Advanced supportive care for patients with cancer in Latin America We read with great interest The Lancet Oncology Commission1 addressing the increasing burden of cancer in Latin American and Caribbean countries and we congratulate the authors for such an initiative. However, we would like to add our perspective regarding the use of advanced life support and in-hospital resources for patients with cancer. Once the disease is established, the management of patients with cancer is invariably complex and multifaceted, irrespective of the disease stage or phase. The implications of providing the most appropriate current and future anticancer treatment modalities, including palliative care in cases of advanced-stage disease, were discussed well and resulted in a series of recommended actions to improve cancer care.1 Use of new and more targeted therapeutic interventions, more intensive chemotherapy and radiation therapy regimens, and the evolution of surgical procedures clearly resulted in higher cancer cure and control rates. However, such aggressive regimens often lead to treatment-related complications, including drug-induced organ toxicities and increased susceptibility to severe infections. Moreover, patients with cancer often have severe comorbidities. In this context, intensive care units have become essential for the supportive care of these patients. They usually need intensive care unit admission for postoperative care after major surgical procedures, severe complications related to the cancer or to chemoradiation, and concurrent serious acute illnesses.2 During the past 15 years, survival of critically ill patients with cancer has improved substantially, including in those with acute respiratory failure, severe sepsis, neutropenia, and recipients of www.thelancet.com/oncology Vol 14 August 2013
autologous bone marrow transplants.2 Consequently, intensivists even outside specialised cancer care centres are increasingly managing patients with cancer and critical illnesses. In 2010, a multicentre study in Brazil reported that 21·5% of all intensive care unit admissions were for patients with cancer.3 However, a shortage of beds in intensive care units exists in developing countries.4 For example, there are 1·3 intensive care unit beds per 10 000 inhabitants in Brazil, by contrast with 2·8 such beds per 10 000 inhabitants in the USA. 5,6 This scenario of low resources could become even more compromised since it does not take into account the potential increase in the number of patients diagnosed with and treated for cancer when the ﬁrst results of the screening and treatment programmes are implemented as planned. In this scenario, the challenge will be not only to increase the number of beds in intensive care units but also to provide training in specialised care of cancer-related severe acute illnesses and end-of-life care issues to intensivists. Therefore, the provision of advanced supportive care to an increasing number of patients with cancer is challenging and deserves to be included in the future agenda of planning the care of these patients. These additional specific considerations in cancer care planning are essential to avoid depriving patients who could beneﬁt from lifesustaining treatments. We declare that we have no conﬂicts of interest.
*Marcio Soares, Jorge I F Salluh [email protected]
D’Or Institute for Research and Education, Rio de Janeiro, Brazil (MS, JIFS); and Postgraduation Program, Instituto Nacional de Câncer, Rio de Janeiro, Brazil (MS, JIFS) 1
Goss PE, Lee BL, Badovinac-Crnjevic T, et al. Planning cancer control in Latin America and the Caribbean. Lancet Oncol 2013; 14: 391–436. Azoulay E, Soares M, Darmon M, Benoit D, Pastores S, Afessa B. Intensive care of the cancer patient: recent achievements and remaining challenges. Ann Intensive Care 2011; 1: 5.
Soares M, Caruso P, Silva E, et al. Characteristics and outcomes of patients with cancer requiring admission to intensive care units: a prospective multicenter study. Crit Care Med 2010; 38: 9–15. Adhikari NK, Fowler RA, Bhagwanjee S, Rubenfeld GD. Critical care and the global burden of critical illness in adults. Lancet 2010; 376: 1339–46. Associação de Medicina Intensiva Brasileira. Censo AMIB. 2008. http://www.amib.org.br/ ﬁleadmin/CensoAMIB2010.pdf (accessed May 21, 2013). Carr BG, Addyson DK, Kahn JM. Variation in critical care beds per capita in the United States: implications for pandemic and disaster planning. JAMA 2010; 303: 1371–72.
This online publication has been corrected. The corrected version ﬁrst appeared at thelancet. com/oncology on October 28, 2013
Cancer control in Chile Having read The Lancet Oncology’s Commission on planning cancer control in Latin America and the Caribbean,1 regrettably we believe the analysis of the situation in Chile is incomplete, lacks depth, and includes several errors. We were particularly surprised, for example, by the scarcity of oﬃcial sources of information in the references. It is imprecise to start the characterisation of Chile’s problems by referring to the priorities set out in the 1997 National Cancer Programme that referred to only to cervical and breast cancer. Chile, in response to the WHO programme Fight against Cancer, actually created a National Commission on Cancer in 1986.2 This shows that for almost three decades, Chile has been addressing issues surrounding cancer control from a public health perspective, taking into account cancer care from prevention to palliative services, and thus making the national cancer strategy progressively stronger. With respect to a lack of a national population-based cancer registry mentioned in the Commission, such registries are not recommended for populations of more than 1 million inhabitants if they are dispersed over a vast geographical area, which is the case in Chile (17 million inhabitants spread over a country that extends 4500 km from north to south). e337