a huge milestone. This is one more treatment option unavailable to me and brings into sharp focus the severity of my illness. Still, as I patient I want to understand the progression of my disease. While optomistic by nature, I am a realist. Thank you for a post even a lay person can understand!

Michael A. Thompson, FASCO, MD, PhD

Jan, 23 2015 8:09 PM

Nick & James - 

(Very) belated thanks for your comments.


Michael A. Thompson, FASCO, MD, PhD

Jan, 23 2015 8:13 PM

Susan -

I am glad that I could be of some assistance in your decision making during this difficult time for you. 
I and others strive to not only spark conversation with our health care colleagues but also inform and help patients online. Information is power.

While code status and "level of care" are often conjoined and correlated, it is still possible to pursue aggresive therapeutic care and be DNR/I.

I wish you peace on your journey forward.

Your feedback is very valuable and really impacted me as I read it.

- Mike 

Michael A. Thompson, FASCO, MD, PhD

Jan, 26 2015 6:18 AM

Here is a recent reference that popped up on ResearchGate.
In tweet form below...

Code status discussions in psychiatric and medical inpatients - Warren et al. 2014 @JClinPsychiatry http://ow.ly/HVZP5 #pallonc #supponc

CONCLUSIONS (excerpt):
A code status discussion with hospitalized patients needs to occur at admission regardless of reason for admission. 

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