Survival difference in NSCLC and SCLC patients with diabetes mellitus according to the first-line therapy

Epidemiological and transcriptome data identify shared gene signatures and immune cell infiltration in type 2 diabetes and non-small cell lung cancer

BACKGROUND

Numerous previous studies have reported an association between type 2 diabetes mellitus (T2DM) and lung cancer risk, but the underlying mechanism of the interaction remains unclear. This study aimed to investigate the shared genetic features and immune infiltration processes between lung cancer and T2DM.

METHODS

Epidemiological data from the National Health and Nutrition Examination Survey (NHANES) 2000-2018 was used to explore the relationship between lung cancer and diabetes systematically. In addition, we also used bioinformatics methods to analyze the transcriptome data from the Gene Expression Omnibus (GEO) to explore the potential functional mechanisms from the perspective of genes and immune infiltration.

RESULTS

Logistic regression analysis showed that prediabetes (OR = 3.289,95%CI 1.231, 8.788, p = 0.01760, model 3)and type 2 diabetes (OR = 3.032 95%CI,1.015, 9.054, p = 0.04689) were significantly associated with an increased risk of lung cancer after adjusting for multiple covariates. Data from NHANES showed an inverted U-shaped relationship between fasting blood glucose and glycosylated haemoglobin and the risk of lung cancer (P for non-linear < 0.001). Transcriptome data showed that we screened 57 co-DEGs, of which 25 were up-regulated co-DEGs and 32 were down-regulated. Ten core DEGs were identified by bioinformatics analysis, which were SMC6, CDC27, CDC7, RACGAP1, SMC4, NCF4, NCF1, NCF2, SELPLG and CFP. Correlation analysis showed that some core DEGs were significantly associated with simultaneous dysregulation of immune cells.

CONCLUSION

The identified core genes of NSCLC and T2DM are associated with dysregulated immune cells, which provides a potential research avenue for diagnosing and treating lung cancer combined with diabetes.

Comorbidity in Small Cell Lung Cancer: Prognostic Impacts of Hypertension/Coronary Artery Disease, Diabetes Mellitus, and Chronic Obstructive Pulmonary Disease

Comorbidity, the most important components of which are hypertension/coronary artery disease (HTN/CAD), diabetes mellitus (DM), and chronic obstructive pulmonary disease (COPD), is frequently encountered in small cell lung cancer (SCLC) patients. We aimed to assess the possible impacts of these major comorbidities on the prognoses of SCLC patients. A total of 378 SCLC patients were analyzed retrospectively. We did not ascertain the effect of comorbidity on survival in SCLC patients in general; and similarly, the presence of HTN/CAD and COPD did not adversely affect the outcome. However, lower survival rates were observed in patients with SCLC coexisting with DM.

Will We Unlock the Benefit of Metformin for Patients with Lung Cancer? Lessons from Current Evidence and New Hypotheses

Metformin has been under basic and clinical study as an oncological repurposing pharmacological agent for several years, stemming from observational studies which consistently evidenced that subjects who were treated with metformin had a reduced risk for development of cancer throughout their lives, as well as improved survival outcomes when diagnosed with neoplastic diseases. As a result, several basic science studies have attempted to dissect the relationship between metformin’s metabolic mechanism of action and antineoplastic cellular signaling pathways. Evidence in this regard was compelling enough that a myriad of randomized clinical trials was planned and conducted in order to establish the effect of metformin treatment for patients with diverse neoplasms, including lung cancer. As with most novel antineoplastic agents, early results from these studies have been mostly discouraging, though a recent analysis that incorporated body mass index may provide significant information regarding which patient subgroups might derive the most benefit from the addition of metformin to their anticancer treatment. Much in line with the current pipeline for anticancer agents, it appears that the benefit of metformin may be circumscribed to a specific patient subgroup. If so, addition of metformin to antineoplastic agents could prove one of the most cost-effective interventions proposed in the context of precision oncology. Currently published reviews mostly rely on a widely questioned mechanism of action by metformin, which fails to consider the differential effects of the drug in lean vs. obese subjects. In this review, we analyze the pre-clinical and clinical information available to date regarding the use of metformin in various subtypes of lung cancer and, further, we present evidence as to the differential metabolic effects of metformin in lean and obese subjects where, paradoxically, the obese subjects have reported more benefit with the addition of metformin treatment. The novel mechanisms of action described for this biguanide may explain the different results observed in clinical trials published in the last decade. Lastly, we present novel hypothesis regarding potential biomarkers to identify who might reap benefit from this intervention, including the role of prolyl hydroxylase domain 3 (PHD3) expression to modify metabolic phenotypes in malignant diseases.

Comorbidities and mortality risk among extensive-stage small-cell lung cancer patients in mainland China: impacts of hypertension, type 2 diabetes mellitus, and chronic hepatitis B virus infection

The present study investigated the impact of major comorbidities, including hypertension, type 2 diabetes mellitus (T2DM), and chronic hepatitis B virus (HBV) infection, on the progression-free survival (PFS) and overall survival (OS) of extensive-stage small-cell lung cancer (ES-SCLC) patients in China. Patients having a pathologic diagnosis of ES-SCLC between 2009 and 2017 were enrolled and grouped according to their specific comorbidities. The PFS and OS for each group were evaluated using the Kaplan-Meier method and Cox proportional hazard models. In total, 632 patients were analyzed. The median PFS (mPFS) of these patients was 9 months [95% confidence interval (CI), 6-12 months]. The mPFS of patients without hypertension or T2DM was 9 months; conversely, it was significantly reduced for patients with hypertension [7 months (P < 0.0001)] or T2DM [5 months (P < 0.0001)]. However, mPFS was not significantly different between patients with and without HBV infection (P = 0.2936). A similar trend was observed for OS as well. Further multivariate analyses showed that the OS of patients with hypertension [hazard ratio (HR), 1.344; 95% CI, 1.073-1.683; P = 0.010] or T2DM (HR, 1.455; 95% CI, 1.134-1.868; P = 0.003) was significantly shorter than that of patients without these comorbidities. Accordingly, mortality risk was the highest in patients with concurrent hypertension and T2DM (HR, 1.665; 95% CI, 1.037-2.672; P = 0.00058). Our study found that hypertension and T2DM may be associated with a worse prognosis in ES-SCLC patients. Considerable attention should be paid to the accompanying anti-comorbidity therapies available for patients with ES-SCLC.

Therapeutic approaches targeting molecular signaling pathways common to diabetes, lung diseases and cancer

Diabetes mellitus (DM), is the most common metabolic disease and is characterized by sustained hyperglycemia. Accumulating evidences supports a strong association between DM and numerous lung diseases including chronic obstructive pulmonary disease (COPD), fibrosis, and lung cancer (LC). The global incidence of DM-associated lung disorders is rising and several ongoing studies, including clinical trials, aim to elucidate the molecular mechanisms linking DM with lung disorders, in particular LC. Several potential mechanisms, including hyperglycemia, hyperinsulinemia, glycation, inflammation, and hypoxia, are cited as plausible links between DM and LC. In addition, studies also propose a connection between the use of anti-diabetic medications and reduction in the incidence of LC. However, the exact cause for DM associated lung diseases especially LC is not clear and is an area under intense investigation. Herein, we review the biological links reported between DM and lung disorders with an emphasis on LC. Furthermore, we report common signaling pathways (eg: TGF-β, IL-6, HIF-1, PDGF) and miRNAs that are dysregulated in DM and LC and serve as molecular targets for therapy. Finally, we propose a nanomedicine based approach for delivering therapeutics (eg: IL-24 plasmid DNA, HuR siRNA) to disrupt signaling pathways common to DM and LC and thus potentially treat DM-associated LC. Finally, we conclude that the effective modulation of commonly regulated signaling pathways would help design novel therapeutic protocols for treating DM patients diagnosed with LC.

Meta-Analysis of ERCC1 Protein Expression and Platinum Chemosensitivity in Non-Small-Cell Lung Cancer

Objective

To carry out the meta-analysis on the relationship between the expression of nucleotide excision repair cross-complementary enzyme 1 (ERCC1) protein and platinum chemosensitivity in patients with advanced non-small-cell lung cancer (NSCLC).

Methods

The literature on the expression of ERCC1 and platinum chemosensitivity in patients with advanced NSCLC was searched in computer, which was published from January 2009 to August 2019 on the databases such as China Journal Full-text Database (CJFD), China National Knowledge Infrastructure (CNKI), Wanfang Database, VIP, PubMed, EMBASE, and others. Stata 15.0 was used for statistical analysis, and ethnicity subgroup analysis was taken.

Results

Finally, 14 studies were included and 1337 patients were involved, of which 697 were ERCC1 positive, with a positive rate of 53.5%. The combined OR was 0.53 (95% CI: 0.30∼0.79; P < 0.01). The results of ethnicity subgroup analysis showed that there was no significant difference, with OR of 0.50 (95% CI: 0.31∼0.82; P=0.001) in Asian population and OR of 0.56 (95% CI: 0.30∼1.07) in Caucasian population.

Conclusion

The sensitivity to platinum chemotherapy in patients with ERCC1 protein negative expression in the middle and late stages of NSCLC is better than that in patients with positive expression, especially in Asian population. There is no correlation in Caucasian population.

Fasting blood glucose levels and prognosis in patients with non-small-cell lung cancer: a prospective cohort study in China

Purpose

Non-small-cell lung cancer (NSCLC) is the most diagnosed lung cancer and is associated with poor prognosis. This study aimed to analyze whether fasting blood glucose (FBG) levels could provide prognostic information in Chinese patients with NSCLC, using the Suzhou Lung Cancer Survival study.

Patients and methods

A prospective cohort study of adult patients with primary NSCLC was performed. The patients who were hospitalized between January 2016 and April 2018 in two hospitals affiliated with Soochow University were recruited. Patient information, including lifestyle habits and clinical and laboratory data, were collected through face-to-face interviews and evaluation of medical records. Follow-up was initiated from the date of patient enrollment until May 8, 2018 or until patient death. The long-term survival of patients was assessed every 6 months. Patient vital status was confirmed by using hospital records, telephone interview, or local death registration system. Cox proportional hazards regression was used to estimate hazard ratio and 95% confidence interval (CI) for death, with adjustment for cancer stage, medical treatments, smoking, and other potential confounders.

Results

A total of 387 patients were included in the analysis, and the numbers (percentages) of patients with stages I, II, III, and IV NSCLC were 53 (13.7%), 41 (10.6%), 64 (16.5%), and 215 (55.6%), respectively. The median duration of follow-up was 19.1 months. Compared with patients in the second tertile of FBG, the HRs for mortality were 2.16 (95% CI: 1.26–3.73) and 1.87 (95% CI: 1.03–3.42) for those in the lowest one and diabetic group, respectively. Subgroup analysis according to various patient characteristics confirmed these associations.

Conclusion

Diabetes and low FBG could be important predictors of death in patients with NSCLC. Maintaining appropriate blood glucose levels may improve prognosis in patients with NSCLC.

Diabetes mellitus and survival of non-small cell lung cancer patients after surgery: A comprehensive systematic review and meta-analysis

Background

Diabetes mellitus (DM) is one of the most common comorbidities in surgically treated non‐small cell lung cancer (NSCLC) patients and has a negative impact on short‐term outcomes. However, the impact of DM on long‐term survival of such patients remains controversial; therefore, we conducted a comprehensive updated meta‐analysis.

Methods

We systematically searched relevant studies in PubMed, Embase, Cochrane Library, and Web of Science up to 6 September 2018. Hazard ratios (HRs) for the impact of DM on overall survival (OS) and recurrence‐free survival (RFS) of patients with surgically treated NSCLC were extracted and analyzed using the STATA 12.0 package.

Results

We included 13 cohort studies consisting of 4343 patients (730 patients with DM and 3613 patients without) with surgically treated NSCLC. Meta‐analysis showed that patients with DM had significantly poorer OS (random effects: HR 1.30, 95% confidence interval 1.05–1.60; P = 0.016) than those without. However, with a limited sample size, there was no significant difference in RFS (random effects: HR 1.06, 95% confidence interval 0.71–1.58; P = 0.786) between patients with and without DM after surgical resection of NSCLC.

Conclusion

DM is an independent unfavorable prognostic factor for patients with surgically treated NSCLC. High‐quality studies with appropriate adjustment for confounding factors are needed to confirm our conclusions.

Histological subtype of lung cancer affects acceptance of illness, severity of pain, and quality of life

Introduction

Histologic classification of lung cancer plays an important role in clinical practice. Two main histological subtype of lung cancer: small-cell lung cancer (SCLC) and nonsmall-cell lung cancer (NSCLC) differ in terms of invasiveness, response to treatment, and risk factors, among others.

Aims

To evaluate differences in acceptance of illness, level of perceived pain, and quality of life (QoL) between patients with SCLC and NSCLC.

Materials and methods

Two hundred and fifty-seven lung cancer patients, who were treated in 2015, completed Acceptance of Illness Scale, Visual Analog Scale for pain, and European Organization for Research and Treatment of Cancer 30-item Core Quality of Life Questionnaire and European Organization for Research and Treatment of Cancer 13-item Lung Cancer specific Quality of Life Questionnaire. Clinical and sociodemographic data were collected. For statistical analysis, the Student t-test and the Mann–Whitney U test were used. For comparisons among three or more groups, analysis of variance was employed.

Results

Patients with SCLC had significantly worse health as measured with the presence of metastases, parameters of lung function, comorbidities, and number of previous hospitalizations. The Acceptance of Illness Scale score and Visual Analog Scale score were significantly worse in patients with SCLC than in those with NSCLC (24.58±8.73 vs 27.05±9.06; p=0.046 and 4.81±2.01 vs 4.17±1.97; p=0.003). Patients with SCLC achieved worse scores of all aspects of QoL than patients with NSCLC. Comparison with the reference values showed that all dimensions of functioning are impaired in patients with lung cancer regardless of its type; only the role functioning in patients with NSCLC remains unaffected.

Conclusion

Monitoring of QoL, personalized approach to treatment, and interventions for symptom management should be conducted in a tailored manner. Socioeconomic status in lung cancer patients, especially those suffering from SCLC, needs to be addressed.

Fasting Blood Glucose Level in Locally Advanced Non-Small Cell Lung Cancer: a New Prognostic Factor?

Hyperglycemia may lead to proliferation, invasion, apoptosis inhibition, migration, and eventually metastasis of cancer cells by several mechanisms. In this study, the effect of hyperglycemia on overall survival (OS), disease-free survival (DFS), and locoregional recurrence (LRR) was investigated in NSCLC. One stage IIIA-IIIB NSCLC patient treated with chemoradiotherapy between 2010 and 2015 was enrolled. Fasting blood glucose (FBG) levels were recorded in pre-treatment, treatment, and post-treatment periods. Median age was 54 years (51-62). Fifty-two patients had squamous cell carcinoma (SCC); 19 had adenocarcinoma. Median follow-up was 19 (11-30), median survival was 19 (13-24), and DFS was 9 (7-11) months. Diabetic patients had shorter survival than non-diabetics 12 (95%CI, 10-14) vs. 25 months (95%CI,18-32), p = 0.005. Number of patients with LRR was also higher in diabetics compared to non-diabetics (8/12 vs. 11/37, p = 0.039). OS was shorter in patients with hyperglycemic-FBG and diabetic-FBG levels in pre-treatment period (log-rank p = 0.03 and 0.023, respectively). Diabetic-FBG level in pre-treatment period was found to be the only independent risk factor for survival. In subgroup analysis, these differences were apparent in SCC (log-rank p = 0.009 for hyperglicemic, log-rank p = 0.017 for diabetic-FBG). LRR was 68% in patients with diabetic-FBG, 36.5% in patients with non-diabetic-FBG in post-treatment period (p = 0.015). Patients with LRR had significantly higher median FBG value in post-treatment period compared to non-relapsing patients, 138 mg/dL (119-228) and 111 mg/dL (99-164), respectively (p = 0.022). The patients with hyperglycemic and diabetic-FBG levels in pre-treatment period had shorter survival compared to normoglycemic ones. The patients with diabetic-FBG level in post-treatment period had higher LRR, and relapsing patients had higher FBG levels in post-treatment period.

The Effect of Diabetes Mellitus on Lung Cancer Prognosis: A PRISMA-compliant Meta-analysis of Cohort Studies

Previous studies suggested that diabetes mellitus (DM) was associated with risk and mortality of cancer, but studies investigating the correlation between DM and lung cancer prognosis remain controversial. Herein, a meta-analysis was performed to derive a more precise estimate of the prognostic role of DM in lung cancer.Medline and Embase were searched for eligible articles from inception to October 25, 2015. The pooled hazard ratio (HR) with its 95% confidence interval (95% CI) was calculated to evaluate the correlation between DM and lung cancer prognosis. Subgroup meta-analysis was performed based on the histology and the treatment methods.A total of 20 cohort studies from 12 articles were included in the meta-analysis. Also, 16 studies investigated the overall survival (OS) and 4 studies investigated the progression-free survival (PFS). DM was significantly associated with the inferior OS of lung cancer with the pooled HR 1.28 (95% CI: 1.10-1.49, P = 0.001). The association was prominent in the nonsmall cell lung cancer (NSCLC) subgroup (HR 1.35, 95%CI: 1.14-1.60, P = 0.002), whereas the association was not significant in the small cell lung cancer (SCLC) subgroup (HR 1.33, 95% CI: 0.87-2.03, P = 0.18). When NSCLC patients were further stratified by treatment methods, DM had more influence on the surgically treated subgroup than the nonsurgically treated subgroup. There was no obvious evidence for publication bias by Begg's and Egger's test.The results of this meta-analysis exhibit an association of DM with inferior prognosis amongst lung cancer patients, especially the surgically treated NSCLC patients. Given the small number of studies included in this meta-analysis, the present conclusion should be consolidated with more high-quality prospective cohort studies or randomized controlled trials.

A Pilot Study Evaluating Steroid-Induced Diabetes after Antiemetic Dexamethasone Therapy in Chemotherapy-Treated Cancer Patients

Purpose

Dexamethasone is a mainstay antiemetic regimen for the prevention of chemotherapy-induced nausea and vomiting. The aim of this pilot study was to assess the incidence of and factors associated with steroid-induced diabetes in cancer patients receiving chemotherapy with dexamethasone as an antiemetic.

Materials and Methods

Non-diabetic patients with newly diagnosed gastrointestinal cancer who received at least three cycles of highly or moderately emetogenic chemotherapy with dexamethasone as an antiemetic were enrolled. Fasting plasma glucose levels, 2-hour postprandial glucose levels, and hemoglobin A_1C tests for the diagnosis of diabetes were performed before chemotherapy and at 3 and 6 months after the start of chemotherapy. The homeostasis model assessment of insulin resistance (HOMA-IR) was used as an index for measurement of insulin resistance, defined as a HOMA-IR ≥ 2.5.

Results

Between January 2012 and November 2013, 101 patients with no history of diabetes underwent laboratory tests for assessment of eligibility; 77 of these patients were included in the analysis. Forty-five patients (58.4%) were insulin resistant and 17 (22.1%) developed steroid-induced diabetes at 3 or 6 months after the first chemotherapy, which included dexamethasone as an antiemetic. Multivariate analysis showed significant association of the incidence of steroid-induced diabetes with the cumulative dose of dexamethasone (p=0.049).

Conclusion

We suggest that development of steroid-induced diabetes after antiemetic dexamethasone therapy occurs in approximately 20% of non-diabetic cancer patients; this is particularly significant for patients receiving high doses of dexamethasone.

Prognostic significance of diabetes mellitus in locally advanced non-small cell lung cancer

Background

To investigate the prognostic significance of patient characteristics and clinical laboratory test results in locally advanced non-small cell lung cancer (NSCLC), and in particular the impact of diabetes mellitus (DM) on the survival of patients who underwent chemoradiotherapy.

Methods

We retrospectively reviewed 159 patients with locally advanced NSCLC with a focus on DM and other potential prognostic factors, using the log-rank test, and univariate and multivariate analyses to assess their association with survival.

Result

Five significant prognostic factors were identified in univariate analysis: stage (p < 0.001), DM (p = 0.04), hemoglobin levels (p = 0.003), serum albumin (p <0.001) and lactate dehydrogenase (LDH) levels (p = 0.01). Furthermore, among the factors tested using Fisher's exact test and the Wilcoxon rank sum test, gender (p = 0.019) and plasma glucose level (p <0.001) were found to have prognostic significance. Multivariate analysis showed that stage, DM, serum albumin and LDH levels were independent prognostic factors for survival (p = 0.007, p = 0.024, p = 0.007 and p = 0.005, respectively).

Conclusions

The presence of DM at the time of diagnosis was identified as an independent and significant prognostic factor for predicting negative outcome in locally advanced NSCLC patients.

Is diabetes mellitus a negative prognostic factor for the treatment of advanced non-small-cell lung cancer?

BACKGROUND

It has been demonstrated that there are a lot of different prognostic factors which are worthy of consideration whereas diabetes mellitus (DM) has not been clearly or consistently identified as a prognostic value in advanced non-small cell lung cancer (NSCLC). The aim of this study was to investigate the prognostic significance of the characteristics of patients in advanced NSCLC. Specifically, we investigated the impact of DM for progression-free survival (PFS) and overall survival (OS) in patients receiving first-line platinum-based doublets chemotherapy.

METHODS

We retrospectively reviewed 442 patients with advanced NSCLC. DM and other potential prognostic variables were chosen for analysis in this study. Univariate and multivariate analyses were conducted to identify prognostic factors associated with survival.

RESULT

The results of univariate analysis for OS were identified as having prognostic significance: performance status (p<0.001), stage (p<0.001), DM (p<0.001), liver metastasis (p=0.02) and brain metastasis (p<0.001). Stage, diabetes mellitus, and liver metastasis were identified as having prognostic significance for PFS. Multivariate analysis showed that poor performance status, presence of DM and advanced stage were considered independent negative prognostic factors for OS (p 0.001, p<0.001 and p<0.001 respectively). Furthermore, DM and stage were considered independent negative prognostic factors for PFS (p 0.005 and p 0.001 respectively).

CONCLUSION

In conclusion, DM at the time of diagnosis was associated with the negative prognostic importance for PFS and OS in the advanced stage patients who were receiving first-line platinum-based doublets chemotherapy. In addition poor performance status and advanced stage were identified as negative prognostic factors.

Hyperglycaemia-induced chemoresistance of prostate cancer cells due to IGFBP2

Clinically relevant prostate cancer (PCa) is more frequent in Westernised societies and increasingly men have co-morbidities associated with a Western lifestyle, primarily diabetes, characterised by hyperinsulinaemia and hyperglycaemia. IGFs and their binding proteins (IGFBPs) are important mediators of the effects of nutrition on growth and play a key role in the development of PCa. We used DU145, PC3 and LNCaP PCa cell lines to examine how hyperglycaemia altered their response to docetaxel. Trypan Blue dye-exclusion assay was used to determine the percentage of cell death. Protein abundance was determined using western immunoblotting. Levels of IGFBP2 were measured using an ELISA. IGFBP2 gene silencing was achieved using siRNA technology. DNA methylation was assessed using combined bisulphide restriction analysis. Acetylation status of histones H3 and H4 associated with IGFBP2 gene was assessed using chromatin immunoprecipitation assay. Hyperglycaemia reduced docetaxel-induced apoptosis by 40% for DU145 cells and by 88% for LNCaP cells. This reduced cell death was mediated by a glucose-induced up-regulation of IGFBP2, as silencing IGFBP2 negated the survival effect of high glucose. Glucose increased IGFBP2 via increasing the acetylation of histones associated with the IGFBP2 gene promoter. This finding could have important implications in relation to therapeutic strategies as epigenetic modulation could be reversible.