Poor glycemic control is associated with reduced prostate specific antigen concentrations in men with type 1 diabetes

PSA, an outdated biomarker for prostate cancer: In search of a more specific biomarker, citrate takes the spotlight

The prevailing biomarker employed for prostate cancer (PCa) screening and diagnosis is the prostate-specific antigen (PSA). Despite excellent sensitivity, PSA lacks specificity, leading to false positives, unnecessary biopsies and overdiagnosis. Consequently, PSA is increasingly less used by clinicians, thus underscoring the imperative for the identification of new biomarkers. An emerging biomarker in this context is citrate, a molecule secreted by the normal prostate, which has been shown to be inversely correlated with PCa. Here, we discuss about PSA and its usage for PCa diagnosis, its lack of specificity, and the various conditions that can affect its levels. We then provide our vision about what we think would be a valuable addition to our PCa diagnosis toolkit, citrate. We describe the unique citrate metabolic program in the prostate and how this profile is reprogrammed during carcinogenesis. Finally, we summarize the evidence that supports the usage of citrate as a biomarker for PCa diagnosis, as it can be measured in various patient samples and be analyzed by several methods. The unique relationship between citrate and PCa, combined with the stability of citrate levels in other prostate-related conditions and the simplicity of its detection, further accentuates its potential as a biomarker.

Poor Glycemic Control Affecting Screening of Prostate Carcinoma

Introduction Diabetes and cancer are commonly linked together. The possible links include insulin resistance, hyperinsulinemia, hyperglycemia, oxidative stress, and chronic inflammation. These are factors that have potential promoting effects on the progression of cancer in many ways. Measurement of prostate-specific antigen (PSA) is widely applied for early detection of prostate cancer. However, several factors influence serum PSA levels in men including age, benign prostatic hyperplasia, prostatitis, and body mass index (BMI). The risk of several malignancies is increased in diabetes but the risk of prostate carcinoma in diabetic patients is reduced secondary to lowering of testosterone levels during the state of hyperinsulinemia. A negative association between serum PSA levels and metformin use is also an explanation of low cancer prostate incidence with diabetes. Objective The study aims to evaluate the PSA levels in diabetic patients with poor glycemic control i.e., glycated hemoglobin (HbA1c) ≥ 7%) vs good glycemic control (HbA1c < 7%). Materials and methods Samples of PSA in diabetic patients collected in the Department of Biochemistry at Indira Gandhi Institute of Medical Sciences (IGIMS), Patna, were included. The observational study was carried out on clinically diagnosed 318 cases of diabetes attending both the outpatient and inpatient Department, IGIMS, Patna. Six ml venous blood samples were collected from patients after obtaining informed consent and ethical clearance. Patient details regarding age, complete clinical details, and general physical examinations were recorded. Serum levels of PSA, fasting plasma glucose (FPG) and HbA1c were analyzed and values were compared. The serum level of PSA was estimated by the chemiluminescent immunoassay (CLIA) method on an automated immunoassay analyzer in the Department of Biochemistry, maintaining all the quality control precautions using a control, calibrator, and reagent kit. HbA1c estimation was by chromatography technique. Fasting plasma glucose was estimated using the hexokinase method on an automated chemistry analyzer. Statistical analyses were performed using SPSS software, version 16.0 (SPSS Inc., Chicago). The median and interquartile range were calculated for numerical variables. Covariance analysis was used in the comparisons among groups. The Mann-Whitney U test was applied to detect the comparison between the two groups. Significance was determined by the P value. P value<0.05 was considered significant. Result Serum PSA value was found to be higher in (the good glycemic control group) with a median of 0.99 with an interquartile range of 3.14, than in (the bad glycemic control group) with a median of 0.49 with an interquartile range of 3.9, and the difference is statistically significant. The difference is also statistically significant in the subgroup (i) with PSA value <4 ng/ml. In subgroups (ii) and (iii), PSA values 4 ng/ml-8 ng/ml and PSA values >8 ng/ml respectively, no significant differences were found. Conclusion It was found that serum prostate-specific antigen levels have been lower in diabetic patients with poor glycemic control than in good glycemic control. Future studies with a larger sample size and detailed information on diabetes duration and management are recommended.

The prevalence and risk factors of prostatic calculi in Han Chinese: a cross-sectional study based on health examinations

PURPOSE

Prostatic calculi (PCal) are commonly present with prostate disease; we aim to map the incidence and associated clinical risk factors of PCal in Han Chinese.

MATERIAL AND METHODS

We retrospectively selected men who sought a medical check-up in 2018. Basic clinical items, including age, weight, height, prostate specific antigen (PSA), uric acid (UA), fasting blood glucose (FBG), urinalysis results, and transabdominal prostate ultrasound, were recorded. Univariate and logistic regression analyses were performed to evaluate whether these factors were associated with the presence of PCal.

RESULT

We recorded the parameters of laboratory tests and clinical information from 14,427 men; men with PCal comprised 51.65% of the total group and 76.61% of the subgroup of benign prostate hyperplasia (BPH) patients. All the enrolled parameters showed meaningful differences, but the logistic regression analysis only indicated significant effects related to age (OR = 1.044, 95% CI = 1.040-1.047, and p < .001), body mass index (BMI) (OR = 1.035, 95% CI = 1.022-1.048, and p < .001), UA (OR = 0.999, 95% CI = 0.999-1.000, and p = .029), BPH (OR = 2.923, 95% CI = 2.678-3.191, and p < .001), and prostate cysts (OR = 0.609, 95% CI = 0.471-0.788, and p < .001). The odds ratio of the predicted combined model is 1.068.

CONCLUSIONS

PCal was detected in 51.65% of men among healthy Han Chinese and in 76.61% of BPH patients. Age, BMI, UA, BPH, and prostate cysts were independent risk factors for the presence of PCal.

Prostate-Specific Antigen Within the Reference Range, Subclinical Coronary Atherosclerosis, and Cardiovascular Mortality

RATIONALE

Although PSA (prostate-specific antigen)-a tumor marker for prostate cancer-has been reported to be associated with cardiovascular disease (CVD) risk factors, studies on the association of PSA with subclinical and clinical CVD remain limited.

OBJECTIVE

We examined the association of total serum PSA within the reference range with coronary artery calcium (CAC) score and CVD mortality.

METHODS AND RESULTS

A cross-sectional study was performed in 88 203 Korean men who underwent a health checkup exam including cardiac tomography estimation of CAC score. Logistic regression model was used to calculate odds ratios with 95% CIs for prevalent CAC. PSA levels were inversely associated with the presence of CAC. After adjusting for potential confounders, multivariable-adjusted odds ratio (95% CIs) for prevalent CAC comparing PSA quartiles 2, 3, and 4 to the first quartile were 0.96 (0.90-1.01), 0.88 (0.83-0.93), and 0.85 (0.80-0.90), respectively ( P for trend, <0.001). A cohort study was performed in 243 435 Korean men with a mean age of 39.3 years, PSA values of <4.0 ng/mL, and without known CVD or prostate disease who were followed up with for ≤14 years for CVD mortality (median, 7.3 years). CVD deaths were ascertained through linkage to national death records. Hazard ratios and 95% CIs for CVD mortality were estimated using Cox proportional hazards regression analyses. During 1 829 070.1 person-years of follow-up, 336 CVD deaths were identified. After adjustment for potential confounders, multivariable-adjusted hazard ratios (95% CIs) for CVD mortality comparing PSA quartiles 2, 3, and 4 to the lowest quartile were 0.90 (0.66-1.22), 0.79 (0.58-1.08), and 0.69 (0.51-0.93), respectively.

CONCLUSIONS

Serum total PSA levels within the reference range showed an inverse association with subclinical atherosclerosis and CVD mortality in young and middle-aged Korean men, indicating a possible role of PSA as a predictive marker for subclinical and clinical CVD.

The impact of type 1 diabetes mellitus on male sexual functions and sex hormone levels

Little is known about type 1 diabetes mellitus (T1DM) impact on the male sexual and reproductive functions. We aim to evaluate the influence of T1DM on male sexual function, quality of sexual life, and sex hormone levels. A total of 57 male patients aged 18 to 50 years (mean = 33) with T1DM (duration mean = 15 years) had a medical examination and completed a set of questionnaires - International Index of Erectile Function-5 (IIEF-5), Beck Depression Inventory (BDI) and Sexual quality of life questionnaire male (SQoL-M). The prevalence of erectile dysfunction was 28.1% (IIEF-5 ≤21). Patients without diabetic nephropathy had better erectile function (p = 0.008). Subjects with better glycemic control (HbA_1c <65 mmol/mol) had also better erectile function (p = 0.041). At least 8.8% patients had retrograde ejaculation. Blood serum levels of sex hormones were determined and compared to laboratory reference values of healthy men. Total testosterone level was not significantly changed, sex hormone binding globulin was higher (p < 0.001) and its level correlated with daily insulin dose adjusted to body weight (p = 0.008). Free androgen index and calculated free testosterone were lower (p = 0.013; p < 0.001), estradiol was not significantly changed, LH was higher (p < 0.001), FSH was unchanged, and prolactin was higher (p < 0.001). Prostate-specific antigen (PSA) negatively correlated with HbA_1c (p < 0.001). To conclude, we found significant changes in sexual functions and sex hormone blood concentrations that indicate impairment of sexual and reproductive functions in T1DM males.

Impact of Poor Preoperative Glycemic Control on Outcomes among Patients with Cervical Cancer Undergoing a Radical Hysterectomy

BACKGROUND

The impact of preoperative glycemic control on the survival outcomes of patients undergoing a radical hysterectomy (RH) for cervical cancer has not been investigated.

PATIENTS AND METHODS

We reviewed patients who underwent a type III RH for cervical cancer between January 2004 and June 2011 in our institution.

RESULTS

A total of 431 patients were included and 83 (19.3%) were diagnosed with diabetes mellitus (DM). Poorly controlled DM (preoperative hemoglobin A1c [HbA1c] ≥7.0%) was observed in 49 (59.0%) diabetic patients. Compared to patients without DM and diabetic patients with good glycemic control (preoperative HbA1c <7.0%), diabetic patients with poor glycemic control had significantly higher risks of tumor recurrence, cervical cancer-specific death, and overall death. In multivariate analysis, DM with poor glycemic control independently predicted recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS). We excluded patients without DM and performed a sensitivity analysis. When HbA1c levels were treated as a dichotomous variable, preoperative HbA1c ≥7.0% was independently associated with RFS, CSS, and OS. When HbA1c level was treated as a continuous variable, it remained an independent predictor of RFS, CSS, and OS.

CONCLUSION

DM with poor glycemic control prior to RH was significantly associated with an increased risk of recurrence and mortality in cervical cancer patients. These results underscore the importance of intensive glycemic control and close follow-up for diabetic patients.

A historical cohort study on glycemic-control and cancer-risk among patients with diabetes

AIMS

This population-based historical cohort study examined whether poor glycemic-control (i.e., high glucose and HbA1c blood levels) in patients with diabetes is associated with cancer-risk.

METHODS

From a large healthcare database, patients aged 21-89 years, diagnosed with diabetes before January 2002 (prevalent) or during 2002-2010 (incident), were followed for cancer during 2004-2012 (excluding cancers diagnosed within the first 2 years since diabetes diagnosis). Risks of selected cancers (all-sites, colon, breast, lung, prostate, pancreas and liver) were estimated according to glycemic-control in a Cox regression model with time-dependent covariates, adjusted for age, sex, ethnic origin, socioeconomic status, smoking and parity. Missing glucose or HbA1c values were imputed.

RESULTS

Among 440,000 patients included in our analysis, cancer was detected more than 2 years after diabetes diagnosis in 26,887 patients (6%) during the follow-up period. Associations of poor glycemic-control with all-sites cancer and most specific cancers were either null or only weak (hazard ratios (HRs) for a 1% HbA1c or a 30 mg/dl glucose increase between 0.94 and 1.09). Exceptions were pancreatic cancer, for which there was a strong positive association (HRs: 1.26-1.51), and prostate cancer, for which there was a moderate negative association (HRs: 0.85-0.96).

CONCLUSION

Overall, poor glycemic-control appears to be only weakly associated with cancer-risk, if at all. A substantial part of the positive association with pancreatic cancer is attributable to reverse causation, with the cancer causing poorer glycemic-control prior to its diagnosis. The negative association with prostate cancer may be related to lower PSA levels in those with poor control.

Impact of poor glycemic control of type 2 diabetes mellitus on serum prostate-specific antigen concentrations in men

BACKGROUND

To evaluate the impact of poor glycemic control of type 2 diabetes mellitus (T2DM) on serum prostate-specific antigen (PSA) concentrations in men.

METHODS

We performed a prospective analysis of 215 consecutive patients affected by erectile dysfunction (ED). ED was evaluated using the IIEF-5 questionnaire and the poor glycemic control (PGC) of T2DM was assessed according to the HbA1c criteria (International Diabetes Federation). Patients were divided into PGC group (HbA1c ≥ 7%) and control group (CG) (HbA1c < 6%). Correlations between serum HbA1c levels and various variables were evaluated and multivariate logistic regression analyses were carried out to identify variables for PGC.

RESULTS

We compared 110 cases to 105 controls men ranging from 44 to 81 years of age, lower PSA concentrations were observed in men with PGC (PGC mean PSA: 0.9 ng/dl, CG mean PSA: 2.1 ng/dl, p < 0.001). Also mean prostate volume was 60% was smaller among men with PGC compared with men with CG (PGC mean prostate volume: 26 ml, CG prostate volume: 43 ml, p < 0.001). A strong negative correlation was found between serum HbA1c levels and serum PSA (p < 0.001 and r = -0.665) concentrations in men with PGC. We also found at the multivariate logistic regression model that PSA, prostate volume and peak systolic velocity were independent predictors of PGC.

CONCLUSION

Our results suggest that there is significant impact of PGC on serum PSA levels in T2DM. Poor glycemic control of type 2 diabetes was associated with lower serum PSA levels and smaller prostate volumes.

Pretreatment glycemic control status is an independent prognostic factor for cervical cancer patients receiving neoadjuvant chemotherapy for locally advanced disease

BACKGROUND

To investigate whether poor glycemic control status has a negative impact on survival outcomes and tumor response to chemotherapy in patients receiving neoadjuvant chemotherapy (NACT) for locally advanced cervical cancer (LACC).

METHODS

A retrospective cohort study was conducted to examine LACC patients undergoing NACT and radical hysterectomy between 2002 and 2011. Patients were divided into three groups: patients without diabetes mellitus (DM), diabetic patients with good glycemic control, and diabetic patients with poor glycemic control. Hemoglobin A_1c (HbA_1c) levels were used to indicate glycemic control status. Recurrence-free survival (RFS), cancer-specific survival (CSS) and overall survival (OS) were analyzed using log-rank tests and Cox proportional hazards models.

RESULTS

In total, 388 patients were included and had a median follow-up time of 39 months (range: 4-67 months). Diabetes mellitus (DM) was diagnosed in 89 (22.9%) patients, only 35 (39.3%) of whom had good glycemic control prior to NACT (HbA_1c < 7.0%). In survival analysis, compared with patients with good glycemic control and patients without DM, patients with poor glycemic control (HbA_1c ≥ 7.0%) exhibited decreased recurrence-free survival (RFS), cancer-specific survival (CSS) and overall survival (OS). In multivariate analysis, HbA_1c ≥ 7.0% was identified as an independent predictor for decreased RFS (hazard ratio [HR] = 3.33, P < 0.0001), CSS (HR = 3.60, P < 0.0001) and OS (HR = 4.35, P < 0.0001). In the subgroup of diabetic patients, HbA_1c ≥ 7.0% prior to NACT had an independent negative effect on RFS (HR = 2.18, P = 0.044) and OS (HR = 2.29, P = 0.012). When examined as a continuous variable, the HbA_1c level was independently associated with decreased RFS (HR = 1.39, P = 0.002), CSS (HR = 1.28, P = 0.021) and OS (HR = 1.27, P = 0.004). Both good (odds ratio [OR] = 0.06, P < 0.0001) and poor glycemic control (OR = 0.04, P < 0.0001) were independently associated with a decreased likelihood of complete response following NACT.

CONCLUSIONS

Poor glycemic control is an independent predictor of survival and tumor response to chemotherapy for patients receiving NACT for LACC.

Diabetes, prostate cancer screening and risk of low- and high-grade prostate cancer: an 11 year historical population follow-up study of more than 1 million men

AIMS/HYPOTHESIS

An inverse association has consistently been shown between diabetes and prostate cancer incidence. We investigated whether lower prostate cancer incidence among men with diabetes is attributable to lower detection due to prostate cancer screening patterns.

METHODS

We studied a population-based historical cohort of 1,034,074 Israeli men aged 21-90 years, without a previous history of cancer. The cohort was followed-up from 2002 to 2012, according to diabetes morbidity, for frequency of prostate-specific antigen (PSA) testing, mean PSA values and detection of prostate cancer, after adjustment for age, ethnic origin, socioeconomic status and PSA testing.

RESULTS

In January 2002, 74,756 men had prevalent diabetes. During the 11 year follow-up, 765,483 (74%) remained diabetes-free and 193,835 developed diabetes. Approximately 10% more PSA screening was performed in men with than without diabetes, but the rate of PSA positivity (>4 μg/l) was 20% lower in men with diabetes. PSA values were already significantly lower in men who developed diabetes than in those who did not, 3 years before diabetes diagnosis. Reduced prostate cancer risk was observed among men with incident diabetes only for low-moderate grade tumours (Gleason score 2-6: adjusted HR 0.83; 95% CI 0.77, 0.89). No association was observed for high-grade tumours (Gleason score 7-10: HR 0.99; 95% CI 0.88, 1.11).

CONCLUSIONS/INTERPRETATION

Our findings suggest that diabetes comorbidity is a factor to be considered in prostate cancer screening strategies, and specifically in the interpretation of PSA levels. Furthermore, our demonstration of reduced incidence of low-moderate grade but not high-grade prostate cancer tumours among men with diabetes supports the possibility that low PSA levels, rather than lower tumour risk, explains the observed reduced incidence of prostate cancer in men with diabetes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02072902.