Correspondence
collects data on type of initial treatment, but not types and doses of initial chemotherapy or subsequent courses of treatment. However, several prior analytic studies with complete chemotherapy information showed significant dose-response relationships between cumulative cisplatin amount and treatment-related leukemia.11,12 As we stated,2 it will be important in future analytic studies to determine the extent to which any dose-response relationship between platinum and solid tumors may exist, the types of cancers, latency patterns, and interactions with other factors,13 including genetic susceptibility14 and other drugs. These future research priorities with regard to second malignant neoplasms in survivors of testicular cancer were recently summarized by Travis et al.15
Chunkit Fung University of Rochester Medical Center, James P. Wilmot Cancer Center, Rochester, NY
Sophie D. Fossa Norwegian Radium Hospital, Oslo, Norway
Michael T. Milano University of Rochester Medical Center, Rochester, NY
Jan Oldenburg Norwegian Radium Hospital, Oslo, Norway
Lois B. Travis Rubin Center for Cancer Survivorship, University of Rochester Medical Center, Rochester, NY
ACKNOWLEDGMENT
C.F. was supported by the James P. Wilmot Foundation Research Fellowship, and L.B.T. was supported by National Cancer Institute Grant No. R01-CA157823-01A1-NCI. AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST
REFERENCES 1. Gandaglia G, Karakiewicz PI, Trinh Q-D, et al: Cisplatin-based chemotherapy and the risk of solid tumors in patients with testicular nonseminoma: Still a matter of debate. J Clin Oncol 32:1167, 2014 2. Fung C, Fossa SD, Milano MT, et al: Solid tumors after chemotherapy or surgery for testicular nonseminoma: A population-based study. J Clin Oncol 31:3807-3814, 2013 3. Einhorn LH, Donohue J: Cis-diamminedichloroplatinum, vinblastine, and bleomycin combination chemotherapy in disseminated testicular cancer. Ann Intern Med 87:293-298, 1977 4. Williams SD, Birch R, Einhorn LH, et al: Treatment of disseminated germ-cell tumors with cisplatin, bleomycin, and either vinblastine or etoposide. N Engl J Med 316:1435-1440, 1987 5. Kondagunta GV, Bacik J, Bajorin D, et al: Etoposide and cisplatin chemotherapy for metastatic good-risk germ cell tumors. J Clin Oncol 23:9290-9294, 2005 6. Hinton S, Catalano PJ, Einhorn LH, et al: Cisplatin, etoposide and either bleomycin or ifosfamide in the treatment of disseminated germ cell tumors: Final analysis of an intergroup trial. Cancer 97:1869-1875, 2003 7. Nichols CR, Catalano PJ, Crawford ED, et al: Randomized comparison of cisplatin and etoposide and either bleomycin or ifosfamide in treatment of advanced disseminated germ cell tumors: An Eastern Cooperative Oncology Group, Southwest Oncology Group, and Cancer and Leukemia Group B Study. J Clin Oncol 16:1287-1293, 1998 8. Kondagunta GV, Bacik J, Donadio A, et al: Combination of paclitaxel, ifosfamide, and cisplatin is an effective second-line therapy for patients with relapsed testicular germ cell tumors. J Clin Oncol 23:6549-6555, 2005 9. Osswald M, Harlan LC, Penson D, et al: Treatment of a population based sample of men diagnosed with testicular cancer in the United States. Urol Oncol 27:604-610, 2009 10. Gordis L: Epidemiology (ed 4). Philadelphia, PA, Saunders, Elsevier, 2009, pp 251-256 11. Travis LB, Andersson M, Gospodarowicz M, et al: Treatment-associated leukemia following testicular cancer. J Natl Cancer Inst 92:1165-1171, 2000 12. Travis LB, Holowaty EJ, Bergfeldt K, et al: Risk of leukemia after platinumbased chemotherapy for ovarian cancer. N Engl J Med 340:351-357, 1999 13. Travis LB: Therapy-associated solid tumors. Acta Oncol 41:323-333, 2002 14. Travis LB, Rabkin CS, Brown LM, et al: Cancer survivorship: Genetic susceptibility and second primary cancers—Research strategies and recommendations. J Natl Cancer Inst 98:15-25, 2006 15. Travis LB, Beard C, Allan JM, et al: Testicular cancer survivorship: Research strategies and recommendations. J Natl Cancer Inst 102:1114-1130, 2010
DOI: 10.1200/JCO.2013.54.6168; published online ahead of print at www.jco.org on March 3, 2014
The author(s) indicated no potential conflicts of interest.
■ ■ ■
Opening the Doors of the Intensive Care Unit to Patients With Hematologic Malignancies TO THE EDITOR: Advances in oncologic and supportive care have led to improved prognosis and extension of survival time in critically ill patients with hematologic malignancies (HMs). Azoulay et al1 reported a large, prospective, multicenter study of intensive care unit (ICU) and post-ICU outcomes in patients with HMs who were admitted to the ICU without following a guideline for ICU admission. ICU admission occurred 4 days after hospital admission; 451 patients (44.6%) were admitted within 1 day, including 267 patients (26%) who were admitted directly to the ICU. The hospital, 90-day, and 1-year mortality rates were 39.3%, 47.5%, and 56.7%, respectively. As acknowledged by the authors, no rigid criteria were used across the different participating centers to make the decision to send patients to ICUs. The ICU triage policies were based on the experience of the clinicians with patients with HMs; however, the clinical judgment of physicians is inaccurate. The mortality rates in patients not admitted www.jco.org
to the ICU because they were considered too well or too sick to benefit from intensive care were 11.3% and 74%, respectively. The mortality rate of the entire group (admitted and not admitted to the ICU), excluding patients who declined to participate in the study, was 46% (624 of 1,355 patients). The principle of justice would dictate that ICUs use a valid and reliable mortality prediction model to determine admission.2 Scoring systems have been developed to measure the severity of illness and predict patient outcome.3 Chan et al4 reported that the Acute Physiology and Chronic Health Evaluation (APACHE) II scores determined at the time of admission to an ICU were predictive of in-hospital mortality in critically ill patients with cancer. Recently, Kopterides et al5 reported that the scoring systems for illness severity, including APACHE II, the Sequential Organ Failure Assessment (SOFA), and the Simplified Acute Physiology Score (SAPS) II, calculated on the first day of ICU stay, were fairly accurate predictors of ICU mortality, with good discrimination and acceptable calibration. Because clinical experience is not accurate, the authors should have used a scoring system for illness severity such as SAPS II or APACHE II, and should have reported the standardized mortality ratios for their patient groups. © 2014 by American Society of Clinical Oncology
Information downloaded from jco.ascopubs.org and provided by at J S GERICKE LIBRARY on October 4, 2014 from Copyright © 2014 American Society of Clinical Oncology. All rights reserved. 146.232.129.75
1169
Correspondence
Patients are treated in the ICU because they are at risk of dying without such care. The ICU may seem to be a good place for patients to stay for their entire admission because of the high level of care; however, ICU care involves a number of risks, particularly the risk of acquiring new infections, and it is quite expensive to provide constant attention to patients who are improving.6 Patients with hematooncologic illness consume more critical care resources and have a longer ICU stay than patients with nononcologic illnesses.7 Many hospitals in low-income countries do not have an ICU, and critically ill patients are treated in the general wards.8 There is a large variation in ICU bed rates across North America and Western Europe. The United States and Canada were found to have the highest number of ICU beds, with 20 and 13.5 beds per population of 100,000, respectively.9 Mexico does not have an accurate record of the number of ICU beds, although it is estimated that there are approximately 1,984 ICU beds with mechanical ventilators.10 According to data reported by The Instituto Nacional de Estadística y Geografía in 2010, the population of Mexico is approximately 112.5 million11; thus, the estimated number of ICU beds in Mexico is 1.76 ICU beds per population of 100,000, similar to that of the United Kingdom (3.5 adult ICU beds per population of 100,000) and less than in France (9.3 adult ICU beds per population of 100,000). The goals of many ICU interventions are to stabilize and support patients, rather than to cure or improve an underlying condition.12 The prioritization model (eg, highest priority with greatest potential benefit) is most often used by critical care physicians.13 Recently, our group reported 20% and 70.1% ICU mortality rates for patients with HMs who had two or fewer organ system dysfunctions and three or more system dysfunctions, respectively (P ⬍ .001).14 Delayed ICU admission is associated with increased mortality in patients with cancer.15 In our institution, critically ill patients with HMs and a SOFA score of ⱖ 10 points during the first 24 hours after ICU admission have an in-hospital mortality rate greater than 80%.14 We therefore suggest admission to the ICU for three or fewer organ dysfunctions or a SOFA score of ⬍ 10 points.14,16 However, the distribution and use of critical care resources must be determined for policy decisions regarding critical care services for critically ill patients with HMs.
˜ amendys-Silva Silvio A. N Instituto Nacional de Cancerología; and Instituto Nacional de Ciencias Me´dicas y Nutricio´n Salvador Zubira´n, Mexico City, Mexico
Francisco J. García-Guille´n and Angel Herrera-Go´mez
AUTHOR’S DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST
The author(s) indicated no potential conflicts of interest. REFERENCES 1. Azoulay E, Mokart D, Pe`ne F, et al: Outcomes of critically ill patients with hematologic malignancies: Prospective multicenter data from France and Belgium—A Groupe de Recherche Respiratoire en Re´animation OncoHe´matologique study. J Clin Oncol 31:2810-2818, 2013 2. Shelton BK: Admission criteria and prognostication in patients with cancer admitted to the intensive care unit. Crit Care Clin 26:1-20, 2010 3. Fullerton JN, Perkins GD: Who to admit to intensive care? Clin Med 11:601-604, 2011 4. Chang L, Horng CF, Huang YC, et al: Prognostic accuracy of Acute Physiology and Chronic Health Evaluation II scores in critically ill cancer patients. Am J Crit Care 15:47-53, 2006 5. Kopterides P, Liberopoulos P, Ilias I, et al: General prognostic scores in outcome prediction for cancer patients admitted to the intensive care unit. Am J Crit Care 20:56-66, 2011 6. American Thoracic Society: What is the purpose of an intensive care unit? New York, NY, American Thoracic Society. http://www.thoracic.org/clinical/ critical-care/patient-information/ccprimer-general-information.php 7. Merz TM, Scha¨r P, Bu¨hlmann M, et al: Resource use and outcome in critically ill patients with hematological malignancy: A retrospective cohort study. Crit Care 12:R75, 2008 8. Baker T: Critical care in low-income countries. Trop Med Int Health 14:143-148, 2009 9. Wunsch H, Angus DC, Harrison DA, et al: Variation in critical care services across North America and Western Europe. Crit Care Med 36:27872793, e1-e9, 2008 10. Volkow P, Bautista E, de la Rosa M, et al: The response of the intensive care units during the influenza A H1N1 pandemic: The experience in Chiapas, Mexico [in Spanish]. Salud Publica Mex 53:345-353, 2011 11. Instituto Nacional de Estadística y Geografía: Censo de Poblacio´n y Vivienda 2010. http://www3.inegi.org.mx/sistemas/mexicocifras/default.aspx? src⫽487 12. [No authors listed]: Understanding costs and cost-effectiveness in critical care: Report from the second American Thoracic Society workshop on outcomes research. Am J Respir Crit Care Med 165:540-550, 2002 13. Task Force of the American College of Critical Care Medicine, Society of Critical Care Medicine: Guidelines for intensive care unit admission, discharge and triage: Task Force of the American College of Critical Care Medicine, Society of Critical Care Medicine. Crit Care Med 27:633-638, 1999 14. N˜amendys-Silva SA, Gonza´lez-Herrera MO, García-Guille´n FJ, et al: Outcome of critically ill patients with hematological malignancies. Ann Hematol 92:699-705, 2013 15. Mokart D, Lambert J, Schnell D, et al: Delayed intensive care unit admission is associated with increased mortality in patients with cancer with acute respiratory failure. Leuk Lymphoma 54:1724-1729, 2013 16. N˜amendys-Silva SA, Gonza´lez-Herrera MO, Texcocano-Becerra J, et al: Clinical characteristics and outcomes of critically ill cancer patients with septic shock. QJM 104:505-511, 2011
DOI: 10.1200/JCO.2013.52.1401; published online ahead of print at www.jco.org on March 10, 2014
Instituto Nacional de Cancerología, Mexico City, Mexico
■ ■ ■
˜ amendys-Silva et al Reply to S.A. N ˜ amendys-Silva et al1 with interest. We have read the letter from N Although use of the severity score for triage purposes is a compelling idea, we disagree with the authors with regard to its feasibility. First, ˜ amendys-Silva et al cite positive studies that suggest the severity N score to be discriminant in predicting outcome. However, several studies2-4 have indicated that the usual severity scores, including the Acute Physiology and Chronic Health Evaluation score, were neither discriminant nor well calibrated in critically ill patients with cancer. We believe that these studies should be taken into consideration. 1170
© 2014 by American Society of Clinical Oncology
Additionally, the inability of these scores to predict individual outcomes because of their lack of calibration was demonstrated two decades ago.5,6 In keeping with these findings, and although we agree that reliance on physician predictions of outcome remains imperfect,7,8 we would strongly discourage outdated triage practices that are based on severity scores. We fully agree that the prioritization of admission policy might be in order in low income countries. However, this can only be performed according to objective criteria. We believe that if intensive care unit admission of patients with cancer is limited, it is first necessary to carefully assess the outcomes of these patients. Our study provides convincing evidence that the prognosis of these patients is no longer JOURNAL OF CLINICAL ONCOLOGY
Information downloaded from jco.ascopubs.org and provided by at J S GERICKE LIBRARY on October 4, 2014 from Copyright © 2014 American Society of Clinical Oncology. All rights reserved. 146.232.129.75
collects data on type of initial treatment, but not types and doses of initial chemotherapy or subsequent courses of treatment. However, several prior analytic studies with complete chemotherapy information showed significant dose-response relationships between cumulative cisplatin amount and treatment-related leukemia.11,12 As we stated,2 it will be important in future analytic studies to determine the extent to which any dose-response relationship between platinum and solid tumors may exist, the types of cancers, latency patterns, and interactions with other factors,13 including genetic susceptibility14 and other drugs. These future research priorities with regard to second malignant neoplasms in survivors of testicular cancer were recently summarized by Travis et al.15
Chunkit Fung University of Rochester Medical Center, James P. Wilmot Cancer Center, Rochester, NY
Sophie D. Fossa Norwegian Radium Hospital, Oslo, Norway
Michael T. Milano University of Rochester Medical Center, Rochester, NY
Jan Oldenburg Norwegian Radium Hospital, Oslo, Norway
Lois B. Travis Rubin Center for Cancer Survivorship, University of Rochester Medical Center, Rochester, NY
ACKNOWLEDGMENT
C.F. was supported by the James P. Wilmot Foundation Research Fellowship, and L.B.T. was supported by National Cancer Institute Grant No. R01-CA157823-01A1-NCI. AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST
REFERENCES 1. Gandaglia G, Karakiewicz PI, Trinh Q-D, et al: Cisplatin-based chemotherapy and the risk of solid tumors in patients with testicular nonseminoma: Still a matter of debate. J Clin Oncol 32:1167, 2014 2. Fung C, Fossa SD, Milano MT, et al: Solid tumors after chemotherapy or surgery for testicular nonseminoma: A population-based study. J Clin Oncol 31:3807-3814, 2013 3. Einhorn LH, Donohue J: Cis-diamminedichloroplatinum, vinblastine, and bleomycin combination chemotherapy in disseminated testicular cancer. Ann Intern Med 87:293-298, 1977 4. Williams SD, Birch R, Einhorn LH, et al: Treatment of disseminated germ-cell tumors with cisplatin, bleomycin, and either vinblastine or etoposide. N Engl J Med 316:1435-1440, 1987 5. Kondagunta GV, Bacik J, Bajorin D, et al: Etoposide and cisplatin chemotherapy for metastatic good-risk germ cell tumors. J Clin Oncol 23:9290-9294, 2005 6. Hinton S, Catalano PJ, Einhorn LH, et al: Cisplatin, etoposide and either bleomycin or ifosfamide in the treatment of disseminated germ cell tumors: Final analysis of an intergroup trial. Cancer 97:1869-1875, 2003 7. Nichols CR, Catalano PJ, Crawford ED, et al: Randomized comparison of cisplatin and etoposide and either bleomycin or ifosfamide in treatment of advanced disseminated germ cell tumors: An Eastern Cooperative Oncology Group, Southwest Oncology Group, and Cancer and Leukemia Group B Study. J Clin Oncol 16:1287-1293, 1998 8. Kondagunta GV, Bacik J, Donadio A, et al: Combination of paclitaxel, ifosfamide, and cisplatin is an effective second-line therapy for patients with relapsed testicular germ cell tumors. J Clin Oncol 23:6549-6555, 2005 9. Osswald M, Harlan LC, Penson D, et al: Treatment of a population based sample of men diagnosed with testicular cancer in the United States. Urol Oncol 27:604-610, 2009 10. Gordis L: Epidemiology (ed 4). Philadelphia, PA, Saunders, Elsevier, 2009, pp 251-256 11. Travis LB, Andersson M, Gospodarowicz M, et al: Treatment-associated leukemia following testicular cancer. J Natl Cancer Inst 92:1165-1171, 2000 12. Travis LB, Holowaty EJ, Bergfeldt K, et al: Risk of leukemia after platinumbased chemotherapy for ovarian cancer. N Engl J Med 340:351-357, 1999 13. Travis LB: Therapy-associated solid tumors. Acta Oncol 41:323-333, 2002 14. Travis LB, Rabkin CS, Brown LM, et al: Cancer survivorship: Genetic susceptibility and second primary cancers—Research strategies and recommendations. J Natl Cancer Inst 98:15-25, 2006 15. Travis LB, Beard C, Allan JM, et al: Testicular cancer survivorship: Research strategies and recommendations. J Natl Cancer Inst 102:1114-1130, 2010
DOI: 10.1200/JCO.2013.54.6168; published online ahead of print at www.jco.org on March 3, 2014
The author(s) indicated no potential conflicts of interest.
■ ■ ■
Opening the Doors of the Intensive Care Unit to Patients With Hematologic Malignancies TO THE EDITOR: Advances in oncologic and supportive care have led to improved prognosis and extension of survival time in critically ill patients with hematologic malignancies (HMs). Azoulay et al1 reported a large, prospective, multicenter study of intensive care unit (ICU) and post-ICU outcomes in patients with HMs who were admitted to the ICU without following a guideline for ICU admission. ICU admission occurred 4 days after hospital admission; 451 patients (44.6%) were admitted within 1 day, including 267 patients (26%) who were admitted directly to the ICU. The hospital, 90-day, and 1-year mortality rates were 39.3%, 47.5%, and 56.7%, respectively. As acknowledged by the authors, no rigid criteria were used across the different participating centers to make the decision to send patients to ICUs. The ICU triage policies were based on the experience of the clinicians with patients with HMs; however, the clinical judgment of physicians is inaccurate. The mortality rates in patients not admitted www.jco.org
to the ICU because they were considered too well or too sick to benefit from intensive care were 11.3% and 74%, respectively. The mortality rate of the entire group (admitted and not admitted to the ICU), excluding patients who declined to participate in the study, was 46% (624 of 1,355 patients). The principle of justice would dictate that ICUs use a valid and reliable mortality prediction model to determine admission.2 Scoring systems have been developed to measure the severity of illness and predict patient outcome.3 Chan et al4 reported that the Acute Physiology and Chronic Health Evaluation (APACHE) II scores determined at the time of admission to an ICU were predictive of in-hospital mortality in critically ill patients with cancer. Recently, Kopterides et al5 reported that the scoring systems for illness severity, including APACHE II, the Sequential Organ Failure Assessment (SOFA), and the Simplified Acute Physiology Score (SAPS) II, calculated on the first day of ICU stay, were fairly accurate predictors of ICU mortality, with good discrimination and acceptable calibration. Because clinical experience is not accurate, the authors should have used a scoring system for illness severity such as SAPS II or APACHE II, and should have reported the standardized mortality ratios for their patient groups. © 2014 by American Society of Clinical Oncology
Information downloaded from jco.ascopubs.org and provided by at J S GERICKE LIBRARY on October 4, 2014 from Copyright © 2014 American Society of Clinical Oncology. All rights reserved. 146.232.129.75
1169
Correspondence
Patients are treated in the ICU because they are at risk of dying without such care. The ICU may seem to be a good place for patients to stay for their entire admission because of the high level of care; however, ICU care involves a number of risks, particularly the risk of acquiring new infections, and it is quite expensive to provide constant attention to patients who are improving.6 Patients with hematooncologic illness consume more critical care resources and have a longer ICU stay than patients with nononcologic illnesses.7 Many hospitals in low-income countries do not have an ICU, and critically ill patients are treated in the general wards.8 There is a large variation in ICU bed rates across North America and Western Europe. The United States and Canada were found to have the highest number of ICU beds, with 20 and 13.5 beds per population of 100,000, respectively.9 Mexico does not have an accurate record of the number of ICU beds, although it is estimated that there are approximately 1,984 ICU beds with mechanical ventilators.10 According to data reported by The Instituto Nacional de Estadística y Geografía in 2010, the population of Mexico is approximately 112.5 million11; thus, the estimated number of ICU beds in Mexico is 1.76 ICU beds per population of 100,000, similar to that of the United Kingdom (3.5 adult ICU beds per population of 100,000) and less than in France (9.3 adult ICU beds per population of 100,000). The goals of many ICU interventions are to stabilize and support patients, rather than to cure or improve an underlying condition.12 The prioritization model (eg, highest priority with greatest potential benefit) is most often used by critical care physicians.13 Recently, our group reported 20% and 70.1% ICU mortality rates for patients with HMs who had two or fewer organ system dysfunctions and three or more system dysfunctions, respectively (P ⬍ .001).14 Delayed ICU admission is associated with increased mortality in patients with cancer.15 In our institution, critically ill patients with HMs and a SOFA score of ⱖ 10 points during the first 24 hours after ICU admission have an in-hospital mortality rate greater than 80%.14 We therefore suggest admission to the ICU for three or fewer organ dysfunctions or a SOFA score of ⬍ 10 points.14,16 However, the distribution and use of critical care resources must be determined for policy decisions regarding critical care services for critically ill patients with HMs.
˜ amendys-Silva Silvio A. N Instituto Nacional de Cancerología; and Instituto Nacional de Ciencias Me´dicas y Nutricio´n Salvador Zubira´n, Mexico City, Mexico
Francisco J. García-Guille´n and Angel Herrera-Go´mez
AUTHOR’S DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST
The author(s) indicated no potential conflicts of interest. REFERENCES 1. Azoulay E, Mokart D, Pe`ne F, et al: Outcomes of critically ill patients with hematologic malignancies: Prospective multicenter data from France and Belgium—A Groupe de Recherche Respiratoire en Re´animation OncoHe´matologique study. J Clin Oncol 31:2810-2818, 2013 2. Shelton BK: Admission criteria and prognostication in patients with cancer admitted to the intensive care unit. Crit Care Clin 26:1-20, 2010 3. Fullerton JN, Perkins GD: Who to admit to intensive care? Clin Med 11:601-604, 2011 4. Chang L, Horng CF, Huang YC, et al: Prognostic accuracy of Acute Physiology and Chronic Health Evaluation II scores in critically ill cancer patients. Am J Crit Care 15:47-53, 2006 5. Kopterides P, Liberopoulos P, Ilias I, et al: General prognostic scores in outcome prediction for cancer patients admitted to the intensive care unit. Am J Crit Care 20:56-66, 2011 6. American Thoracic Society: What is the purpose of an intensive care unit? New York, NY, American Thoracic Society. http://www.thoracic.org/clinical/ critical-care/patient-information/ccprimer-general-information.php 7. Merz TM, Scha¨r P, Bu¨hlmann M, et al: Resource use and outcome in critically ill patients with hematological malignancy: A retrospective cohort study. Crit Care 12:R75, 2008 8. Baker T: Critical care in low-income countries. Trop Med Int Health 14:143-148, 2009 9. Wunsch H, Angus DC, Harrison DA, et al: Variation in critical care services across North America and Western Europe. Crit Care Med 36:27872793, e1-e9, 2008 10. Volkow P, Bautista E, de la Rosa M, et al: The response of the intensive care units during the influenza A H1N1 pandemic: The experience in Chiapas, Mexico [in Spanish]. Salud Publica Mex 53:345-353, 2011 11. Instituto Nacional de Estadística y Geografía: Censo de Poblacio´n y Vivienda 2010. http://www3.inegi.org.mx/sistemas/mexicocifras/default.aspx? src⫽487 12. [No authors listed]: Understanding costs and cost-effectiveness in critical care: Report from the second American Thoracic Society workshop on outcomes research. Am J Respir Crit Care Med 165:540-550, 2002 13. Task Force of the American College of Critical Care Medicine, Society of Critical Care Medicine: Guidelines for intensive care unit admission, discharge and triage: Task Force of the American College of Critical Care Medicine, Society of Critical Care Medicine. Crit Care Med 27:633-638, 1999 14. N˜amendys-Silva SA, Gonza´lez-Herrera MO, García-Guille´n FJ, et al: Outcome of critically ill patients with hematological malignancies. Ann Hematol 92:699-705, 2013 15. Mokart D, Lambert J, Schnell D, et al: Delayed intensive care unit admission is associated with increased mortality in patients with cancer with acute respiratory failure. Leuk Lymphoma 54:1724-1729, 2013 16. N˜amendys-Silva SA, Gonza´lez-Herrera MO, Texcocano-Becerra J, et al: Clinical characteristics and outcomes of critically ill cancer patients with septic shock. QJM 104:505-511, 2011
DOI: 10.1200/JCO.2013.52.1401; published online ahead of print at www.jco.org on March 10, 2014
Instituto Nacional de Cancerología, Mexico City, Mexico
■ ■ ■
˜ amendys-Silva et al Reply to S.A. N ˜ amendys-Silva et al1 with interest. We have read the letter from N Although use of the severity score for triage purposes is a compelling idea, we disagree with the authors with regard to its feasibility. First, ˜ amendys-Silva et al cite positive studies that suggest the severity N score to be discriminant in predicting outcome. However, several studies2-4 have indicated that the usual severity scores, including the Acute Physiology and Chronic Health Evaluation score, were neither discriminant nor well calibrated in critically ill patients with cancer. We believe that these studies should be taken into consideration. 1170
© 2014 by American Society of Clinical Oncology
Additionally, the inability of these scores to predict individual outcomes because of their lack of calibration was demonstrated two decades ago.5,6 In keeping with these findings, and although we agree that reliance on physician predictions of outcome remains imperfect,7,8 we would strongly discourage outdated triage practices that are based on severity scores. We fully agree that the prioritization of admission policy might be in order in low income countries. However, this can only be performed according to objective criteria. We believe that if intensive care unit admission of patients with cancer is limited, it is first necessary to carefully assess the outcomes of these patients. Our study provides convincing evidence that the prognosis of these patients is no longer JOURNAL OF CLINICAL ONCOLOGY
Information downloaded from jco.ascopubs.org and provided by at J S GERICKE LIBRARY on October 4, 2014 from Copyright © 2014 American Society of Clinical Oncology. All rights reserved. 146.232.129.75
