Patients with cancer on the ICU: time for optimism.

Severely ill patients with solid cancers or haematological malignancies are often considered poor candidates for intensive care treatments. Not so long ago, in guidelines for ICU admission, a taskforce of the American College of Critical Care Medicine concluded that patients with haematological or metastasised solid malignancies were poor candidates for ICU admission. In a Dutch study from Nijmegen, published in 1992, it was reported that of 13 patients admitted to the ICU after bone marrow transplant, only one patient survived. The authors argued that physicians should be reluctant to admit these patients to an ICU. In this issue of the Netherlands Journal of Medicine, Van Vliet and coworkers, again from the Nijmegen University Medical Center, report a marked improvement of 100-day post-transplant survival in patients admitted to the ICU after haematopoietic stem cell transplantation (HSCT) from 22% in 2004/2005 to 65% in 2008/2009. Although these results are from a single-centre study, it is likely that outcomes after ICU admission in haematology patients have also been improving in many hospitals worldwide over the last years. Indeed, in a review of the literature, it was shown that survival of patients after HSCT who received mechanical ventilation improved from lower than 10% in the period before 1990 to 25-50% in the period 1994-2000. It is possible that the improved survival of critically ill haematology patients is a reflection of an improvement in the quality of intensive care in general. In accordance, the standardised mortality ratio for all non-surgical ICU patients in the Netherlands, adjusted for reason for ICU admission and severity of illness using the APACHE IV model, decreased from 0.94 in 2007 to 0.77 in 2012 [NICE-online, Stichting Nationale Intensive Care Evaluatie; unpublished data]. However, the magnitude of the improvement of survival in patients after HSCT makes it unlikely that improved quality of ICU care can fully explain these findings. Alternatively, the characteristics of patients