To the Editor We read with interest the article by Nabozny et al1 concerning withholding or withdrawing care from some intensive care unit (ICU) patients. We agree with much of their analysis. However, we were surprised by their conclusion about the futility of cardiopulmonary resuscitation (CPR) in patients with metastatic cancer. In our opinion, the reference cited to support this point of view2 is outdated because the patients included in the study were recruited between 2000 and 2004, and the study was also questionable in its methodology. In a meta-analysis of 42 studies including patients with cancer who underwent CPR between 1967 and 2004, Reisfield and al3 observed a global rate of hospital survival of 5.6% for patients with metastatic cancer. However, this low rate of survival masked a substantial temporal change in survival. It is fundamental to clarify that most studies about CPR and patients with cancer are old and do not take into account the progress that has been made in the care of these patients (including patients with metastases) and ICU management of patients who had cardiac arrest. Data about CPR and patients with cancer remain scarce and only 2 studies4,5 were recently published on this subject. The first focused on patients with cancer who underwent CPR during an ICU stay; if the outcome of these critically ill patients was poor (ICU and hospital survival, 7.7% and 5.8%, respectively), the only factor associated with outcome was CPR duration.4 In a recent retrospective and multicenter study including 133 patients with cancer, we found that of the 35 (26%) patients alive at ICU discharge, 32 (91%) had a good neurological outcome.5 Twenty-four (18%) patients were alive at hospital discharge, including 23 (17%) with good neurological outcomes and 1 with a severe disability. In our study,5 significant differences between ICU and non-ICU survivors only concerned previous global conditions and cardiac arrest characteristics without significant difference regarding the type of cancer or cancer status at ICU admission. Our recent data confirm that CPR can be beneficial to patients with cancer, even with metastases. We must, however, as suggested by Nabozny et al,1 be very careful with this type of resuscitation and not hesitate to reassess daily the number of organ failures to prevent the use of unreasonable and futile ICU care after initial successful CPR.1 Thus, we believe that more than the cancer status (including metastasis), some simple factors, such as performance status and cancer treatment plan, should be taken into account when deciding whether to perform initial CPR on these patients.
Champigneulle B, Cariou A, Vincent F, for the Groupe de recherche en réanimation respiratoire en Onco-Hématologie (GrrrOH). Cardiopulmonary Resuscitation and Benefit to Patients With Metastatic Cancer. JAMA Intern Med. 2016;176(1):142. doi:10.1001/jamainternmed.2015.7415