Impact of diabetes mellitus on complications and outcomes of adjuvant chemotherapy in older patients with breast cancer

Pre-diagnosis blood glucose and prognosis in women with breast cancer

Background

The effect of moderately elevated blood glucose levels among non-diabetic subjects on cancer prognosis is not well described. The goal of this study was to examine the association of elevated random blood glucose (RBG) levels in non-diabetic breast cancer patients with overall survival (OS) and time to tumor recurrence (TTR).

Results

Forty-nine deaths and 32 recurrences occurred among 148 eligible study subjects during 855.44 person-years of follow-up, with median follow-up of 5.97 years. We observed that patients with elevated RBG levels experienced significantly shorter OS (hazard ratio [HR], 3.01; 95 % confidence interval [CI] (1.70–5.33); P < 0.001) and shorter TTR (HR, 2.08; CI (1.04–4.16); P = 0.04) as compared to patients with non-elevated RBG levels. After controlling for tumor grade, tumor stage, race, and BMI, elevated RBG continued to display high and statistically significant association with shorter OS (HR, 3.50; CI (1.87–6.54); P < 0.001). Adjustment for age, race, and BMI strengthened HR of RBG for TTR. The association of RGB with TTR lost its borderline statistical significance upon controlling for both tumor grade and stage.

Conclusions

The data suggest that elevated blood glucose is associated with poor prognosis of breast cancer patients. Given the potential clinical implication, these findings warrant further investigation.

Pharmacokinetics of Selected Anticancer Drugs in Elderly Cancer Patients: Focus on Breast Cancer

Background: Elderly patients receiving anticancer drugs may have an increased risk to develop treatment-related toxicities compared to their younger peers. However, a potential pharmacokinetic (PK) basis for this increased risk has not consistently been established yet. Therefore, the objective of this study was to systematically review the influence of age on the PK of anticancer agents frequently administered to elderly breast cancer patients. Methods: A literature search was performed using the PubMed electronic database, Summary of Product Characteristics (SmPC) and available drug approval reviews, as published by EMA and FDA. Publications that describe age-related PK profiles of selected anticancer drugs against breast cancer, excluding endocrine compounds, were selected and included. Results: This review presents an overview of the available data that describe the influence of increasing age on the PK of selected anticancer drugs used for the treatment of breast cancer. Conclusions: Selected published data revealed differences in the effect and magnitude of increasing age on the PK of several anticancer drugs. There may be clinically-relevant, age-related PK differences for anthracyclines and platina agents. In the majority of cases, age is not a good surrogate marker for anticancer drug PK, and the physiological state of the individual patient may better be approached by looking at organ function, Charlson Comorbidity Score or geriatric functional assessment.

Obesity and cancer: mechanistic insights from transdisciplinary studies

Obesity is associated with a range of health outcomes that are of clinical and public health significance, including cancer. Herein, we summarize epidemiologic and preclinical evidence for an association between obesity and increased risk of breast and prostate cancer incidence and mortality. Moreover, we describe data from observational studies of weight change in humans and from calorie-restriction studies in mouse models that support a potential role for weight loss in counteracting tumor-promoting properties of obesity in breast and prostate cancers. Given that weight loss is challenging to achieve and maintain, we also consider evidence linking treatments for obesity-associated co-morbidities, including metformin, statins and non-steroidal anti-inflammatory drugs, with reduced breast and prostate cancer incidence and mortality. Finally, we highlight several challenges that should be considered when conducting epidemiologic and preclinical research in the area of obesity and cancer, including the measurement of obesity in population-based studies, the timing of obesity and weight change in relation to tumor latency and cancer diagnosis, and the heterogeneous nature of obesity and its associated co-morbidities. Given that obesity is a complex trait, comprised of behavioral, epidemiologic and molecular/metabolic factors, we argue that a transdisciplinary approach is the key to understanding the mechanisms linking obesity and cancer. As such, this review highlights the critical need to integrate evidence from both epidemiologic and preclinical studies to gain insight into both biologic and non-biologic mechanisms contributing to the obesity-cancer link.

The Interactions of Obesity, Inflammation and Insulin Resistance in Breast Cancer

Obese postmenopausal women have an increased breast cancer risk, the principal mechanism for which is elevated estrogen production by adipose tissue; also, regardless of menstrual status and tumor estrogen dependence, obesity is associated with biologically aggressive breast cancers. Type 2 diabetes has a complex relationship with breast cancer risk and outcome; coexisting obesity may be a major factor, but insulin itself induces adipose aromatase activity and estrogen production and also directly stimulates breast cancer cell growth and invasion. Adipose tissue inflammation occurs frequently in obesity and type 2 diabetes, and proinflammatory cytokines and prostaglandin E2 produced by cyclooxygenase-2 in the associated infiltrating macrophages also induce elevated aromatase expression. In animal models, the same proinflammatory mediators, and the chemokine monocyte chemoattractant protein-1, also stimulate tumor cell proliferation and invasion directly and promote tumor-related angiogenesis. We postulate that chronic adipose tissue inflammation, rather than body mass index-defined obesity per se, is associated with an increased risk of type 2 diabetes and postmenopausal estrogen-dependent breast cancer. Also, notably before the menopause, obesity and type 2 diabetes, or perhaps the associated inflammation, promote estrogen-independent, notably triple-negative, breast cancer development, invasion and metastasis by mechanisms that may involve macrophage-secreted cytokines, adipokines and insulin.

Understanding the Association of Type 2 Diabetes Mellitus in Breast Cancer Among African American and European American Populations in South Carolina

BACKGROUND

In South Carolina, the co-occurrence of diabetes mellitus (DM) and breast cancer (BrCA) is much more prevalent among African American populations than among European American populations. The underlying relationship between diabetes and breast cancer may influence breast cancer survival. The purpose of this investigation is to examine the effect of diabetes on developing breast cancer and to reduce racial disparities in breast cancer outcomes.

METHODS

Study participants included women of European American (EA) and African American (AA) ethnicity from both the Medicaid ICD-9 designations and the South Carolina Central Cancer Registry (SCCCR). A historical prospective cohort design was used to determine the risk of developing breast cancer among women of different ethnicities with and without DM. The chi-square test was used to determine the significance of the association; the logistic model was used to assess the relationship between breast cancer and other factors among EA and AA women.

RESULTS

Menopause may have protective properties for AA compared to EA women. AA women have twice the odds of not surviving from each breast cancer stage compared to EA women with respect to their breast cancer stage. Adherence to diabetes medication may contribute to lower breast cancer death in EA.

CONCLUSION

This study illustrates the discrepancy between EA and AA women in terms of breast cancer survival. AA women bear a higher disease burden than EA women. To create ethnic-appropriate public health policies, it is imperative that we understand the effect of comorbidities on breast cancer and how we can prevent them from occurring.

Pre-existing diabetes and breast cancer prognosis among elderly women

BACKGROUND

The objective of this study was to assess the impact of pre-existing diabetes on breast cancer prognosis.

METHODS

Women (n=2833) with centrally confirmed invasive breast cancer in the Women's Health Initiative, who were linked to Medicare claims data (CMS) were followed from the date of breast cancer diagnosis to date of death or 20 September 2013. Information on diabetes was identified through the CMS Chronic Condition Warehouse algorithm. Cox proportional hazard regression was used to estimate adjusted hazard ratios for overall mortality. A competing risks model (proportional subdistribution) model was used to estimate hazard ratios for breast cancer-specific mortality.

RESULTS

Women with diabetes were more likely to have factors related to delayed diagnosis (less recent mammograms, and more advanced cancer stage) and were less likely to receive radiation therapy. Compared with women without diabetes, women with diabetes had significantly increased risk of overall mortality (HR=1.57, 95% CI: 1.23-2.01) and had nonsignificantly increased risk for breast cancer-specific mortality (HR=1.36, 95% CI: 0.86-2.15) before adjustment for factors related to delayed diagnosis and treatment. Adjustment for these factors resulted in a little change in the association of diabetes with overall mortality risk, but further attenuated the point estimate for breast cancer-specific mortality.

CONCLUSIONS

Our study provides additional evidence that pre-existing diabetes increases the risk of total mortality among women with breast cancer. Very large studies with data on breast cancer risk factors, screening and diagnostic delays, treatment choices, and the biological influence of diabetes on breast cancer will be needed to determine whether diabetes also increases the risk for breast cancer-specific mortality.

Clinical benefits of metformin in gynecologic oncology

Evidence has suggested that diabetes may contribute to the initiation and progression of specific types of cancer. Metformin, a biguanide, has become the preferred first-line therapy for the treatment of type 2 diabetes. Metformin is inexpensive, has a proven safety profile and is able to be safely combined with additional antidiabetic agents. In addition to the well-established antidiabetic effects of metformin, there has also been notable interest in its antitumor properties. The present review discusses the emerging role of metformin as an example of an existing drug, used worldwide in the treatment of diabetes, which has been demonstrated to exert significant in vitro and in vivo anticancer activities and has thus been investigated in clinical trials. In gynecologic oncology, metformin has been suggested to exhibit significant treatment efficacy against endometrial cancer. Three studies have demonstrated the potential therapeutic effects of metformin on the survival outcome of patients with ovarian cancer and in ovarian cancer prevention. However, this evidence was based on observational studies. Metformin has been shown to exert no statistically significant beneficial effect on cervical cancer incidence or mortality. By cancer site, the current limited insights highlight the need for clinical investigations and better-designed studies, along with evaluation of the effects of metformin on cancer at other sites.

Clinicopathological characteristics and prognosis of breast cancer patients with type 2 diabetes mellitus

Type 2 diabetes mellitus (T2DM) can increase the risk of several common cancers, including breast cancer (BC). The purpose of the present study was to investigate the clinicopathological features and prognosis of BC patients with or without T2DM. Seventy-eight patients were diagnosed with T2DM prior to the diagnosis of BC in the Cancer Hospital of Shantou University Medical College (Shantou, China) between 2002 and 2008. A total of 300 BC patients without T2DM were randomly selected as study controls during the same period. The clinicopathological characteristics, overall survival (OS) and disease-free survival (DFS) rates of these two groups were compared. Fifty-five BC patients and 133 control patients with T2DM were >50 years old (70.5 and 44.3%, respectively). There were more T2DM BC patients with body mass index (BMI) ≥25 kg/m² (46.2 vs. 23.3%) and these patients had a higher rate of lymph node involvement (67.9 vs. 55.0%). The DFS of the two groups was 32.1 vs. 22.3%. The OS of the two groups was 24.4 vs. 13.7%. Following adjustment for BMI, tumor-node metastasis stage and stratification of age, the relapse risk of T2DM BC patients was >2-fold higher than that of the control group in the estrogen receptor/progesterone receptor (ER/PR)-positive patients. In Her-2-negative BC patients, the relapse risk of T2DM patients was 2.237-fold higher than that of the non-T2DM patients. In conclusion, T2DM BC patients were significantly older and more likely to be overweight, and had more lymph nodes involvement. T2DM was associated with poor prognosis in ER/PR positive or Her-2-negative BC patients.

Clinical pathological characteristics of breast cancer patients with secondary diabetes after systemic therapy: a retrospective multicenter study

The objective of this study was to investigate the clinical pathological characteristics of breast cancer (BC) patients with secondary diabetes after systemic therapy without preexisting diabetes. A total of 1434 BC patients received systemic therapy and were analyzed retrospectively. Fasting plasma glucose (FPG) levels were monitored prior to the treatments, during the course of systemic therapy, and at the follow-up visits. Cox regression models were used to estimate the associations between the clinical pathological characteristics of BC and the cause-specific hazard of developing secondary diabetes. Among the 1434 BC patients, 151 had preexisting type 2 diabetes. Of the remaining 1283 patients with normal FPG levels prior to the systemic therapy, 59 developed secondary diabetes and 72 displayed secondary impaired fasting glucose (IFG) over a mean follow-up of 41 months. The prevalence of secondary type 2 diabetes in BC patients was 4.6 % (59/1283), which was obviously higher than that of the normal control group (1.4 %, P < 0.001). The percentage of older patients (P < 0.05), menopausal patients (P < 0.001), and obese patients (P < 0.01) tended to be lower in the secondary diabetic group. In addition, these patients with secondary diabetes had later pathological stages (P < 0.01), more lymph node metastasis (P < 0.05), negative estrogen receptor (ER) expression (P < 0.05), and smaller size of tumors (P < 0.05). After adjusting for age and BMI, the risk of developing secondary diabetes and IFG in subjects with later pathological stage BC (hazard ratio (HR) = 1.623; 95 % confidence interval (CI) 1.128–2.335 (P < 0.01)), negative progesterone receptor (PR) expression (HR = 0.530; 95 % CI 0.372–0.755 (P < 0.001)), positive human epidermal growth factor receptor 2 (HER2) expression (HR = 1.822; 95 % CI 1.230–2.700 (P < 0.01)), and more lymph node metastasis (HR = 1.595; 95 % CI 1.128–2.258 (P < 0.01)) was significantly higher. In conclusion, this study shows that an increase in the incidence of diabetes among breast cancer survivors after systemic therapy, especially the patients with later pathological stages, more lymph node metastasis, negative hormone receptor expression, and positive HER2 expression. Our study suggests that greater diabetes screening and prevention strategies among breast cancer patients after systemic treatment are needed in China.

Indispensability of chemotherapy in estrogen receptor-negative early breast cancer in elderly women with diabetes mellitus

To evaluate whether chemotherapy is indispensable in elderly patients with early estrogen receptor (ER)-negative breast cancer and diabetes mellitus (DM), the data on 112 patients, ≥70 years of age, with early, operable ER-negative breast cancer who were treated at the Cancer Hospital of Fudan University, Shanghai, China, between 2000 and 2010, were analyzed. The overall survival (OS), disease-free survival (DFS), and breast cancer-specific survival (BCS) were compared. Survival analysis was performed using the Kaplan-Meier method. The Cox proportional hazards model was used to evaluate the prognostic value of DM and chemotherapy for OS, DFS, and BCS. The univariate Cox regression analysis revealed that DM at diagnosis, the number of positive lymph nodes, and radiotherapy were associated with OS, the number of positive lymph nodes, human epidermal growth factor 2 (HER2/neu) status, and radiotherapy were associated with DFS, and the number of positive lymph nodes, tumor size, HER2/neu status, chemotherapy, and radiotherapy were associated with BCS. The subsequent multivariate analysis identified DM at diagnosis (hazard ratio [HR]=3.797; 95% confidence interval [CI], 1.515-9.520; P=0.004) as an independent prognostic factor for OS (with the addition of chemotherapy regimen). Chemotherapy was not an independent prognostic factor for either OS (HR=1.275; 95% CI, 0.614-2.646; P=0.515) or DFS (HR=0.849; 95% CI, 0.445-1.619; P=0.619) when other possible factors that may affect the results were adjusted. In conclusion, chemotherapy was not found to be indispensable for elderly (≥70 years of age) female patients with early ER-negative breast cancer with DM because, particularly in such patients, the treatment of DM may be more important compared with chemotherapy.

The association between diabetes and breast cancer stage at diagnosis: a population-based study

Women with diabetes have higher breast cancer incidence and mortality. The purpose of this study was to examine the impact of diabetes on stage at breast cancer diagnosis, as a possible reason for their higher mortality. Using population-based health databases from Ontario, Canada, this retrospective cohort study examined stage at diagnosis (II, III, or IV vs I) among women aged 20-105 years who were newly diagnosed with invasive breast cancer between 2007 and 2012. We compared those with diabetes to those without diabetes. Diabetes was defined based on medical records using a validated algorithm. Among 38,407 women with breast cancer, 6115 (15.9 %) women had diabetes. Breast cancer patients with diabetes were significantly more likely to present with advanced-stage breast cancer than those without diabetes. After adjustment for mammograms and other covariates, diabetes was associated with a significantly increased risk of Stage II [adjusted odds ratio (aOR) 1.14, 95 % confidence interval (CI) 1.07, 1.22], Stage III (aOR 1.21, 95 % CI 1.11, 1.33), and Stage IV (aOR 1.16, 95 % CI 1.01, 1.33) versus Stage I breast cancer. Women with diabetes had a higher risk of lymph node metastases (aOR 1.16, 95 % CI 1.06, 1.27) and tumors with size over 2 cm (aOR 1.16, 95 % CI 1.06, 1.28). Diabetes was associated with more advanced-stage breast cancer, even after accounting for differences in screening mammogram use and other factors. Our findings suggest that diabetes may predispose to more aggressive breast cancer, which may be a contributor to their higher cancer mortality.

Association of type 2 diabetes genetic variants with breast cancer survival among Chinese women

Objective

To evaluate whether the genetic susceptibility of T2D was associated with overall survival (OS) and disease-free survival (DFS) outcomes for breast cancer (BC).

Methods

Included in the study were 6346 BC patients who participated in three population-based epidemiological studies of BC and were genotyped with either GWAS or Exome-chip. We constructed a genetic risk score (GRS) for diabetes using risk variants identified from the GWAS catalog (http://genome.gov/gwastudies) that were associated with T2D risk at a minimum significance level of P ≤ 5.0E-8 among Asian population and evaluated its associations with BC outcomes with Cox proportional hazards models.

Results

During a median follow-up of 8.08 years (range, 0.01–16.95 years), 1208 deaths were documented in 6346 BC patients. Overall, the diabetes GRS was not associated with OS and DFS. Analyses stratified by estrogen receptor status (ER) showed that the diabetes GRS was inversely associated with OS among women with ER- but not in women with ER+ breast cancer; the multivariable adjusted HR was 1.38 (95% CI: 1.05–1.82) when comparing the highest to the lowest GRS quartiles. The association of diabetes GRS with OS varied by diabetes status (P for interaction <0.01). In women with history of diabetes, higher diabetes GRS was significantly associated with worse OS, with HR of 2.22 (95% CI: 1.28–3.88) for the highest vs. lowest quartile, particularly among women with an ER- breast cancer, with corresponding HR being 4.59 (95% CI: 1.04–20.28). No significant association between the diabetes GRS and OS was observed across different BMI and PR groups.

Conclusions

Our study suggested that genetic susceptibility of T2D was positively associated with total mortality among women with ER- breast cancer, particularly among subjects with a history of diabetes. Additional studies are warranted to verify the associations and elucidate the underlying biological mechanism.

Diabetes and other comorbidities in breast cancer survival by race/ethnicity: the California Breast Cancer Survivorship Consortium (CBCSC)

BACKGROUND

The role of comorbidities in survival of patients with breast cancer has not been well studied, particularly in non-white populations.

METHODS

We investigated the association of specific comorbidities with mortality in a multiethnic cohort of 8,952 breast cancer cases within the California Breast Cancer Survivorship Consortium (CBCSC), which pooled questionnaire and cancer registry data from five California-based studies. In total, 2,187 deaths (1,122 from breast cancer) were observed through December 31, 2010. Using multivariable Cox proportional hazards regression, we estimated HRs and 95% confidence intervals (CI) for overall and breast cancer-specific mortality associated with previous cancer, diabetes, high blood pressure (HBP), and myocardial infarction.

RESULTS

Risk of breast cancer-specific mortality increased among breast cancer cases with a history of diabetes (HR, 1.48; 95% CI, 1.18-1.87) or myocardial infarction (HR, 1.94; 95% CI, 1.27-2.97). Risk patterns were similar across race/ethnicity (non-Latina white, Latina, African American, and Asian American), body size, menopausal status, and stage at diagnosis. In subgroup analyses, risk of breast cancer-specific mortality was significantly elevated among cases with diabetes who received neither radiotherapy nor chemotherapy (HR, 2.11; 95% CI, 1.32-3.36); no increased risk was observed among those who received both treatments (HR, 1.13; 95% CI, 0.70-1.84; P(interaction) = 0.03). A similar pattern was found for myocardial infarction by radiotherapy and chemotherapy (P(interaction) = 0.09).

CONCLUSION

These results may inform future treatment guidelines for patients with breast cancer with a history of diabetes or myocardial infarction.

IMPACT

Given the growing number of breast cancer survivors worldwide, we need to better understand how comorbidities may adversely affect treatment decisions and ultimately outcome.

Cancer risk among people with type 1 and type 2 diabetes: disentangling true associations, detection bias, and reverse causation

OBJECTIVE

Evidence indicates an increased risk of certain cancers among people with type 2 diabetes. Evidence for rarer cancers and for type 1 diabetes is limited. We explored the excess risk of site-specific cancer incidence and mortality among people with type 1 and type 2 diabetes, compared with the general Australian population.

RESEARCH DESIGN AND METHODS

Registrants of a national diabetes registry (953,382) between 1997 and 2008 were linked to national death and cancer registries. Standardized incidence and mortality ratios (SIRs/SMRs) are reported.

RESULTS

For type 1 diabetes, significant elevated SIRs were observed for pancreas, liver, esophagus, colon and rectum (females only [F]), stomach (F), thyroid (F), brain (F), lung (F), endometrium, and ovary, and decreased SIRs were observed for prostate in males. Significantly increased SMRs were observed for pancreas, liver, and kidney (males only), non-Hodgkin's lymphoma, brain (F), and endometrium. For type 2 diabetes, significant SIRs were observed for almost all site-specific cancers, with highest SIRs observed for liver and pancreas, and decreased risks for prostate and melanoma. Significant SMRs were observed for liver, pancreas, kidney, Hodgkin's lymphoma, gallbladder (F), stomach (F), and non-Hodgkin's lymphoma (F). Cancer risk was significantly elevated throughout follow-up time but was higher in the first 3 months postregistration, suggesting the presence of detection bias and/or reverse causation.

CONCLUSIONS

Type 1 and type 2 diabetes are associated with an excess risk of incidence and mortality for overall and a number of site-specific cancers, and this is only partially explained by bias. We suggest that screening for cancers in diabetic patients is important.

Myelotoxicity of carboplatin is increased in vivo in db/db mice, the animal model of obesity-associated diabetes mellitus

PURPOSE

Some authors observed increased carboplatin-associated myelotoxicity in obese patients which was exclusively attributed to elevated AUC. To investigate the potential contribution of functional changes of cells primarily responsible for myelopoiesis, granulocyte-macrophage progenitors (CFU-GM) were studied in obesity-associated diabetes mellitus (DMT2).

METHODS

The most frequently used animal model of human obesity with DMT2 is db/db mouse. Cellularity, frequency of CFU-GM and total CFU-GM content of femoral bone marrow were measured after 100 mg/kg dose of carboplatin in vivo. To exclude influence of pharmacokinetic changes, direct toxicity of carboplatin on CFU-GM was also determined in vitro and was compared with other anticancer agents, namely doxorubicin, 5-fluorouracil and 4-thiouridylate.

RESULTS

After intraperitoneal administration of carboplatin, each measured characteristics of bone marrow function was more significantly suppressed and the induced neutropenia was more serious in db/db mice than in the controls. The increased myelotoxicity seemed to be a direct effect on myeloid progenitor cells since their increased in vitro sensitivity was found in db/db mice. This was not specific for carboplatin, a similar double to fivefold increase in myelotoxicity of each cytotoxic drug with different mechanism of action was observed. Four-thiouridylate, a promising antileukemic molecule with good therapeutic index, was by far the least toxic for CFU-GM of db/db mice.

CONCLUSIONS

A serious disorder of CFU-GM progenitors was suggested in obese mice with DMT2, which eventually might lead to more severe myelotoxicity and neutropenia. Weight loss and normalization of glucose homeostasis may be important before chemotherapy of malignant diseases in obesity with DMT2.

Racial disparities and colorectal cancer survival in older adults with and without diabetes mellitus

BACKGROUND AND AIM

To investigate whether pre-existing diabetes modifies racial disparities in colorectal cancer (CRC) survival.

METHODS

We analyzed prospective data from 16 977 patients (age ≥ 67 years) with CRC from the Surveillance Epidemiology and End Results (SEER)-Medicare database. SEER registries included data on demographics, tumor characteristics, and treatment. Medicare claims were used to define pre-existing diabetes and comorbid conditions. Mortality was confirmed in both sources.

RESULTS

At baseline, 1332 (8%) were African Americans and 26% had diabetes (39% in blacks; 25% in whites). From 2000 to 2005, more than half of the participants died (n = 8782, 52%). This included 820 (62%) deaths (23.8 per 100 person-years) among blacks, and 7962 (51%) deaths (16.6 per 100 person-years) among whites. Among older adults with diabetes, blacks had significantly higher risk of all-cause and CRC mortality after adjustments for demographic characteristics (hazard ratio [HR], 95% confidence interval [CI]: 1.21 [1.08-1.37] and 1.21 [1.03-1.42]), respectively, but these associations attenuated to null after additional adjustments for cancer stage and grade. Among adults without diabetes, the risk of all-cause mortality (HR [95% CI]: 1.14 [1.04-1.25]) and CRC mortality (HR [95% CI]: 1.21 [1.08-1.36]) remained higher in blacks than whites in fully adjusted models that included demographic variables, cancer stage, grade, treatments, and comorbidities.

CONCLUSIONS

Among older adults with CRC, diabetes is an effect modifier on the relationship between race and mortality. Racial disparities in survival were explained by demographics, cancer stage, and grade in patients with diabetes.

Impact of type 2 diabetes mellitus on the prognosis of early stage triple-negative breast cancer in People's Republic of China

Background

Type 2 diabetes mellitus (T2DM) is one of the most common chronic metabolic diseases. Increased cause-specific mortality and decreased disease-free survival (DFS) have been reported among cancer patients with T2DM compared with patients without T2DM, even after adjustments of other comorbidities. However, less is known about the impact of T2DM and other comorbidities on DFS in Chinese patients with early stage triple-negative breast cancer (TNBC).

Patients and methods

We assessed patients who were newly diagnosed with early stage primary TNBC at the Department of Breast Surgery, Fudan University, from 2003 to 2011. Of the 1,100 TNBC patients, 865 female patients had invasive and early stage TNBC. The association of the variables in the T2DM and non-T2DM groups was compared using the Pearson’s chi-square and independent t-tests. DFS was estimated using the Kaplan–Meier method. The effects of T2DM and other possible risk factors on DFS were assessed by Cox proportional hazards regression using univariate or multivariate analysis.

Results

A total of 865 early stage primary TNBC cases were studied, including 104 (12.02%) subjects with T2DM. Metastatic or recurrent disease was detected in 24 (23.08%) patients in the T2DM group and 35 (4.60%) patients in the non-T2DM group. Patients with T2DM exhibited a significantly lower DFS than patients without T2DM (log-rank P<0.001). Similar results were observed when patients with positive lymph nodes were compared with patients with negative lymph nodes (log-rank P=0.003). T2DM was independently associated with a lower DFS after adjustments of other variables (adjusted hazard ratio, 7.719; 95% confidence interval, 4.304–13.843; P<0.001) and adjustments of lymph node positivity (adjusted hazard ratio, 2.407; 95% confidence interval, 1.391–4.166; P=0.002). The DFS rates at 2 years for the T2DM group and the non-T2DM group were 78% and 97%, respectively. The prognostic influence of T2DM was consistent across the subgroups, including subgroups by age (>50 or ≤50), menopausal status (post- or premenopausal), tumor size (>5 cm or ≤5 cm), lymph node involvement (positive or negative), and adjuvant chemotherapy (received or not) using the Kaplan–Meier method (log-rank P<0.05).

Conclusion

In the People’s Republic of China, T2DM is an independent prognostic risk factor that indicates an increased likelihood of recurrence and metastasis in patients with early stage TNBC. The presence of T2DM should be taken into account when evaluating the risk for an early stage TNBC patient. More effective therapeutic regimens are needed for early stage TNBC patients with T2DM.

Diabetes, diabetes treatment and breast cancer prognosis

The objectives of this study are to assess the impact of pre-existing diabetes and diabetes treatment on breast cancer prognosis. 8,108 women with centrally confirmed invasive breast cancer in the Women's Health Initiative diagnosed between 1998 and 2013 were followed through the date of death or September 20, 2013. Information on diabetes and diabetes therapy were obtained via self-report and face-to-face review of current medication containers, respectively. Cox proportional hazard regression was used to estimate adjusted relative hazard ratios for overall mortality. The proportional subdistribution hazard model was used to estimate hazard ratios for breast cancer-specific mortality. Compared with women without diabetes, women with diabetes had significantly increased risk of overall mortality (HR 1.26 95 % CI 1.06-1.48), especially among those who took insulin or had longer duration of diabetes. However, diabetes was not associated with increased risk of breast cancer-specific mortality, regardless of type of treatment and duration of diabetes, despite the significant association of diabetes with unfavorable tumor characteristics. Our large prospective cohort study provides additional evidence that pre-existing diabetes increases risk of total mortality among women with breast cancer. The increased total mortality associated with diabetes was mainly driven by increased risk of dying from diseases other than breast cancer. Thus, the continuum of care for breast cancer patients with diabetes should include careful attention to CVD risk factors and other non-cancer conditions.

The influence of diabetes severity on receipt of guideline-concordant treatment for breast cancer

Diabetes severity may influence breast cancer treatment choices. We examined whether receipt of guideline-concordant breast cancer treatment varied with diabetes severity. Cancer registry data from seven states regarding 6,912 stage I-III breast cancers were supplemented by medical record abstraction and physician verification. We used logistic regression models to examine associations of diabetes severity with guideline-concordant locoregional treatment, adjuvant chemotherapy, and hormonal therapy adjusted for sociodemographics, comorbidity, and tumor characteristics. We defined guideline concordance using National Comprehensive Cancer Network guidelines, and diabetes and comorbidities using the Adult Comorbidity Evaluation-27 index. After adjustment, there was significant interaction of diabetes severity with age for locoregional treatment (p = 0.001), with many diabetic women under age 70 less frequently receiving guideline-concordant treatment than non-diabetic women. Among similarly aged women, guideline concordance was lower for women with mild diabetes in their late fifties through mid-sixties, and with moderate/severe diabetes in their late forties to early sixties. Among women in their mid-seventies to early eighties, moderate/severe diabetes was associated with increased guideline concordance. For adjuvant chemotherapy, moderate/severe diabetes was less frequently associated with guideline concordance than no diabetes [OR 0.58 (95 % CI 0.36-0.94)]. Diabetes was not associated with guideline-concordant hormonal treatment (p = 0.929). Some diabetic women were less likely to receive guideline-concordant treatment for stage I-III breast cancer than non-diabetic women. Diabetes severity was associated with lower guideline concordance for locoregional treatment among middle-aged women, and lower guideline concordance for adjuvant chemotherapy. Differences were not explained by comorbidity and may contribute to potentially worse breast cancer outcomes.

Prognostic impact of body mass index in patients with squamous cell carcinoma of the esophagus

PURPOSE

To clarify the prognostic impact of body mass index (BMI) in patients with esophageal squamous cell carcinoma (ESCC).

METHODS

Two hundred forty-three patients who underwent esophagectomy for ESCC from April 2005 through December 2010 were eligible. Prognoses of the patients were compared between groups stratified according to BMI. We also analyzed the survival difference using propensity score matching to adjust differences in staging and treatment.

RESULTS

Low, normal, and high BMI groups had 35, 177, and 31 patients, respectively. The low BMI group included more advanced cases than did the normal BMI group, while tumor stage was equivalent in the normal and high BMI groups. Disease-free survival of the low and high BMI groups was significantly worse than that of the normal BMI group (P<0.0001 between the low and normal BMI groups; P = 0.0076 between the normal and high BMI groups). Disease-free survival of the high BMI group was significantly worse than that of the normal BMI group in the propensity score-matched cohort (P = 0.0020). Multivariate analysis in this cohort demonstrated that high BMI was an independent prognostic factor (hazard ratio 2.949, 95% confidence interval, 1.132-7.683).

CONCLUSIONS

High BMI was an independent prognostic factor after curative esophagectomy for ESCC. Although further analysis is required to clarify the influence of overweight on the biological features of ESCC, glucose metabolism may be a therapeutic target for ESCC.

Cancer biology in diabetes

Diabetes is a serious metabolic disease that causes multiple organ dysfunctions. Recent evidence suggests that diabetes could contribute to the initiation and progression of certain cancers in addition to the classic diabetic complications. Furthermore, some of the drugs used clinically to treat patients with diabetes might affect cancer initiation, progression and mortality. The recent discovery of the possible anticancer effects of metformin, a classic antidiabetic drug, has led physicians and scientists to reconsider the interaction between diabetes and cancer. In the present review, we analyze recent reports in this field, and explore possible mechanistic links between diabetes and cancer biology.

On the status and comparison of glucose intolerance in female breast cancer patients at initial diagnosis and during chemotherapy through an oral glucose tolerance test

Aims

This study is to estimate the status and comparison of glucose intolerance in female breast cancer patients at initial diagnosis and during chemotherapy through an oral glucose tolerance test (OGTT), as well as to learn the effect of chemotherapy on the glucose metabolism of breast cancer patients.

Methods

All the 79 breast cancer patients at initial diagnosis, with the mean age of 53.2 years, and 96 breast cancer patients before the 5th or 6th cycle of chemotherapy, with the mean age of 51.5 years, participated in the study from December 2012 to October 2013. After an overnight fast, participants underwent OGTT test, and fasting and 2-hour glucose levels were measured to identify undiagnosed diabetes and prediabetes (i.e., impaired fasting glucose or impaired glucose tolerance) in them. Previously diagnosed diabetes among the female breast cancer patients was determined on the self-report and the medical record.

Results

The overall incidences of total normal glucose tolerance, prediabetes, diabetes in female breast cancer patients at initial diagnosis and during chemotherapy were 24.1% and 38.5% (p<0.05), 50.6% and 28.1% (p<0.05), and 25.3% and 33.3% (p>0.05), respectively, and the differences of normal glucose tolerance and prediabetes instead of diabetes between the two groups were statistically significant. About 84% of the total diabetes and prediabetes in the female breast cancer patients at initial diagnosis and 79.7% of those during chemotherapy need to be diagnosed with OGTT.

Conclusions

Breast cancer patients have high incidences of diabetes and prediabetes. After chemotherapy even with steroids, some breast cancer patients with abnormal glucose metabolism may even become normal. Isolated hyperglycemia 2 hours after glucose loading is common, and OGTT should be made for breast cancer patients at initial diagnosis and during chemotherapy.

High glucose level promotes migration behavior of breast cancer cells through zinc and its transporters

Background

The diabetes patients have been associated with an increased risk of mortality by breast cancer and there are difference between the breast cancer patients with diabetes, and their nondiabetic counterparts in the regimen choice and effects of breast cancer treatment. However, the pathophysiological relationships of diabetes and breast cancer have not yet been elucidated in detail. In this study, we investigate the breast cancer cell line, MCF-7 motility, which linked to invasion and metastasis, in high glucose level corresponding to hyperglycemia and the role of Zn and its transporter.

Methodology/Principal findings

We demonstrated the significant motility of MCF-7 cultured in hyperglycemic level (25 mM glucose) in comparison to normal physiological glucose level (5.5 mM glucose). The other hand, the osmotic control medium, 5.5 mM glucose with 19.5 mM mannitol or fructose had no effect on migratory, suggesting that high glucose level promotes the migration of MCF-7. Moreover, the activity of intracellular Zn²⁺ uptake significantly increased in high glucose-treated cells in comparison to 5.5 mM glucose, and the mRNA expression of zinc transporters, ZIP6 and ZIP10, was upregulated in 25 mM glucose-treated cells. The deficiency of ZIP6 or ZIP10 and intracellular Zn²⁺ significantly inhibited the high migration activity in 25 mM glucose medium, indicating that Zn²⁺ transported via ZIP6 and ZIP10 play an essential role in the promotion of cell motility by high glucose stimulation.

Conclusion/Significance

Zinc and its transporters, ZIP6 and ZIP10, are required for the motility stimulated with high glucose level. These findings provide the first evidence proposing the novel strategies for the diagnosis and therapy of breast cancer with hyperglycemia.

Clinicopathologic features of breast cancer patients with type 2 diabetes mellitus in southwest of China

The aim of this study was to study the prevalence and clinicopathologic features of breast cancer patients with type 2 diabetes mellitus in southwest of China for providing clinical guidance and prognosis appreciation for these patients. Through a case-control study of 3,381 primary breast cancer patients initially diagnosed from January 2007 to May 2013, one case group (164 female breast cancer patients with type 2 diabetes) and two control groups (first control group consists of 328 randomly selected nondiabetic breast cancer patients and second control group consists of 279 nondiabetic breast cancer patients without diabetes-related diseases such as cardiovascular or cerebrovascular diseases) were selected. The clinicopathological features between them were statistically analyzed. (1) Of 3,381 primary breast cancer patients with the average age of 50.5, ranging from 21 to 97 years of age, 164 (4.9 %) cases (with the average age of 60.7) suffered diabetes (previously diagnosed diabetes). (2) The differences of clinicopathologic features between the case group and first control group (with the average age of 61.5) were the ratio of hypertension (41.5 vs 26.1 %, P = 0.001) and axillary lymph node metastasis (51.1 vs 38.1 %, P = 0.046); and the differences of clinicopathologic features between the case group and second control group (with the average age of 64.3) were axillary lymph node metastasis (51.1 vs 35.8 %, P = 0.017), tumor size (≥ T2: 62.3 vs 53.1 %, P = 0.019) and p53 expression (51.0 vs 62.7 %, P = 0.018). No statistical significances (P > 0.05) of histological type, histological grade, or the expressions of estrogen receptor (ER), progesterone receptor, human epidermal growth factor 2 (HER2) and Ki67 were found between them. (3) The clinicopathologic features of ER-positive and ER-negative patients in each group were as follows: (1) In the case group, the ER-negative patients have more advanced tumor histological grade (G3, 19.0 vs 2.8 %, P = 0.012), more positive expression of Her-2 (16.9 vs 8.1 %, P = 0.029) and more axillary lymph node metastasis (63.3 vs 44.4 %, P = 0.048). (2) In the first control group, the same results with tumor histological grade (G3, 15.6 vs 6.2 %, P = 0.025) and positive expression of Her-2 (16.7 vs 4.3 %, P = 0.001), and more positive expression of Ki67 (65.1 vs 52.0 %, P < 0.001) were found. (3) In the second control group, the ER-negative patients have more positive expression of Ki67 (70.5 vs 55.7 %, P = 0.009) and fewer family history of malignancy (1.9 vs 10.0 %, P = 0.013). Diabetes has a high incidence in breast cancer patients and is more common with postmenopausal patients. It is suggested that initially diagnosed breast cancer patients should undertake oral glucose tolerance test screening for occult diabetes and prediabetes. More concerns should be put onto diabetic patients with breast cancer.

Obesity, diabetes, and survival outcomes in a large cohort of early-stage breast cancer patients

BACKGROUND

To determine the relationship between obesity, diabetes, and survival in a large cohort of breast cancer patients receiving modern chemotherapy and endocrine therapy.

PATIENTS AND METHODS

We identified 6342 patients with stage I-III breast cancer treated between 1996 and 2005. Patients were evaluated according to body mass index (BMI) category and diabetes status.

RESULTS

In a multivariate model adjusted for body mass index, diabetes, medical comorbidities, patient- and tumor-related variables, and adjuvant therapies, relative to the normal weight, hazard ratios (HRs) for recurrence-free survival (RFS), overall survival (OS), and breast cancer-specific survival (BCSS) for the overweight were 1.18 [95% confidence interval (CI) 1.02-1.36], 1.20 (95% CI 1.00-1.42), and 1.21 (95% CI 0.98-1.48), respectively. HRs for RFS, OS, and BCSS for the obese were 1.13 (95% CI 0.98-1.31), 1.24 (95% CI 1.04-1.48), and 1.23 (95% CI 1.00-1.52), respectively. Subset analyses showed these differences were significant for the ER-positive, but not ER-negative or HER2-positive, groups. Relative to nondiabetics, HRs for diabetics for RFS, OS, and BCSS were 1.21 (95% CI 0.98-1.49), 1.39 (95% CI 1.10-1.77), and 1.04 (95% CI 0.75-1.45), respectively.

CONCLUSIONS

In patients receiving modern adjuvant therapies, obesity has a negative impact on RFS, OS, and BCSS; and diabetes has a negative impact on RFS and OS. Control of both may be important to improving survival in obese and diabetic breast cancer patients.

Identifying specific chemotherapeutic agents in Medicare data: a validation study

BACKGROUND

Large health care databases are increasingly used to examine the dissemination and benefits and harms of chemotherapy treatment in routine practice, particularly among patients excluded from trials (eg, the elderly). Misclassification of chemotherapy could bias estimates of frequency and association, warranting an updated assessment.

METHODS

We evaluated the validity of Medicare claims to identify receipt of chemotherapy and specific agents delivered to elderly stage II/III colorectal (CRC), in situ/early-stage breast, non-small-cell lung, and ovarian cancer patients using the National Cancer Institute's Patterns of Care studies (POC) as the gold standard. The POC collected data on chemotherapy treatment by reabstracting hospital records, contacting physicians, and reviewing medical records. Patients' POC data were linked and compared with their Medicare claims for 2 to 12 months postdiagnosis. κ, sensitivity, specificity, positive and negative predictive values and 95% confidence intervals were calculated for the receipt of any chemotherapy and specific agents.

RESULTS

Sensitivity and specificity of Medicare claims to identify any chemotherapy were high across all cancer sites. We found substantial variation in validity across agents, by site and administration modality. Capecitabine, an oral CRC treatment, was identified in claims with high specificity (98%) but low sensitivity (47%), whereas oxaliplatin, an intravenously administered CRC agent had higher sensitivity (75%) and similar specificity (97%).

CONCLUSIONS

Receipt of chemotherapy and specific intravenous agents can be identified using Medicare claims, showing improvement from prior reports; yet, variation exists. Future studies should assess newly approved agents and the impact of coverage decisions for these agents under the Medicare Part D program.

Identifying specific chemotherapeutic agents in Medicare data: a validation study

BACKGROUND

Large health care databases are increasingly used to examine the dissemination and benefits and harms of chemotherapy treatment in routine practice, particularly among patients excluded from trials (eg, the elderly). Misclassification of chemotherapy could bias estimates of frequency and association, warranting an updated assessment.

METHODS

We evaluated the validity of Medicare claims to identify receipt of chemotherapy and specific agents delivered to elderly stage II/III colorectal (CRC), in situ/early-stage breast, non-small-cell lung, and ovarian cancer patients using the National Cancer Institute's Patterns of Care studies (POC) as the gold standard. The POC collected data on chemotherapy treatment by reabstracting hospital records, contacting physicians, and reviewing medical records. Patients' POC data were linked and compared with their Medicare claims for 2 to 12 months postdiagnosis. κ, sensitivity, specificity, positive and negative predictive values and 95% confidence intervals were calculated for the receipt of any chemotherapy and specific agents.

RESULTS

Sensitivity and specificity of Medicare claims to identify any chemotherapy were high across all cancer sites. We found substantial variation in validity across agents, by site and administration modality. Capecitabine, an oral CRC treatment, was identified in claims with high specificity (98%) but low sensitivity (47%), whereas oxaliplatin, an intravenously administered CRC agent had higher sensitivity (75%) and similar specificity (97%).

CONCLUSIONS

Receipt of chemotherapy and specific intravenous agents can be identified using Medicare claims, showing improvement from prior reports; yet, variation exists. Future studies should assess newly approved agents and the impact of coverage decisions for these agents under the Medicare Part D program.

Incidence and predictors of febrile neutropenia during chemotherapy in patients with head and neck cancer

PURPOSE

Febrile neutropenia (FN) is an oncologic emergency, and its management is critical during chemotherapy. However, little is known about FN in patients with head and neck cancer. The purpose of this study was to investigate the incidence and predictors of FN in patients with head and neck cancer.

METHODS

We performed a retrospective study in a university hospital in Japan between January 2008 and December 2012. Head and neck cancer patients treated with a platinum-based regimen were included in the analysis.

RESULTS

FN occurred in 47 out of 138 cycles, and the incidence of FN was highest during the first cycle. Severe sepsis or more serious events were observed in 46 % of FN episodes. Patients treated with TPF (docetaxel, cisplatin, and fluorouracil) were more susceptible to FN than those treated with DC (docetaxel, cisplatin). The patient-specific risk factors revealed using univariate analysis were tube feeding, the presence of diabetes mellitus, and gastrointestinal adverse effects. Of these, logistic regression analysis demonstrated tube feeding and diabetes mellitus as independent predictors of FN.

CONCLUSIONS

The incidence of FN in head and neck cancer patients in the community setting is higher than previously reported. Patients receiving enteral nutrition and those with diabetes are at high risk for FN.

Obesity and risk of breast cancer mortality in Hispanic and Non-Hispanic white women: the New Mexico Women's Health Study

Obesity is reported to be associated with poorer survival in women with breast cancer, regardless of menopausal status. Our purpose was to determine if the associations of obesity with breast cancer-specific, all-cause, and non-breast cancer mortality differ between Hispanic and non-Hispanic white (NHW) women with breast cancer. Data on lifestyle and medical history were collected for incident primary breast cancer cases (298 NHW, 279 Hispanic) in the New Mexico Women's Health Study. Mortality was ascertained through the National Death Index and New Mexico Tumor Registry over 13 years of follow-up. Adjusted Cox regression models indicated a trend towards increased risk for breast cancer-specific mortality in obese NHW women (hazard ratio [HR] 2.07; 95% confidence interval [CI] 0.98-4.35) but not in Hispanic women (HR 1.32; 95% CI 0.64-2.74). Obese NHW women had a statistically significant increased risk for all-cause mortality (HR 2.12; 95% CI 1.15-3.90) while Hispanic women did not (HR 1.23; 95% CI 0.71-2.12). Results were similar for non-breast cancer mortality: NHW (HR 2.65; 95% CI 0.90-7.81); Hispanic (HR 2.18; 95% CI 0.77-6.10). Our results suggest that obesity is associated with increased risk for breast cancer-specific mortality in NHW women; however, this association is attenuated in Hispanic women.

Diabetes and cancer: impact on health-related quality of life

PURPOSE/OBJECTIVES

To explore whether three factors (physical function, mental health, and social function) of health-related quality of life (HRQOL) are impacted differently in patients with cancer and diabetes when compared to those with cancer who do not have diabetes at the beginning of chemotherapy.

DESIGN

Secondary analysis using baseline data from two randomized, controlled trials.

SETTING

Two comprehensive cancer centers, one community cancer oncology program, and six hospital-affiliated community oncology centers.

SAMPLE

661 patients aged 21 years or older with a solid tumor cancer or lymphoma undergoing cancer treatment.

METHODS

Baseline data from both randomized, controlled trials were used. The SF-36® was used to measure physical function, mental health, and social function. Analysis included descriptive statistics and a general linear model.

MAIN RESEARCH VARIABLES

Presence or absence of diabetes and physical function, social function, and mental health.

FINDINGS

Patients with cancer and diabetes had significantly lower levels of physical function (p < 0.001) when compared to those who had cancer without diabetes. The interaction of diabetes and age was found to be significantly predictive of mental health (p < 0.05).

CONCLUSIONS

The presence of diabetes negatively impacts physical function and mental health in patients undergoing chemotherapy.

IMPLICATIONS FOR NURSING

Nurses should be aware of diabetes' effect on HRQOL in patients with cancer. In addition, nurses may need to intervene earlier for patients with diabetes and cancer to maintain or improve their quality of life.

Diabetes and risk of cancer

Diabetes and cancer represent two complex, diverse, chronic, and potentially fatal diseases. Cancer is the second leading cause of death, while diabetes is the seventh leading cause of death with the latter still likely underreported. There is a growing body of evidence published in recent years that suggest substantial increase in cancer incidence in diabetic patients. The worldwide prevalence of diabetes was estimated to rise from 171 million in 2000 to 366 million in 2030. About 26.9% of all people over 65 have diabetes and 60% have cancer. Overall, 8–18% of cancer patients have diabetes. In the context of epidemiology, the burden of both diseases, small association between diabetes and cancer will be clinically relevant and should translate into significant consequences for future health care solutions. This paper summarizes most of the epidemiological association studies between diabetes and cancer including studies relating to the general all-site increase of malignancies in diabetes and elevated organ-specific cancer rate in diabetes as comorbidity. Additionally, we have discussed the possible pathophysiological mechanisms that likely may be involved in promoting carcinogenesis in diabetes and the potential of different antidiabetic therapies to influence cancer incidence.

Impact of chronic conditions on the cost of cancer care for Medicaid beneficiaries

BACKGROUND

No study has assessed the cost of treating adult Medicaid cancer patients with preexisting chronic conditions. This information is essential for understanding the cost of cancer care to the Medicaid program above that expended for other chronic conditions, given the increasing prevalence of chronic conditions among cancer patients.

RESEARCH DESIGN

We used administrative data from 3 state Medicaid programs' linked cancer registry data to estimate cost of care during the first 6 months following cancer diagnosis for beneficiaries with 4 preexisting chronic conditions: cardiac disease, respiratory diseases, diabetes, and mental health disorders. Our base cohort consisted of 6,212 Medicaid cancer patients aged 21 to 64 years (cancer diagnosed during 2001-2003) who were continuously enrolled in fee-for-service Medicaid for 6 months after diagnosis. A subset of these patients who did not die during the 6-month follow-up (n=4,628), were matched with 2 non-cancer patients each (n=8,536) to assess incremental cost of care.

RESULTS

The average cost of care for cancer patients with the chronic conditions studied was higher than for cancer patients without any of these conditions. The increase in cancer treatment cost associated with the chronic conditions ranged from $4,385 for cardiac disease to $11,009 for mental health disorders.

CONCLUSIONS

Chronic conditions, especially the presence of multiple conditions, are associated with a higher cost of care among Medicaid cancer patients, and these increased costs should be reflected in projections of future Medicaid cancer care costs. The implementation of better care-management processes for cancer patients with preexisting chronic conditions may be one way to reduce these costs.

Febrile neutropenia rates with adjuvant docetaxel and cyclophosphamide chemotherapy in early breast cancer: discrepancy between published reports and community practice-an updated analysis

Chemotherapy in the adjuvant setting for early breast cancer (EBC) has improved disease-free and overall survival, with benefits extended to elderly patients and to those with lymph-node-negative pathology. [...]

Epidemiology and outcomes of previously undiagnosed diabetes in older women with breast cancer: an observational cohort study based on SEER-Medicare

Background

In breast cancer, diabetes diagnosed prior to cancer (previously diagnosed) is associated with advanced cancer stage and increased mortality. However, in the general population, 40% of diabetes is undiagnosed until glucose testing, and evidence suggests one consequence of increased evaluation and management around breast cancer diagnosis is the increased detection of previously undiagnosed diabetes. Biological factors – for instance, higher insulin levels due to untreated disease - and others underlying the association between previously diagnosed diabetes and breast cancer could differ in those whose diabetes remains undiagnosed until cancer. Our objectives were to identify factors associated with previously undiagnosed diabetes in breast cancer, and to examine associations between previously undiagnosed diabetes and cancer stage, treatment patterns, and mortality.

Methods

Using Surveillance, Epidemiology, and End Results-Medicare, we identified women diagnosed with breast cancer and diabetes between 01/2001 and 12/2005. Diabetes was classified as previously diagnosed if it was identified within Medicare claims between 24 and 4 months before cancer diagnosis, and previously undiagnosed if it was identified from 3 months before to ≤ 3 months after cancer. Patients were followed until 12/2007 or death, whichever came first. Multivariate analyses were performed to examine risk factors for previously undiagnosed diabetes and associations between undiagnosed (compared to previously diagnosed) diabetes, cancer stage, treatment, and mortality.

Results

Of 2,418 patients, 634 (26%) had previously undiagnosed diabetes; the remainder had previously diagnosed diabetes. The mean age was 77.8 years, and 49.4% were diagnosed with in situ or stage I disease. Age > 80 years (40% of the cohort) and limited health system contact (primary care physician and/or preventive services) prior to cancer were associated with higher adjusted odds of previously undiagnosed diabetes. Previously undiagnosed diabetes was associated with higher adjusted odds of advanced stage (III/IV) cancer (Odds Ratio = 1.37: 95% Confidence Interval (CI) 1.05 – 1.80; P = 0.02), and a higher adjusted mortality rate due to causes other than cancer (Hazard Ratio = 1.29; 95% CI 1.02 – 1.63; P = 0.03).

Conclusions

In breast cancer, previously undiagnosed diabetes is associated with advanced stage cancer and increased mortality. Identifying biological factors would require further investigation.

Real-world experience with adjuvant fec-d chemotherapy in four Ontario regional cancer centres

BACKGROUND

The efficacy of adjuvant chemotherapy with fec-d (5-fluorouracil-epirubicin-cyclophosphamide followed by docetaxel) is superior to that with fec-100 alone in women with early-stage breast cancer. As the use of fec-d increased in clinical practice, health care providers anecdotally noted higher-than-expected toxicity rates and frequent early treatment discontinuations because of toxicity. In the present study, we compared the rates of serious adverse events in patients who received adjuvant fec-d chemotherapy in routine clinical practice with the rates reported in the pacs-01 trial.

METHODS

We retrospectively reviewed all patients prescribed adjuvant fec-d for early-stage breast cancer at 4 regional cancer centres in Ontario. Information was collected from electronic and paper charts by a physician investigator from each centre. Data were analyzed using chi-square tests, independent samples t-tests, one-way analysis of variance, and univariate regression.

RESULTS

The 671 electronic and paper patient records reviewed showed a median patient age of 52.2 years, 229 patients (34.1%) with N0 disease, 508 patients (75.7%) with estrogen or progesterone receptor-positive disease (or both), and 113 patients (26%) with her2/neu-overexpressing breast cancer. Febrile neutropenia occurred in 152 patients (22.7%), most frequently at cycle 4, coincident with the initiation of docetaxel [78/152 (51.3%)]. Primary prophylaxis with hematopoietic growth factor support was used in 235 patients (35%), and the rate of febrile neutropenia was significantly lower in those who received prophylaxis than in those who did not [15/235 (6.4%) vs. 137/436 (31.4%); p < 0.001; risk ratio: 0.20].

CONCLUSIONS

In routine clinical practice, treatment with fec-d is associated with a higher-than-expected rate of febrile neutropenia, in light of which, primary prophylaxis with growth factor should be considered, per international guidelines. Adoption based on clinical trial reports of new therapies into mainstream practice must be done carefully and with scrutiny.

Visualizing clinical predictors of febrile neutropenia in Asian cancer patients receiving myelosuppressive chemotherapy

PURPOSE

Febrile neutropenia is a serious complication among cancer patients receiving myelosuppressive chemotherapy. Patient-specific risk factors, chemotherapy-related and disease-related characteristics can affect the clinical outcome and management of febrile neutropenia. Although many factors have been identified, they vary among different patient populations. We identified clinically-relevant febrile neutropenia predictors in Asian cancer patients through visualization of these factors.

METHODS

A single-centered, retrospective study was conducted from May to July 2011 at a local cancer center. Demographics and risk factor data were collated from electronic health records and four cancer registries. Data were summarized using descriptive statistics. Additionally, potential febrile neutropenia predictors were identified using categorical principal component and multiple correspondence analyses.

RESULTS

A total of 583 patients were analyzed. Majority was females (79%), Chinese (75%) and diagnosed with breast cancers (60%). Six risk factors were identified as potential predictors: types of cancer (16.9-19.8% of variance), chemotherapy regimen (anthracycline-based 11.8-12.9%, taxane-based 8.1%), liver function tests (alanine transaminase 8.6%, alkaline phosphatase 4.0%), renal function tests (serum creatinine 3.1%), prior granulocyte colony stimulating factor use (5.6%) and diabetes mellitus (6.6-6.9%). In terms of cancer types, lymphomas were more predictive than breast cancers.

CONCLUSION

From our knowledge, this is the first study that has identified clinically-relevant febrile neutropenia predictors in Asian cancer patients through visualization of their risk factors. The use of these predictors to identify patients at risk for adverse reactions, such as FN, can allow clinicians to optimize prophylactic granulocyte colony stimulating factor usage in these patients.

Perceived impact of cancer treatment on diabetes self-management

PURPOSE

The purpose of this study was to identify the impact that cancer and its treatment had on diabetes self-management and to identify common issues that individuals with diabetes encounter while undergoing chemotherapy.

METHODS

This exploratory study utilized a baseline self-administered written survey and an 8-week telephone follow-up survey that included 2 open-ended questions. Forty-three adults aged 50 or older with diabetes and a solid tumor cancer receiving chemotherapy were recruited from 8 community outpatient cancer centers in Michigan and Ohio. Descriptives, t tests, and correlations were utilized to analyze the data. Content analysis was used to analyze the data from the open-ended questions.

RESULTS

After a minimum of 8 weeks of chemotherapy, patients performed significantly fewer diabetes self-management behaviors. The majority of individuals experienced a moderate to high impact on their ability to perform diabetes self-management activities while receiving chemotherapy. Exercise, ability to eat and drink, and monitoring blood sugars were most affected. Three themes identifying patient issues were noted: self-management issues, health issues, and prioritization.

CONCLUSIONS

Cancer treatment and cancer-related symptoms can have a negative impact on diabetes self-management behaviors in adults with diabetes who are undergoing chemotherapy. Diabetes self-management education is targeted to improve health outcomes in patients with diabetes and cancer and addresses the "cause" not just the "source" of the problem needs to be developed. Further research needs to be done to address issues related to glycemic control and health-related outcomes in this population.

Impact of diabetes and hyperglycemia on survival in advanced breast cancer patients

Purpose. We examined the impact of diabetes and hyperglycemia on cancer-specific survival of patients with metastatic or recurrent breast cancer (BC). Methods. We performed a retrospective analysis of 265 patients with advanced BC receiving palliative chemotherapy. BC-specific mortality was compared for diabetic and nondiabetic patients as well as for patients that presented hyperglycemia during treatment. Results. No difference was observed between the diabetic and nondiabetic patients in terms of overall survival (OS). A difference in OS was observed between nondiabetic patients and diabetic patients who had hyperglycemia. The OS was greater in diabetic patients with proper metabolic control than diabetic patients with hyperglycemia. The risk of death was higher in patients with mean glucose levels >130 mg/dL during treatment. Several factors were associated with poor OS: tumor stage, hormone-receptor-negative tumors, HER2 negative disease, multiple metastatic sites, presence of visceral metastases, and mean glucose >130 mg/dL. Conclusion. Elevated glucose levels are associated with a poor outcome in diabetic and nondiabetic patients in contrast to patients with normoglycemic levels, conferring an elevated risk of death. According to these results, clinicians should monitor glucose levels during treatment for advanced breast cancer disease and take action to maintain normal glucose levels.

Diabetes, metformin, and breast cancer in postmenopausal women

PURPOSE

Emerging evidence suggests that metformin may reduce breast cancer incidence, but reports are mixed and few provide information on tumor characteristics. Therefore, we assessed associations among diabetes, metformin use, and breast cancer in postmenopausal women participating in Women's Health Initiative clinical trials.

PATIENTS AND METHODS

In all, 68,019 postmenopausal women, including 3,401 with diabetes at study entry, were observed over a mean of 11.8 years with 3,273 invasive breast cancers diagnosed. Diabetes incidence status was collected throughout follow-up, with medication information collected at baseline and years 1, 3, 6, and 9. Breast cancers were confirmed by review of central medical records and pathology reports. Cox proportional hazards regression, adjusted for breast cancer risk factors, compared breast cancer incidence in women with diabetes who were metformin users or nonusers with breast cancer incidence in women without diabetes.

RESULTS

Compared with that in women without diabetes, breast cancer incidence in women with diabetes differed by diabetes medication type (P = .04). Women with diabetes receiving medications other than metformin had a slightly higher incidence of breast cancer (hazard ratio [HR], 1.16; 95% CI, 0.93 to 1.45), and women with diabetes who were given metformin had lower breast cancer incidence (HR, 0.75; 95% CI, 0.57 to 0.99). The association was observed for cancers positive for both estrogen receptor and progesterone receptor and those that were negative for human epidermal growth factor receptor 2.

CONCLUSION

Metformin use in postmenopausal women with diabetes was associated with lower incidence of invasive breast cancer. These results can inform future studies evaluating metformin use in breast cancer management and prevention.

Diabetes and cancer (2): evaluating the impact of diabetes on mortality in patients with cancer

In this paper we address methodological aspects of aetiological importance in the link between diabetes and mortality in patients with cancer. We identified nine key points on the cancer pathway at which confounding may arise-cancer screening use, stage at diagnosis, cancer treatment selection, cancer treatment complications and failures, peri-treatment mortality, competing risks for long-term mortality, effects of type 2 diabetes on anti-cancer therapies, effects of glucose-lowering treatments on cancer outcome and differences in tumour biology. Two types of mortality studies were identified: (1) inception cohort studies that evaluate the effect of baseline diabetes on cancer-related mortality in general populations, and (2) cohorts of patients with a cancer diagnosis and pre-existing type 2 diabetes. We demonstrate, with multiple examples from the literature, that pre-existing diabetes affects presentation, cancer treatment, and outcome of several common cancer types, often to varying extents. Diabetes is associated with increased all-cause mortality in cancer patients, but the evidence that it influences cancer-specific mortality is inconsistent. In the absence of data that address the potential biases and confounders outlined in the above framework, we caution against the reporting of cancer-related mortality as a main endpoint in analyses determining the impact of diabetes and glucose-lowering medications on risk of cancer.

The association of diabetes with breast cancer incidence and mortality in the Long Island Breast Cancer Study Project

PURPOSE

Diabetes has been associated with increased risk of breast cancer in a number of epidemiologic studies, but its effects on survival among women diagnosed with breast cancer have been examined less frequently. Importantly, prior investigations have rarely considered the influence of factors associated with diabetes such as obesity, age at diabetes diagnosis, duration of diabetes, or diabetes treatments.

METHODS

We evaluated the effect of self-reported diabetes on breast cancer incidence and mortality in the Long Island Breast Cancer Study Project, which includes 1,447 breast cancer cases and 1,453 controls. Follow-up data for all-cause (n = 395) and 5-year breast cancer-specific mortality (n = 104) through December 2005 were determined for case women from the National Death Index. Adjusted logistic regression and Cox proportional hazards models were used to estimate odds ratios (OR) and hazards ratios (HR), respectively.

RESULTS

Postmenopausal women with diabetes were at increased risk of developing breast cancer [OR = 1.35; 95 % confidence interval (CI) = 0.99-1.85], as were those who were not of white race regardless of menopausal status [OR = 3.89; 95 % CI = 1.66-9.11]. Among case women, diabetes was associated with a modestly increased risk of death from all causes [HR = 1.65; 95 % CI = 1.18-2.29], an association that was stronger in women who were obese at breast cancer diagnosis [HR = 2.49; 94 % CI = 1.58-3.93]. In analyses restricted to diabetics, there was no statistically significant effect of duration of diabetes or type of treatment on breast cancer incidence or mortality.

CONCLUSIONS

Our findings suggest that diabetes may increase incidence of breast cancer in older women and non-whites, and mortality due to all causes.

The impact of diabetes mellitus on prognosis of early breast cancer in Asia

BACKGROUND

Diabetes mellitus (DM) has been implicated in influencing the survival duration of patients with breast cancer. However, less is known about the impact of DM and other comorbidities on the breast cancer-specific survival (BCS) and overall survival (OS) outcomes of Asian patients with early-stage breast cancer.

PATIENTS AND METHODS

The characteristics of female patients with newly diagnosed, early-stage breast cancer were collected from the Taiwan Cancer Registry database for 2003-2004. DM status and other comorbidities were retrieved from Taiwan's National Health Insurance database. The BCS and OS times of patients according to DM status were estimated via the Kaplan-Meier method. Cox's proportional hazard model was used to estimate adjusted hazard ratios (HRs) for the effects of DM, comorbidities, and other risk factors on mortality.

RESULTS

In total, 4,390 patients were identified and 341 (7.7%) presented with DM. The 5-year BCS and OS rates were significantly greater in DM patients than in non-DM patients (BCS, 85% versus 91%; OS, 79% versus 90%). Furthermore, after adjusting for clinicopathologic variables and comorbidities, DM remained an independent predictor of shorter BCS (adjusted HR, 1.53) and OS (adjusted HR, 1.71) times. Subgroup analyses also demonstrated a consistent prognostic influence of DM across different groups.

CONCLUSION

In Asian patients with early-stage breast cancer, DM is an independent predictor of lower BCS and OS rates, even after adjusting for other comorbidities. The integration of DM care as part of the continuum of care for early-stage breast cancer should be emphasized.

Ethnic differences in breast cancer survival: status and determinants

Ethnic differences in breast cancer survival have been a long-standing concern. The objective of this article is to present relevant studies for all major US racial/ethnic groups including African-Americans, Latinos, Native Americans, Japanese-Americans and Native Hawaiians, and to discuss underlying causes of disparity. In comparison to Caucasian women, African-American women continue to experience the poorest breast cancer-specific survival of all ethnic groups in the USA. The prognosis for Latinos, Native Hawaiians and Native Americans is intermediate, better than for African-Americans but not as good as for Caucasians, whereas Japanese-American women tend to have better outcomes. The following possible contributors to the observed differences are discussed in detail: unfavorable distribution of stage at diagnosis due to low screening rates, limited access to care and treatment, tumor type, comorbidities, socioeconomic status, obesity and physical activity.

Diabetes, cancer, and metformin: connections of metabolism and cell proliferation

Diabetes is associated with an increased risk of developing and dying from cancer. This increased risk may be due to hyperglycemia, hyperinsulinemia, and insulin resistance or other factors. Metformin has recently gained much attention as it appears to reduce cancer incidence and improve prognosis of patients with diabetes. In vitro data and animal studies support these findings from human epidemiological studies. Metformin has multiple potential mechanisms by which it inhibits cancer development and growth. For example, metaformin inhibits hepatic gluconeogenesis, thus decreasing circulating glucose levels, and it increases insulin sensitivity, thus reducing circulating insulin levels. Intracellularly, metformin activates AMPK, which decreases protein synthesis and cell proliferation. Metaformin also reduces aromatase activity in the stromal cells of the mammary gland. Finally, metformin may diminish the recurrence and aggressiveness of tumors by reducing the stem cell population and inhibiting epithelial to mesenchymal transition. Here, we discuss the metabolic abnormalities that occur in tumor development and some of the mechanisms through which metformin may alter these pathways and reduce tumor growth.