In the Journals

Survival rates after cardiac arrest lower in patients with cancer

Patients with advanced cancer had significantly lower survival rates following in-hospital cardiac arrest than those without advanced cancer, according to a retrospective study published in Journal of Oncology Practice.

These data highlight the need for discussions of resuscitation care wishes in patients with advanced cancer.

“An advanced cancer diagnosis is one of the most difficult situations patients and families can face, in part because of the gravity of the decisions that have to be made,” Jeffrey T. Bruckel, MD, MPH, fellow in cardiovascular medicine at University of Rochester Medical Center, said in a press release. “Reliable and evidence-based information can help patients make more informed decisions about resuscitation, especially those who don’t have effective long-term treatment options.”

From April 2006 to June 2010 researchers evaluated resuscitation quality and survival in patients with and without advanced cancer who experienced cardiac arrests in 369 hospitals throughout the United States.

The analysis included data from 47,157 adults (57.8% men; median age, 65.9 years; 68.6% white, 21% black), 14% of whom (59% men; median age, 65.1 years; 68.9% white, 22.3% black) had advanced cancer — defined as metastatic or hematologic malignancy.

Researchers compared rates of return of spontaneous circulation, survival to discharge rates and quality of resuscitation between the groups.

Overall, 62.2% of patients achieved return of spontaneous circulation, and 17.9% survived to hospital discharge.

Patients with advanced cancer had lower multivariable-adjusted rates of return of spontaneous circulation (52.3% vs. 56.6%; RR = 0.93; 95% CI, 0.9-0.95) and survival to discharge (7.4% vs. 13.4%; RR = 0.55; 95% CI, 0.51-0.6).

“The most significant aspect of our findings was that patients with advanced cancer had higher survival rates than previously reported, although still much lower than patients without cancer,” Bruckel told HemOnc Today. “Patients with advanced cancer can expect, on average, a survival rate to hospital discharge of less than 10%. Although the survival rate is low, it is not so low as to be considered futile, as has been suggested by some single-center studies.”

Researchers then evaluated whether survival differences could be explained by less aggressive resuscitations among those with advanced cancer.

Results showed few clinically significant differences; however, mean duration of resuscitation among nonsurvivors appeared significantly shorter in patients with advanced cancer after adjusting for potential confounders (22.5 minutes vs. 24.1 minutes; P < .001).

Among patients with return of spontaneous circulation, those with advanced cancer appeared more likely to give do not resuscitate orders within 48 hours after the arrest (OR = 1.3; 95% CI, 1.24-1.37).

Bruckel noted the nonadvanced cancer group potentially could have included patients with nonmetastatic solid tumors.

“This study reinforces the fact that doctors need to have early and frank discussions with their patients about end-of-life care,” Merry Markham, MD, FACP, associate professor in the division of hematology and oncology at University of Florida and an ASCO expert who was not involved in the study, said in a press release. “Although in some cases it may be appropriate to attempt to resuscitate people with advanced cancer, patients should know all the facts and understand their options ahead of time. Greater substance is given to our sometimes-difficult discussions with patients and their families when we are able to present data such as these.”

Goals of care ideally would be discussed with patients before the need for hospitalization, Bruckel noted, adding his team’s study data provide needed prognostic information to patients and families contemplating resuscitation goals.

“A large component of end-of-life care involves patient and family care decision-making and a lot of that is driven by the routine discussions we have,” Bruckel said. “Not every patient is going to want detailed information, but for those that do, it’s important to have it; it’s important to tell them what we know.” – by Chuck Gormley

For more information:

Jeffrey T. Bruckel, MD, MPH, can be reached at University of Rochester Medical Center, Cardiology Division AC-G, 601 Elmwood Ave., Rochester, NY 14642; email: jeffrey_bruckel@urmc.rochester.edu.

Disclosure s : NHLBI and the Veterans Administration Health Services Research and Development funded this study. Bruckel reports he has stock or other ownership in AvantGarde Health. Please see the full study for a list of all other researchers’ relevant financial disclosures.

Patients with advanced cancer had significantly lower survival rates following in-hospital cardiac arrest than those without advanced cancer, according to a retrospective study published in Journal of Oncology Practice.

These data highlight the need for discussions of resuscitation care wishes in patients with advanced cancer.

“An advanced cancer diagnosis is one of the most difficult situations patients and families can face, in part because of the gravity of the decisions that have to be made,” Jeffrey T. Bruckel, MD, MPH, fellow in cardiovascular medicine at University of Rochester Medical Center, said in a press release. “Reliable and evidence-based information can help patients make more informed decisions about resuscitation, especially those who don’t have effective long-term treatment options.”

From April 2006 to June 2010 researchers evaluated resuscitation quality and survival in patients with and without advanced cancer who experienced cardiac arrests in 369 hospitals throughout the United States.

The analysis included data from 47,157 adults (57.8% men; median age, 65.9 years; 68.6% white, 21% black), 14% of whom (59% men; median age, 65.1 years; 68.9% white, 22.3% black) had advanced cancer — defined as metastatic or hematologic malignancy.

Researchers compared rates of return of spontaneous circulation, survival to discharge rates and quality of resuscitation between the groups.

Overall, 62.2% of patients achieved return of spontaneous circulation, and 17.9% survived to hospital discharge.

Patients with advanced cancer had lower multivariable-adjusted rates of return of spontaneous circulation (52.3% vs. 56.6%; RR = 0.93; 95% CI, 0.9-0.95) and survival to discharge (7.4% vs. 13.4%; RR = 0.55; 95% CI, 0.51-0.6).

“The most significant aspect of our findings was that patients with advanced cancer had higher survival rates than previously reported, although still much lower than patients without cancer,” Bruckel told HemOnc Today. “Patients with advanced cancer can expect, on average, a survival rate to hospital discharge of less than 10%. Although the survival rate is low, it is not so low as to be considered futile, as has been suggested by some single-center studies.”

Researchers then evaluated whether survival differences could be explained by less aggressive resuscitations among those with advanced cancer.

Results showed few clinically significant differences; however, mean duration of resuscitation among nonsurvivors appeared significantly shorter in patients with advanced cancer after adjusting for potential confounders (22.5 minutes vs. 24.1 minutes; P < .001).

Among patients with return of spontaneous circulation, those with advanced cancer appeared more likely to give do not resuscitate orders within 48 hours after the arrest (OR = 1.3; 95% CI, 1.24-1.37).

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Bruckel noted the nonadvanced cancer group potentially could have included patients with nonmetastatic solid tumors.

“This study reinforces the fact that doctors need to have early and frank discussions with their patients about end-of-life care,” Merry Markham, MD, FACP, associate professor in the division of hematology and oncology at University of Florida and an ASCO expert who was not involved in the study, said in a press release. “Although in some cases it may be appropriate to attempt to resuscitate people with advanced cancer, patients should know all the facts and understand their options ahead of time. Greater substance is given to our sometimes-difficult discussions with patients and their families when we are able to present data such as these.”

Goals of care ideally would be discussed with patients before the need for hospitalization, Bruckel noted, adding his team’s study data provide needed prognostic information to patients and families contemplating resuscitation goals.

“A large component of end-of-life care involves patient and family care decision-making and a lot of that is driven by the routine discussions we have,” Bruckel said. “Not every patient is going to want detailed information, but for those that do, it’s important to have it; it’s important to tell them what we know.” – by Chuck Gormley

For more information:

Jeffrey T. Bruckel, MD, MPH, can be reached at University of Rochester Medical Center, Cardiology Division AC-G, 601 Elmwood Ave., Rochester, NY 14642; email: jeffrey_bruckel@urmc.rochester.edu.

Disclosure s : NHLBI and the Veterans Administration Health Services Research and Development funded this study. Bruckel reports he has stock or other ownership in AvantGarde Health. Please see the full study for a list of all other researchers’ relevant financial disclosures.