Metabolic syndrome as a prognostic factor for breast cancer recurrences

Effects of Exercise on Insulin, IGF Axis, Adipocytokines, and Inflammatory Markers in Breast Cancer Survivors: A Systematic Review and Meta-analysis

Background: Insulin, IGF axis, adiponectin, and inflammatory markers are associated with breast cancer. Given that physical activity improves prognosis of breast cancer survivors, we investigated the effects of exercise on these markers as potential mediators between physical activity and breast cancer.Methods: PubMed, EMBASE, CENTRAL, CINAHL, and SportDiscus were searched up to December 3, 2015, to identify randomized controlled trials (RCT) that investigated the effect of exercise on insulin, IGF axis, and cytokines in breast cancer survivors. Weighted mean difference (WMD) was calculated using either fixed- or random-effects models on the basis of the heterogeneity of the studies.Results: A total of 18 studies involving 681 breast cancer survivors were included, and these numbers were reduced for individual biomarker analyses. We found that exercise significantly reduced fasting insulin levels [WMD, -3.46 μU/mL; 95% confidence interval (CI), -5.97 to -0.95; P = 0.007]. Furthermore, potentially meaningful but statistically nonsignificant changes were observed in insulin resistance (WMD, -0.73; 95% CI, -0.54 to 0.13; P = 0.23), adiponectin (WMD, 1.17 μg/mL; 95% CI, -0.87 to 3.20; P = 0.26), and C-reactive protein (WMD, -1.10 mg/L; 95% CI, -2.39 to 0.20; P = 0.10). Subgroup analyses showed that fasting insulin levels were significantly more impacted in studies in which intervention participants experienced a weight reduction (WMD, -7.10 μU/mL; 95% CI, -10.31 to -3.90; P < 0.001).Conclusions: Exercise reduces fasting insulin levels in breast cancer survivors. This may be due to exercise-induced reductions in body weight.Impact: Practitioners and clinicians may better help breast cancer prognosis be improved through exercise, anticipating physiological effects on cancer. Cancer Epidemiol Biomarkers Prev; 26(3); 355-65. ©2016 AACR.

Preoperative Metabolic Syndrome Is Predictive of Significant Gastric Cancer Mortality after Gastrectomy: The Fujian Prospective Investigation of Cancer (FIESTA) Study

Metabolic syndrome (MetS) has been shown to be associated with an increased risk of gastric cancer. However, the impact of MetS on gastric cancer mortality remains largely unknown. Here, we prospectively examined the prediction of preoperative MetS for gastric cancer mortality by analyzing a subset of data from the ongoing Fujian prospective investigation of cancer (FIESTA) study. This study was conducted among 3012 patients with gastric cancer who received radical gastrectomy between 2000 and 2010. The latest follow-up was completed in 2015. Blood/tissue specimens, demographic and clinicopathologic characteristics were collected at baseline. During 15-year follow-up, 1331 of 3012 patients died of gastric cancer. The median survival time (MST) of patients with MetS was 31.3months, which was significantly shorter than that of MetS-free patients (157.1months). The coexistence of MetS before surgery was associated with a 2.3-fold increased risk for gastric cancer mortality (P<0.001). The multivariate-adjusted hazard ratios (HRs) were increased with invasion depth T1/T2 (HR=2.78, P<0.001), regional lymph node metastasis N0 (HR=2.65, P<0.001), positive distant metastasis (HR=2.53, P<0.001), TNM stage I/II (HR=3.00, P<0.001), intestinal type (HR=2.96, P<0.001), negative tumor embolus (HR=2.34, P<0.001), and tumor size ≤4.5cm (HR=2.49, P<0.001). Further survival tree analysis confirmed the top splitting role of TNM stage, followed by MetS or hyperglycemia with remarkable discrimination ability. In this large cohort study, preoperative MetS, especially hyperglycemia, was predictive of significant gastric cancer mortality in patients with radical gastrectomy, especially for early stage of gastric cancer.

Serum adiponectin, insulin resistance, and uveal melanoma: clinicopathological correlations

To investigate the status of insulin resistance, metabolic syndrome, dyslipidemia, and serum adiponectin levels in patients with uveal melanoma and choroidal nevus were investigated. Our study included 86 patients with uveal melanoma, 38 patients with choroidal nevus, and 86 controls. Uveal melanomas were classified as small, medium, and large on the basis of Collaborative Ocular Melanoma Study (COMS) criteria. Patients with uveal melanoma had significantly higher homeostatic model assessment scores compared with patients with choroidal nevus (P<0.001). Patients with uveal melanoma and choroidal nevus had significantly lower levels of serum adiponectin compared with controls (P<0.001). Patients with uveal melanoma who developed systemic metastases had significantly lower levels of serum adiponectin levels compared with patients with nonmetastases during follow-up (P=0.018). When the largest tumors (COMS III) were compared, ciliary body melanomas were associated with significantly lower levels of serum adiponectin than choroidal melanomas. In patients who were treated with enucleation, epitheloid predominant and mixed cell-type tumors were associated with lower levels of serum adiponectin compared with tumors with spindle cell type, but this did not reach statistical significance. By providing an antiapoptotic and proangiogenic environment, low serum adiponectin levels and insulin resistance may play a role in promoting the growth of uveal melanocytic tumors and may contribute toward a more aggressive clinical course, adversely affecting the prognosis.

Novel applications of COX-2 inhibitors, metformin, and statins for the primary chemoprevention of breast cancer

Recent evidence shows that commonly prescribed drugs, such as non-steroidal anti-inflammatory drugs (NSAIDs), metformin, and statins, may have beneficial roles in the primary chemoprevention of breast cancer. Therefore, these drugs could potentially be used in addition to the hormonal drugs currently used for this purpose (namely, selective estrogen receptor modulators and aromatase inhibitors) due to their alternative mechanisms of action.

Characteristics associated with nonadherence to medications for hypertension, diabetes, and dyslipidemia among breast cancer survivors

OBJECTIVE

Comorbidity among breast cancer survivors is prevalent, and adherence to medication management of comorbidities may be important for both chronic disease and cancer-related outcomes. Our objective was to determine characteristics associated with nonadherence to common chronic medications among breast cancer survivors.

METHODS

We conducted a retrospective cohort study of 4216 women in an integrated care system diagnosed with early-stage breast cancer between 1990 and 2008 and alive without recurrence or second primary breast cancer in the second-year following diagnosis. Adherence to antihypertensives, oral diabetes medications, and statins was measured during the second-year post-breast cancer diagnosis using medication possession ratios (MPR). Nonadherence was defined as MPR <0.80. We estimated odds ratios (OR) and 95% confidence intervals (CI) for nonadherence to antihypertensives, oral diabetes medications, and statins by various characteristics using multivariable logistic regression.

RESULTS

Among 2308 users of antihypertensives (n = 1779), diabetes medications (n = 499) and/or statins (n = 1072), 37% were nonadherent to antihypertensives; 75% were nonadherent to diabetes medications; 39% were nonadherent to statins. In adjusted models, younger age was associated with nonadherence to all three therapeutic classes. Certain cancer treatments were associated with nonadherence to antihypertensives (radiation: OR 1.21, 95% CI 1.01-1.47; endocrine therapy: OR 1.27, 95% CI 1.03-1.52) and diabetes medications (chemotherapy: OR 1.69, 95% CI 1.17-2.21). Less frequent primary care provider visits were associated with higher odds of nonadherence to antihypertensives (OR 1.70, 95% CI 1.19-2.22); and trends showed higher Charlson comorbidity scores associated with greater adherence to diabetes medications (P < 0.001) and statins (P = 0.032).

CONCLUSIONS

Nonadherence to medications is high among breast cancer survivors, particularly diabetes medications, and is associated with cancer treatments and other patient characteristics. Additional research is warranted to understand the needs of cancer patients taking chronic medications and explore patient and provider factors influencing adherence.

Insulin Resistance and Inflammation in Black Women with and without Breast Cancer: Cause for Concern

OBJECTIVE

After chemotherapy for breast cancer, Black women gain more weight and have an increased mortality rate compared with White women. Our study objective was to compare biomarkers associated with obesity in Black women with and without a history of breast cancer.

DESIGN

Case-control.

SETTING

Academic/federal institution.

PARTICIPANTS

Black women with a history of breast cancer (cases) and age-matched controls.

MAIN OUTCOME MEASURES

Insulin resistance (HOMA-IR); inflammation (TNF-α, IL-1b, IL-6, IL-8, CRP); lipids (cholesterol, triglycerides).

METHODS

We compared insulin resistance, inflammation, and lipids in overweight and obese Black women with a history of breast cancer (n=19), age similar controls (n=25), and older controls (n=32). Groups did not differ on mean body mass index (BMI), which was 35.4 kg/m², 36.0 kg/m², and 33.0 kg/m², respectively.

RESULTS

Cases had 1.6 and 1.38 times higher HOMA-IR values compared with age similar and older controls, respectively (P≤.001 for both). TNF-α and IL-1b were significantly higher in cases compared with both control groups (P<.001 for both). IL-6 was also higher in cases compared with age-similar controls (P=.007), and IL-8 was lower in cases compared with older controls (P<.05). Lipids did not differ between cases and either control group.

CONCLUSIONS

Black women with breast cancer were significantly more insulin resistant with increased inflammation compared not only with age similar controls but with women who were, on average, a decade older. These biomarkers of insulin resistance and inflammation may be associated with increased risk of breast cancer recurrence and require ongoing evaluation, especially given the relatively abnormal findings compared with the controls in this underserved group.

Metabolic syndrome in breast cancer survivors with high carbohydrate consumption: The first report in community setting

BACKGROUND & AIMS

This study was conducted to examine the prevalence of and lifestyle factors associated with the metabolic syndrome in breast cancer survivors and to compare those factors with controls without cancer in a community setting.

METHODS

This study included 584 female breast cancer survivors ≥3 years after the initial diagnosis and 2336 age-matched cancer-free female controls from 39 community health examination centers located in 14 urban areas in Korea. The prevalence of the metabolic syndrome is shown. Factors associated with the metabolic syndrome were analyzed as odds ratios (ORs) in cancer survivors and controls; differences between the two groups in the ORs of associated factors were evaluated by calculating p-heterogeneity values.

RESULTS

The prevalence of metabolic syndrome in breast cancer survivors and age-matched controls were 26.8% and 26.9%, respectively. Higher percentage of caloric intake from carbohydrates was associated with increased metabolic syndrome only in the breast cancer survivors (OR for the highest vs. lowest quartile for survivors = 2.48 [95% CI = 1.20-5.14]; OR for controls = 1.11 [95% CI = 0.81-1.51]; P-heterogeneity = 0.046). Sweat-inducing exercise for ≥150 min/week was associated with a lower risk of metabolic syndrome only in controls (controls: OR = 0.72 [95% CI = 0.58-0.89]; survivors: OR = 0.88 [95% CI = 0.57-1.36]). Older age, higher body mass index, and a lower education level (≤12 years) was associated with an increased prevalence of metabolic syndrome in both groups.

CONCLUSIONS

Our results suggest that, in regions with excess carbohydrate intake, the association of the metabolic syndrome with percentage of caloric intake from carbohydrate might be more prominent than exercise in breast cancer survivors, compared with general population.

Impact of metabolic syndrome on the survival of Chinese patients with resectable esophageal squamous cell carcinoma

Metabolic syndrome (MetS) is associated with the risk of esophageal squamous cell carcinoma (ESCC). However, the impact of MetS on survival has not been evaluated. A retrospective review was performed on 596 consecutive Chinese patients with esophageal squamous cell carcinoma who received surgery between January 2005 and October 2007. The clinical data and pretreatment information related to MetS were reviewed. The impact of MetS on overall survival (OS) was estimated by Kaplan-Meier and Cox proportional hazards analyses. MetS was a significant and independent predictor for better survival in patients with resectable ESCC. The 3-year OS and 5-year OS for patients with and without MetS were 75.0% versus 57.8% and 65.1% versus 44.6%, respectively (P = 0.005 in the univariate analysis, P = 0.010 in multivariate analysis). However, there was no apparent influence of any single component of MetS on OS. The other independent prognostic factors identified in the univariate analysis included the following: gender, smoking status, alcohol use, the extent of radical surgical resection, T and N stage, and tumor differentiation. The results of the multivariate analysis included the extent of radical surgery resection, T and N stage, and tumor differentiation. MetS was also associated with greater tumor cell differentiation (P = 0.036). There was no association found between MetS status and postoperative complications. MetS is an independent prognostic factor for OS in patients with ESCC and is associated with better tumor cell differentiation.

The development of the metabolic syndrome and insulin resistance after adjuvant treatment for breast cancer

BACKGROUND

Adjuvant breast cancer treatment is associated with a number of adverse physical changes, including weight gain, and therefore may represent a critical period for the development of metabolic disturbance.

OBJECTIVE

The aim of this study was to evaluate changes in the presentation of the metabolic syndrome (MetSyn) and insulin resistance from breast cancer surgery to postcompletion of adjuvant treatment.

METHODS

Sixty-one participants who had completed metabolic screening, including fasting blood samples and anthropometric measurements, on the morning of breast cancer surgery were recruited. Measures were repeated after completion of adjuvant treatment. Change in the proportion of participants presenting with the MetSyn was evaluated using the related-samples McNemar test, and changes in measures of glucose metabolism (fasting insulin, insulin resistance [homeostatic model assessment index], and glycosylated hemoglobin [HbA1c]) were analyzed using paired t tests. The Kruskal-Wallis test was used to compare differences in changes in metabolic parameters across clinical and lifestyle characteristics.

RESULTS

There was a significant (P < .001) increase in fasting insulin (mean [SE] change, 2.73 [0.57] mU/L), homeostatic model assessment index (0.58 [0.14]), and HbA1c level (4.49 [5.63] mmol/mol) from baseline to follow-up along with an increase in the proportion diagnosed with the MetSyn (P = .03). Those with the MetSyn at diagnosis experienced a greater increase in insulin resistance. Premenopausal women experienced greatest increases in HbA1c level.

CONCLUSIONS

Results demonstrate the development of significant metabolic dysfunction, characterized by glucose dysmetabolism and MetSyn, after adjuvant treatment for breast cancer.

IMPLICATIONS FOR PRACTICE

Interventions to improve the metabolic profile of breast cancer survivors are warranted.

Community-based participatory research to improve life quality and clinical outcomes of patients with breast cancer (DianaWeb in Umbria pilot study)

INTRODUCTION

Breast cancer (BC) is the most frequent cancer in Europe and the International Agency for Research on Cancer (IARC) has estimated over 460 000 incident cases per year. Survival among patients with BC has increased in the past decades and EUROCARE-5 has estimated a 5-year relative survival rate of 82% for patients diagnosed in 2000-2007. There is growing evidence that lifestyle (such as a diet based on Mediterranean principles associated with moderate physical activity) may influence prognosis of BC; however, this information is not currently available to patients and is not considered in oncology protocols. Only a few epidemiological studies have investigated the role of diet in BC recurrence and metastasis.

METHODS AND ANALYSIS

DianaWeb is a community-based participatory research dedicated to patients with BC and represents a collaborative effort between participants and research institutions to determine if specified changes in lifestyle would result in improved outcomes in terms of quality of life or survival. The aim of the study is to recruit a large number of participants, to monitor their lifestyle and health status over time, to provide them tips to encourage sustainable lifestyle changes, to analyse clinical outcomes as a function of baseline risk factors and subsequent changes, and to share with patients methodologies and results. DianaWeb uses a specific interactive website (http://www.dianaweb.org/) and, with very few exceptions, all communications will be made through the web. In this paper we describe the pilot study, namely DianaWeb in Umbria.

ETHICS AND DISSEMINATION

DianaWeb does not interfere with prescribed oncological treatments; rather, it recommends that participants should follow the received prescriptions. The results will be used to plan guidelines for nutrition and physical activity for patients with BC. The pilot study was approved by the ethics committee of the University of Perugia (reference number 2015-002), and is supported by Fondazione Cassa di Risparmio di Perugia (2013.0185 021).

The Role of Docosahexaenoic Acid (DHA) in the Control of Obesity and Metabolic Derangements in Breast Cancer

Obesity represents a major under-recognized preventable risk factor for cancer development and recurrence, including breast cancer (BC). Healthy diet and correct lifestyle play crucial role for the treatment of obesity and for the prevention of BC. Obesity is significantly prevalent in western countries and it contributes to almost 50% of BC in older women. Mechanisms underlying obesity, such as inflammation and insulin resistance, are also involved in BC development. Fatty acids are among the most extensively studied dietary factors, whose changes appear to be closely related with BC risk. Alterations of specific ω-3 polyunsaturated fatty acids (PUFAs), particularly low basal docosahexaenoic acid (DHA) levels, appear to be important in increasing cancer risk and its relapse, influencing its progression and prognosis and affecting the response to treatments. On the other hand, DHA supplementation increases the response to anticancer therapies and reduces the undesired side effects of anticancer therapies. Experimental and clinical evidence shows that higher fish consumption or intake of DHA reduces BC cell growth and its relapse risk. Controversy exists on the potential anticancer effects of marine ω-3 PUFAs and especially DHA, and larger clinical trials appear mandatory to clarify these aspects. The present review article is aimed at exploring the capacity of DHA in controlling obesity-related inflammation and in reducing insulin resistance in BC development, progression, and response to therapies.

The Contribution of Cholesterol and Its Metabolites to the Pathophysiology of Breast Cancer

As the most common cancer in women, one in eight will develop invasive breast cancer over their lifetime making it the second most common cause of cancer-related death among women. Of the many known risk factors for developing breast cancer, obesity stands out as prominent and modifiable. Interestingly, elevated cholesterol is highly associated with obesity and has emerged as an independent risk factor for breast cancer onset and recurrence. This indicates that cholesterol also contributes to the breast cancer pathogenicity of obesity. This review highlights our current understanding of the mechanisms by which cholesterol impacts breast cancer. Key preclinical studies have been highlighted, including the discussion of homeostatic control of cholesterol levels, signaling by cholesterol metabolites through the estrogen receptors, cholesterol formation of lipid rafts and subsequent signaling, and the potential roles of cholesterol in creating a pro-inflammatory tumor microenvironment. Future directions and avenues for therapeutic exploitation are also considered.

Prognostic and predictive effects of diabetes, hypertension, and coronary artery disease among women on extended adjuvant letrozole: NCIC CTG MA.17

BACKGROUND

Women with breast cancer and diabetes mellitus (DM) have poorer survival. Mechanisms include insulin dysregulation and/or DM related co-morbidities (CM). In MA.17 adjuvant letrozole (LET) after 5 years of tamoxifen (TAM) reduced the risk of recurrence and improved survival. We evaluated DM, hypertension (HTN), and coronary artery disease (CAD) as prognostic and predictive factors in MA.17.

PATIENTS AND METHODS

Disease free survival, distant disease free survival (DDFS) and overall survival (OS) were compared using Cox regression model adjusting for other prognostic factors: in women treated by placebo (PLAC) based on the presence or absence of baseline DM (n = 462), HTN (n = 1627), CAD (n = 604) or any one of these CM (n = 2049), and between LET and PLAC groups in each CM. Analyses based on nodal status were performed.

RESULTS

DM was neither prognostic nor predictive for women on extended LET. Women with one CM had similar outcomes on LET compared to women free of CM. For node positive women, the difference between LET and PLAC in DDFS was greater among women with one CM (hazard ratio [HR] = 0.30 [0.15-0.60], p = 0.001) compared to those without CM (HR = 0.72 [0.45-1.16], p = 0.17, p interaction = 0.04). Women on PLAC with HTN trended towards lower DDFS (HR = 1.50 [0.98-2.3], p = 0.06) and OS (HR = 1.61 [0.95-2.72], p = 0.08) than non-HTN women. HTN women had better DDFS on LET than non-HTN women. Women with one CM on PLAC had lower OS (HR = 2.10 [1.26-3.51], p = 0.004) than those free of CM.

CONCLUSIONS

DM was not prognostic or predictive of outcomes. Women with CM who remain disease free after 5 years of TAM should be offered LET. HTN trended towards a negative prognosticator and outcomes among this group were improved on LET. More studies are needed to assess impact of adrenergic stimulation as a possible link to poorer breast cancer outcomes.

Association Between Insulin Resistance and Luminal B Subtype Breast Cancer in Postmenopausal Women

Currently, there is limited information on the clinical characteristics of breast cancer patients with insulin resistance. Hence, the purpose of this study was to investigate the association between insulin resistance and clinicopathological factors in newly diagnosed breast cancer patients without diabetes. We assessed 760 patients with breast cancer treated between 2012 and 2014. We compared the clinicopathological characteristics between patients with and without insulin resistance using univariate and multivariate analyses, including after stratification by menopausal status. Insulin resistance was defined according to the homeostatic model assessment of insulin resistance. Of 760 patients, 26.4% had insulin resistance. Age, menopausal status, body mass index, tumor size, histologic grade, Ki-67 expression, and breast cancer subtype significantly differed according to the presence of insulin resistance. Multivariate analysis revealed that postmenopausal status and obesity were significantly associated with insulin resistance. In postmenopausal women, older age, obesity, larger tumor size, advanced stage, and high proliferative luminal B subtype were significantly associated with insulin resistance. In contrast, in premenopausal patients, only obesity was related to insulin resistance. Multivariate analysis indicated that insulin resistance was independently correlated with obesity, larger tumor size, and the luminal B/human epidermal growth factor receptor-2-negative subtype in postmenopausal but not premenopausal patients. Insulin resistance was significantly associated with larger tumors and proliferative luminal B subtype breast cancer in postmenopausal women only. These findings suggest that insulin resistance could mechanistically induce tumor progression and might be a good prognostic factor, and that it could represent a therapeutic target in postmenopausal patients with breast cancer.

Cardiopulmonary fitness, adiponectin, chemerin associated fasting insulin level in colorectal cancer patients

PURPOSE

Since circulating level of insulin is associated with colorectal cancer prognosis, it is important to identify factors contributing to fasting insulin level in colorectal cancer patients. The purpose of the current study is to investigate the association of physical fitness, adiponectin, and chemerin levels with circulating level of insulin in colorectal cancer patients.

METHODS

A total of 123 stage II-III colorectal cancer patients who completed standard cancer treatment were recruited. Anthropometric characteristics, fitness measurements, fasting insulin level, homeostasis model assessment of insulin resistance, lipid profiles, and adiponectin and chemerin levels were analyzed.

RESULT

Cardiopulmonary fitness level inversely associated with fasting insulin levels (the least fit (1st tertile): 8.11 ± 0.64, moderately fit (2nd tertile): 6.02 ± 0.63, and highly fit (3rd tertile): 5.58 ± 0.66 μU/ml, unfit vs. moderately fit, p < 0.01; unfit vs. highly fit, p < 0.05) after adjustment for gender, age, stage, and BMI. In addition, fasting adiponectin and chemerin levels were associated with fasting insulin levels after adjustment for gender, age, stage, and BMI. In our combined analyses, participants with high adiponectin and low chemerin levels showed significantly lower fasting insulin levels (4.92 ± 0.75 vs. 8.07 ± 0.80 μU/ml, p < 0.01) compared with participants with low adiponectin and high chemerin levels. Multiple linear regression analysis confirmed that cardiopulmonary fitness and adiponectin levels (β = -0.299, p = 0.002; β = -0.201, p = 0.033) were independently associated with fasting insulin level.

CONCLUSION

Our results suggest that physical fitness and adiponectin and chemerin levels may contribute to circulating levels of insulin. These results suggest that exercise may influence the prognosis of colorectal cancer patients by influencing physical fitness level, circulating levels of adiponectin and chemerin.

Increased depression and metabolic risk in postmenopausal breast cancer survivors

OBJECTIVE

Breast cancer survivors (BCS) are at high risk for the development of obesity, type 2 diabetes mellitus, and metabolic syndrome. There is increasing interest in the association between depression and metabolic dysfunction, which is relevant in this population as depression is often present in the chronic phase of cancer recovery. Thus, the aim of this study was to evaluate metabolic risk in BCS with and without depression compared to non-cancer controls.

METHODS

African American (46 %) and Caucasian (54 %) postmenopausal BCS (N = 28; age: 60 ± 2 years; mean ± SEM) were matched for race, age (±2 years), and BMI (±2 kg/m(2)) to non-cancer controls (N = 28). Center for Epidemiologic Studies Depression Scale (CES-D) >16 or antidepressant medication usage was used to classify depression. Metabolic status was defined by 2-hr glucose during an OGTT and classification of metabolic syndrome.

RESULTS

Compared to non-cancer controls, BCS had similar 2-hr glucose, but higher fasting glucose and total cholesterol, and were 2.5 times more likely to have metabolic syndrome (21 vs. 52 %)(P's < 0.05). Conversely, HDL-C was 16 % higher in BCS (P < 0.05). Forty three % of BCS were on antidepressants compared to 14 % in non-cancer controls, despite similar mean CES-D scores (6 ± 1). Depressed BCS (46 %) had a higher BMI, waist circumference, fasting glucose, and more metabolic syndrome components than non-depressed BCS (P's < 0.05).

CONCLUSIONS

BCS have a heightened prevalence of depression that may be associated with an increased prevalence of metabolic syndrome. These results support the need to monitor weight gain, depression, and the progression of metabolic abnormalities after cancer diagnosis and treatment. Further studies into the mechanistic link between depression and metabolic disease are necessary to identify strategies that can offset their impact on obesity and associated cardiovascular risk following a breast cancer diagnosis.

Assessment of serum adiponectin in Egyptian patients with HCV-related cirrhosis and hepatocellular carcinoma

BACKGROUND AND AIM

Hepatitis C-associated insulin resistance is involved in the development of various complications including hepatocarcinogenesis. Low plasma levels of adiponectin contribute to the pathogenesis of insulin resistance and type II diabetes mellitus. The aim of this study was to determine the value of serum adiponectin in Egyptian patients with hepatitis C-related cirrhosis and hepatocellular carcinoma.

PATIENTS AND METHODS

90 Egyptian patients with hepatitis C-related liver cirrhosis were enrolled in this study. Patients were divided into two groups as follows: group I: 61 patients with hepatitis C-related cirrhosis and hepatocellular carcinoma, group II: 29 patients with hepatitis C-related cirrhosis (hepatocellular carcinoma was excluded in these patients at the time of recruitment in the study). Serum adiponectin level was measured and correlated with all other studied parameters.

RESULTS

Serum adiponectin was significantly lower in patients with hepatocellular carcinoma and it had significant negative correlations with both the overall tumor size and the number of tumor foci. Highly significant negative correlations were found between adiponectin and all markers of insulin resistance in both groups. At a cut-off value ≤5.4 μg/ml, adiponectin had a sensitivity of 60.7%, a specificity of 93.1%, a positive predictive value of 94.9%, and a negative predictive value of 52.9% for detection of hepatocellular carcinoma (with an overall accuracy of 77.6%).

CONCLUSION

An independent association exists between serum adiponectin and hepatocellular carcinoma in Egyptian patients with hepatitis C-related cirrhosis. Therapy to increase circulating adiponectin concentration might represent a novel strategy to prevent hepatitis C-related hepatic complications.

Effect of specific educational program on dietary change and weight loss in breast-cancer survivors

AIMS

Consumption of Western foods with high dietary glycemic load is associated with breast cancer development, whereas adherence to Mediterranean diet has been linked to a reduced risk. Changing lifestyle can decrease risk of recurrences and mortality. Thus decreasing the weight, improving the diet and promoting lifestyle are among of the most important issues of public health. We evaluated the effects of a specific educational intervention conducted by dietitians, nutritionists physicians, oncologist and sport physician to promote lifestyle in breast cancer survivors.

METHODS

We recruited 100 pts in breast cancer follow up. The intervention program consisted of four meetings once a week including lectures, training sessions and workshops lasting overall a month. Dietary recommendations were provided on the basis of WCRF/AICR guidelines and were modelled on Mediterranean diet. Sport physician recommended adapted physical activity, based on clinical experiences and scientific evidences.

RESULTS

Significantly decrease of BMI and waist circumference was observed after 2 and 6 months. Adherence to Mediterranean diet was significantly improved, both in heightening typical Mediterranean foods, both in decreasing consumption of non typical foods. At baseline 63% of women was inactive, 37% was mild active and 0% active, while at the end inactive patients felt by half (30%) and mild active women almost doubled (67%).

CONCLUSIONS

We found this dietary intervention effective in reducing BMI and waist circumference, and enhancing healthy lifestyle in BC survivors. It has surely contributed to achieve these results besides the change in diet quality, mostly a marked reduction in sedentary habits.

Effects of metabolic syndrome and findings from baseline colonoscopies on occurrence of colorectal neoplasms

BACKGROUND & AIMS

Metabolic syndrome is associated with increased risk of colorectal neoplasm, but little is known about its effects on the occurrence of neoplasm after colonoscopy. We investigated the effects of metabolic syndrome on the risk of advanced neoplasm after colonoscopy.

METHODS

We performed a prospective study of 4483 subjects age 50 years and older who underwent screening and surveillance colonoscopies as part of an annual health check-up at National Taiwan University Hospital. Baseline demographic data and colonoscopic findings were recorded. Subjects with either advanced adenoma or 3 or more adenomas detected at baseline were classified as high risk; those with fewer than 3 nonadvanced adenomas were classified as low risk; and those without any neoplastic lesions were classified as normal. The cumulative risk of detecting an advanced neoplasm during surveillance colonoscopies (3 and 5 years later) was correlated with risk group and metabolic syndrome. Hazard ratios (HRs) were calculated for occurrence of neoplasm according to baseline colonoscopic findings and clinical risk factors, including metabolic syndrome.

RESULTS

Advanced neoplasms were detected during the surveillance colonoscopies in 1.3% of subjects in the normal group and in 2.4% of those in the low-risk group at 5 years, and in 8.5% of subjects in the high-risk group at 3 years. Subjects with metabolic syndrome had a significantly higher risk for subsequent advanced neoplasms (P < .0001). After stratification based on findings from baseline colonoscopies, the risk for neoplasm was significant in the normal (P < .001) and low-risk groups (P = .04), but not in the high-risk group (P = .48). In Cox regression analysis, metabolic syndrome had significant effects on the risk for advanced neoplasms in the normal (HR, 2.07; 95% confidence interval, 1.13-3.81) and low-risk groups (HR, 2.34; 95% confidence interval, 1.01-5.41), but not in the high-risk group.

CONCLUSIONS

Metabolic syndrome is a significant risk factor for occurrence of an advanced adenoma after a negative or low-risk finding from a baseline colonoscopy. Metabolic syndrome should be considered in risk stratification for surveillance intervals.

Decreased serum HDL at initial diagnosis correlates with worse outcomes for triple-negative breast cancer but not non-TNBCs

PURPOSE

This study aimed to evaluate the associations between metabolic syndrome (MS) and its components at initial diagnosis and outcomes of breast cancer including triple-negative breast cancer (TNBC) and non-TNBC.

METHODS

A cohort of 1,391 patients was reviewed between January 2004 and July 2008 (including 394 TNBC and 855 non-TNBC cases). MS and its components including body mass index (BMI), serum high-density lipoprotein (HDL) and triglycerides (TG) and their relationships with clinical outcomes were analyzed and then compared between groups.

RESULTS

The incidences of MS and its components including BMI, the levels of HDL and TG were not differently distributed between the 2 groups (all p's >0.05). However, more TNBC than non-TNBC patients presented with hypertension and elevated serum glucose (20.3% vs. 14.9% and 16.0% vs. 10.8%, p = 0.018 and p = 0.012, respectively). TNBC patients had poorer 5-year relapse-free survival (RFS) than non-TNBC patients (72.8% vs. 84.2%, p<0.0001). Only in the TNBC group, patients with low high-density lipoprotein (HDL) demonstrated worse RFS and overall survival (OS; p<0.0001). Multivariate analysis identified that low HDL was an independent worse prognostic factor for both RFS (hazard ratio [HR] = 3.266, 95% confidence interval [95%CI], 2.087-5.112, p<0.0001) and OS (HR = 3.071, 95%CI, 1.732-5.445, p<0.0001) in TNBC patients.

CONCLUSIONS

Decreased level of HDL may predict worse outcomes both in terms of RFS and OS for TNBC patients but not for non-TNBC patients. Further investigations are warranted to detect the underlying mechanisms.

An exercise trial targeting African-American women with metabolic syndrome and at high risk for breast cancer: Rationale, design, and methods

BACKGROUND

Metabolic syndrome and obesity are known risk factors for breast cancers. Exercise interventions can potentially modify circulating biomarkers of breast cancer risk but evidence in African-Americans and women with metabolic syndrome is lacking.

METHODS/DESIGN

The Focused Intervention on Exercise to Reduce CancEr (FIERCE) trial is a prospective, 6-month, 3-arm, randomized controlled trial to examine the effect of exercise on obesity, metabolic syndrome components, and breast cancer biomarkers among African-American women at high risk of breast cancer. Two hundred-forty inactive women with metabolic syndrome and absolute risk of breast cancer ≥ 1.40 will be randomized to one of the three trial arms: 1) a supervised, facility-based exercise arm; 2) a home-based exercise arm; and 3) a control group that maintains physical activity levels through the course of the trial. Assessments will be conducted at baseline, 3 months, and 6 months. The primary outcome variables are anthropometric indicators of obesity, metabolic syndrome components, and inflammatory, insulin-pathway, and hormonal biomarkers of breast cancer risk.

DISCUSSION

The FIERCE trial will provide evidence on whether a short-term exercise intervention might be effective in reducing breast cancer risk among African-American women with comorbidities and high breast cancer risk--a group traditionally under-represented in non-therapeutic breast cancer trials.

CLINICAL TRIAL REGISTRATION NUMBER

NCT02103140.

Effect of metformin vs placebo on and metabolic factors in NCIC CTG MA.32

BACKGROUND

Metformin may improve metabolic factors (insulin, glucose, leptin, highly sensitive C-reactive protein [hs-CRP]) associated with poor breast cancer outcomes. The NCIC Clinical Trials Group (NCIC CTG) MA.32 investigates effects of metformin vs placebo on invasive disease-free survival and other outcomes in early breast cancer. Maintaining blinding of investigators to outcomes, we conducted a planned, Data Safety Monitoring Committee-approved, analysis of the effect of metformin vs placebo on weight and metabolic factors at six months, including examination of interactions with baseline body mass index (BMI) and insulin, in the first 492 patients with paired blood samples.

METHODS

Eligible nondiabetic subjects with T1-3, N0-3, M0 breast cancer who had completed surgery and (neo)adjuvant chemotherapy (if given) provided fasting plasma samples at random assignment and at six months. Glucose was measured locally; blood was aliquoted, frozen, and stored at -80°C. Paired plasma aliquots were analyzed for insulin, hs-CRP, and leptin. Spearman correlation coefficients were calculated and comparisons analyzed using Wilcoxon signed rank test. All statistical tests were two-sided.

RESULTS

Mean age was 52.1±9.5 years in the metformin group and 52.6 ± 9.8 years in the placebo group. Arms were balanced for estrogen/progesterone receptor, BMI, prior (neo)adjuvant chemotherapy, and stage. At six months, decreases in weight and blood variables were statistically significantly greater in the metformin arm (vs placebo) in univariate analyses: weight -3.0%, glucose -3.8%, insulin -11.1%, homeostasis model assessment -17.1%, leptin -20.2%, hs-CRP -6.7%; all P values were less than or equal to .03. There was no statistically significant interaction of change in these variables with baseline BMI or insulin.

CONCLUSIONS

Metformin statistically significantly improved weight, insulin, glucose, leptin, and CRP at six months. Effects did not vary by baseline BMI or fasting insulin.

Changes in insulin receptor signaling underlie neoadjuvant metformin administration in breast cancer: a prospective window of opportunity neoadjuvant study

INTRODUCTION

The antidiabetic drug metformin exhibits potential anticancer properties that are believed to involve both direct (insulin-independent) and indirect (insulin-dependent) actions. Direct effects are linked to activation of AMP-activated protein kinase (AMPK) and an inhibition of mammalian target of rapamycin mTOR signaling, and indirect effects are mediated by reductions in circulating insulin, leading to reduced insulin receptor (IR)-mediated signaling. However, the in vivo impact of metformin on cancer cell signaling and the factors governing sensitivity in patients remain unknown.

METHODS

We conducted a neoadjuvant, single-arm, "window of opportunity" trial to examine the clinical and biological effects of metformin on patients with breast cancer. Women with untreated breast cancer who did not have diabetes were given 500 mg of metformin three times daily for ≥2 weeks after diagnostic biopsy until surgery. Fasting blood and tumor samples were collected at diagnosis and surgery. Blood glucose and insulin were assayed to assess the physiologic effects of metformin, and immunohistochemical analysis of tumors was used to characterize cellular markers before and after treatment.

RESULTS

Levels of IR expression decreased significantly in tumors (P = 0.04), as did the phosphorylation status of protein kinase B (PKB)/Akt (S473), extracellular signal-regulated kinase 1/2 (ERK1/2, T202/Y204), AMPK (T172) and acetyl coenzyme A carboxylase (S79) (P = 0.0001, P < 0.0001, P < 0.005 and P = 0.02, respectively). All tumors expressed organic cation transporter 1, with 90% (35 of 39) exhibiting an Allred score of 5 or higher.

CONCLUSIONS

Reduced PKB/Akt and ERK1/2 phosphorylation, coupled with decreased insulin and IR levels, suggest insulin-dependent effects are important in the clinical setting. These results are consistent with beneficial anticancer effects of metformin and highlight key factors involved in sensitivity, which could be used to identify patients with breast cancer who may be responsive to metformin-based therapies.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT00897884. Registered 8 May 2009.

A review of obesity, insulin resistance, and the role of exercise in breast cancer patients

Breast cancer, the most common female malignancy in the world, has a strong association with obesity and insulin resistance. The importance of these risk factors goes up significantly in patients already affected by this cancer as they negatively affect the prognosis, recurrence rate, and survival by various mechanisms. The literature on the role of physical activity and aerobic exercise on modifying the above risks is debatable with data both for and against it. In this article, we have reviewed the risks of obesity and insulin resistance in breast cancer patients and the controversy associated with the impact of exercise. Ultimately, we have concluded that a randomized control trial is necessary with an individualized aerobic exercise program for a minimum duration of 20 wk on breast cancer patients, who are undergoing or recently completed chemotherapy, to study its effects on insulin resistance, weight, and clinical outcome.

Metabolic syndrome is associated with increased breast cancer risk: a systematic review with meta-analysis

Background. Although individual metabolic risk factors are reported to be associated with breast cancer risk, controversy surrounds risk of breast cancer from metabolic syndrome (MS). We report the first systematic review and meta-analysis of the association between MS and breast cancer risk in all adult females. Methods. Studies were retrieved by searching four electronic reference databases [PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, and ProQuest through June 30, 2012] and cross-referencing retrieved articles. Eligible for inclusion were longitudinal studies reporting associations between MS and breast cancer risk among females aged 18 years and older. Relative risks and 95% confidence intervals were calculated for each study and pooled using random-effects models. Publication bias was assessed quantitatively (Trim and Fill) and qualitatively (funnel plots). Heterogeneity was examined using Q and I² statistics. Results. Representing nine independent cohorts and 97,277 adult females, eight studies met the inclusion criteria. A modest, positive association was observed between MS and breast cancer risk (RR: 1.47, 95% CI, 1.15–1.87; z = 3.13; p = 0.002; Q = 26.28, p = 0.001; I² = 69.55%). No publication bias was observed. Conclusions. MS is associated with increased breast cancer risk in adult women.

Metabolic syndrome and outcomes following early-stage breast cancer

The prevalence of risk factors contributing to metabolic syndrome (MetS) is increasing, and numerous components of MetS are associated with increased primary breast cancer (BC) risk. However, less is known about the relationship of MetS to BC outcomes. The aim of this study was to evaluate whether MetS, characterized by increased weight, hypertension, low HDL-cholesterol, high triglycerides, and diabetes or impaired glucose tolerance, is associated with risk of second breast cancer events (SBCE) and BC-specific mortality. Retrospective cohort study of women diagnosed with incident early-stage (I-II) BC between 1990 and 2008, enrolled in an integrated health plan. Outcomes of interest were SBCE, defined as recurrence or second primary BC, and BC-specific mortality. We used multivariable Cox proportional hazards models to estimate adjusted hazard ratios (HR) and 95% confidence intervals (CI) for time-varying exposure to MetS components while accounting for potential confounders and competing risks. Among 4,216 women in the cohort, 26% had ≥3 MetS components and 13% developed SBCE during median follow-up of 6.3 years. Compared to women with no MetS components, presence of MetS (≥3 components) was associated with increased risk of SBCE (HR = 1.50, 95% CI 1.08-2.07) and BC-specific mortality (HR = 1.65, 95% CI 1.02-2.69). Of the individual components, only increased weight was associated with increased risk of SBCE (HR = 1.26, 95% CI 1.06-1.49). MetS is associated with modestly increased risk of SBCE and BC-specific mortality. Given the growing population of BC survivors, further research in larger and more diverse populations is warranted.

Metabolic syndrome and outcome after breast reconstruction

Metabolic syndrome with its core components including obesity, insulin resistance, dyslipidemia and hypertension; is has been proven as a multiplex risk factor for cardiovascular disease. It is also recently shown by meta-analysis for its association with increased risk of common cancers including breast cancer. Multiple studies have shown metabolic syndrome prone to have poor perioperative outcome and complications for multiple type of surgery including vascular and flap surgery due to compromising microvascular circulation in this group of patient. However, lack of data on consequences of metabolic syndrome on breast cancer surgery as well as in breast reconstructive surgery indicate the need of further study in this area for the improvement of outcome of breast cancer and reconstructive surgery.

Metabolic syndrome and renal cell carcinoma

BACKGROUND

Metabolic syndrome (MS) is a cluster of metabolic abnormalities, which has been regarded as a pivotal risk factor for cardiovascular diseases. Recent studies focusing on the relationship between MS and cancer have recognized the significant role of MS on carcinogenesis. Likewise, growing evidence suggests that MS has a strong association with increased renal cell carcinoma (RCC) risk. This review outlines the link between MS and RCC, and some underlying mechanisms responsible for MS-associated RCC.

MATERIALS AND METHODS

A National Center for Biotechnology Information PubMed search (http://www.pubmed.gov) was conducted using medical subject headings 'metabolic syndrome', 'obesity', 'hypertension', 'diabetes', 'dyslipidemia', and 'renal cell carcinoma'.

RESULTS

This revealed that a variety of molecular mechanisms secondary to MS are involved in RCC formation, progression, and metastasis. A deeper understanding of these molecular mechanisms may provide some strategies for the prevention and treatment of RCC.

CONCLUSIONS

In summary, there is a large body of evidence regarding the link between MS and RCC, within which each component of MS is considered to have a close causal association with RCC.

Randomized trial of a telephone-based weight loss intervention in postmenopausal women with breast cancer receiving letrozole: the LISA trial

PURPOSE

Obesity is associated with poor outcomes in women with operable breast cancer. Lifestyle interventions (LIs) that help women reduce their weight may improve outcomes.

PATIENTS AND METHODS

We conducted a multicenter randomized trial comparing mail-based delivery of general health information alone or combined with a 24-month standardized, telephone-based LI that included diet (500 to 1,000 kcal per day deficit) and physical activity (150 to 200 minutes of moderate-intensity physical activity per week) goals to achieve weight loss (up to 10%). Women receiving adjuvant letrozole for T1-3N0-3M0 breast cancer with a body mass index (BMI) ≥ 24 kg/m(2) were eligible. Weight was measured in the clinic, and self-report physical activity, quality-of-life (QOL), and diet questionnaires were completed. The primary outcome was disease-free survival. Accrual was terminated at 338 of 2,150 planned patients because of loss of funding.

RESULTS

Mean weight loss was significantly (P < .001) greater in the LI arm versus the comparison arm (4.3 v 0.6 kg or 5.3% v 0.7% at 6 months and 3.1 v 0.3 kg or 3.6% v 0.4% at 24 months) and occurred consistently across strata (BMI 24 to < 30 v ≥ 30 kg/m(2); prior v no prior adjuvant chemotherapy). Weight loss was greatest in those with higher baseline levels of moderate-intensity physical activity or improvement in QOL. Hospitalization rates and medical events were similar.

CONCLUSION

A telephone-based LI led to significant weight loss that was still evident at 24 months, without adverse effects on QOL, hospitalizations, or medical events. Adequately powered randomized trials with cancer end points are needed.

Impact of metabolic syndrome on oncologic outcome after radical gastrectomy for gastric cancer

BACKGROUND

Few studies have reported the relationship between MS and the prognosis of gastric cancer.

METHODS

Data were collected from 505 patients who underwent radical gastrectomy for gastric cancer between January 2006 and December 2007. After exclusion, remaining 204 patients were divided into two groups based on the presence of MS.

RESULTS

No significant differences were observed in tumor stage and grade between the MS (n=60) and non-MS (n=144) groups. The median follow-up periods were 53.2±23.5 and 54.7±22.1 months in for the MS and non-MS groups, respectively (P=0.677). Seventeen (28.3%) and 21 (14.6%) patients showed tumor recurrence in the MS and non-MS groups, respectively (P=0.022). In addition, disease-free survival of patients in the MS group was less than in non-MS group (P=0.036). The Cox regression hazard model demonstrated that advanced tumor stage (stage III or IV, HR=17.8, 95% CI=5.3 to 59.4) and presence of MS (HR=2.8, 95% CI=1.3 to 5.8) were independent risk factors for recurrence.

CONCLUSION

MS may be an important prognostic factor for gastric cancer. Control of MS could improve the therapeutic efficacy of gastric cancer.

Patients with old age or proximal tumors benefit from metabolic syndrome in early stage gastric cancer

Background

Metabolic syndrome and/or its components have been demonstrated to be risk factors for several cancers. They are also found to influence survival in breast, colon and prostate cancer, but the prognostic value of metabolic syndrome in gastric cancer has not been investigated.

Methods

Clinical data and pre-treatment information of metabolic syndrome of 587 patients diagnosed with early stage gastric cancer were retrospectively collected. The associations of metabolic syndrome and/or its components with clinical characteristics and overall survival in early stage gastric cancer were analyzed.

Results

Metabolic syndrome was identified to be associated with a higher tumor cell differentiation (P = 0.036). Metabolic syndrome was also demonstrated to be a significant and independent predictor for better survival in patients aged >50 years old (P = 0.009 in multivariate analysis) or patients with proximal gastric cancer (P = 0.047 in multivariate analysis). No association was found between single metabolic syndrome component and overall survival in early stage gastric cancer. In addition, patients with hypertension might have a trend of better survival through a good control of blood pressure (P = 0.052 in univariate analysis).

Conclusions

Metabolic syndrome was associated with a better tumor cell differentiation in patients with early stage gastric cancer. Moreover, metabolic syndrome was a significant and independent predictor for better survival in patients with old age or proximal tumors.

Multiple metabolic risk factors and mammographic breast density

PURPOSE

We examined whether obesity and a history of diabetes, hypertension, and elevated cholesterol, individually and in combination, are associated with breast density, a strong risk factor for breast cancer.

METHODS

We measured percent density and dense area using a computer-assisted method (n = 191; age range = 40-61 years). We used linear regression models to examine the associations of each metabolic condition and the number of metabolic conditions (zero, one, two, and three or four conditions) with breast density.

RESULTS

Among individual metabolic conditions, only high blood cholesterol was inversely associated with percent density (β = -5.4, 95% confidence interval [CI]: -8.5, -2.2) and dense area (β = -6.7, 95% CI = -11.1, -2.4). Having multiple metabolic conditions was also associated with lower breast density, with two conditions and three or four conditions versus zero conditions associated with 6.4% (95% CI: -11.2, -1.6) and 7.4% (95% CI: -12.9, -1.9) reduction in percent density and with 6.5 cm(2) (95% CI: -13.1, -0.1) and 9.5 cm(2) (95% CI: -17.1, -1.9) decrease in dense area.

CONCLUSIONS

A history of high blood cholesterol and multiple metabolic conditions were associated with lower relative and absolute measures of breast density. The positive association between metabolic abnormalities and breast cancer risk may be driven by pathways unrelated to mammographic breast density.

Gender-specific effects of oral hypoglycaemic agents on cancer risk in type 2 diabetes mellitus

AIMS

To analyse the association between cancer incidence and oral diabetes therapy (biguanide, sulphonylurea, thiazolidinedione and meglitinide) in men and women with type 2 diabetes mellitus.

METHODS

A retrospective analysis of the electronic health record-based Cleveland Clinic Diabetes Registry (25 613 patients) was cross-indexed with the histology-based tumour registry (48 051 cancer occurrences) over an 8-year period (1998-2006). Multiple imputations were used to account for missing data. Cox regression with propensity scores was used to model time for the development of incident cancer in each of the imputed datasets and the results were pooled.

RESULTS

During 51 994 person follow-up years, 892 incident cancer cases were identified; prostate (14.5%) and breast (11.7%) malignancies were most frequent. In women, thiazolidinedione use was associated with a 32% decreased cancer risk compared with sulphonylurea use [hazard ratio (HR) 0.68; 95% confidence interval (CI) 0.48-0.97, in the adjusted analysis]. Comparison of insulin secretagogues (sulphonylurea and meglitinide) versus insulin sensitizers (biguanide and thiazolidinedione) demonstrated a 21% decreased cancer risk in insulin sensitizers [HR 0.79 (95% CI 0.64-0.98) in the adjusted analysis]. Oral diabetes therapy showed no significant difference in men. Adjustments were made for age, body mass index (BMI), low-density lipoprotein (LDL), high-density lipoprotein (HDL), triglycerides, coronary heart disease (CHD), diabetes oral monotherapy, race, gender, haemoglobin A1c, statin use, income, insulin use, glomerular filtration rate (GFR), new diabetes status, prior cancer, prior cerebrovascular accident (stroke or transient ischaemic event), systolic/diastolic blood pressure, tobacco use (ever/never) and the propensity score for receiving a biguanide.

CONCLUSIONS

Oral insulin sensitizers, particularly thiazolidinedione, are associated with decreased malignancy risk in women with type 2 diabetes mellitus.

Breast cancer: current and future endocrine therapies

Endocrine therapy forms a central modality in the treatment of estrogen receptor positive breast cancer. The routine use of 5 years of adjuvant tamoxifen has improved survival rates for early breast cancer, and more recently has evolved in the postmenopausal setting to include aromatase inhibitors. The optimal duration of adjuvant endocrine therapy remains an active area of clinical study with recent data supporting 10 years rather than 5 years of adjuvant tamoxifen. However, endocrine therapy is limited by the development of resistance, this can occur by a number of possible mechanisms and numerous studies have been performed which combine endocrine therapy with agents that modulate these mechanisms with the aim of preventing or delaying the emergence of resistance. Recent trial data regarding the combination of the mammalian target of rapamycin (mTOR) inhibitor, everolimus with endocrine therapy have resulted in a redefinition of the clinical treatment pathway in the metastatic setting. This review details the current endocrine therapy utilized in both early and advanced disease, as well as exploring potential new targets which modulate pathways of resistance, as well as agents which aim to modulate adrenal derived steroidogenic hormones.

Life style prevention of cancer recurrence: the yin and the yang

There is increasing evidence that lifestyle after the diagnosis of cancer may affect prognosis. Several studies have shown that a Western dietary pattern, obesity, weight gain, a sedentary lifestyle, metabolic syndrome, high serum levels of insulin, growth factors, and inflammatory cytokines after the diagnosis of cancer are associated with an increased incidence of recurrences. Most studies have been on breast and colon cancer. However, in the clinical management of cancer, little attention is presently paid to improving lifestyle and controlling body weight. Lifestyle intervention trials are needed to corroborate or confute the observational results on cancer recurrences, but, even now, there is no contraindication to promoting moderate physical exercise, moderate calorie restriction (CR), and a Mediterranean dietary pattern. In fact, the AICR/WCRF 2007 systematic literature review recommends cancer patients to adopt the lifestyle recommended for the prevention of cancer. Interestingly, the evidence-based AICR/WCRF recommendations coincide with traditional rules, based on far Eastern philosophy, of avoiding extremely yin food, such as sugared beverages and calorie-dense foods, and extremely yang food, such as processed meat, and relying on the equilibrium of slightly yang food, such as whole-grain unprocessed cereals, eaten with slightly yin food, such as legumes and vegetables.

Glucose promotes breast cancer aggression and reduces metformin efficacy

Metformin treatment has been associated with a decrease in breast cancer risk and improved survival. Metformin induces complex cellular changes, resulting in decreased tumor cell proliferation, reduction of stem cells, and apoptosis. Using a carcinogen-induced rodent model of mammary tumorigenesis, we recently demonstrated that overfeeding in obese animals is associated with a 50% increase in tumor glucose uptake, increased proliferation, and tumor cell reprogramming to an "aggressive" metabolic state. Metformin significantly inhibited these pro-tumorigenic effects. We hypothesized that a dynamic relationship exists between chronic energy excess (glucose by dose) and metformin efficacy/action. Media glucose concentrations above 5 mmol/L was associated with significant increase in breast cancer cell proliferation, clonogenicity, motility, upregulation/activation of pro-oncogenic signaling, and reduction in apoptosis. These effects were most significant in triple-negative breast cancer (TNBC) cell lines. High-glucose conditions (10 mmol/L or above) significantly abrogated the effects of metformin. Mechanisms of metformin action at normal vs. high glucose overlapped but were not identical; for example, metformin reduced IGF-1R expression in both the HER2+ SK-BR-3 and TNBC MDA-MB-468 cell lines more significantly at 5, as compared with 10 mmol/L glucose. Significant changes in gene profiles related to apoptosis, cellular processes, metabolic processes, and cell proliferation occurred with metformin treatment in cells grown at 5 mmol/L glucose, whereas under high-glucose conditions, metformin did not significantly increase apoptotic/cellular death genes. These data indicate that failure to maintain glucose homeostasis may promote a more aggressive breast cancer phenotype and alter metformin efficacy and mechanisms of action.

High fasting blood glucose and obesity significantly and independently increase risk of breast cancer death in hormone receptor-positive disease

PURPOSE

We investigated the effect of fasting blood glucose and body mass index (BMI) at diagnosis on risk of breast cancer death for cases diagnosed in five Italian cancer registries in 2003-2005 and followed up to the end of 2008.

METHODS

For 1607 Italian women (≥15 years) with information on BMI or blood glucose or diabetes, we analysed the risk of breast cancer death in relation to glucose tertiles (≤84.0, 84.1-94.0, >94.0 mg/dl) plus diabetic and unspecified categories; BMI tertiles (≤23.4, 23.5-27.3, >27.3 kg/m(2), unspecified), stage (T1-3N0M0, T1-3N+M0 plus T4anyNM0, M1, unspecified), oestrogen (ER) and progesterone (PR) status (ER+PR+, ER-PR-, ER and PR unspecified, other), age, chemotherapy and endocrine therapy, using multiple regression models. Separate models for ER+PR+ and ER-PR- cases were also run.

RESULTS

Patients often had T1-3N0M0, ER+PR+ cancers and received chemotherapy or endocrine therapy; only 6% were M1 and 17% ER-PR-. Diabetic patients were older and had more often high BMI (>27 kg/m(2)), ER-PR-, M1 cancers than other patients. For ER+PR+ cases, with adjustment for other variables, breast cancer mortality was higher in women with high BMI than those with BMI 23.5-27.3 kg/m(2) (hazard ratio (HR)=2.9, 95% confidence interval (CI) 1.2-6.9). Breast cancer mortality was also higher in women with high (>94 mg/dl) blood glucose compared to those with glucose 84.1-94.0mg/dl (HR=2.6, 95% CI 1.2-5.7).

CONCLUSION

Our results provide evidence that in ER+PR+ patients, high blood glucose and high BMI are independently associated with increased risk of breast cancer death. Detection and correction of these factors in such patients may improve prognosis.

Exercise after diagnosis and metabolic syndrome among breast cancer survivors: a report from the Shanghai Breast Cancer Survival Study

Metabolic syndrome (MetS) is an established risk factor for cardiovascular diseases and mortality. Limited data are available on the prevalence of MetS and its association with exercise among breast cancer survivors. The present study included 1,696 breast cancer survivors from the Shanghai Breast Cancer Survival Study, a population-based prospective cohort study conducted between April 2002 and October 2011 in Shanghai, China. All women had a physical examination taken at study clinic approximately 60 months post-diagnosis. Exercise was assessed at approximately 6, 18, 36, and 60 months post-diagnosis. Information on medical history, tumor characteristics, cancer treatment, anthropometrics, and lifestyle was collected at study enrollment. Associations between exercise and MetS at 60 months post-diagnosis were evaluated with multivariable logistic regression models. The mean age of the study population was 56.68 at 60-month survey, and the mean follow-up since cancer diagnosis was 63.66 months. The prevalence of MetS using National Cholesterol Education Program Adult Treatment Panel III criteria at approximately 60 months after diagnosis was 33.14%. Among overweight and obesity breast cancer survivors (body mass index (BMI) ≥ 25 kg/m(2) at baseline), the prevalence was 55.18%. The most common type of exercise in this population was walking (45.40%) at baseline. Exercise participation between 6 and 60 months post-diagnosis was inversely associated with the prevalence of MetS with the adjusted odds ratio (OR) for exercise participation of ≥ 3.5 h/week (30 min/day) being 0.69 (95% confidence interval (CI) 0.48-0.98). In addition consistent exercise participation reduced the prevalence of MetS (adjusted OR 0.70 (95% CI 0.50-1.00). Associations of exercise with MetS were not modified by baseline waist circumference, BMI, comorbidity, baseline menopausal status, TNM stage, cancer treatment, or ER/PR status (p interactions > 0.05). Regular and persistent exercise after cancer diagnosis, even at low-to-moderate intensity level, decreases the prevalence of MetS among long-term breast cancer survivors.

Age and the effect of physical activity on breast cancer survival: A systematic review

The effect of physical activity (PA) on cancer survival is still the topic of debate in oncology research focusing on survivorship, and has been investigated retrospectively in several large clinical trials. PA has been shown to improve quality of life, fitness and strength, and to reduce depression and fatigue. At present, there is a growing body of evidence on the effects of PA interventions for cancer survivors on health outcomes. PA and functional limitations are interrelated in the elderly. However the relationship between breast cancer survival and PA in older breast cancer patients has not yet been fully investigated. Our systematic review of the existing literature on this topic yielded seventeen studies. Most reports demonstrated an improved overall and breast cancer-specific survival. Furthermore, in studies that compared younger women with older or postmenopausal women, it was suggested that the beneficial effect of PA may be even greater in older women. Understanding the interaction between physical functioning and cancer survival in older breast cancer patients is key, and may contribute to successful treatment and survival. In this population of cancer survivors it is therefore imperative to embark on research focused on improving physical functioning in the context of comorbidities and functional limitations.

Fasting blood glucose and long-term prognosis of non-metastatic breast cancer: a cohort study

High circulating glucose has been associated with increased risk of breast cancer (BC). There may also be a link between serum glucose and prognosis in women treated for BC. We assessed the effect of peridiagnostic fasting blood glucose and body mass index (BMI) on long-term BC prognosis. We retrospectively investigated 1,261 women diagnosed and treated for stage I-III BC at the National Cancer Institute, Milan, in 1996, 1999 and 2000. Data on blood tests and follow-up were obtained by linking electronic archives, with follow-up to end of 2009. Multivariate Cox modelling estimated hazard ratios (HR) with 95 % confidence intervals (CI) for distant metastasis, recurrence and death (all causes) in relation to categorized peridiagnostic fasting blood glucose and BMI. Mediation analysis investigated whether blood glucose mediated the BMI-breast cancer prognosis association. The risks of distant metastasis were significantly higher for all other quintiles compared to the lowest glucose quintile (reference <87 mg/dL) (respective HRs: 1.99 95 % CI 1.23-3.24, 1.85 95 % CI 1.14-3.0, 1.73 95 % CI 1.07-2.8, and 1.91 95 % CI 1.15-3.17). The risk of recurrence was significantly higher for all other glucose quintiles compared to the first. The risk of death was significantly higher than reference in the second, fourth and fifth quintiles. Women with BMI ≥ 25 kg/m(2) had significantly greater risks of recurrence and distant metastasis than those with BMI < 25 kg/m(2), irrespective of blood glucose. The increased risks remained invariant over a median follow-up of 9.5 years. Mediation analysis indicated that glucose and BMI had independent effects on BC prognosis. Peridiagnostic high fasting glucose and obesity predict worsened short- and long-term outcomes in BC patients. Maintaining healthy blood glucose levels and normal weight may improve prognosis.

Favorable changes in serum estrogens and other biologic factors after weight loss in breast cancer survivors who are overweight or obese

BACKGROUND

Obesity is associated with an increased risk for recurrence and all-cause mortality in breast cancer survivors. Excess adiposity is associated with increased estrogen, insulin, and leptin, and with decreased sex hormone binding globulin (SHBG) concentrations, which may promote breast cancer progression and recurrence. This study aimed to assess the effects of weight loss on these factors.

PATIENTS AND METHODS

Breast cancer survivors who were overweight or obese (n = 220) and who were enrolled in a weight loss intervention study provided baseline and follow-up blood samples and weight data. Serum estrogens, SHBG, insulin, and leptin were measured at baseline, 6 months, and 18 months.

RESULTS

Weight loss of ≥5% of initial weight decreased leptin and insulin compared with those who did not achieve that amount of weight loss (P < .0001). Weight loss also increased SHBG at 6 and 18 months (P < .01). Postmenopausal women who lost ≥5% of body weight at 6 months had lower estrone (P = .02), estradiol (P = .002), and bioavailable estradiol (P = .001) concentrations than women who did not lose at least 5% of body weight, and weight loss at 18 months was significantly related to a change in serum bioavailable estradiol concentration (P = .02).

CONCLUSIONS

Favorable changes in estrogens, SHBG, insulin, and leptin were observed in association with weight loss in these women who were overweight or obese and who had been diagnosed and treated for breast cancer. Weight loss appears to have favorable effects on hormonal and biologic factors associated with increased risk for recurrence and poorer prognosis.

Effect of exercise on metabolic syndrome variables in breast cancer survivors

Objective. Breast cancer survivors are highly sedentary, overweight, or obese, which puts them at increased risk for comorbid chronic disease. We examined the prevalence of, and changes in, metabolic syndrome following 6 months of an aerobic exercise versus usual care intervention in a sample of sedentary postmenopausal breast cancer survivors. Design and Methods. 65 participants were randomized to an aerobic exercise intervention (EX) (n = 35) mean BMI 30.8 (±5.9) kg/m(2) or usual care (UC) (n = 30) mean BMI 29.4 (±7.4) kg/m(2). Metabolic syndrome prevalence was determined, as well as change in criteria and overall metabolic syndrome. Results. At baseline, 55.4% of total women met the criteria for metabolic syndrome. There was no statistically significant change in metabolic syndrome when comparing EX and UC. However, adhering to the exercise intervention (at least 120 mins/week of exercise) resulted in a significant (P = .009) decrease in metabolic syndrome z-score from baseline to 6 months (-0.76 ± 0.36) when compared to those who did not adhere (0.80 ± 0.42). Conclusions. Due to a higher prevalence of metabolic syndrome in breast cancer survivors, lifestyle interventions are needed to prevent chronic diseases associated with obesity. Increasing exercise adherence is a necessary target for further research in obese breast cancer survivors.

Efficacy of combined therapy of goserelin and letrozole on very young women with advanced breast cancer as first-line endocrine therapy

Breast cancer in young women younger than 35 years old is rare, aggressive and associated with a poor prognosis. Endocrine therapy is a preferred treatment modality in hormone receptor-positive early stage and advanced breast cancer, combined therapy of goserelin and letrozole presents an option for premenopausal women. We reported the efficacy and safety of therapy of goserelin plus letrozole on very young women with advanced breast cancer as first-line endocrine therapy. Thirty-five patients with first diagnosed as advanced breast cancer, age younger than 35 years, were enrolled in the study. All patients received goserelin 3.6 mg by subcutaneous injection every 4 weeks along with letrozole 2.5mg daily by mouth as first-line endocrine therapy. The study endpoints were objective response rate (ORR), clinical benefit (CB), progression-free survival (PFS), overall survival (OS) and toxicity. The median duration of response to the therapy was 21 (range, 10-56) months, and median duration of follow-up was 44 (range, 5-79) months. The ORR was 25.7%, with one complete response (CR, 2.9%) and eight partial response (PR, 22.9%). Twenty-two patients had stable disease at 24 weeks, for a clinical benefit rate of 65.7%. The median PFS was 9.6 (range 5-58) months and median OS was 33 (range 6-72) months. During the therapy and follow-up, no serious toxicities were reported. Combined therapy of goserelin and letrozole appears to be an efficacious and well-tolerated therapy for very young women with advanced breast cancer. Further investigations involving more patients, combination of other therapies and longer follow-up are requisite.

Obesity and risk of recurrence or death after adjuvant endocrine therapy with letrozole or tamoxifen in the breast international group 1-98 trial

PURPOSE

To examine the association of baseline body mass index (BMI) with the risk of recurrence or death in postmenopausal women with early-stage breast cancer receiving adjuvant tamoxifen or letrozole in the Breast International Group (BIG) 1-98 trial at 8.7 years of median follow-up.

PATIENTS AND METHODS

This report analyzes 4,760 patients with breast cancer randomly assigned to 5 years of monotherapy with letrozole or tamoxifen in the BIG 1-98 trial with available information on BMI at randomization. Multivariable Cox modeling assessed the association of BMI with disease-free survival, overall survival (OS), breast cancer-free interval, and distant recurrence-free interval and tested for treatment-by-BMI interaction. Median follow-up was 8.7 years.

RESULTS

Seventeen percent of patients have died. Obese patients (BMI ≥ 30 kg/m(2)) had slightly poorer OS (hazard ratio [HR] = 1.19; 95% CI, 0.99 to 1.44) than patients with normal BMI (< 25 kg/m(2)), whereas no trend in OS was observed in overweight (BMI 25 to < 30 kg/m(2)) versus normal-weight patients (HR = 1.02; 95% CI, 0.86 to 1.20). Treatment-by-BMI interactions were not statistically significant. The HRs for OS comparing obese versus normal BMI were HR = 1.22 (95% CI, 0.93 to 1.60) and HR = 1.18 (95% CI, 0.91 to 1.52) in the letrozole and tamoxifen groups, respectively.

CONCLUSION

There was no evidence that the benefit of letrozole over tamoxifen differed according to patients' BMI.

Effect of different doses of metformin on serum testosterone and insulin in non-diabetic women with breast cancer: a randomized study

This is a randomized controlled trial to test the effect of different doses of metformin in patients with breast cancer and without diabetes, with the aim of modifying the hormonal and metabolic parameters linked to breast cancer prognosis. Analysis of the results suggest that the dose of 1500 mg/d of metformin causes a significant reduction of insulin and testosterone serum levels.

BACKGROUND

Serum levels of insulin and testosterone may affect both breast cancer (BC) incidence and prognosis. Metformin reduces hyperglycemia and insulin levels in patients with diabetes. In women without diabetes and with polycystic ovary syndrome, metformin lowers both insulin and testosterone levels. Patients with diabetes who are treated with metformin showed a lower risk of cancer; a protective effect of metformin also was observed for BC. Recently, studies on metformin use for prevention or treatment of BC have been proposed in patients who are not diabetic. The aim of the present study was to test the effect of different doses of metformin on serum levels of insulin and testosterone in those postmenopausal patients with breast cancer and without diabetes who have basal testosterone levels ≥0.28 ng/mL (median value).

PATIENTS AND METHODS

A total of 125 eligible women were initially invited to take metformin 500 mg/d for 3 months. The 108 women who completed the first 3 months were invited to continue the study with metformin 1000 mg/d (500 mg twice a day [b.i.d.]) for 1 month. The women were then randomized into 2 groups, and, for the subsequent 5 months, 1 group increased the dose by taking metformin 1500 mg/d (500 mg 3 times a day [t.i.d.]), and the other group continued with metformin 1000 mg /d (500 [b.i.d.]).

RESULTS

A total of 96 women completed the study: 43 women received 1500 mg/d, and 53 women received 1000 mg/d. The women who took 1500 mg/d showed a significant reduction of insulin level, HOMA-IR index (homeostasis model assessment-insulin resistance index), testosterone level, and free androgen index compared with women treated with 1000 mg/d. After treatment with 1500 mg/d, the insulin level decreased by 25% and the testosterone level decreased by 23%.

CONCLUSION

Both these changes might have a prognostic importance.