Response to: Immune-mediated toxicity leading to organ failure may achieve good outcomes from ICU admission

Dear Editor-in-Chief,

We are pleased that colleagues found our recent QJM paper describing intensive care requirements of patients treated with immune checkpoint inhibitors (ICIs) to be of interest.¹ Our series describes not only patients with critical illness from immune-related adverse events but the entire cohort of emergency admission patients requiring intensive care unit (ICU) admission whilst being treated with ICI therapy. We believe it is important to detail the diversity of reasons for ICU admission in ICI-treated patients. Our data demonstrate benefit to ICU admission irrespective of whether patients present with ICI-related adverse events. We hope that the clear separation of these patient cohorts in our manuscript allows for appropriate interpretation of the relationship between ICU admission reason and outcomes.

With respect to whether a 6-month minimum follow-up is sufficient; we believe this period of time in ICU patients with cancer is a reasonable initial outcome measure to demonstrate benefits of ICU admission in this population. Further with regards to low-grade toxicities from ICIs; these are important and potentially missed by clinicians. However, such patients are highly unlikely to require ICU admission and are thus outside the scope of this article.

Worldwide, epitomized by the UK, emergency care systems are under huge pressures.² Oncologic emergency presentations are not immune to these pressures and timely delivery of care is often aspirational rather than reality in many acute care systems. Shortage of ICU beds in many systems may impact decisions to admit cancer patients with treatment-related toxicities.

There is significant heterogeneity in the models of emergency cancer services in the UK and internationally.³ Increasingly, much of the management of emergency presentations from ICI therapy may be delivered in general emergency settings without access to immediate specialist oncology advice. The resource required to delivery optimal emergency and intensive care management of immune-related adverse events may be beyond the operational capacity of many settings, especially in more developing regions or those with fewer resources. Despite these caveats, we believe our data represents an important contribution providing details of outcomes for ICI-treated patients admitted to the ICU and showing significant proportions of these patients survive to discharge and beyond.

Early recognition and aggressive treatment for high-risk immune-related adverse events are essential for delivering good outcomes.⁴ Equally recognition of patients who have progressive cancer and are unlikely to benefit from intensive care interventions is essential for both appropriate patient care and pragmatic resource utilization. Both these tenets are imperative to ensure that the growing field of ICU ICI patients receive high-quality, research-led care.

Author contributions

Jamie M.J. Weaver (Writing—original draft [equal], Writing—review & editing [equal]), and Tim Cooksley (Writing—original draft [equal], Writing—review & editing [equal])

Conflict of interest

None declared.

References