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Vainer N, Rotbain Curovic V, Niemann CU, Slager SL, Rotbain EC. Understanding the interplay between chronic lymphocytic leukemia and type 2 diabetes. Expert Rev Hematol 2024; 17:617-629. [PMID: 39041465 DOI: 10.1080/17474086.2024.2383417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 07/18/2024] [Indexed: 07/24/2024]
Abstract
INTRODUCTION Comorbidities play an important role in the management of chronic lymphocytic leukemia (CLL) and may influence survival and treatment outcomes. Considering the aging general population and increasing incidence of type 2 diabetes (T2D), a comprehensive understanding of the interplay between CLL and T2D is essential for optimizing care and outcomes. AREAS COVERED We present current knowledge on co-existing CLL and T2D including prevalence, shared etiology and risk factors and how the conditions and treatment hereof may influence the outcome of one another. A literature search was performed using PubMed with the cutoff date on 1 February 2024. EXPERT OPINION The increased mortality observed in persons with CLL who have co-existing T2D is partially ascribed to infections, prompting physicians managing individuals with both conditions to consider closer monitoring during instances of infection and individualized prophylaxis. People with CLL and T2D should be managed for CLL in accordance with the international working group on CLL criteria, and we recommend that physicians exercise particular care not to delay treatment for these individuals. Multidisciplinary approaches with involvement of several specialties may be required for optimal supportive care of co-occurring T2D and CLL.
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Affiliation(s)
- Noomi Vainer
- Department of Hematology, Rigshospitalet, Copenhagen, Denmark
- Hematology Group, Danish Cancer Institute, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | - Carsten Utoft Niemann
- Department of Hematology, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Susan L Slager
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Emelie Curovic Rotbain
- Department of Hematology, Rigshospitalet, Copenhagen, Denmark
- Hematology Group, Danish Cancer Institute, Copenhagen, Denmark
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Shah UA, Rögnvaldsson S, Derkach A, Björkholm M, Turesson I, David Y, Hultcrantz M, Tan C, Hassoun H, Korde N, Lesokhin A, Mailankody S, Kristinsson SY, Landgren CO. Diabetes mellitus and risk of plasma cell and lymphoproliferative disorders in 94,579 cases and 368,348 matched controls. Haematologica 2021; 107:284-286. [PMID: 34474548 PMCID: PMC8719074 DOI: 10.3324/haematol.2021.278772] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Indexed: 12/02/2022] Open
Affiliation(s)
- Urvi A Shah
- Department of Medicine, Myeloma Service, Memorial Sloan Kettering Cancer Center, New York.
| | | | - Andriy Derkach
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York
| | - Magnus Björkholm
- Department of Medicine, Karolinska University Hospital and Karolinska Institutet, Stockholm
| | | | - Yael David
- Department of Chemical Biology, Sloan Kettering Institute, New York
| | - Malin Hultcrantz
- Department of Medicine, Myeloma Service, Memorial Sloan Kettering Cancer Center, New York
| | - Carlyn Tan
- Department of Medicine, Myeloma Service, Memorial Sloan Kettering Cancer Center, New York
| | - Hani Hassoun
- Department of Medicine, Myeloma Service, Memorial Sloan Kettering Cancer Center, New York
| | - Neha Korde
- Department of Medicine, Myeloma Service, Memorial Sloan Kettering Cancer Center, New York
| | - Alexander Lesokhin
- Department of Medicine, Myeloma Service, Memorial Sloan Kettering Cancer Center, New York
| | - Sham Mailankody
- Department of Medicine, Myeloma Service, Memorial Sloan Kettering Cancer Center, New York
| | - Sigurður Yngvi Kristinsson
- Department of Medicine, University of Iceland, Iceland; Department of Medicine, Karolinska University Hospital and Karolinska Institutet, Stockholm
| | - C Ola Landgren
- Department of Medicine, Sylvester Comprehensive Cancer Center, University of Miami, Miami
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Zhang C, Sha Y, Liu H, Guo D, Jiang Y, Hong L, Shi L, Huang H. Type 2 diabetes mellitus does not increase the risk of multiple myeloma: a systematic review and meta-analysis. Transl Cancer Res 2020; 9:2884-2894. [PMID: 35117645 PMCID: PMC8798954 DOI: 10.21037/tcr.2020.03.36] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 02/28/2020] [Indexed: 01/11/2023]
Abstract
Background Epidemiological studies have shown that patients with type 2 diabetes mellitus (T2DM) are at a higher risk of secondary tumors. However, no consensus has been made about whether T2DM can increase the risk of multiple myeloma (MM). Methods We searched the databases of PubMed, Cochrane Library and EMBASE and cross-checked the bibliography. Data quality was assessed using the Newcastle-Ottawa scale (NOS). Heterogeneity was calculated as the odds ratio (OR) using a random-effects model. Data were analyzed using Stata version 12.0 software. Results A total of 13 articles were selected into this meta-analysis. Initially, we found that diabetic patients had a higher risk of myeloma than non-diabetic patients (OR =1.60, 95% CI: 1.13–2.26, I2=98%, P=0.000). But the data in these articles were highly heterogeneous (I2>75%). Therefore, eight of the included articles showed a moderate heterogeneity (I2=71.6%). We used Galbraith heterogeneity map to analyze the causes of heterogeneity. Two articles with high heterogeneity were excluded. Then, we found the heterogeneity of the left six articles was reduced from moderate to mild (I2=45.9%, P=0.100). The final results of this meta-analysis showed that T2DM was not a risk factor for increased incidence of MM (OR =1.05, 95% CI: 0.83–1.33, I2=45.9%, P=0.100). Also, the subgroup analysis (case-control studies vs. cohort studies) showed no statistical difference (OR =1.19, 95% CI: 0.76–1.85, I2=1%, P=0.364; OR =1.00, 95% CI: 0.75–1.33, I2=71.2%, P=0.031; respectively). Conclusions T2DM is not a risk factor for the increased incidence of MM, a finding that should be validated with more strictly designed randomized controlled trials (RCTs).
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Affiliation(s)
- Chenlu Zhang
- Department of Hematology, The Affiliated Hospital of Nantong University, Nantong 226001, China
| | - Yuou Sha
- Department of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430074, China
| | - Haiyan Liu
- Department of Hematology, The Affiliated Hospital of Nantong University, Nantong 226001, China
| | - Dan Guo
- Department of Hematology, The Affiliated Hospital of Nantong University, Nantong 226001, China
| | - Yijing Jiang
- Department of Hematology, The Affiliated Hospital of Nantong University, Nantong 226001, China
| | - Lemin Hong
- Department of Hematology, The Affiliated Hospital of Nantong University, Nantong 226001, China
| | - Lili Shi
- Department of Medical Informatics, Medical School of Nantong University, Nantong 226001, China
| | - Hongming Huang
- Department of Hematology, The Affiliated Hospital of Nantong University, Nantong 226001, China
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Wang Y, Liu X, Yan P, Bi Y, Liu Y, Zhang ZJ. Association between type 1 and type 2 diabetes and risk of non-Hodgkin's lymphoma: A meta-analysis of cohort studies. DIABETES & METABOLISM 2019; 46:8-19. [PMID: 31039401 DOI: 10.1016/j.diabet.2019.04.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 04/12/2019] [Accepted: 04/14/2019] [Indexed: 12/14/2022]
Abstract
AIM Diabetes mellitus (DM) is thought to be associated with an increased risk of non-Hodgkin's lymphoma (NHL), although the evidence so far remains inconsistent. Thus, our study aimed to further assess this association. METHODS Electronic searches were performed of the PubMed, Web of Science and Embase databases up to 11 March 2019. A random-effects model was used to calculate summary relative risks (RRs) with corresponding 95% confidence intervals (CIs). RESULTS A total of 20 articles including data from 35 cohort studies matched our inclusion criteria, and 31 RRs were calculated for type 2 DM; the summary RR was 1.20 (95% CI: 1.12-1.30, I2 = 84.7%). Also, four RRs were calculated for type 1 DM, and the result was significant (RR: 1.55, 95% CI: 1.15-2.08, I2 = 0.0%). The results of subgroup analyses demonstrated that the association between DM and NHL was much more substantial in an Asian population, while sensitivity analyses suggested the robustness of a positive association between DM and NHL risk. In addition, the RR of NHL correlated negatively with duration of DM, with the highest risk found in patients within 1-2 years of DM diagnosis. CONCLUSION Our study findings suggest a moderate increase in risk of NHL in type 1 and 2 DM patients. Future studies should investigate the effects of duration of DM and antidiabetes interventions on NHL risk.
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Affiliation(s)
- Y Wang
- Department of Preventive Medicine, School of Health Sciences, Wuhan University, No. 185 Donghu road, Wuhan 430071, PR China
| | - X Liu
- Department of Preventive Medicine, School of Health Sciences, Wuhan University, No. 185 Donghu road, Wuhan 430071, PR China
| | - P Yan
- Department of Preventive Medicine, School of Health Sciences, Wuhan University, No. 185 Donghu road, Wuhan 430071, PR China
| | - Y Bi
- Department of Preventive Medicine, School of Health Sciences, Wuhan University, No. 185 Donghu road, Wuhan 430071, PR China
| | - Y Liu
- Department of Statistics and Management, School of Management, Wuhan Institute of Technology, Wuhan, 430205, PR China
| | - Z-J Zhang
- Department of Preventive Medicine, School of Health Sciences, Wuhan University, No. 185 Donghu road, Wuhan 430071, PR China.
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Benavente Y, Casabonne D, Costas L, Robles C, Alonso E, de la Banda E, Gonzalez-Barca E, Marcos-Gragera R, Llorca J, Tardón A, Monleon JJ, Aymerich M, Campo E, Gimeno-Vázquez E, Castaño-Vinyals G, Aragonés N, Pollán M, Kogevinas M, de Sanjosé S. Established and suggested exposures on CLL/SLL etiology: Results from the CLL-MCC-Spain study. Cancer Epidemiol 2018; 52:106-111. [PMID: 29289901 DOI: 10.1016/j.canep.2017.12.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 11/13/2017] [Accepted: 12/19/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Chronic Lymphocytic Leukemia (CLL/SLL) is the most common adult leukemia in Western countries. Although it is mostly an indolent disease it is still incurable and with limited knowledge in relation to its etiology. We aim to confirm and quantify established risk factors for CLL/SLL using a multi-center epidemiological population-based case-control study on CLL/SLL as well as to explore new exposures inconclusively associated with CLL/SLL METHODS: Using the framework provided by the large MCC-Spain case-control study, we explored established and suggested risk factors associated with CLL/SLL using data collected through a face-to-face interview. We estimated odds ratios (OR) and confidence intervals (CI) adjusted by basic confounders, in 1,845 controls from the general population and 560 CLL/SLL from 5 different Spanish regions. RESULTS Among the established risk factors, CLL/SLL cases were 3 times more likely to report first degree relatives with an hematological cancer (OR = 3.11, 95% CI 2.10 to 4.61) and nearly twice likely to have ever worked in agriculture (OR = 1.70, 95% CI = 1.34 to 2.16). New findings suggest that women with CLL/SLL were more likely to have central obesity (OR = 1.67 95% CI = 1.12 to 2.48). An inverse association was found for current alcohol consumption (p-trend<0.016) and for type II diabetes. CONCLUSION We confirmed previous established risk factors for CLL/SLL. Among the new findings, further research of central obesity as preventable exposure and the treatment for type II diabetes are warranted.
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Affiliation(s)
- Yolanda Benavente
- Unit of Infections and Cancer (UNIC), Cancer Epidemiology Research Programme, IDIBELL, Institut Català d'Oncologia, 08908, L'Hospitalet De Llobregat, Barcelona, Spain; CIBER Epidemiología y Salud Pública (CIBERESP), 28029, Madrid, Spain.
| | - Delphine Casabonne
- Unit of Infections and Cancer (UNIC), Cancer Epidemiology Research Programme, IDIBELL, Institut Català d'Oncologia, 08908, L'Hospitalet De Llobregat, Barcelona, Spain; CIBER Epidemiología y Salud Pública (CIBERESP), 28029, Madrid, Spain
| | - Laura Costas
- Unit of Infections and Cancer (UNIC), Cancer Epidemiology Research Programme, IDIBELL, Institut Català d'Oncologia, 08908, L'Hospitalet De Llobregat, Barcelona, Spain; CIBER Epidemiología y Salud Pública (CIBERESP), 28029, Madrid, Spain
| | - Claudia Robles
- Prevention and Implementation Group, Section of Early Detection and Prevention, International Agency for Research on Cancer, Lyon, France
| | - Esther Alonso
- Hematology Laboratory, Pathology Department, Hospital Universitari de Bellvitge, 08908, L'Hospitalet De Llobregat, Barcelona, Spain
| | - Esmeralda de la Banda
- Hematology Laboratory, Pathology Department, Hospital Universitari de Bellvitge, 08908, L'Hospitalet De Llobregat, Barcelona, Spain
| | - Eva Gonzalez-Barca
- Hematology, IDIBELL, Institut Català d' Oncologia, 08908, L'Hospitalet De Llobregat, Barcelona, Spain
| | - Rafael Marcos-Gragera
- Epidemiology Unit and Girona Cancer Registry, Oncology Coordination Plan, Department of Health, Autonomous Government of Catalonia, Catalan Institute of Oncology, Girona Biomedical Research Institute (IdiBGi), 17007, Girona, Spain
| | - Javier Llorca
- CIBER Epidemiología y Salud Pública (CIBERESP), 28029, Madrid, Spain; University of Cantabria - IDIVAL, Santander, Spain
| | - Adonina Tardón
- CIBER Epidemiología y Salud Pública (CIBERESP), 28029, Madrid, Spain; Oncology Institute (IUOPA), University of Oviedo, Asturias, Spain
| | - José J Monleon
- CIBER Epidemiología y Salud Pública (CIBERESP), 28029, Madrid, Spain; Department of Preventive Medicine and Public Health, University of Granada, 18071, Granada, Spain; Instituto de Investigación Biosanitaria de Granada, Servicio Andaluz de Salud/Universidad de Granada, 18012, Granada, Spain
| | - Marta Aymerich
- Hematopathology Unit, Pathology Department, Hospital Clínic, University of Barcelona, Institute of Biomedical Research August Pi i Sunyer (IDIBAPS), 08036, Barcelona, Spain
| | - Elías Campo
- Hematopathology Unit, Pathology Department, Hospital Clínic, University of Barcelona, Institute of Biomedical Research August Pi i Sunyer (IDIBAPS), 08036, Barcelona, Spain
| | - Eva Gimeno-Vázquez
- Department of Clinical Hematology, Hospital del Mar, Barcelona, 08003, Spain; Grup de Recerca Aplicada en Neoplasies Hematològiques-PSMAR, Barcelona, Spain
| | - Gemma Castaño-Vinyals
- CIBER Epidemiología y Salud Pública (CIBERESP), 28029, Madrid, Spain; ISGlobal, Centre for Research in Environmental Epidemiology (CREAL), Barcelona, Spain; Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain; Universitat Pompeu Fabra (UPF), Barcelona, Spain
| | - Nuria Aragonés
- CIBER Epidemiología y Salud Pública (CIBERESP), 28029, Madrid, Spain; Cancer and Environmental Epidemiology Unit, National Center for Epidemiology, Carlos III Institute of Health, Madrid, Spain
| | - Marina Pollán
- CIBER Epidemiología y Salud Pública (CIBERESP), 28029, Madrid, Spain; Cancer and Environmental Epidemiology Unit, National Center for Epidemiology, Carlos III Institute of Health, Madrid, Spain; Cancer Epidemiology Research Group, Oncology and Hematology Area, IIS Puerta de Hierro (IDIPHIM), Madrid, Spain
| | - Manolis Kogevinas
- CIBER Epidemiología y Salud Pública (CIBERESP), 28029, Madrid, Spain; ISGlobal, Centre for Research in Environmental Epidemiology (CREAL), Barcelona, Spain; Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain; Universitat Pompeu Fabra (UPF), Barcelona, Spain
| | - Sílvia de Sanjosé
- Unit of Infections and Cancer (UNIC), Cancer Epidemiology Research Programme, IDIBELL, Institut Català d'Oncologia, 08908, L'Hospitalet De Llobregat, Barcelona, Spain; CIBER Epidemiología y Salud Pública (CIBERESP), 28029, Madrid, Spain; Department of Medicine, University of Barcelona, Barcelona, Spain
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Scotti L, Tavani A, Bosetti C, Maso LD, Talamini R, Montella M, Franceschi S, La Vecchia C. Diabetes and Risk of Non-Hodgkin Lymphoma: A Case-Control Study. TUMORI JOURNAL 2018; 93:1-3. [PMID: 17455863 DOI: 10.1177/030089160709300101] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Aims and background We investigated the relation between diabetes and the risk of non-Hodgkin lymphoma, as epidemiological results are controversial and diabetes has been related to the risk of several neoplasms. Patients and methods We analyzed the combined dataset of two Italian case-control studies conducted in 1985-1997 and 1999-2002. Cases were 671 patients, aged <85 years, with incident, histologically confirmed non-Hodgkin lymphoma, and controls were 1799 patients admitted to hospitals for acute non-neoplastic conditions. Odds ratios were estimated using unconditional multiple logistic regression models including terms for age, center, sex, residence and educational level. Results No material association between diabetes and non-Hodgkin lymphoma risk was observed, with an odds ratio of 1.12 (95% confidence intervals, 0.70-1.77). No association was found in relation to age at first diagnosis of diabetes, years since diagnosis, or in younger and older subjects at diagnosis of non-Hodgkin lymphoma. Conclusions The results of the study allow to exclude a strong association between diabetes and non-Hodgkin lymphoma, although the small number of cases with diabetes leaves open the possibility of a moderate direct relation.
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Affiliation(s)
- Lorenza Scotti
- Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
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Type 2 diabetes and the risk of non-Hodgkin's lymphoma: a report from two population-based cohort studies in China. Eur J Cancer Prev 2016; 25:149-54. [PMID: 25793918 DOI: 10.1097/cej.0000000000000150] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Coinciding with the increased incidence of non-Hodgkin's lymphoma (NHL) during the past decades, there has been a significant increase in the prevalence of diabetes mellitus in mainland China. We therefore evaluated whether type 2 diabetes (T2D) is associated with the risk of NHL using data from the Shanghai Men's Health Study (SMHS) and the Shanghai Women's Health Study (SWHS). The SMHS and SWHS are two on-going, prospective, population-based cohorts of more than 130 000 Chinese adults in urban Shanghai. Self-reported diabetes was recorded on the baseline questionnaire and updated in follow-up surveys. Cox regression models with T2D as a time-varying exposure were used to estimate hazard ratios and 95% confidence intervals, adjusting for covariates. After a median follow-up of 12.9 years for SWHS and 7.4 years for SMHS, 172 NHL cases were identified. Patients with T2D have a higher risk of incident NHL with a hazard ratio of 2.00 (95% confidence interval: 1.32-3.03) compared with those without diabetes. This positive association remained when the analysis was restricted to untreated diabetes or after excluding NHL cases that occurred within 3 years after the onset of diabetes. No interaction effect was found in the development of NHL between T2D and other potential risk factors. A linear inverse association was found between T2D duration and the risk of NHL in both men and women (Pfor linearity<0.01), with a highest risk of incident NHL in the first 5 years after the diagnosis of diabetes. Our study suggested that T2D might be associated with an increased risk of NHL.
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Saito E, Charvat H, Goto A, Matsuda T, Noda M, Sasazuki S, Inoue M. Burden of cancer associated with type 2 diabetes mellitus in Japan, 2010-2030. Cancer Sci 2016; 107:521-7. [PMID: 27079439 PMCID: PMC4832854 DOI: 10.1111/cas.12902] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2015] [Revised: 01/23/2016] [Accepted: 01/27/2016] [Indexed: 12/27/2022] Open
Abstract
Diabetes mellitus constitutes a major disease burden globally, and the prevalence of diabetes continues to increase worldwide. We aimed to estimate the burden of cancer associated with type 2 diabetes mellitus in Japan between 2010 and 2030. In this study, we estimated the population attributable fraction of cancer risk associated with type 2 diabetes in 2010 and 2030 using the prevalence estimates of type 2 diabetes in Japan from 1990 to 2030, summary hazard ratios of diabetes and cancer risk from a pooled analysis of eight large‐scale Japanese cohort studies, observed incidence/mortality of cancer in 2010 and predicted incidence/mortality for 2030 derived from the age–period–cohort model. Our results showed that between 2010 and 2030, the total numbers of cancer incidence and mortality were predicted to increase by 38.9% and 10.5% in adults aged above 20 years, respectively. In the number of excess incident cancer cases associated with type 2 diabetes, an increase of 26.5% in men and 53.2% in women is expected between 2010 and 2030. The age‐specific analysis showed that the population attributable fraction of cancer will increase in adults aged >60 years over time, but will not change in adults aged 20–59 years. In conclusion, this study suggests a modest but steady increase in cancers associated with type 2 diabetes. This study provides the first comprehensive evidence on the current and future burden of cancer associated with type 2 diabetes mellitus. Between 2010 and 2030, the incident cancer cases associated with type 2 diabetes were found to increase constantly over time, particularly in liver, pancreas and colon in Japan. Given the prolonged life expectancy in Japan, increase in people living with type 2 diabetes and subsequent cancer will be a public health issue in the years to come.
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Affiliation(s)
- Eiko Saito
- AXA Department of Health and Human Security, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Epidemiology and Prevention Group, Center for Public Health Sciences, National Cancer Center, Tokyo, Japan
| | - Hadrien Charvat
- Epidemiology and Prevention Group, Center for Public Health Sciences, National Cancer Center, Tokyo, Japan
| | - Atsushi Goto
- Department of Diabetes Research, National Center for Global Health and Medicine, Tokyo, Japan.,Department of Public Health, Tokyo Women's Medical University, Tokyo, Japan
| | - Tomohiro Matsuda
- Division of Surveillance, Center for Cancer Control and Information Services, National Cancer Center, Tokyo, Japan
| | - Mitsuhiko Noda
- Department of Diabetes Research, National Center for Global Health and Medicine, Tokyo, Japan.,Department of Endocrinology and Diabetes, Saitama Medical University, Moroyama, Japan
| | - Shizuka Sasazuki
- Epidemiology and Prevention Group, Center for Public Health Sciences, National Cancer Center, Tokyo, Japan
| | - Manami Inoue
- AXA Department of Health and Human Security, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Epidemiology and Prevention Group, Center for Public Health Sciences, National Cancer Center, Tokyo, Japan
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Karlstad O, Starup-Linde J, Vestergaard P, Hjellvik V, Bazelier MT, Schmidt MK, Andersen M, Auvinen A, Haukka J, Furu K, de Vries F, De Bruin ML. Use of insulin and insulin analogs and risk of cancer - systematic review and meta-analysis of observational studies. Curr Drug Saf 2014; 8:333-48. [PMID: 24215311 PMCID: PMC3899599 DOI: 10.2174/15680266113136660067] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Revised: 10/29/2013] [Accepted: 10/31/2013] [Indexed: 12/12/2022]
Abstract
Background: An association of insulin use and risk of cancer has been reported but evidence is conflicting and methodological issues have been identified. Objective: To summarize results regarding insulin use and cancer risk by a systematic review and meta-analysis of cohort and case-control studies examining risk of cancer associated with insulin use in patients with diabetes. Data Sources: Systematic literature search in 5 databases: PubMed, Embase, Web of Science, Scopus and Cochrane Library. Study Eligibility Criteria (PICOS): Population: diabetes patients. Exposure: Users of any exogenous insulin. Comparison: Diabetes patients with or without use of antidiabetic drugs. Outcome: Any incident cancer. Study Design: Cohort and case-control studies. Results: 42 eligible studies examined risk of any cancer and 27 site-specific cancers. Results of individual studies were heterogeneous. Meta-analyses were significant for: Insulin vs No Insulin: Increased risk for pancreas, liver, kidney, stomach and respiratory cancer, decreased risk for prostate cancer. Insulin vs Non-Insulin Antidiabetics: Increased risk for any, pancreatic and colorectal cancer. Glargine vs Non-Glargine Insulin: Increased risk for breast cancer, decreased risk for colon cancer. Limitations: Few studies available for most cancer sites and exposure contrasts, and few assess effect of dose and duration of exposure. Methodological issues in several studies. Availability of confounders. Conclusions: Insulin use was associated with risk of cancer at several sites. Cautious interpretation of results is warranted as methodological issues and limitations in several of the included studies have been identified. Choice of study design may have a profound effect on estimated cancer risk.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Marie L De Bruin
- Norwegian Institute of Public Health, P.O.Box 4404 Nydalen, N-0403 Oslo, Norway.
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Starup-Linde J, Karlstad O, Eriksen SA, Vestergaard P, Bronsveld HK, de Vries F, Andersen M, Auvinen A, Haukka J, Hjellvik V, Bazelier MT, Boer AD, Furu K, De Bruin ML. CARING (CAncer Risk and INsulin analoGues): the association of diabetes mellitus and cancer risk with focus on possible determinants - a systematic review and a meta-analysis. Curr Drug Saf 2014; 8:296-332. [PMID: 24215312 PMCID: PMC5421136 DOI: 10.2174/15748863113086660071] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Revised: 10/27/2013] [Accepted: 10/30/2013] [Indexed: 12/11/2022]
Abstract
Background: Patients suffering from diabetes mellitus (DM) may experience an increased risk of cancer; however, it is not certain whether this effect is due to diabetes per se. Objective: To examine the association between DM and cancers by a systematic review and meta-analysis according to the PRISMA guidelines. Data Sources: The systematic literature search includes Medline at PubMed, Embase, Cinahl, Bibliotek.dk, Cochrane library, Web of Science and SveMed+ with the search terms: “Diabetes mellitus”, “Neoplasms”, and “Risk of cancer”. Study Eligibility Criteria: The included studies compared the risk of cancer in diabetic patients versus non-diabetic patients. All types of observational study designs were included. Results: Diabetes patients were at a substantially increased risk of liver (RR=2.1), and pancreas (RR=2.2) cancer. Modestly elevated significant risks were also found for ovary (RR=1.2), breast (RR=1.1), cervix (RR=1.3), endometrial (RR=1.4), several digestive tract (RR=1.1-1.5), kidney (RR=1.4), and bladder cancer (RR=1.1). The findings were similar for men and women, and unrelated to study design. Meta-regression analyses showed limited effect modification of body mass index, and possible effect modification of age, gender, with some influence of study characteristics (population source, cancer- and diabetes ascertainment). Limitations: Publication bias seemed to be present. Only published data were used in the analyses. Conclusions: The systematic review and meta-analysis confirm the previous results of increased cancer risk in diabetes and extend this to additional cancer sites. Physicians in contact with patients with diabetes should be aware that diabetes patients are at an increased risk of cancer.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | - Marie L De Bruin
- Department of Endocrinology and Internal Medicine (MEA), Aarhus University Hospital, Tage Hansens Gade 2, 8000 Aarhus C, Denmark.
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Wu W, Merriman K, Nabaah A, Seval N, Seval D, Lin H, Wang M, Qazilbash MH, Baladandayuthapani V, Berry D, Orlowski RZ, Lee MH, Yeung SCJ. The association of diabetes and anti-diabetic medications with clinical outcomes in multiple myeloma. Br J Cancer 2014; 111:628-36. [PMID: 24921909 PMCID: PMC4119980 DOI: 10.1038/bjc.2014.307] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Revised: 05/10/2014] [Accepted: 05/12/2014] [Indexed: 12/15/2022] Open
Abstract
Background: Insulin/insulin-like growth factor-1 signalling may underlie the promoting effect of type 2 diabetes on cancer. This study examined the association of diabetes, including steroid-induced diabetes (SID), and the impact of anti-diabetic medication on clinical outcomes of multiple myeloma (MM). Methods: A retrospective review was conducted of 1240 MM patients. Overall survival (OS) and MM disease status prior to death were analysed. Results: Diabetic patients had a significantly shorter OS than non-diabetic patients (median: 65.4 vs 98.7 months). In multivariate analysis, SID was a significant predictor of decreased OS, along with age, comorbidity, MM stage, and cytogenetic abnormalities. Analyzing only the diabetic MM patients, Cox regression showed that metformin predicted an increased OS, whereas use of insulin/analogues predicted a decreased OS. Competing risk analysis showed that DM was associated with increased cumulative incidence of death with progressive MM. Among the diabetics, multivariate regression showed that insulin/analogues were associated with increased, but metformin with decreased death with progressive MM. Potential immortal time bias was evaluated by landmark analyses. Conclusions: DM, SID in particular, is associated with poor clinical outcomes in MM. Insulin/analogues are associated with poor outcomes, whereas metformin is associated with improved outcomes. No conclusion about causal relationships can be made at this time. Managing hyperglycaemia with non-insulin regimens should be investigated in randomised trials.
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Affiliation(s)
- W Wu
- 1] Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA [2] Zhongshan Hospital, Xiamen University, Xiamen, Fujian, People's Republic of China
| | - K Merriman
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - A Nabaah
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - N Seval
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - D Seval
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - H Lin
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - M Wang
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - M H Qazilbash
- Department of Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - V Baladandayuthapani
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - D Berry
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - R Z Orlowski
- 1] Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA [2] Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - M-H Lee
- Department of Molecular and Cellular Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - S-C J Yeung
- 1] Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA [2] Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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12
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Casabonne D, Almeida J, Nieto WG, Romero A, Fernández-Navarro P, Rodriguez-Caballero A, Muñoz-Criado S, Díaz MG, Benavente Y, de Sanjosé S, Orfao A. Common infectious agents and monoclonal B-cell lymphocytosis: a cross-sectional epidemiological study among healthy adults. PLoS One 2012; 7:e52808. [PMID: 23285188 PMCID: PMC3532166 DOI: 10.1371/journal.pone.0052808] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2012] [Accepted: 11/21/2012] [Indexed: 11/19/2022] Open
Abstract
Background Risk factors associated with monoclonal B-cell lymphocytosis (MBL), a potential precursor of chronic lymphocytic leukaemia (CLL), remain unknown. Methods Using a cross-sectional study design, we investigated demographic, medical and behavioural risk factors associated with MBL. “Low-count” MBL (cases) were defined as individuals with very low median absolute count of clonal B-cells, identified from screening of healthy individuals and the remainder classified as controls. 452 individuals completed a questionnaire with their general practitioner, both blind to the MBL status of the subject. Odds ratios (OR) and 95% confidence interval (CI) for MBL were estimated by means of unconditional logistic regression adjusted for confounding factors. Results MBL were detected in 72/452 subjects (16%). Increasing age was strongly associated with MBL (P-trend<0.001). MBL was significantly less common among individuals vaccinated against pneumococcal or influenza (OR 0.49, 95% confidence interval (CI): 0.25 to 0.95; P-value = 0.03 and OR: 0.52, 95% CI: 0.29 to 0.93, P-value = 0.03, respectively). Albeit based on small numbers, cases were more likely to report infectious diseases among their children, respiratory disease among their siblings and personal history of pneumonia and meningitis. No other distinguishing epidemiological features were identified except for family history of cancer and an inverse relationship with diabetes treatment. All associations described above were retained after restricting the analysis to CLL-like MBL. Conclusion Overall, these findings suggest that exposure to infectious agents leading to serious clinical manifestations in the patient or its surroundings may trigger immune events leading to MBL. This exploratory study provides initial insights and directions for future research related to MBL, a potential precursor of chronic lymphocytic leukaemia. Further work is warranted to confirm these findings.
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Affiliation(s)
- Delphine Casabonne
- Unit of Infections and Cancer, IDIBELL, Institut Català d' Oncologia, L' Hospitalet de Llobregat, Barcelona, Spain.
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13
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Castillo JJ, Mull N, Reagan JL, Nemr S, Mitri J. Increased incidence of non-Hodgkin lymphoma, leukemia, and myeloma in patients with diabetes mellitus type 2: a meta-analysis of observational studies. Blood 2012; 119:4845-50. [PMID: 22496152 PMCID: PMC3367891 DOI: 10.1182/blood-2011-06-362830] [Citation(s) in RCA: 144] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2011] [Accepted: 03/28/2012] [Indexed: 12/21/2022] Open
Abstract
Hematologic malignancies are a heterogeneous group of conditions with an unclear etiology. We hypothesized that diabetes mellitus type 2 is associated with increased risk of developing lymphoma, leukemia, and myeloma. A literature search identified 26 studies (13 case-control and 13 cohort studies) evaluating such an association. Outcome was calculated as the odds ratio (OR) using a random effects model. Heterogeneity and publication bias were evaluated using the I(2) index and the trim-and-fill analysis, respectively. Quality was assessed using the Newcastle-Ottawa scale. The OR for non-Hodgkin lymphoma was increased at 1.22 (95% confidence interval [CI], 1.07-1.39; P < .01) but the OR for Hodgkin lymphoma was not. There was an increased OR for peripheral T-cell lymphoma (OR = 2.42, 95% CI, 1.24-4.72; P = .009) but not for other non-Hodgkin lymphoma subtypes. The OR for leukemia was 1.22 (95% CI, 1.03-1.44; P = .02) and the OR for myeloma was 1.22 (95% CI, 0.98-1.53; P = .08). Although diabetes mellitus type 2 seems to increase the risk of developing lymphoma, leukemia, and myeloma, future studies should focus on evaluating other potential confounders such as obesity, dietary habits, physical activity, and/or antidiabetic therapy.
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Affiliation(s)
- Jorge J Castillo
- Division of Hematology and Oncology, Rhode Island Hospital/The Miriam Hospital, The Warren Alpert Medical School of Brown University, Providence, RI 02906, USA.
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14
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Tseng CH. Diabetes and non-Hodgkin's lymphoma: analyses of prevalence and annual incidence in 2005 using the National Health Insurance database in Taiwan. Ann Oncol 2012; 23:153-158. [PMID: 21765043 DOI: 10.1093/annonc/mdr334] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The association between diabetes and non-Hodgkin's lymphoma (NHL) is rarely studied and the risk associated with insulin use is not known. MATERIALS AND METHODS The crude and age-standardized trends of NHL incidence in the general population from 1979 to 2007 were first calculated. NHL prevalence and annual incidence in 2005 were calculated in 329,198 insurants aged≥45 years from a random sample of 1,000,000 insurants of the National Health Insurance. The risk factors were evaluated using logistic regression. RESULTS NHL incidence trends increased significantly in either sex. A total of 1079 and 148 NHL cases were identified for prevalence and incidence analyses, respectively. The respective prevalence (per 100,000) for diabetic and nondiabetic subjects was 480.2 and 269.9 (P<0.01), and the respective incidence (per 100,000) was 70.9 and 35.3 (P<0.01). Odds ratio for diabetic versus nondiabetic subjects after adjustment for age, sex, occupation, and living region was 1.51 (95% confidence interval 1.33-1.71) for prevalence and 1.48 (1.06-2.06) for incidence. In diabetic patients, the adjusted odds ratio for insulin users versus nonusers was 1.63 (1.23-2.15) for prevalence and 2.52 (1.37-4.64) for incidence. CONCLUSIONS NHL incidence is increasing in Taiwan. Diabetes and insulin use are associated with a higher risk.
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Affiliation(s)
- C-H Tseng
- Department of Internal Medicine, National Taiwan University College of Medicine, Taipei; Division of Endocrinology and Metabolism, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
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15
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Muntoni S, Muntoni S. Insulin resistance: pathophysiology and rationale for treatment. ANNALS OF NUTRITION AND METABOLISM 2011; 58:25-36. [PMID: 21304221 DOI: 10.1159/000323395] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2009] [Accepted: 12/06/2010] [Indexed: 12/29/2022]
Abstract
After binding to its receptor and activating the β-subunit, insulin is faced with two divergent pathways: one is phosphatidylinositol 3-kinase (PI 3-K) dependent, while another is dependent upon activation of mitogen-activated protein kinase (MAP-K). The former is absolutely necessary for mediating most metabolic and antiapoptotic effects; the latter is linked to nonmetabolic, proliferative and mitogenic effects. In obese patients, especially with type 2 diabetes mellitus (DM2), only the PI 3-K, but not the MAP-K, is resistant to insulin stimulation: hence insulin resistance is better defined as metabolic insulin resistance. The resulting 'compensatory hyperinsulinemia' is an unsuccessful attempt to overcome the inhibition of the metabolic pathway at the price of unopposed stimulation of the MAP-K pathway, and the administration of exogenous insulin might worsen the metabolic dysfunction. As the preferential activation of the MAP-K pathway in insulin-resistant patients has atherogenic and mitogenic properties, this leads to atherosclerosis and cancer. Metformin may carry out direct protective action on human β cells, inasmuch as it improves both primary and secondary endpoints through selective inhibition of fatty acyl oxidation.
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Affiliation(s)
- Sergio Muntoni
- Centre for Metabolic Diseases and Atherosclerosis, The ME.DI.CO. Association, Unit of Oncology and Molecular Pathology, University Medical School, Cagliari, Italy.
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16
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Insulin is a potent myeloma cell growth factor through insulin/IGF-1 hybrid receptor activation. Leukemia 2010; 24:1940-50. [PMID: 20844560 DOI: 10.1038/leu.2010.192] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Insulin and insulin growth factor type 1 (IGF-1) and their receptors are closely related molecules, but both factors bind to the receptor of the other one with a weak affinity. No study has presently documented a role of insulin as a myeloma growth factor (MGF) for human multiple myeloma cells (MMCs), whereas many studies have concluded that IGF-1 is a major MGF. IGF-1 receptor (IGF-1R) is aberrantly expressed by MMCs in association with a poor prognosis. In this study we show that insulin receptor (INSR) is increased throughout normal plasma cell differentiation. INSR gene is also expressed by MMCs of 203/206 newly diagnosed patients. Insulin is an MGF as potent as IGF-1 at physiological concentrations and requires the presence of insulin/IGF-1 hybrid receptors, stimulating INSR(+)IGF-1R(+) MMCs, unlike INSR(+)IGF-1R(-) or INSR(-)IGF-1R(-) MMCs. Immunoprecipitation experiments indicate that INSR is linked with IGF-1R in MMCs and that insulin induces both IGF-1R and INSR phosphorylations and vice versa. In conclusion, we demonstrate for the first time that insulin is an MGF as potent as IGF-1 at physiological concentrations and its activity necessitates insulin/IGF-1 hybrid receptor activation. Further therapeutic strategies targeting the IGF/IGF-1R pathway have to take into account neutralizing the IGF-1R-mediated insulin MGF activity.
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17
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Intentional weight loss and risk of lymphohematopoietic cancers. Cancer Causes Control 2009; 21:223-36. [DOI: 10.1007/s10552-009-9453-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2009] [Accepted: 10/06/2009] [Indexed: 12/13/2022]
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18
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Medical history and risk of lymphoma: results of a European case–control study (EPILYMPH). J Cancer Res Clin Oncol 2009; 135:1099-107. [DOI: 10.1007/s00432-009-0551-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2008] [Accepted: 01/19/2009] [Indexed: 02/07/2023]
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Mitri J, Castillo J, Pittas AG. Diabetes and risk of Non-Hodgkin's lymphoma: a meta-analysis of observational studies. Diabetes Care 2008; 31:2391-7. [PMID: 19033419 PMCID: PMC2584201 DOI: 10.2337/dc08-1034] [Citation(s) in RCA: 109] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To examine the epidemiologic association between diabetes and risk of non-Hodgkin's lymphoma (NHL). RESEARCH DESIGN AND METHODS We searched MEDLINE for observational studies on the association between diabetes and NHL in adults using the keywords "diabetes" and "lymphoma." Prospective cohort studies that reported relative risks or standardized incidence ratios and case-control studies that reported odds ratios with 95% CIs were included. A random-effects model was used to combine results from the individual studies. RESULTS A total of 15 manuscripts (reporting data from 5 prospective cohort and 11 case-control studies) met the inclusion criteria. Combining data from all studies, the risk ratio (RR) of developing NHL in patients with diabetes was 1.19 (95% CI 1.04-1.35). Based on prospective studies, patients with diabetes had an RR of developing NHL of 1.41 (1.07-1.88), without heterogeneity among studies (I(2) = 34.3%; P > 0.10). Based on case-control studies, patients with diabetes had an RR of 1.12 (95% CI 0.95-1.31) of developing NHL compared with people without diabetes, with some heterogeneity among studies (I(2) = 36.28%; P = 0.09). CONCLUSIONS Diabetes is associated with a moderately increased risk of NHL, which is consistent with other reported associations between diabetes and malignancies. Future studies should focus on elucidating potential pathophysiologic links between diabetes and NHL.
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Affiliation(s)
- Joanna Mitri
- Department of Medicine, Roger Williams Hospital, Boston University School of Medicine, Providence, Rhode Island, USA
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20
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Chao C, Page JH. Type 2 diabetes mellitus and risk of non-Hodgkin lymphoma: a systematic review and meta-analysis. Am J Epidemiol 2008; 168:471-80. [PMID: 18611954 DOI: 10.1093/aje/kwn160] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Type 2 diabetes mellitus is associated with altered immune function and chronic inflammation. Both of these immune conditions are implicated in the pathogenesis of non-Hodgkin lymphoma. The authors performed a systematic review to summarize findings from the current literature on the association between history of type 2 diabetes mellitus and risk of non-Hodgkin lymphoma. Ten case-control studies and three prospective cohort studies were included in this review. Meta-analysis found that a history of type 2 diabetes mellitus was positively associated with overall non-Hodgkin lymphoma risk. However, there was significant heterogeneity between studies. Study design was an important source of heterogeneity. The rate ratio between type 2 diabetes mellitus and non-Hodgkin lymphoma was found to be 1.18 (95% confidence interval: 0.99, 1.42) among case-control studies and 1.79 (95% confidence interval: 1.30, 2.47) among the prospective cohort studies. Weaknesses were identified in some of the included studies in the areas of case and control selection, measurement of covariates and non-Hodgkin lymphoma, and confounding control. Although a positive association between type 2 diabetes mellitus and risk of non-Hodgkin lymphoma was suggested, the evidence is inconclusive because of methodological limitations of the included case-control studies. More prospective studies with improved control of confounding are needed to confirm these findings.
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Affiliation(s)
- Chun Chao
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA 91101-2453, USA.
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21
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2006. [DOI: 10.1002/pds.1176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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