Survival in cancer patients undergoing in-hospital cardiopulmonary resuscitation: A meta-analysis

doi:10.1016/j.resuscitation.2006.02.022

Resuscitation

Volume 71, Issue 2, November 2006, Pages 152-160

https://doi.org/10.1016/j.resuscitation.2006.02.022 Get rights and content

Summary

Introduction

Cardiopulmonary resuscitation is thought to be a low-yield intervention in cancer patients. In patients with metastatic disease the procedure is thought to be futile. Comprehensive data on survival to discharge in subsets of cancer patients undergoing in-hospital cardiopulmonary resuscitation, however, are lacking.

Objective

To determine the rate of survival to discharge for adult cancer patients undergoing in-hospital cardiopulmonary resuscitation.

Method

A systematic search of MEDLINE and our primary sources’ references was performed for studies involving in-hospital cardiac arrest, in clearly defined subsets of adult cancer patients, with outcomes that included survival to hospital discharge.

Results

Forty-two studies from 1966–2005, comprising 1707 patients met our minimal inclusion criteria. Overall survival to discharge was 6.2%. Survival in patients with localized disease was 9.5%, and in patients with metastatic disease was 5.6%. Analysis of data reported since 1990 reveals a narrowing of the survival gap, with survival rates in patients with localised disease of 9.1%, and in patients with metastatic disease of 7.8%. Survival in patients resuscitated on the general medical/surgical wards was 10.1%, while survival in patients resuscitated on intensive care units (ICUs) was 2.2%.

Conclusions

Overall survival of CPR to hospital discharge in cancer patients compares favorably to survival rates in unselected inpatients. Improved outcomes in recent years in patients with metastatic disease are likely to reflect more selective use of CPR in cancer patients, with the sickest patients deselected.

Introduction

Cancer is the second leading cause of death in both the United States¹ and the European Union,² and is expected to be the overall leading cause of death within the next decade.³ It follows that physician–patient discussions concerning “do not attempt resuscitation” (DNAR) status in the context of cancer diagnoses occur with relative frequency. Respect for patient autonomy in end-of-life decision-making is determined, in part, on the provision of adequate information concerning cardiopulmonary resuscitation (CPR) outcomes.⁴ Several studies have shown that CPR outcomes data indeed influence patient preferences, thus making accurate data imperative.5, 6 Evidence indicates, however, that physicians are neither accurate7, 8 nor forthcoming9, 10 with CPR outcomes data in their discussions with patients. This may be especially true in discussions with cancer patients, where older data – data suggesting the probability of successful resuscitation is very small, and in the presence of metastatic disease is zero – is perpetuated as present fact.11, 12, 13, 14, 15 Several recent papers on the subject of CPR discussions with cancer patients have simply omitted any mention of outcome data.12, 16 In an effort to promote more informed end-of-life decision-making, we conducted a meta-analysis of survival to discharge in cancer patients undergoing in-hospital CPR, with particular emphasis on more recent outcomes data.

Section snippets

Data sources

Studies were identified by querying the National Library of Medicine's MEDLINE database (1966–2005) via the PubMed retrieval system, using the keywords CPR, resuscitation, cancer, and survival in varying combinations. Additional studies were identified by screening our primary studies’ cited references. No language restrictions were set.

Study selection and data abstraction

Each of the retrieved papers was reviewed by the primary investigator (GMR). All studies were reviewed independently by the co-investigators. Studies not

Results

Forty-seven studies between 1966 and August 2005 that reported survival to discharge in hospitalized adult cancer patients who underwent CPR were identified. Seven studies or portions thereof were excluded because they included pediatric patients,18, 19, 20, 21 out-of-hospital arrests,22, 23 or subjects that were included in earlier or less complete analyses.20, 24 Forty-two studies, in whole or in part, comprising 1707 patients met the minimal inclusion criteria.

Discussion

Clearly, the broad concept of resuscitation success in the “cancer patient” is of limited value: cancer is a heterogeneous disease affecting heterogeneous populations. Thus, for example, the overall rate of survival to hospital discharge of 6.2% obscures a substantial survival difference between those with localised (9.5%) and metastatic (5.6%) disease. As a point of reference, overall rate of survival to discharge in unselected in-hospital arrests is approximately15%.65, 66

Neither we nor others

Conclusions

This meta-analysis of in-hospital resuscitation of cancer patients has shown rates of survival to discharge in localised and metastatic disease of 9.5% and 5.6%, respectively. Using only data since 1990, the numbers for localized and metastatic disease are 9.1% and 7.8%, respectively, likely reflecting the more selective use of CPR in recent years. These numbers are lower than the approximately 15% survival rate for unselected in-hospital arrests, but they refute suggestions that CPR is futile

Acknowledgments

The authors would like to thank Dorothy Kim Waller, PhD and Benjamin Nebiyou Bekele, PhD for their expertise and assistance with the analysis.

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It is important to standardize the admission processes to the Intensive Care Units (ICU), and the practices established by consensus determine quality interventions that can enhance specific contexts. ICU are finite, high-cost services that require policies to ensure rational use and to provide quality care to patients. In response to the variability of ICU admission criteria in the country, the Colombian Association of Critical Medicine and Intensive Care (AMCI) convened a multidisciplinary team of experts in critical medicine to establish a scientific statement using the formal consensus methodology, mainly by the Delphi method, about the recommendations and practices that allow to homogenize the criteria for admission to ICU in Colombia. As part of the mission of the AMCI, it is intended to have a positive impact on the different levels of the health system — providers, administrators, insurers and government — and that in the end it will be reflected in benefits for critically ill or at-risk patients. The consensus invites all ICU in the country to select their own criteria taking into account the list of recommendations it contains; it is clarified that the contents are generated in a scientific, academic and non-commercial context. Each health institution must be a guarantor, through the care coordination of the ICUs, of the responsible use of these criteria both for the safe and quality care of patients and to use them for the different commercial relationships established with the administrators of the regimens of health. This document has a national scope and its content is expected to be updated in no more than 4 years.
Post-cardiac arrest PCI is underutilized among cancer patients: Machine learning augmented nationally representative case-control study of 30 million hospitalizations
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Cancer patients are less likely to undergo percutaneous coronary intervention (PCI) after cardiac arrest, although they demonstrate improved mortality benefit from the procedure. We produced the largest nationally representative analysis of mortality of cardiac arrest and PCI for patients with cancer versus non-cancer.
Propensity score adjusted multivariable regression for mortality was performed in this case-control study of the United States’ largest all-payer hospitalized dataset, the 2016 National Inpatient Sample. Regression models of mortality and PCI weighted by the complex survey design were fully adjusted for age, race, income, cancer metastases, NIS-calculated mortality risk by Diagnosis Related Group (DRG), acute coronary syndrome, and likelihood of undergoing PCI.
Of the 30,195,722 hospitalized adult patients, 15.43% had cancer, and 0.79% of the whole sample presented with cardiac arrest (of whom 20.57% underwent PCI). In fully adjusted regression analysis among patients with cardiac arrest, PCI significantly reduced mortality (OR 0.15, 95 %CI 0.13–0.19; p < 0.001) among patients with cancer greater than those without it (OR 0.21, 95 %CI 0.20–0.23; p < 0.001).
This nationally representative study suggests that post-cardiac arrest PCI is underutilized among patients with cancer despite its significant mortality reduction for such patients (independent of clinical acuity).
Outcomes of Cardiac Arrest Complicating Acute Myocardial Infarction in Patients With Current and Historical Cancer: An 18-Year United States Cohort Study
2022, Cardiovascular Revascularization Medicine
Data regarding cardiac arrest (CA) complicating acute myocardial infarction (AMI) in patients with cancers are limited.
Using the HCUP-NIS database (2000–2017), we identified adult admissions with AMI-CA and current or historical cancers to evaluate in-hospital mortality, utilization of coronary angiography, percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), mechanical circulatory support (MCS), palliative care consultation, do-not-resuscitate status use, among those with current, historical and without cancer.
Of 11,622,528 AMI admissions, CA was noted in 584,263 (5.0%). Current and historical cancers were identified in 14,790 (2.5%) and 26,939 (4.6%), respectively. Both current and historical cancer groups were on average older, of white race, had greater comorbidity, and received care at small/medium-sized hospitals compared to those without. The current cancer cohort had the lowest rates of coronary angiography (45.2% vs. 59.2% vs. 63.3%), PCI (32.4% vs. 42.3% vs. 47.0%), MCS (13.5% vs. 16.5% vs. 20.9%) and CABG (4.1% vs. 7.6% vs. 10.2%) compared to the historical cancer and no cancer cohorts (all p < 0.001). Compared to those without, the current (61.1% vs. 44.0%; adjusted odds ratio [OR] 1.25 [95% confidence interval {CI} 1.20–1.31], p < 0.001) and historical cancer cohorts (52.2% vs. 44.0%; adjusted OR 1.05 [95% CI 1.01–1.08], p = 0.003) had higher in-hospital mortality. Cancer admissions had higher rates of palliative care consultations and do-not-resuscitate status.
AMI-CA admissions with cancer were older, had lower utilization of cardiac procedures, and higher rates of palliative care and do-not-resuscitate status and in-hospital mortality compared to those without cancer.
Medical futility regarding cardiopulmonary resuscitation in in-hospital cardiac arrests of adult patients: A systematic review and Meta-analysis
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For some patients, survival with good neurologic function after cardiopulmonary resuscitation (CPR) is highly unlikely, thus CPR would be considered medically futile. Yet, in clinical practice, there are no well-established criteria, guidelines or measures to determine futility. We aimed to investigate how medical futility for CPR in adult patients is defined, measured, and associated with do-not-resuscitate (DNR) code status as well as to evaluate the predictive value of clinical risk scores through meta-analysis.
We searched Embase, PubMed, CINAHL, and PsycINFO from the inception of each database up to January 22, 2021. Data were pooled using a fixed-effects model. Data collection and reporting followed the PRISMA guidelines.
Thirty-one studies were included in the systematic review and 11 in the meta-analysis. Medical futility defined by risk scores was associated with a significantly higher risk of in-hospital mortality (5 studies, 3102 participants with Pre-Arrest Morbidity (PAM) and Prognosis After Resuscitation (PAR) score; overall RR 3.38 [95% CI 1.92–5.97]) and poor neurologic outcome/in-hospital mortality (6 studies, 115,213 participants with Good Outcome Following Attempted Resuscitation (GO-FAR) and Prediction of Outcome for In-Hospital Cardiac Arrest (PIHCA) score; RR 6.93 [95% CI 6.43–7.47]). All showed high specificity (>90%) for identifying patients with poor outcome.
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Citation Excerpt :
They concluded that providing CPR to cancer patients receiving life support is costly and does not lead to long-term survival. Similar results were reported by Khasawneh and colleagues65 and Reisfield and colleagues,66 with survival to discharge rates of 5.8% and 6.2%, respectively. In contrast, Champigneulle and colleagues67 showed an 18% hospital survival rate in cancer patients after cardiac arrest with an overall 6-month survival rate of 14%.
Impact of Cardiopulmonary Resuscitation on Survival in Cancer Patients: Do Not Resuscitate Before or After CPR?
2020, JACC: CardioOncology

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^☆: A Spanish translated version of the summary of this article appears as Appendix in the online version at doi:10.1016/j.resuscitation.2006.02.022.

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Clinical paperSurvival in cancer patients undergoing in-hospital cardiopulmonary resuscitation: A meta-analysis☆

Summary

Introduction

Objective

Method

Results

Conclusions

Introduction

Section snippets

Data sources

Study selection and data abstraction

Results

Discussion

Conclusions

Acknowledgments

Am J Emerg Med

Resuscitation

Resuscitation

Resuscitation

Mayo Clin Proc

Resuscitation

J Crit Care

Resuscitation

Resuscitation

Chest

Chest

Lancet

Lancet

Am J Surg

Am J Cardiol

Resuscitation

Crit Care Nurs Clin North Am

Resuscitation

Health statistics. Atlas on mortality in the European Union

Cancer mortality surveillance – United States, 1990–2000

MMWR Surveillance

Providing CPR survival data to patients

J Gen Intern Med

The influence of the probability of survival on patients’ preferences regarding cardiopulmonary resuscitation

N Engl J Med

Resuscitation decision marking in the elderly: the value of outcome data

J Gen Intern Med

The inability of physicians to predict the outcome of in-hospital resuscitation

J Gen Intern Med

How do medical residents discuss resuscitation with patients?

J Gen Intern Med

Opening the black box: how do physicians communicate about advance directives?

Ann Intern Med

Discussing do-not-resuscitate status

J Clin Oncol

CPR directives. Part II: resuscitation decisions – the physician's role

Clin Geriat

Do not attempt resuscitation decision in a cancer center: addressing difficult ethical and communication issues

Br J Cancer

Sampling techniques

Cardiopulmonary resuscitation on the general ward: no category of patients should be excluded in advance

Resuscitation

Cardiopulmonary resuscitation in a community hospital

J Kans Med Soc

Characteristics of cardiac arrest in cancer patients as a predictor of survival after cardiopulmonary resuscitation

Cancer

Clinical paper
Survival in cancer patients undergoing in-hospital cardiopulmonary resuscitation: A meta-analysis☆