Patients with advanced liver cancer are often excluded from intensive care based on the assumption that their prognosis is too poor. New research published in Liver International shows that many of these patients do survive critical illness and even restart cancer treatment after intensive care. The findings challenge traditional barriers to intensive care unit (ICU) admission and highlight the vital role of critical care in the era of immunotherapy.

For many years, people with advanced forms of HCC and underlying cirrhosis were rarely admitted to ICUs. Clinicians assumed the chances of survival were too low to justify intensive care treatment in these patients. However, in recent years immunotherapy has markedly improved the prognosis of patients with advanced cancer, raising the question of whether routine denial of critical care to these patients remains justified.

A new international study led by Hospital Clínic de Barcelona, Spain, shows this restrictive approach should be reconsidered. Researchers reviewed outcomes from more than 1000 patients receiving immunotherapy for advanced HCC across 20 medical centers worldwide. Of these, 47 patients required ICU admission, most often because of severe immune-related adverse events effects of treatment or variceal bleeding. 

The study is the first and largest international analysis of patients with advanced HCC treated with immune checkpoint inhibitors and admitted to ICU. It demonstrates that access to intensive care can make a real difference in survival and long-term cancer treatment.

Indeed, almost two-thirds of patients admitted to ICU for immune-related adverse events were still alive 28 days after discharged from ICU, with high survival rates—83% at three months and 69% at six months. More than half of these survivors were able to resumed cancer treatment after their ICU stay.

“These findings challenge the old belief that patients with advanced liver cancer cannot benefit from intensive care,” said Javier Fernández, Head of the Intensive Care Unit at Hospital Clínic de Barcelona, researcher at Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), and Head of Clinical Operations at EF CLIF. “In fact, many of them not only survive, but are able to restart effective immunotherapy. Decisions about ICU admission in patients with advanced HCC receiving immune checkpoint inhibitors should be individualized. Automatic denials are no longer acceptable”, he declared.

The authors emphasize that future research should focus on identifying which patients benefit most from intensive care and developing standardized strategies to manage severe immune-related adverse events of immunotherapy.

The study has two main limitations, its retrospective nature (inherent selection bias of the patients admitted to the ICU) and the heterogeneity of the treatment strategies used in  immune-related adverse events. “The key implication of this research is that it highlights the need to break down barriers to ICU admission for patients with advanced HCC”, concluded Fernández.

This study was supported  by Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Spain and Asociación Española Contra el Cáncer (AECC).

Other authors in the study are Marta Fortuny, Leonardo G da Fonseca, Manon Allaire, Rocío Sánchez, Jean-Charles Nault, Massimo Iavarone, Sofia Ridolfo, Sonia Pascual, Raquel Jimeno, Mariona Calvo, Raimon Rifà, Marco Sanduzzi-Zamparelli, Natalia Jiménez-Esquivel, Sarah Mouri, Mercedes Iñarrairaegui, Josepmaria Argemi, Tania Hernaez, José Enrique Lorenzo-Barreto, María Teresa Ferrer, Susana Coll, Ángela Lamarca, Juan Ignacio Marin, Enric Reverter, Ana María López, Alberto Lue, María Varela, Ana Matilla, and Maria Reig.