C. Parker1, T. J. Miner1, D. S. Heffernan1 1Brown University School Of Medicine,Department Of Surgery,Providence, RI, USA
Introduction: Trauma remains a leading cause of death and, among survivors, long term disability and organ dysfunction. Underlying medical comorbidities are significant drivers of trauma related complications. A history of having survived a prior cancer diagnosis is also a common finding among the general population. Cancer survivors often display long term depressed physiologic and/or immunologic reserve. Given that robust immune and physiologic systems are critical to trauma survival, we hypothesize that trauma patients with a history of a prior cancer will display markedly worsened compared to patients with no prior malignancy.
Methods: This is a retrospective review of 4 years of prospectively collected data from a Level 1 trauma center. Charts were reviewed for patient characteristics, injuries sustained and injury severity score (ISS), medical history, with a focus on prior malignancy, presence of DNR/DNI upon presentation, hospital course, and trauma related outcomes, including mortality and discharge disposition. Patients were divided into those with a History of Cancer (HxC) versus those with no prior Cancer (noC). Given the considerable age difference between groups, from among the noC patients, we selected an age matched cohort for comparison.
Results: Among the trauma population as a whole HxC patients were older (73.4 vs 59.2 years; p<0.001). HxC patients, compared to the selected aged matched control displayed no difference in male gender (50.5% vs 49.3%;p=0.9) or ISS (11.2 +/-0.8 vs 10.2+/-0.1; p=0.2). HxC patients had higher average number of non-cancer medical comorbidities (3.1 +/-0.2 vs 2.5+/-0.02; p=0.005). With respect to specific comorbidities, there was no difference in CHF (10.1% vs 7.9%;p=0.5) but HxC patients had significantly higher rates of COPD (23.6% vs 10.6%; p<0.001) and were markedly more likely to be DNR/DNI upon initial presentation following the traumatic injury (27% vs 10.6%; p<0.001). There was no difference in overall hospital length of stay (5.7 +/-0.3 vs 6.4+/-0.1 days; p=0.3). HxC patients had overall greater mortality (13.5% vs 5.4%; p=0.002). Among survivors, HxC patients were less likely to be discharged home (25.9% vs 44.7%; p=0.002) and were markedly more likely to discharged to a hospice (11.7% vs 2.2%; p<0.001).
Conclusion: Among our trauma population, patients with a prior history of a malignancy present with higher rates of DNR and exhibit overall lower survival and higher rate of discharge to hospice. It is possible that having survived a major cancer diagnosis, HxC patients cannot tolerate the physiologic or immunologic “second hit” burden of a major traumatic injury. We further speculate that our data may have uncovered an unconscious lack of motivation to undergo extensive lifesaving measures after being exhausted by a cancer diagnosis.