Oncology ICU (Cancer Intensive Care Unit)

Having cancer is no reason to be refused intensive care. In a study across 28 hospitals, seven in ten such patients left hospital alive.

An oncology intensive care unit treats people with cancer when the disease, its treatment or an infection puts the lungs, the circulation or the kidneys in danger. Twenty years ago many hospitals turned these patients away. The evidence has since reversed that habit, and a prospective study of 717 cancer patients in the intensive care units of 28 hospitals recorded hospital survival of 70 percent (Soares and colleagues, Critical Care Medicine, 2010). This page explains who the Oncology ICU at Biruni Hospital in Istanbul treats, how decisions are made there, and what families coming from abroad should expect.

Hours count

Two large studies point the same way on delay. Among 1,011 patients with blood cancers treated in France and Belgium, admission to intensive care within 24 hours of the first sign of trouble was associated with better hospital survival (Azoulay and colleagues, Journal of Clinical Oncology, 2013). In a Brazilian study of 717 cancer patients in 28 hospitals, each additional day spent on a ward before intensive care raised the odds of death by 18 percent (Soares and colleagues, Critical Care Medicine, 2010). The mechanism is no mystery. Septic shock treated at the first drop in blood pressure involves one organ, and septic shock treated twelve hours later involves three.

Ask early. A ward team that calls the intensive care doctor to the bedside is doing its job, and a relative who asks whether that call has been made is doing theirs.

Why cancer patients need the unit

Six situations bring most of them in. Each is set out below.

A trial of intensive care

Sometimes nobody can tell on the first day whether intensive care will work. Doctors in Paris designed an answer to that uncertainty and named it the ICU trial.

They studied 188 cancer patients who needed a ventilator and had a second organ failing, the group with the poorest outlook in any unit. Hospital survival was 21.8 percent overall and 40 percent among those still alive on day five. Nothing about the cancer itself distinguished survivors from the rest. The organs did. Their course told the story, and scores measured on day six predicted survival better than the same scores on admission. Every patient who needed a ventilator, blood pressure drugs or dialysis started for the first time after the third day died (Lecuyer and colleagues, Critical Care Medicine, 2007). For families this approach has two merits. No one is denied a chance on the strength of a guess, and no one is kept on machines for weeks after the answer has become clear. Palliative care specialists join the team early, to treat pain, breathlessness and fear whatever the direction, and their presence does not mean treatment is stopping.

Some patients should not come to intensive care at all. Someone confined to bed by cancer for which no further treatment exists gains nothing from a ventilator, and good comfort care on a ward serves them better.

Cancer no longer closes the door

One in seven patients in a general intensive care unit has cancer, according to a systematic review in Intensive Care Medicine (Puxty and colleagues, 2014). They are there because the results justify it.

This table scrolls sideways on a narrow screen. Swipe or drag to see every column.

Read the last column from top to bottom and one pattern stands out. The reason for admission and the number of failing organs separate the rows far more than the cancer does. The Brazilian study tested this directly. After adjusting for other factors, death in hospital was linked to the severity of organ failure, to how active and independent the patient had been beforehand, to the need for a ventilator and to cancer that was progressing despite treatment, while the type of cancer and a low white cell count made no independent difference. Age alone did not decide it either. The lesson is plain. The same antibiotics, the same fluids and the same ventilator settings that save a patient without cancer are the ones that save a patient with cancer too, provided they are started without delay and without a debate at the door about whether the cancer makes the effort worthwhile.

Admission policies changed as a result, and a diagnosis of cancer written on the referral is no longer accepted as a reason to say no.

Two teams at one bedside

Cancer treatment does not always wait for the patient to leave the unit. In the French and Belgian study 38.2 percent of patients had a cancer diagnosed only days or weeks earlier, and for a leukemia filling the lungs or a lymphoma crushing an airway the chemotherapy is the intensive care.

Radiotherapy and chemotherapy are both delivered at Biruni Hospital on the same site as the intensive care unit and the operating rooms, with radiotherapy given on an Elekta Versa HD linear accelerator. A patient who needs urgent radiation for a compressed spinal cord, or the next cycle of chemotherapy while still recovering, stays under one roof with one set of records.

Life after the unit

Families fear that intensive care will cost the patient their cancer treatment. The French and Belgian researchers followed their survivors to find out. The answer was reassuring on all three counts they measured (Azoulay and colleagues, Journal of Clinical Oncology, 2013).

Recovery still takes work. Months of it. Weakness, poor sleep and low mood are common after any critical illness, and physiotherapy starts in the unit.

The next chemotherapy cycle is planned once blood counts, kidneys and strength allow.

Families coming to Istanbul

Patients with low white cells are nursed in single rooms, and the bedside rules follow from that.

• One or two visitors at a time.
• Hands washed, mask and gown on before entering.
• Flowers and fresh fruit stay outside.
• Anyone with a cough or a fever stays away.

A coordinator from the international patients team is assigned from the first message and stays with the family through discharge, and the same WhatsApp number works after you are back home. The team speaks English, Arabic, French, Russian, Serbian, Romanian and Spanish and arranges interpreters for other languages, which matters most on the day the doctors sit down with the family to review progress. The office arranges accommodation near the hospital, airport transfers, daily transport and the invitation letter that consulates request with a visa application. Halal, vegetarian and diabetic meals come from the hospital kitchen, a prayer room is on site, and a request for a female physician goes to the department and is met wherever the rota allows. After the move to a ward room, one relative stays overnight on the companion bed. None of this is extra. It is how the office works for every family that arrives from abroad, whether the patient walks in for a planned operation or lands at night on a stretcher with a flight nurse, and it continues by phone once you are back home and the first questions about the next cycle come up.

A critically ill patient travels by air ambulance, bed to bed, once the treating doctors and the flight medical team agree in writing that the journey is safe. Records come first. Send us the pathology report, the latest letter from the oncologist with the dates and doses of treatment, recent blood counts, imaging reports and the current intensive care summary. An oncologist and an intensive care doctor read the file together, free of charge, and they answer three things in writing, namely whether the unit can offer something the current hospital cannot, whether the cancer still has a treatment worth traveling for, and whether the journey itself is a risk worth taking this week. Acceptance is confirmed in writing before a flight is booked.

Cost

Days in the unit, days on a ventilator, dialysis, blood and platelet transfusions, antifungal drugs and isolation drive an intensive care estimate for a cancer patient. Chemotherapy or radiotherapy given during the stay is quoted separately by the oncology team. Low blood counts lengthen everything, because a patient who cannot fight infection or stop bleeding without help needs more days of isolation, more transfusions and more expensive drugs than a patient of the same age with the same pneumonia and a healthy bone marrow.

Hospitals in this market quote intensive care as a daily rate with a list of what it covers, and drugs, blood products, dialysis and procedures appear as separate lines in nearly all published terms. Ask who updates the estimate, how often and in which language, and give the hospital your insurer or assistance company details on the first day. No figure means anything before both teams have read the file, and that review is free.

Oncology ICU FAQ

Does going to the ICU mean the cancer treatment has failed?

No. Infection during chemotherapy, a reaction to treatment and planned monitoring after surgery account for a large share of admissions, and six months later 80 percent of survivors in one large study were in remission.

What is the survival rate for cancer patients in intensive care?

Survival depends on the reason for admission. In a study of 717 cancer patients in 28 hospitals, 70 percent left hospital alive, ranging from 89 percent after planned surgery to 42 percent after a medical complication. Among 1,011 patients with blood cancers, hospital survival was 60.7 percent.

Can chemotherapy be given in an oncology intensive care unit?

Yes. When the cancer itself is causing the emergency, as with some leukemias and lymphomas, chemotherapy starts in the unit with doses agreed between the oncologist and the intensive care doctor.

Can family visit a cancer patient in the ICU at Biruni Hospital?

Yes, one or two at a time, with hand washing, a mask and a gown. After the patient moves to a ward room, one relative stays overnight on the companion bed.

Can a critically ill cancer patient be transferred to Istanbul?

Yes, by air ambulance, once the treating doctors and the flight team confirm in writing that the patient is fit to fly. Biruni Hospital reviews the oncology file and the intensive care summary free of charge first.

Will staff speak our language?

The international patients team works in English, Arabic, French, Russian, Serbian, Romanian and Spanish and arranges interpreters for other languages on request.