Is aggressive care appropriate for patients with cancer complicated by pneumonia? A retrospective chart review in a tertiary hospital

In this study, the in-hospital death rate of cancer patients who were admitted with pneumonia between January 1, 2016, and December 31, 2017, was 29.4%. This rate is considered clinically high.

Similar studies by Gonzalez et al. [5] and Ahn et al. [6] found the 30- and 28-day mortality rates were 20.2% and 19.3%, respectively. Although the definition of mortality rate in this study was different from Gonzalez et al. and Ahn et al.‘s studies, they are roughly comparable. In this study more than 94% of the population were discharged within 28 days of admission, and our mortality rate did not account for patients who died after discharge. If we compare mortality rates using 28-day mortality rate definition, 29.39% would be an underestimation. A possible explanation for the large difference between studies is that ours only included admitted patients, whereas the other studies included outpatient cases as well. In addition, most of the patients included in our study had advanced cancer.

The four factors associated with the in-hospital death rate for cancer patients admitted with pneumonia were: PPS at 40–50%, PPS at 10–30%, percentage of lymphocytes ≤ 8.0%, and oxygen saturation ≤ 90%. Patient confusion was a factor that could not be assessed due to incomplete information in our electronic database.

The association between patient’s performance status and in-hospital mortality in our study was similar to Ahn et al.‘s study, [6] which also found that poor performance status was associated with the mortality rate. Although the Eastern Cooperative Oncology Group (ECOG) scale [16] was used to assess performance status in Ahn et al.‘s study, the ECOG and PPS can be used interchangeably [15, 17] PPS is a tool that is useful in estimating survival time in cancer patients [12]. The direction of association between PPS and the in-hospital mortality found in this study is also similar to the association between PPS and survival time observed in cancer patients.

The association between oxygen saturation and in-hospital mortality found in our study was also similar to Ahn et al.‘s [6] study. Oxygen saturation represents the ability of the lungs to oxygenate the blood. Low oxygen saturation is indicative of impaired lung function [18]. In this study population, impaired oxygen saturation would indicate severe pneumonia with a greater likelihood of death during the hospital stay.

Lymphocyte was found to be an important factor associated with the in-hospital mortality in this study. This finding is similar to Zhao et al. report [11]. Lymphocyte is a type of white blood cell responsible for reinforcing the immune system to fight infections [19, 20]. Moreover, lymphocytes are among the primary white blood cells to inhibit and kill cancer cells [20, 21]. Hence, they are important to the survivability of patients in this study. A decreased number of lymphocytes in cancer patients can be due to malnutrition, [22, 23] possibly due to the presence of cancer itself. Some cancer treatments can also decrease the number of lymphocytes, [24, 25] such as, radiation therapy and chemotherapy, making the body susceptible to numerous infectious attacks.

This study did not find a statistically significant association between the age of more than 65 years and the in-hospital mortality. However, studies have found that an age of more than 65 years was associated with mortality in the general population with pneumonia [3, 4]. Cancer treatments and cancer itself can weaken the immune system and overall body function [24, 25]. This process might be more pronounced than the effects of aging in the population with cancer, which may explain why age was not found to be associated with the in-hospital mortality in this study.

BUN level was found to be associated with the in-hospital mortality in the univariate logistic regression analysis but not in multivariate analysis. Ugajin et al. [26] proposed that the elevation of BUN levels in patients with pneumonia is probably due to dehydration. Under such conditions, the kidneys reabsorb urea along with water, which ultimately causes an elevation in BUN levels. However, in cancer population, performance status, lymphocytes, and oxygen saturation may be factors that are more closely associated to the mortality that attenuate association of BUN level.

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