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Vázquez-Ibarra KC, Sánchez López JY, Pineda Razo TD, Cruz Lozano JR, Ortiz-Tamayo BG, Palafox-Mariscal LA, González Arreola RM, González-García JR, Ortiz-Lazareno PC. Metformin in combination with chemotherapy increases apoptosis in gastric cancer cells and counteracts senescence induced by chemotherapy. Oncol Lett 2024; 28:457. [PMID: 39114572 PMCID: PMC11304395 DOI: 10.3892/ol.2024.14590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 06/10/2024] [Indexed: 08/10/2024] Open
Abstract
Gastric cancer (GC) is the fourth leading cause of cancer death in the world, and there is a demand for new therapeutic agents to treat GC. Metformin has been demonstrated to be an antineoplastic agent in some types of cancer; however, it has not been sufficiently valued in treating GC because the effect of metformin in combination with chemotherapy regimens has not yet been evaluated. The present study aimed to evaluate the mechanisms underlying cell death induced by metformin alone or when combined with chemotherapy. The cytogenetic characteristics of the NCI-N87 cell line were determined by fluorescence in situ hybridization (FISH). To determine viability, the cells were treated with metformin, epirubicin, cisplatin, docetaxel and 5-fluorouracil (individually and at different concentrations). Subsequently, the cells were treated with metformin alone, and in combination with the chemotherapeutic drugs and the epirubicin + cisplatin + 5-fluorouracil, docetaxel + cisplatin + 5-fluorouracil, and cisplatin + 5-fluorouracil regimens. Cell viability, proliferation and mitochondrial membrane potential (ΔΨm) were analyzed by spectrophotometry. Apoptosis, caspase activity and cell cycle progression were assessed by flow cytometry. Finally, light microscopy was used to evaluate senescence and clonogenicity. The results revealed that metformin, alone and when combined with chemotherapy, increased the proportion of apoptotic cells, promoted the loss of ΔΨm, and induced apoptosis through caspase activity in GC cells. Moreover, metformin decreased cell proliferation. In addition, metformin alone did not induce senescence and it counteracted the effects of chemotherapy-induced senescence in GC cells. Additionally, metformin, alone and when combined with chemotherapy, decreased the clonogenic capacity of NCI-N87 GC cells. In conclusion, metformin may increase the effects of chemotherapy on NCI-N87 cell death and could represent an option to improve the treatment of GC.
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Affiliation(s)
- Katia Carolina Vázquez-Ibarra
- Department of Molecular Biology and Genomics, University Center for Health Sciences, University of Guadalajara, Guadalajara, Jalisco 44340, Mexico
| | - Josefina Yoaly Sánchez López
- Genetic Division, Western Biomedical Research Center, Mexican Social Security Institute, Guadalajara, Jalisco, 44340, Mexico
| | - Tomás Daniel Pineda Razo
- Medical Oncology Service, Western National Medical Center, Mexican Social Security Institute, Guadalajara, Jalisco 44329, Mexico
| | - José Roberto Cruz Lozano
- Department of Physiology, University Center for Health Sciences, University of Guadalajara, Guadalajara, Jalisco 44340, Mexico
| | - Brenda Guadalupe Ortiz-Tamayo
- Division of Biological and Environmental Sciences, University Center of Biological and Agricultural Sciences, University of Guadalajara, Guadalajara, Jalisco 44600, Mexico
| | - Luis Arturo Palafox-Mariscal
- Department of Physiology, University Center for Health Sciences, University of Guadalajara, Guadalajara, Jalisco 44340, Mexico
| | - Rosa María González Arreola
- Department of Molecular Biology and Genomics, University Center for Health Sciences, University of Guadalajara, Guadalajara, Jalisco 44340, Mexico
| | - Juan Ramón González-García
- Genetic Division, Western Biomedical Research Center, Mexican Social Security Institute, Guadalajara, Jalisco, 44340, Mexico
| | - Pablo Cesar Ortiz-Lazareno
- Immunology Division, Western Biomedical Research Center, Mexican Social Security Institute, Guadalajara, Jalisco 44340, Mexico
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Bahardoust M, Mousavi S, Moezi ZD, Yarali M, Tayebi A, Olamaeian F, Tizmaghz A. Effect of Metformin Use on Survival and Recurrence Rate of Gastric Cancer After Gastrectomy in Diabetic Patients: A Systematic Review and Meta-analysis of Observational Studies. J Gastrointest Cancer 2024; 55:65-76. [PMID: 37526857 DOI: 10.1007/s12029-023-00955-y] [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] [Accepted: 06/24/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND Gastric cancer (GC) is one of the most common worldwide cancers and causes of death. Various studies have investigated the effect of metformin on overall survival (OS), cancer-specific survival (CSS), recurrence-free survival (RFS), and recurrence rate in diabetic patients after gastrectomy, and their results have been contradictory. This meta-analysis aimed to evaluate the effect of metformin use compared to sulfonylurea compounds with OS, CSS, RFS, and recurrence rate after gastrectomy in diabetic patients. METHODS We reviewed the Scopus, Google Scholar, PubMed, Web of Science, and Embassy databases until September 2022 based on appropriate MESH terms. All observational studies that evaluated the effect of metformin on survival in diabetic patients who underwent surgery for GC were included. The hazard ratio (HR) with a 95% confidence interval was used to estimate the effect size. The Egger test was used to evaluate publication bias. RESULTS Overall, nine studies, including 245,387 GC patients who underwent surgery, were included. The use of metformin significantly increased the OS rate (HR: 0.81, 95% CI: 0.78, 0.86, P: 0.001, I2: 4.5%), CSS rate (HR: 0.72, 95% CI: 0.63, 0.81, P: 0.011, I2 = 0%), and RFS rate (HR: 719, 95% CI: 0.524, 0.986, P: 0.001) and decreased the recurrence rate after gastrectomy (HR: 0.83, 95% CI: 0.77, 0.87, P: 0.001, I2: 0%). The use of metformin was significantly associated with a greater increase in OS and CSS rate and a greater decrease in recurrence rate in the Asian population than in the Western population. CONCLUSION The use of metformin in diabetic patients with GC can be associated with improved OS, CSS, RFS, and reduced recurrence rate after gastrectomy, especially in the Asian population.
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Affiliation(s)
- Mansour Bahardoust
- Department of Epidemiology, School of Public Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Safa Mousavi
- Department of Public Health, College of Health and Human Services, California State University, Fresno, CA, USA
| | - Zahra Deylami Moezi
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohsen Yarali
- School of Medicine, Kashan University of Medical Sciences, Kashan, Iran
| | - Ali Tayebi
- Department of General Surgery, School of Medicine, Firoozabadi Clinical Research Development Unit (FACRDU), Iran University of Medical Sciences, Tehran, Iran.
| | - Faranak Olamaeian
- Department of General Surgery, School of Medicine, Firoozabadi Clinical Research Development Unit (FACRDU), Iran University of Medical Sciences, Tehran, Iran
| | - Adnan Tizmaghz
- Department of General Surgery, School of Medicine, Firoozabadi Clinical Research Development Unit (FACRDU), Iran University of Medical Sciences, Tehran, Iran.
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Gaertner F, Preissner S, Heiland M, Preissner R, Wüster J. Beneficial Effect of Metformin on the Five-Year Survival in about 40,000 Patients with Head and Neck Cancer. Cancers (Basel) 2024; 16:982. [PMID: 38473343 DOI: 10.3390/cancers16050982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 02/24/2024] [Accepted: 02/26/2024] [Indexed: 03/14/2024] Open
Abstract
INTRODUCTION Even in times of new therapy regimes, the overall survival of patients with head and neck cancer remains low. Since the previous studies showed the beneficial effect of metformin medication on the survival of patients with cancer, our objective was to investigate if-and in which way-metformin medication affects the overall survival of patients with head and neck cancer. METHODS Clinical data pertaining to patients diagnosed with head and neck cancer (International Classification of Diseases 10 codes C00-C14, C31, and C32) were retrospectively retrieved from the TriNetX network (TriNetX, Cambridge, MA, USA). The initial cohort extracted from the network was stratified into two groups: patients on metformin medication (cohort I), and individuals not on metformin medication (cohort II). The matching criteria included age, gender, BMI, type 2 diabetes, and risk factors, such as nicotine and alcohol abuse/dependence. Kaplan-Meier analysis, risk analysis, and the calculation of odds and hazard ratios were conducted. Additionally, the Hemoglobin A1c values were subject to analysis. RESULTS Following matching, each cohort comprised 20,416 patients. Cohort I exhibited a higher five-year survival rate at 75.3%, in contrast to cohort II, which registered a rate of 69.8%. The odds ratio was 0.79 (95% CI = 0.75-0.83), and the hazard ratio was 0.78 (95% CI = 0.75-0.82). CONCLUSION Metformin medication may correlate with improved five-year survival rates in patients with head and neck cancer. Since potentially influencing factors such as comorbidities and the initial tumor stage were not available, the results of our retrospectively conducted study must be interpreted with caution.
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Affiliation(s)
- Florian Gaertner
- Department of Oral and Maxillofacial Surgery, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Saskia Preissner
- Department of Oral and Maxillofacial Surgery, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Max Heiland
- Department of Oral and Maxillofacial Surgery, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Robert Preissner
- Institute of Physiology and Science-IT, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Philippstr. 12, 10115 Berlin, Germany
| | - Jonas Wüster
- Department of Oral and Maxillofacial Surgery, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353 Berlin, Germany
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Wang L, Zhang Z. Diabetes Mellitus and Gastric Cancer: Correlation and Potential Mechanisms. J Diabetes Res 2023; 2023:4388437. [PMID: 38020199 PMCID: PMC10653978 DOI: 10.1155/2023/4388437] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 10/22/2023] [Accepted: 10/27/2023] [Indexed: 12/01/2023] Open
Abstract
This review summarizes the correlation between diabetes mellitus (DM) and gastric cancer (GC) from the perspectives of epidemiology, drug use, and potential mechanisms. The association between DM and GC is inconclusive, and the positive direction of the association reported in most published meta-analyses suggests that DM may be an independent risk factor for GC. Many clinical investigations have shown that people with DM and GC who undergo gastrectomy may have better glycemic control. The potential link between DM and GC may involve the interaction of multiple common risk factors, such as obesity, hyperglycemia and hyperinsulinemia, H. pylori infection, and the use of metformin. Although in vitro and in vivo data support that H. pylori infection status and metformin can influence GC risk in DM patients, there are conflicting results. Patient survival outcomes are influenced by multiple factors, so further research is needed to identify the patients who may benefit.
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Affiliation(s)
- Li Wang
- Department of Emergency, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310052, China
- Zhejiang Provincial Critical Research Center for Emergency Medicine Clinic, Hangzhou 310052, China
- Key Laboratory of Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Hangzhou 310052, China
| | - Zhe Zhang
- Department of Emergency Medicine, The First People's Hospital of Linping District, 311100, Hangzhou, Zhejiang, China
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Maeda Y, Eto K, Yoshida N, Iwatsuki M, Iwagami S, Ogawa K, Sawayama H, Baba Y, Miyamoto Y, Baba H. The 5-factor modified frailty index is a novel predictive marker of death from other diseases after curative gastrectomy for gastric cancer. Geriatr Gerontol Int 2023; 23:750-756. [PMID: 37596938 DOI: 10.1111/ggi.14648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 06/23/2023] [Accepted: 07/14/2023] [Indexed: 08/21/2023]
Abstract
AIM The 5-factor modified frailty index (MFI-5) is a stratification tool to evaluate a patient's frailty. This study determined whether the MFI-5 is associated with short- and long-term outcomes after curative gastrectomy in patients with gastric cancer. METHODS We retrospectively reviewed 447 consecutive patients who underwent curative gastrectomy, and evaluated their overall survival (OS), relapse-free survival (RFS) and cancer-specific survival. RESULTS A total of 75 patients (16.8%) had high MFI-5 scores (MFI-5 ≥3). A high MFI-5 score was significantly associated with advanced age, male sex and severe postoperative complications. Patients with high MFI-5 scores had significantly poorer OS and RFS than those with low MFI-5 scores (5-year OS, 80.3% vs 59.7%, P < 0.01; 5-year RFS, 77.4% vs 54.9%, P < 0.01). Additionally, a high MFI-5 score was an independent predictor for OS (hazard ratio 1.69, 95% CI 1.09-2.61; P = 0.02) and RFS (hazard ratio, 1.80, 95% CI 1.19-2.74; P = 0.01). However, cancer-specific survival was not significantly different between the two groups. CONCLUSIONS The MFI-5 score can be predictive of postoperative morbidity and deaths from other disease after curative gastrectomy after curative gastrectomy for gastric cancer. Geriatr Gerontol Int 2023; 23: 750-756.
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Affiliation(s)
- Yuto Maeda
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Kojiro Eto
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Naoya Yoshida
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Masaaki Iwatsuki
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Shiro Iwagami
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Katsuhiro Ogawa
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Hiroshi Sawayama
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Yoshifumi Baba
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Yuji Miyamoto
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Hideo Baba
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
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Joo JH, Zhang HS, Chun J, Park EC, Park S. Association of Metformin Treatment with Risk for Death in Diabetic Patients with Concomitant Gastric Cancer. Cancers (Basel) 2023; 15:4134. [PMID: 37627162 PMCID: PMC10452498 DOI: 10.3390/cancers15164134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 08/06/2023] [Accepted: 08/13/2023] [Indexed: 08/27/2023] Open
Abstract
IMPORTANCE Despite the existing guideline's recommendation of metformin therapy as the initial approach for managing diabetes mellitus (DM), there remains a scarcity of comprehensive documentation regarding metformin's impact on outcomes that are important for patients. OBJECTIVES The objective of this study was to assess the potential impact of metformin treatment on the risk of death in individuals diagnosed with both gastric cancer and pre-existing diabetes mellitus (DM); Design, Setting, and Participants: The study made use of a dataset encompassing nationwide health insurance claims, allowing for a retrospective analysis of all patients with a history of gastric cancer diagnosis (classified under International Classification of Diseases 10th Revision code: C16.X) spanning from 1 January 2002 to 31 December 2012. The primary objective was to observe death within a 5-year follow-up period. The study population comprised 63,664 individuals who fell into two categories: those treated with metformin (n = 29,548) and those who did not receive metformin treatment (n = 34,116). This classification was based on the initial treatment allocation following the diagnosis of gastric cancer. EXPOSURES Metformin treatment, comorbidities, concurrent medication, and procedural information. OUTCOMES All-cause death, disease-specific death, cardiovascular death. RESULTS During the 5-year follow-up period, the metformin treatment group exhibited a lower cumulative incidence of all-cause death (27.5%) in comparison to the group not receiving metformin treatment (32.8%). Furthermore, the relative hazards for all-cause death were significantly reduced in the metformin treatment group (HR: 0.80, 95% CI 0.78-0.82), indicating a lower risk of death when compared to the non-metformin group. In addition, metformin treatment was associated with lower occurrences of disease-specific death (related to gastric cancer) and cardiovascular death when compared to the group not undergoing metformin treatment. CONCLUSIONS The findings demonstrated that the use of metformin was effective at improving prognosis among gastric cancer patients documented with prior DM. In this population-based cohort study, metformin treatment was associated with reduced risk of mortality.
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Affiliation(s)
- Jae-Hong Joo
- Department of Public Health, Graduate School, Yonsei University, Seoul 03722, Republic of Korea; (J.-H.J.); (E.-C.P.)
- Institute of Health Services Research, Yonsei University, Seoul 03722, Republic of Korea
| | - Hyun-Soo Zhang
- Department of Public Health, Graduate School, Yonsei University, Seoul 03722, Republic of Korea; (J.-H.J.); (E.-C.P.)
- Department of Biostatistics, Graduate School of Public Health, Yonsei University, Seoul 03722, Republic of Korea
| | - Jiyeon Chun
- Department of Public Health, Graduate School, Yonsei University, Seoul 03722, Republic of Korea; (J.-H.J.); (E.-C.P.)
| | - Eun-Cheol Park
- Department of Public Health, Graduate School, Yonsei University, Seoul 03722, Republic of Korea; (J.-H.J.); (E.-C.P.)
- Institute of Health Services Research, Yonsei University, Seoul 03722, Republic of Korea
| | - Sohee Park
- Department of Public Health, Graduate School, Yonsei University, Seoul 03722, Republic of Korea; (J.-H.J.); (E.-C.P.)
- Department of Biostatistics, Graduate School of Public Health, Yonsei University, Seoul 03722, Republic of Korea
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Han R, Li J, Wang Y, He T, Zheng J, He Y. Low BMI patients with advanced EGFR mutation-positive NSCLC can get a better outcome from metformin plus EGFR-TKI as first-line therapy: A secondary analysis of a phase 2 randomized clinical trial. CHINESE MEDICAL JOURNAL PULMONARY AND CRITICAL CARE MEDICINE 2023; 1:119-124. [PMID: 39170825 PMCID: PMC11332817 DOI: 10.1016/j.pccm.2023.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Indexed: 08/23/2024]
Abstract
Background The synergistic association between metformin and epidermal growth factor receptor (EGFR)-tyrosine kinase inhibitors (TKIs) has been confirmed in in vitro studies. It is still controversial which patients can benefit from metformin plus EGFR-TKIs treatment. Body mass index (BMI) was proved to be independently associated with prolonged progression-free survival (PFS) and overall survival (OS). This study aimed to investigate whether BMI is associated with the synergistic effect of metformin and EGFR-TKIs in advanced EGFR mutation (EGFRm)-positive non-small cell lung cancer (NSCLC) among nondiabetic Asian population. Methods We performed a post hoc analysis of a prospective, double-blind phase II randomized clinical trial (COAST, NCT01864681), which enrolled 224 patients without diabetes with treatment-naïve stage IIIB-IV EGFRm NSCLC. We stratified patients into those with a high BMI (≥24 kg/m2) and those with a low BMI (<24 kg/m2) to allow an analysis of the difference in PFS and OS between the two groups. The PFS and OS were analyzed using Kaplan-Meier curves, and the differences between groups were compared using log-rank test. Results In the univariate analysis, patients who had a high BMI (n = 56) in the gefitinib + metformin group (n = 28) did not have a better PFS (8.84 months vs. 11.67 months; P = 0.351) or OS (15.58 months vs. 24.36 months; P = 0.095) than those in the gefitinib + placebo group (n = 28). Similar results were also observed in the low-BMI groups. Strikingly, in the metformin plus gefitinib group, patients who had low BMI (n = 69) showed significantly better OS than those with high BMI (24.89 months [95% CI, 20.68 months-not reached] vs. 15.58 months [95% CI, 13.78-31.53 months]; P = 0.007), but this difference was not observed in PFS (10.78 months vs. 8.84 months; P = 0.285). Conclusions Our study showed that nondiabetic Asian advanced NSCLC patients with EGFR mutations who have low BMI seem to get better OS from metformin plus EGFR-TKI treatment.
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Affiliation(s)
| | | | - Yubo Wang
- Department of Respiratory Disease, Daping Hospital, Army Medical University, Chongqing 400042, China
| | - Tingting He
- Department of Respiratory Disease, Daping Hospital, Army Medical University, Chongqing 400042, China
| | - Jie Zheng
- Department of Respiratory Disease, Daping Hospital, Army Medical University, Chongqing 400042, China
| | - Yong He
- Department of Respiratory Disease, Daping Hospital, Army Medical University, Chongqing 400042, China
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Mlicka A, Mlicki P, Niewiadomski P, Zielińska W, Hałas-Wiśniewska M, Izdebska M. Synergistic effect of metformin and doxorubicin on the metastatic potential of T24 cells. Acta Histochem 2023; 125:151975. [PMID: 36455340 DOI: 10.1016/j.acthis.2022.151975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 11/14/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND The motor ability of cancer cells to cross the basement membrane contributes to their implantation in a new location. Metastasis is a significant factor that worsens the prognosis of cancer patients. Thus, reducing cell invasiveness is an important aspect of anticancer therapy, also in bladder cancer treatment. MATERIAL The study material was the T24 cell line of human urinary bladder cancer. The migratory potential of the cells and the effect of the treatment with individually doses and synergistic combination of doxorubicin and metformin in the 500:1 ratio for 24 h were analyzed. RESULTS The results obtained show a compound-initiated decrease in the motor abilities of bladder cancer cells compared to controls. A decrease in the rate of colony formation was observed, as well as inhibition of migration through inserts. The visualized reorganization of the vimentin and actin networks confirms the drug-initiated limitation of the metastatic potential of T24 cells. CONCLUSION According to our knowledge, we are the first to show, that combination of doxorubicin and metformin also worth considering in the treatment of bladder cancer. We showed that simultaneous administration of these cytostatic enhances the antiproliferative effect of drugs, but also limits cells' migratory potential.
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Affiliation(s)
- Agnieszka Mlicka
- Students Research Group of Cell Biology and Ultrastructure at Department of Histology and Embryology, Nicolaus Copernicus University in Toruń, Collegium Medicum in Bydgoszcz, Poland
| | - Paweł Mlicki
- Students Research Group of Cell Biology and Ultrastructure at Department of Histology and Embryology, Nicolaus Copernicus University in Toruń, Collegium Medicum in Bydgoszcz, Poland
| | - Paweł Niewiadomski
- Students Research Group of Cell Biology and Ultrastructure at Department of Histology and Embryology, Nicolaus Copernicus University in Toruń, Collegium Medicum in Bydgoszcz, Poland
| | - Wioletta Zielińska
- Department of Histology and Embryology, Nicolaus Copernicus University in Toruń, Faculty of Medicine, Collegium Medicum in Bydgoszcz, Karłowicza 24, 85-092 Bydgoszcz, Poland
| | - Marta Hałas-Wiśniewska
- Department of Histology and Embryology, Nicolaus Copernicus University in Toruń, Faculty of Medicine, Collegium Medicum in Bydgoszcz, Karłowicza 24, 85-092 Bydgoszcz, Poland.
| | - Magdalena Izdebska
- Department of Histology and Embryology, Nicolaus Copernicus University in Toruń, Faculty of Medicine, Collegium Medicum in Bydgoszcz, Karłowicza 24, 85-092 Bydgoszcz, Poland; Students Research Group of Cell Biology and Ultrastructure at Department of Histology and Embryology, Nicolaus Copernicus University in Toruń, Collegium Medicum in Bydgoszcz, Poland
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9
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Li L, Huang J, Huang T, Yao J, Zhang Y, Chen M, Shentu H, Lou H. Effect of Metformin on the Prognosis of Gastric Cancer Patients with Type 2 Diabetes Mellitus: A Meta-Analysis Based on Retrospective Cohort Studies. Int J Endocrinol 2023; 2023:5892731. [PMID: 36915376 PMCID: PMC10008112 DOI: 10.1155/2023/5892731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 02/17/2023] [Accepted: 02/20/2023] [Indexed: 03/07/2023] Open
Abstract
BACKGROUND Metformin is one of the most common drugs for type 2 diabetes mellitus (T2DM) treatment. In addition, metformin intends to have a positive effect on the prognosis of several cancers. However, the therapeutic effect of metformin on gastric cancer (GC) remains controversial. This study explores and updates the therapeutic effect of metformin in GC patients with T2DM. METHODS We searched through PubMed, Embase, Web of Science, and the Cochrane Library for relevant articles by July 2022. The relationship between metformin therapy and the prognosis of GC patients with T2DM was evaluated based on the hazard ratio (HR) at a 95% confidence interval (95% CI). Overall survival (OS), cancer-specific survival (CSS), and progression-free survival (PFS) were the primary outcomes analyzed. RESULTS Seven retrospective cohort studies with a combined 2,858 patients met the inclusion criteria. OS and CSS were reported in six studies, and PFS was reported in four studies. Pooled results showed that, compared to the nonmetformin group, the prolonged OS (HR = 0.72, p = 0.001), CSS (HR = 0.81, p = 0.001), and PFS (HR = 0.70, p = 0.008) of the experimental group may be associated with the exposure to metformin. CONCLUSION Metformin may have a beneficial effect on the prognosis of GC patients with T2DM.
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Affiliation(s)
- Lingna Li
- Pharmacy Department, The Affiliated Hospital of Ningbo University, Li Huili Hospital, Ningbo, China
| | - Jianing Huang
- School of Public Health, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Tongmin Huang
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Jie Yao
- School of Public Health, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Yeyuan Zhang
- School of Public Health, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Meiling Chen
- School of Public Health, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Haojie Shentu
- School of Medical Imaging, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Haiying Lou
- Department of Endocrinology, Zhuji People's Hospital, Shaoxing, Zhejiang, China
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10
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Yang J, Yang H, Cao L, Yin Y, Shen Y, Zhu W. Prognostic value of metformin in cancers: An updated meta-analysis based on 80 cohort studies. Medicine (Baltimore) 2022; 101:e31799. [PMID: 36626437 PMCID: PMC9750609 DOI: 10.1097/md.0000000000031799] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Experiments have shown that metformin can inhibit cancer cell growth, but clinical observations have been inconsistent, so we pooled the currently available data to evaluate the impact of metformin on cancer survival and progression. METHODS PubMed, web of science, Embase, and Cochrane databases were searched. Pooled hazard ratios (HRs) were identified using a random-effects model to estimate the strength of the association between metformin and survival and progression in cancer patients. RESULTS We incorporated 80 articles published from all databases which satisfied the inclusion criterion. It showed that metformin was associated with better overall survival (hazard ratio [HR] = 0. 81; 95% confidence interval [CI]: [0.77-0.85]) and cancer-specific survival (HR = 0.79; 95% CI: [0.73-0.86]), and metformin was associated with progression-free survival (HR = 0.76; 95% CI: [0.66-0.87]). In patients with diabetes mellitus, the HR of overall survival was 0.79(95% CI: [0.75-0.83]), progression-free survival was 0.72(95% CI: [0.60-0.85]), and the cancer-specific survival was 0.76(95% CI: [0.68-0.86]). It was proposed that metformin can improve the prognosis of cancer patients with diabetes mellitus. CONCLUSION Based on cohort studies, metformin therapy has potential survival benefits for patients with malignancy, especially with the greatest benefits seen in breast cancer on overall survival, progression-free survival, and cancer-specific survival. And metformin also showed potential benefits in cancer-specific survival in colorectal and prostate cancer.
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Affiliation(s)
- Jing Yang
- Oncology Center, The Affiliated Jiangsu Shengze Hospital of Nanjing Medical University, Wujiang, Jiangsu Province, P.R. China
| | - Hang Yang
- Oncology Center, The Affiliated Jiangsu Shengze Hospital of Nanjing Medical University, Wujiang, Jiangsu Province, P.R. China
| | - Ling Cao
- Oncology Center, The Affiliated Jiangsu Shengze Hospital of Nanjing Medical University, Wujiang, Jiangsu Province, P.R. China
| | - Yuzhen Yin
- Oncology Center, The Affiliated Jiangsu Shengze Hospital of Nanjing Medical University, Wujiang, Jiangsu Province, P.R. China
| | - Ying Shen
- Department of Endocrinology, The Affiliated Jiangsu Shengze Hospital of Nanjing Medical University, Wujiang, Jiangsu Province, P.R. China
| | - Wei Zhu
- Department of Oncology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, P.R. China
- * Correspondence: Wei Zhu, Department of Oncology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province 210029, P.R. China (e-mail: )
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11
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Lan WH, Lin TY, Yeh JA, Feng CL, Hsu JT, Lin HJ, Kuo CJ, Lai CH. Mechanism Underlying Metformin Action and Its Potential to Reduce Gastric Cancer Risk. Int J Mol Sci 2022; 23:ijms232214163. [PMID: 36430639 PMCID: PMC9695469 DOI: 10.3390/ijms232214163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 11/10/2022] [Accepted: 11/11/2022] [Indexed: 11/18/2022] Open
Abstract
Diabetes mellitus is associated with a high risk of developing gastric cancer (GC). Metformin, which is conventionally used to treat type 2 diabetes, induces AMP-activated protein kinase signaling and suppresses gluconeogenesis. Recent studies have reported that metformin is associated with beneficial effects in cancer prevention and treatment owing to its anti-tumor effects. This makes metformin a potential medication for GC therapy. However, contradicting reports have emerged regarding the efficacy of metformin in reducing the risk of GC. This review summarizes the impact of metformin on mitigating GC risk by analyzing clinical databases. The mechanism underlying the anti-tumor effect of metformin on GC is also discussed.
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Affiliation(s)
- Wen-Hsi Lan
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
- Department of Microbiology and Immunology, Graduate Institute of Biomedical Sciences, Chang Gung University, Taoyuan 33302, Taiwan
| | - Ting-Yu Lin
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
- Department of Microbiology and Immunology, Graduate Institute of Biomedical Sciences, Chang Gung University, Taoyuan 33302, Taiwan
| | - Jia-Ai Yeh
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
- Department of Microbiology and Immunology, Graduate Institute of Biomedical Sciences, Chang Gung University, Taoyuan 33302, Taiwan
| | - Chun-Lung Feng
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, China Medical University Hsinchu Hospital, Hsinchu 30272, Taiwan
- Department of Internal Medicine, Department of Medical Research, School of Medicine, China Medical University and Hospital, Taichung 40402, Taiwan
| | - Jun-Te Hsu
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
- Department of General Surgery, Chang Gung Memorial Hospital at Linkou, Taoyuan 33305, Taiwan
| | - Hwai-Jeng Lin
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Shuang-Ho Hospital, New Taipei 23562, Taiwan
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
| | - Chia-Jung Kuo
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital at Linkou, Taoyuan 33305, Taiwan
- Chang Gung Microbiota Therapy Center, Chang Gung Memorial Hospital at Linkou, Taoyuan 33305, Taiwan
- Correspondence: (C.-J.K.); (C.-H.L.)
| | - Chih-Ho Lai
- Department of Microbiology and Immunology, Graduate Institute of Biomedical Sciences, Chang Gung University, Taoyuan 33302, Taiwan
- Department of Internal Medicine, Department of Medical Research, School of Medicine, China Medical University and Hospital, Taichung 40402, Taiwan
- Molecular Infectious Disease Research Center, Department of Pediatrics, Chang Gung Memorial Hospital at Linkou, Taoyuan 33305, Taiwan
- Department of Nursing, Asia University, Taichung 41354, Taiwan
- Correspondence: (C.-J.K.); (C.-H.L.)
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12
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Lyu T, Zhou H, Wang Y, Jiang M, Tao Q, Chen J, Guo Y, Zhang Q, Wang X, Guo X. High-dose metformin induces a low-glucose dependent genotoxic stress. Food Chem Toxicol 2022; 165:113129. [PMID: 35568294 DOI: 10.1016/j.fct.2022.113129] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 04/11/2022] [Accepted: 05/06/2022] [Indexed: 11/28/2022]
Abstract
Epidemiological studies have demonstrated that metformin (a cornerstone of diabetes treatment) has anticancer activity, but the underlying mechanism remains elusive. We aimed to investigate whether metformin elicits anticancer activity via increasing genotoxic stress, a state of increased genome damage that becomes tumor-suppressing if it goes beyond an intolerable threshold. We found that metformin (1-16 mM) suppressed proliferation and colony formation in a panel of cancer cell lines (HeLa, A375, A549 and QGY). Metformin induced a dose-dependent increase of genotoxic stress (including micronucleus, nucleoplasmic bridge and nuclear bud) and the increase of genotoxic stress correlated well with metformin's anticancer potential. Metformin deregulated the expression of BUBR1 and MAD2, two core genes of spindle assembly checkpoint (SAC) that surveillances chromosome segregation. Metformin had weakened antiproliferative effect and a corresponding attenuated genotoxic effect in HeLa cells cultured in high glucose (16 mg/ml). Meanwhile, metformin significantly increased genotoxicity in non-cancer cells (NCM460 and HUVECs). Metformin became non-genotoxic to HUVECs in high-glucose (8 and 16 mg/ml) conditions and reduced the genotoxicity of high glucose. Overall, these results infer a new mechanism of high-dose metformin, whereby low-glucose dependent genotoxic stress derived from SAC dysfunction might mediate some of the anticancer effect of this drug.
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Affiliation(s)
- Ting Lyu
- School of Life Sciences, Yunnan Normal University, Kunming, Yunnan, 650500, China
| | - Hongyuan Zhou
- School of Life Sciences, Yunnan Normal University, Kunming, Yunnan, 650500, China
| | - Yihui Wang
- School of Life Sciences, Yunnan Normal University, Kunming, Yunnan, 650500, China
| | - Minyan Jiang
- School of Life Sciences, Yunnan Normal University, Kunming, Yunnan, 650500, China
| | - Qian Tao
- School of Life Sciences, Yunnan Normal University, Kunming, Yunnan, 650500, China
| | - Juanlin Chen
- School of Life Sciences, Yunnan Normal University, Kunming, Yunnan, 650500, China
| | - Yitong Guo
- School of Life Sciences, Yunnan Normal University, Kunming, Yunnan, 650500, China
| | - Qiuping Zhang
- School of Life Sciences, Yunnan Normal University, Kunming, Yunnan, 650500, China
| | - Xu Wang
- School of Life Sciences, Yunnan Normal University, Kunming, Yunnan, 650500, China; The Engineering Research Center of Sustainable Development and Utilization of Biomass Energy, Yunnan Normal University, Kunming, Yunnan, 650500, China; Yunnan Environmental Mutagen Society, Kunming, Yunnan, 650500, China
| | - Xihan Guo
- School of Life Sciences, Yunnan Normal University, Kunming, Yunnan, 650500, China; The Engineering Research Center of Sustainable Development and Utilization of Biomass Energy, Yunnan Normal University, Kunming, Yunnan, 650500, China; Yunnan Environmental Mutagen Society, Kunming, Yunnan, 650500, China.
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13
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Remission of type 2 diabetes after gastrectomy for gastric cancer: diabetes prediction score. Gastric Cancer 2022; 25:265-274. [PMID: 34296379 DOI: 10.1007/s10120-021-01216-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 07/08/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although type 2 diabetes (T2D) remission after gastric cancer surgery has been reported, little is known about the predictors of postoperative T2D remission. METHODS This study used data from a nationwide cohort provided by the National Health Insurance Service in Korea. We developed a diabetes prediction (DP) score, which predicted postoperative T2D remissions using a logistic regression model based on preoperative variables. We applied machine-learning algorithms [random forest, XGboost, and least absolute shrinkage and selection operator (LASSO) regression] and compared their predictive performances with those of the DP score. RESULTS The DP score comprised five parameters: baseline body mass index (< 25 or ≥ 25 kg/m2), surgical procedures (subtotal or total gastrectomy), age (< 65 or ≥ 65 years), fasting plasma glucose levels (≤ 130 or > 130 mg/dL), and antidiabetic medications (combination therapy including sulfonylureas, combination therapy not including sulfonylureas, single sulfonylurea, or single non-sulfonylurea]). The DP score showed a clinically useful predictive performance for T2D remission at 3 years after surgery [training cohort: area under the receiver operating characteristics (AUROC) 0.73, 95% confidence interval (CI), 0.71-0.75; validation cohort: AUROC 0.72, 95% CI 0.69-0.75], which was comparable to that of the machine-learning models (random forest: AUROC 0.71, 95% CI 0.68-0.74; XGboost: AUROC 0.70, 95% CI 0.67-0.73; LASSO regression: AUROC 0.75, 95% CI 0.73-0.78 in the validation cohort). It also predicted the T2D remission at 6 and 9 years after surgery. CONCLUSIONS The DP score is a useful scoring system for predicting T2D remission after gastric cancer surgery.
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14
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Wang Z, Wei Y, Liu X, Li Z, Zhu G, Li Y, Wang K. Application value of hand-sewn anastomosis in totally laparoscopic total gastrectomy for gastric cancer. World J Surg Oncol 2021; 19:229. [PMID: 34348716 PMCID: PMC8340376 DOI: 10.1186/s12957-021-02249-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 04/21/2021] [Indexed: 12/14/2022] Open
Abstract
Background Digestive tract reconstruction in totally laparoscopic total gastrectomy can be divided into two types: instrument anastomosis and hand-sewn anastomosis. This study explored the feasibility and safety of hand-sewn sutures in esophagojejunostomy of totally laparoscopic total gastrectomy, compared with instrument anastomosis using an overlap linear cutter. Methods This retrospective cohort study was conducted from January 2017 to January 2020 at one institution. The clinical data of 50 patients who underwent totally laparoscopic total gastrectomy, with an average follow-up time of 12 months, were collected. The clinicopathologic data, short-term survival prognosis, and results of patients in the hand-sewn anastomosis (n=20) and the overlap anastomosis (n=30) groups were analyzed. Results There were no significant differences between the groups in sex, age, body mass index, American Society of Anesthesiologists score, tumor location, preoperative complications, abdominal operation history, tumor size, pTNM stage, blood loss, first postoperative liquid diet, exhaust time, or postoperative length of hospital stay. The hand-sewn anastomosis group had a significantly prolonged operation time (204±26.72min versus 190±20.90min, p=0.04) and anastomosis time (58±22.0min versus 46±15.97min, p=0.029), and a decreased operation cost (CNY 77,100±1700 versus CNY 71,900±1300, p<0.0001). Postoperative complications (dynamic ileus, abdominal infection, and pancreatic leakage) occurred in three patients (15%) in the hand-sewn anastomosis group and in four patients (13.3%) in the overlap anastomosis group (anastomotic leakage, anastomotic bleeding, dynamic ileus, and duodenal stump leakage). Conclusion The hand-sewn anastomosis method of esophagojejunostomy under totally laparoscopic total gastrectomy is safe and feasible and is an important supplement to linear and circular stapler anastomosis. It may be more convenient regarding obesity, a relatively high position of the anastomosis, edema of the esophageal wall, and short jejunal mesentery.
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Affiliation(s)
- Zeshen Wang
- Department of Gastrointestinal Surgery, Harbin Medical University Cancer Hospital, No.150, Haping Road, Nangang District, Harbin, 150086, Heilongjiang, China
| | - Yuzhe Wei
- Department of Gastrointestinal Surgery, Harbin Medical University Cancer Hospital, No.150, Haping Road, Nangang District, Harbin, 150086, Heilongjiang, China
| | - Xirui Liu
- Department of Gastrointestinal Surgery, Harbin Medical University Cancer Hospital, No.150, Haping Road, Nangang District, Harbin, 150086, Heilongjiang, China
| | - Zhenglong Li
- Department of Gastrointestinal Surgery, Harbin Medical University Cancer Hospital, No.150, Haping Road, Nangang District, Harbin, 150086, Heilongjiang, China
| | - Guanyu Zhu
- Department of Gastrointestinal Surgery, Harbin Medical University Cancer Hospital, No.150, Haping Road, Nangang District, Harbin, 150086, Heilongjiang, China
| | - Yanfeng Li
- Department of Gastrointestinal Surgery, Harbin Medical University Cancer Hospital, No.150, Haping Road, Nangang District, Harbin, 150086, Heilongjiang, China
| | - Kuan Wang
- Department of Gastrointestinal Surgery, Harbin Medical University Cancer Hospital, No.150, Haping Road, Nangang District, Harbin, 150086, Heilongjiang, China.
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15
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Zheng J, Santoni G, Xie SH, Lagergren J. Improved prognosis in gastric adenocarcinoma among metformin users in a population-based study. Br J Cancer 2021; 125:277-283. [PMID: 33972744 PMCID: PMC8292480 DOI: 10.1038/s41416-021-01408-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 04/07/2021] [Accepted: 04/15/2021] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Metformin may improve the prognosis in gastric adenocarcinoma, but the existing literature is limited and contradictory. METHODS This was a Swedish population-based cohort study of diabetes patients who were diagnosed with gastric adenocarcinoma in 2005-2018 and followed up until December 2019. The data were retrieved from four national health data registries: Prescribed Drug Registry, Cancer Registry, Patient Registry and Cause of Death Registry. Associations between metformin use before the gastric adenocarcinoma diagnosis and the risk of disease-specific and all-cause mortality were assessed using multivariable Cox proportional hazard regression. The hazard ratios (HRs) and 95% confidence intervals (CIs) were adjusted for sex, age, calendar year, comorbidity, use of non-steroidal anti-inflammatory drugs or aspirin, and use of statins. RESULTS Compared with non-users, metformin users had a decreased risk of disease-specific mortality (HR 0.79, 95% CI 0.67-0.93) and all-cause mortality (HR 0.78, 95% CI 0.68-0.90). The associations were seemingly stronger among patients of female sex (HR 0.66, 95% CI 0.49-0.89), patients with tumour stage III or IV (HR 0.71, 95% CI 0.58-0.88), and those with the least comorbidity (HR 0.71, 95% CI 0.57-0.89). CONCLUSIONS Metformin use may improve survival in gastric adenocarcinoma among diabetes patients.
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Affiliation(s)
- Jiaojiao Zheng
- grid.24381.3c0000 0000 9241 5705Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Giola Santoni
- grid.24381.3c0000 0000 9241 5705Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Shao-Hua Xie
- grid.24381.3c0000 0000 9241 5705Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Jesper Lagergren
- grid.24381.3c0000 0000 9241 5705Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden ,grid.13097.3c0000 0001 2322 6764School of Cancer and Pharmaceutical Sciences, King’s College London, London, UK
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16
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Tseng CH. The Relationship between Diabetes Mellitus and Gastric Cancer and the Potential Benefits of Metformin: An Extensive Review of the Literature. Biomolecules 2021; 11:biom11071022. [PMID: 34356646 PMCID: PMC8301937 DOI: 10.3390/biom11071022] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 07/02/2021] [Accepted: 07/08/2021] [Indexed: 12/14/2022] Open
Abstract
The objective of this review is to summarize the findings of published research that investigated the relationship between diabetes mellitus and gastric cancer (GCa) and the potential benefits of metformin on GCa. Related literature has been extensively reviewed, and findings from studies investigating the relationship between diabetes mellitus and GCa suggest that hyperglycemia, hyperinsulinemia and insulin resistance are closely related to the development of GCa. Although not supported by all, most observational studies suggest an increased risk of GCa in patients with type 2 diabetes mellitus, especially in women and in Asian populations. Incidence of second primary malignancy diagnosed after GCa is significantly higher in diabetes patients. Diabetes patients with GCa may have more complications after gastrectomy or chemotherapy and they may have a poorer prognosis than patients with GCa but without diabetes mellitus. However, glycemic control may improve in the diabetes patients with GCa after receiving gastrectomy, especially after procedures that bypass the duodenum and proximal jejunum, such as Roux-en-Y gastric bypass or Billroth II reconstruction. The potential links between diabetes mellitus and GCa may involve the interactions with shared risk factors (e.g., obesity, hyperglycemia, hyperinsulinemia, insulin resistance, high salt intake, smoking, etc.), Helicobacter pylori (HP) infection, medications (e.g., insulin, metformin, statins, aspirin, proton pump inhibitors, antibiotics, etc.) and comorbidities (e.g., hypertension, dyslipidemia, vascular complications, heart failure, renal failure, etc.). With regards to the potential benefits of metformin on GCa, results of most observational studies suggest a reduced risk of GCa associated with metformin use in patients with T2DM, which can be supported by evidence derived from many in vitro and animal studies. Metformin use may also reduce the risk of HP infection, an important risk factor of GCa. In patients with GCa, metformin users may have improved survival and reduced recurrence. More studies are required to clarify the pathological subtypes/anatomical sites of GCa associated with type 2 diabetes mellitus or prevented by metformin, to confirm whether GCa risk can also be increased in patients with type 1 diabetes mellitus and to explore the possible role of gastric microbiota in the development of GCa.
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Affiliation(s)
- Chin-Hsiao Tseng
- Department of Internal Medicine, National Taiwan University College of Medicine, Taipei 10051, Taiwan; ; Tel.: +886-2-2388-3578
- Division of Endocrinology and Metabolism, Department of Internal Medicine, National Taiwan University Hospital, Taipei 10051, Taiwan
- Division of Environmental Health and Occupational Medicine, National Health Research Institutes, Zhunan 350, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital, No. 7 Chung-Shan South Road, Taipei 100, Taiwan
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Fiala O, Ostašov P, Rozsypalová A, Hora M, Šorejs O, Šustr J, Bendová B, Trávníček I, Filipovský J, Fínek J, Büchler T. Metformin Use and the Outcome of Metastatic Renal Cell Carcinoma Treated with Sunitinib or Pazopanib. Cancer Manag Res 2021; 13:4077-4086. [PMID: 34054309 PMCID: PMC8153069 DOI: 10.2147/cmar.s305321] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 04/10/2021] [Indexed: 12/25/2022] Open
Abstract
Background The anticancer properties of metformin have been suggested in numerous experimental studies and several retrospective clinical studies show that its use is associated with improved outcome of patients with cancer. However, limited data are available for patients with metastatic renal cell carcinoma (mRCC) treated with targeted therapy. The aim of this retrospective study was to assess the impact of the metformin use on survival of mRCC patients treated with sunitinib or pazopanib. Methods Clinical data from 343 patients with mRCC treated with sunitinib or pazopanib in the first line were analyzed. Progression-free survival (PFS) and overall survival (OS) were compared according to the use of metformin. Results The median PFS and OS for patients using metformin was 31.1 (95% CI 20.6–35.1) and 51.6 (95% CI 44.7-NR) months compared to 9.3 (95% CI 8.0–12.0) and 22.4 (95% CI 19.4–26.8) months for patients not using metformin (p<0.0001 and p=0.0002, respectively). Cox multivariate analysis shows that the use of metformin remains a significant factor for PFS (HR=0.55 [95% CI 0.343–0.883], p=0.013) and also for OS (HR=0.45 [95% CI 0.256–0.794], p=0.006). Conclusion The present study results suggest that the use of metformin was associated with favorable outcome of mRCC patients treated with sunitinib or pazopanib.
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Affiliation(s)
- Ondřej Fiala
- Department of Oncology and Radiotherapy, Faculty of Medicine and University Hospital in Pilsen, Charles University, Pilsen, Czech Republic.,Laboratory of Cancer Treatment and Tissue Regeneration, Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech, Czech Republic
| | - Pavel Ostašov
- Laboratory of Tumor Biology and Immunotherapy, Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech, Czech Republic
| | - Aneta Rozsypalová
- Department of Oncology, First Faculty of Medicine, Charles University and Thomayer Hospital, Prague, Czech Republic
| | - Milan Hora
- Department of Urology, Faculty of Medicine and University Hospital in Pilsen, Charles University, Pilsen, Czech Republic
| | - Ondřej Šorejs
- Department of Oncology and Radiotherapy, Faculty of Medicine and University Hospital in Pilsen, Charles University, Pilsen, Czech Republic.,Laboratory of Cancer Treatment and Tissue Regeneration, Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech, Czech Republic
| | - Jan Šustr
- Department of Oncology and Radiotherapy, Faculty of Medicine and University Hospital in Pilsen, Charles University, Pilsen, Czech Republic
| | - Barbora Bendová
- Department of Urology, Faculty of Medicine and University Hospital in Pilsen, Charles University, Pilsen, Czech Republic
| | - Ivan Trávníček
- Department of Urology, Faculty of Medicine and University Hospital in Pilsen, Charles University, Pilsen, Czech Republic
| | - Jan Filipovský
- 2nd Department of Internal Medicine, Faculty of Medicine and University Hospital in Pilsen, Charles University, Pilsen, Czech Republic
| | - Jindřich Fínek
- Department of Oncology and Radiotherapy, Faculty of Medicine and University Hospital in Pilsen, Charles University, Pilsen, Czech Republic
| | - Tomáš Büchler
- Department of Oncology, First Faculty of Medicine, Charles University and Thomayer Hospital, Prague, Czech Republic
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Cunha Júnior AD, Bragagnoli AC, Costa FO, Carvalheira JBC. Repurposing metformin for the treatment of gastrointestinal cancer. World J Gastroenterol 2021; 27:1883-1904. [PMID: 34007128 PMCID: PMC8108031 DOI: 10.3748/wjg.v27.i17.1883] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 03/13/2021] [Accepted: 04/07/2021] [Indexed: 02/06/2023] Open
Abstract
Diabetes mellitus type 2 and cancer share many risk factors. The pleiotropic insulin-dependent and insulin-independent effects of metformin might inhibit pathways that are frequently amplified in neoplastic tissue. Particularly, modulation of inflammation, metabolism, and cell cycle arrest are potential therapeutic cancer targets utilized by metformin to boost the anti-cancer effects of chemotherapy. Studies in vitro and in vivo models have demonstrated the potential of metformin as a chemo- and radiosensitizer, besides its chemopreventive and direct therapeutic activity in digestive system (DS) tumors. Hence, these aspects have been considered in many cancer clinical trials. Case-control and cohort studies and associated meta-analyses have evaluated DS cancer risk and metformin usage, especially in colorectal cancer, pancreatic cancer, and hepatocellular carcinoma. Most clinical studies have demonstrated the protective role of metformin in the risk for DS cancers and survival rates. On the other hand, the ability of metformin to enhance the actions of chemotherapy for gastric and biliary cancers is yet to be investigated. This article reviews the current findings on the anti-cancer mechanisms of metformin and its apparatus from pre-clinical and ongoing studies in DS malignancies.
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Affiliation(s)
- Ademar Dantas Cunha Júnior
- Department of Internal Medicine, Division of Oncology, University of Campinas (UNICAMP), Campinas 13083-970, São Paulo, Brazil
| | | | - Felipe Osório Costa
- Department of Internal Medicine, Division of Oncology, University of Campinas (UNICAMP), Campinas 13083-970, São Paulo, Brazil
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19
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Anticancer potential of metformin: focusing on gastrointestinal cancers. Cancer Chemother Pharmacol 2021; 87:587-598. [PMID: 33744985 DOI: 10.1007/s00280-021-04256-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 03/08/2021] [Indexed: 12/15/2022]
Abstract
Gastrointestinal cancers are one of the most common types of cancer that have high annual mortality; therefore, identification and introduction of safe drugs in the control and prevention of these cancers are of particular importance. Metformin, a lipophilic biguanide, is the most commonly prescribed agent for type 2 diabetes management. In addition to its great effects on lowering the blood glucose concentrations, the anti-cancer properties of this drug have been reported in many types of cancers such as gastrointestinal cancers. Hence the effects of this agent as a safe drug on the reduction of gastrointestinal cancer risk and suppression of these types of cancers have been studied in different clinical trials. Furthermore, the proposed mechanisms of metformin in preventing the growth of these cancers have been investigated in several studies. In this review, we discuss recent advances in elucidating the molecular mechanisms that are relevant for metformin use in gastrointestinal cancer treatment.
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20
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Leng W, Jiang J, Chen B, Wu Q. Metformin and Malignant Tumors: Not Over the Hill. Diabetes Metab Syndr Obes 2021; 14:3673-3689. [PMID: 34429626 PMCID: PMC8380287 DOI: 10.2147/dmso.s326378] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 08/06/2021] [Indexed: 12/11/2022] Open
Abstract
Malignant tumors are a major cause of death, and their incidence is increasing worldwide. Although the survival rate for some cancers has improved, treatments for other malignant tumors are limited, and their mortality rate continues to increase. People with type 2 diabetes have a higher risk of malignant tumors and a higher mortality rate than those without diabetes. Metformin is a commonly used hypoglycemic drug. In recent years, a growing number of studies have indicated that metformin has antitumor effects and increases the sensitivity of malignant tumors to chemotherapy. However, the effect of metformin on different tumors is currently controversial, and the mechanism of metformin's antitumor action is not fully understood. Insights into the effect of metformin on malignant tumors and the possible mechanism may contribute to the development of antitumor drugs.
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Affiliation(s)
- Weiling Leng
- Endocrinology Department, The First Affiliated Hospital of the Third Military Medical University (Army Medical University), Chongqing, People’s Republic of China
| | - Juan Jiang
- Endocrinology and Nephrology Department, Chongqing University Cancer Hospital and Chongqing Cancer Institute and Chongqing Cancer Hospital, Chongqing, People’s Republic of China
| | - Bing Chen
- Endocrinology Department, The First Affiliated Hospital of the Third Military Medical University (Army Medical University), Chongqing, People’s Republic of China
- Bing Chen Endocrinology Department, The First Affiliated Hospital of the Third Military Medical University (Army Medical University), Chongqing, People’s Republic of China Email
| | - Qinan Wu
- Endocrinology Department, Dazu Hospital of Chongqing Medical University, The People’s Hospital of Dazu, Chongqing, People’s Republic of China
- Correspondence: Qinan Wu Endocrinology Department, Dazu Hospital of Chongqing Medical University, The People’s Hospital of Dazu, Chongqing, People’s Republic of China Email
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21
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Soraya H, Sani NA, Jabbari N, Rezaie J. Metformin Increases Exosome Biogenesis and Secretion in U87 MG Human Glioblastoma Cells: A Possible Mechanism of Therapeutic Resistance. Arch Med Res 2020; 52:151-162. [PMID: 33059952 DOI: 10.1016/j.arcmed.2020.10.007] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 06/02/2020] [Accepted: 10/02/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Glioblastoma multiforme (GBM) is the most common and aggressive brain tumor. Metformin, an anti-diabetic drug, can suppress tumor cells. Exosomes from GBM cells contribute to intercellular communication, tumor aggressiveness, and therapeutic resistance. We studied the effect of metformin on the exosomal secretory pathway in U87 MG cells. METHODS Cell survival against metformin was investigated using MTT assay. Expression of miRNA-21, miRNA-155, and miRNA-182, as well as the genes involved in exosome biogenesis and secretion such as Rab27a, Rab27b, Rab11, CD63, and Alix were calculated by real time-PCR. The expression of CD63 protein was analyzed by western blotting, while the subcellular distribution of CD63 protein was monitored by flow cytometry. Exosomes were characterized by transmission and scanning electron microscopes, and flow cytometry. Amount of exosomes was assayed using acetylcholinesterase activity assay and ELISA. The expression of autophagic markers LC3 and P62 were assessed using ELISA. RESULTS Data showed that metformin decreased cell survival and expression of miRNA-21, miRNA-155, and miRNA-182 (p <0.05). Expression of Rab27a, Rab27b, Rab11, CD63, and Alix as well as protein level of CD63 up-regulated in treated cells (p <0.05). Concurrently, flow cytometry analysis showed that surface CD63/total CD63 ratio was increased in treated cells (p <0.05). We found that acetylcholinesterase activity and CD63 protein of exosomes from treated cells increased (p <0.05). The expression of LC3 and P62 was not affected by metformin (p >0.05). CONCLUSION Data indicates metformin could promote exosome biogenesis and secretion in U87 MG cells, proposing the therapeutic response against metformin.
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Affiliation(s)
- Hamid Soraya
- Solid Tumor Research Center, Cellular and Molecular Medicine Institute, Urmia University of Medical Sciences, Urmia, Iran
| | - Neda Abbaspour Sani
- Solid Tumor Research Center, Cellular and Molecular Medicine Institute, Urmia University of Medical Sciences, Urmia, Iran
| | - Nassrollah Jabbari
- Solid Tumor Research Center, Cellular and Molecular Medicine Institute, Urmia University of Medical Sciences, Urmia, Iran; Department of Medical Physics and Imaging, Urmia University of Medical Sciences, Urmia, Iran
| | - Jafar Rezaie
- Solid Tumor Research Center, Cellular and Molecular Medicine Institute, Urmia University of Medical Sciences, Urmia, Iran.
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22
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Zhang J, Wen L, Zhou Q, He K, Teng L. Preventative and Therapeutic Effects of Metformin in Gastric Cancer: A New Contribution of an Old Friend. Cancer Manag Res 2020; 12:8545-8554. [PMID: 32982447 PMCID: PMC7505710 DOI: 10.2147/cmar.s264032] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 08/19/2020] [Indexed: 12/18/2022] Open
Abstract
Gastric cancer (GC) is a cancer with high prevalence, and is one of the leading causes of cancer death worldwide. Metformin is a widely used hypoglycemic agent for type-2 diabetes mellitus (T2DM). Recently, metformin has drawn increasing attention in the field of cancer research for its emerging anti-cancer roles. However, the efficacy and underlying molecular mechanisms of metformin in the prevention and treatment for GC remain controversial. This review summarized the present clinical and mechanistic studies that investigated the efficacy of metformin in GC. It was found that the majority of clinical studies affirmed protective roles of metformin in both gastric cancer risk and survival rate. In addition, metformin’s effects in the prevention and treatment for GC involve multiple pathways mainly via AMPK and IGF-1R. It was concluded that metformin presents a unique opportunity for application against GC, but further clinical and mechanistic investigations are required to solidify the roles of metformin in GC.
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Affiliation(s)
- Jing Zhang
- Department of Surgical Oncology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
| | - Liping Wen
- Department of Surgical Oncology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
| | - Quan Zhou
- Department of Surgical Oncology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
| | - Kuifeng He
- Department of Surgical Oncology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
| | - Lisong Teng
- Department of Surgical Oncology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
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23
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Cho MH, Yoo TG, Jeong SM, Shin DW. Association of Aspirin, Metformin, and Statin Use with Gastric Cancer Incidence and Mortality: A Nationwide Cohort Study. Cancer Prev Res (Phila) 2020; 14:95-104. [PMID: 32938643 DOI: 10.1158/1940-6207.capr-20-0123] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 07/06/2020] [Accepted: 09/04/2020] [Indexed: 12/24/2022]
Abstract
Anticancer effects of aspirin, metformin, and statins against gastric cancer, one of the most common cancers in the world, have been reported. This retrospective cohort study aimed to investigate independent associations of aspirin, metformin, and statin use with gastric cancer incidence and mortality after adjustment for concomitant use of other drugs, using pooled cohort data extracted from the Korean National Health Insurance claim database. Follow-up started on January 1, 2004 and ended at the date of gastric cancer diagnosis, death, or December 31, 2013. Exposures to drugs were defined as cumulative duration of use for aspirin and cumulative defined daily dose for metformin and statin, and were entered as time-dependent variables in Cox analysis models to avoid immortal time bias. Use of aspirin for longer than 182.5 and 547.5 days during 2-year interval was associated with reduced risks of gastric cancer incidence and mortality, respectively. Patients with diabetes were at higher risk of gastric cancer incidence and mortality than nondiabetic people, regardless of metformin treatment. However, metformin use among patients with diabetes was associated with a reduction in gastric cancer mortality in a dose-response manner. Statin use was also associated with a reduction of gastric cancer mortality in the general population, but not with gastric cancer incidence. In conclusion, long-term use of aspirin was independently associated with reduced incidence and mortality of gastric cancer in the general population, but metformin or statin use was only associated with a reduction of gastric cancer mortality in patients with diabetes and in the general population, respectively. PREVENTION RELEVANCE: Long-term use of aspirin was independently associated with reduced incidence and mortality of gastric cancer in the general population. Metformin or statin use, however, was only associated with a reduction of gastric cancer mortality in diabetic patients and in the general population in a dose-response manner, respectively.
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Affiliation(s)
- Mi Hee Cho
- Samsung C&T Medical Clinic, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Jongno-gu, Seoul, Republic of Korea (South)
| | - Tae Gon Yoo
- Department of Family Medicine, Hongseong Medical Center, Hongseong-gun, Chungcheongnam-do, Republic of Korea (South)
| | - Su-Min Jeong
- Department of Family Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Gwanak-gu, Seoul, Republic of Korea (South)
- Department of Family Medicine, Seoul National University Health Service Center, Gwanak-gu, Seoul, Republic of Korea (South)
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Family Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Jongno-gu, Seoul, Republic of Korea (South)
| | - Dong Wook Shin
- Department of Family Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Jongno-gu, Seoul, Republic of Korea (South).
- Supportive Care Center, Samsung Comprehensive Cancer Center, Gangnam-gu, Seoul, Republic of Korea (South)
- Department of Digital Health, SAIHST, Sungkyunkwan University, Jongno-gu, Seoul, Republic of Korea (South)
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Chung WS, Le PH, Kuo CJ, Chen TH, Kuo CF, Chiou MJ, Chou WC, Yeh TS, Hsu JT. Impact of Metformin Use on Survival in Patients with Gastric Cancer and Diabetes Mellitus Following Gastrectomy. Cancers (Basel) 2020; 12:cancers12082013. [PMID: 32717852 PMCID: PMC7465508 DOI: 10.3390/cancers12082013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 07/15/2020] [Accepted: 07/21/2020] [Indexed: 12/19/2022] Open
Abstract
Studies have shown the anticancer effects of metformin in vitro. However, whether metformin can prevent cancer recurrence or prolong survival in patients with gastric cancer (GC) and diabetes mellitus (DM) post-gastrectomy remains unknown. We evaluated the beneficial effects of metformin in patients with GC and DM post-gastrectomy. We recruited 2400 patients with GC (1749 without DM, 651 with DM) who underwent surgery between 1997 and 2010. Patients with DM were stratified into metformin (group 1) and non-metformin (group 2) users. Their clinicopathological data were recorded prospectively, and demographics, recurrence-free survival (RFS), and cancer-specific survival (CSS) were compared. Tumour recurrence risk and cause of death were analysed between groups 1 and 2 among patients with DM stratified by tumour stage. We also compared RFS and overall survival among patients with and without DM. Tumour recurrence occurred in 201 patients with GC: 57 (25%) in group 1 and 144 (37%) in group 2. After adjusting for confounders, metformin significantly prolonged CSS (hazard ratio (HR) = 0.54, 95% confidence interval (CI) = 0.38-0.77) in patients with stage I-III GC and DM. In subgroup analysis, metformin users with stage III GC and DM had significantly prolonged CSS compared to non-metformin users (HR = 0.45, 95% CI = 0.30-0.68), with an insignificant difference in patients with stage I-II GC. Adjusted HRs for RFS and CSS were significantly lower in patients with stage I-III GC and DM than those in patients without DM (0.67 (95% CI = 0.54-0.92) and 0.62 (95% CI = 0.50-0.77), respectively), with an insignificant difference in patients with stage I GC. Metformin significantly reduces tumour recurrence risk and improves CSS in patients with stage III GC and DM post-gastrectomy. Further prospective studies may confirm the efficacy of metformin as an adjunctive treatment for advanced GC postoperatively.
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Affiliation(s)
- Wai-Shan Chung
- Department of General Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan 33305, Taiwan; (W.-S.C.); (T.-S.Y.)
| | - Po-Hsien Le
- Department of Gastroenterology, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan 33305, Taiwan; (P.-H.L.); (C.-J.K.); (T.-H.C.)
| | - Chiang-Jung Kuo
- Department of Gastroenterology, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan 33305, Taiwan; (P.-H.L.); (C.-J.K.); (T.-H.C.)
| | - Tsung-Hsing Chen
- Department of Gastroenterology, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan 33305, Taiwan; (P.-H.L.); (C.-J.K.); (T.-H.C.)
| | - Chang-Fu Kuo
- Department of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan 33305, Taiwan;
| | - Meng-Jiun Chiou
- Center for Artificial Intelligence in Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan 33305, Taiwan;
| | - Wen-Chi Chou
- Department of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan 33305, Taiwan;
| | - Ta-Sen Yeh
- Department of General Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan 33305, Taiwan; (W.-S.C.); (T.-S.Y.)
| | - Jun-Te Hsu
- Department of General Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan 33305, Taiwan; (W.-S.C.); (T.-S.Y.)
- Correspondence: ; Tel.: +886-3-3281200 (ext. 3219)
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25
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Guo J, Li Y, Duan H, Yuan L. Metformin Suppresses the Proliferation and Promotes the Apoptosis of Colon Cancer Cells Through Inhibiting the Expression of Long Noncoding RNA-UCA1. Onco Targets Ther 2020; 13:4169-4181. [PMID: 32523353 PMCID: PMC7234977 DOI: 10.2147/ott.s245091] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 04/28/2020] [Indexed: 12/17/2022] Open
Abstract
PURPOSE LncRNA-UCA1 has been proven to facilitate the proliferation and metastasis of colon cancer. Whether metformin inhibits the progression of colon cancer by suppressing lncRNA-UCA1 remains unknown. In this research, we aimed to explore the role of Metformin playing in pathogenesis of colon cancer. MATERIALS AND METHODS Using qRT-PCR, we measured the expression of five tumor-promoting lncRNAs in SW480 and SW620 colon cancer cells. Then, we conducted Western blotting and immunohistochemistry to evaluate the effects of MET or UCA1 knockdown or the combined MET+ UCA1 knockdown on the activities of the PI3K/AKT and ERK pathways in vitro and in tumor tissues obtained from tumor-bearing nude mice. RESULTS The results from CCK-8 assays showed that MET dose-dependently and time-dependently inhibited the viability of the colon cancer cells in vitro. Flow cytometry revealed that MET promoted the apoptosis of the SW480 and SW620 cells. qRT-PCR showed that lncRNA-UCA1 had the highest expression among the five lncRNAs. Suppressing UCA1 expression by siRNA or shRNA could further enhance the metformin-mediated anticancer effects against colon cancer in vitro and in vivo. Metformin decreased the UCA1 expression and further inhibited the proliferation and promoted the apoptosis of the colon cancer cells, which were associated with inactivation of the PI3K/AKT and ERK signaling pathways in vitro and in the tumor tissues obtained from the mice. CONCLUSION These results indicated that metformin has potential anticancer properties and revealed the anticancer mechanisms of metformin against colon cancer via regulating lncRNA-UCA1.
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Affiliation(s)
- Jianbo Guo
- Department of General Surgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, People’s Republic of China
| | - Yan Li
- Department of General Surgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, People’s Republic of China
| | - He Duan
- Department of General Surgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, People’s Republic of China
| | - Lu Yuan
- Department of General Surgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, People’s Republic of China
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26
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Miao ZF, Adkins-Threats M, Burclaff JR, Osaki LH, Sun JX, Kefalov Y, He Z, Wang ZN, Mills JC. A Metformin-Responsive Metabolic Pathway Controls Distinct Steps in Gastric Progenitor Fate Decisions and Maturation. Cell Stem Cell 2020; 26:910-925.e6. [PMID: 32243780 DOI: 10.1016/j.stem.2020.03.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 12/06/2019] [Accepted: 03/10/2020] [Indexed: 02/06/2023]
Abstract
Cellular metabolism plays important functions in dictating stem cell behaviors, although its role in stomach epithelial homeostasis has not been evaluated in depth. Here, we show that the energy sensor AMP kinase (AMPK) governs gastric epithelial progenitor differentiation. Administering the AMPK activator metformin decreases epithelial progenitor proliferation and increases acid-secreting parietal cells (PCs) in mice and organoids. AMPK activation targets Krüppel-like factor 4 (KLF4), known to govern progenitor proliferation and PC fate choice, and PGC1α, which we show controls PC maturation after their specification. PC-specific deletion of AMPKα or PGC1α causes defective PC maturation, which could not be rescued by metformin. However, metformin treatment still increases KLF4 levels and suppresses progenitor proliferation. Thus, AMPK activates KLF4 in progenitors to reduce self-renewal and promote PC fate, whereas AMPK-PGC1α activation within the PC lineage promotes maturation, providing a potential suggestion for why metformin increases acid secretion and reduces gastric cancer risk in humans.
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Affiliation(s)
- Zhi-Feng Miao
- Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA; Department of Surgical Oncology and General Surgery, Key Laboratory of Precision Diagnosis and Treatment of Gastrointestinal Tumors, First Hospital of China Medical University, Shenyang, China
| | - Mahliyah Adkins-Threats
- Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Joseph R Burclaff
- Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Luciana H Osaki
- Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Jing-Xu Sun
- Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA; Department of Surgical Oncology and General Surgery, Key Laboratory of Precision Diagnosis and Treatment of Gastrointestinal Tumors, First Hospital of China Medical University, Shenyang, China
| | - Yan Kefalov
- Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Zheng He
- Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA; Department of Radiation Oncology, First Hospital of China Medical University, Shenyang, China
| | - Zhen-Ning Wang
- Department of Surgical Oncology and General Surgery, Key Laboratory of Precision Diagnosis and Treatment of Gastrointestinal Tumors, First Hospital of China Medical University, Shenyang, China
| | - Jason C Mills
- Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA; Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA; Department of Developmental Biology, Washington University School of Medicine, St. Louis, MO, USA.
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27
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The Effect of Metformin on Prognosis in Patients With Locally Advanced Gastric Cancer Associated With Type 2 Diabetes Mellitus. Am J Clin Oncol 2020; 42:909-917. [PMID: 31693512 DOI: 10.1097/coc.0000000000000627] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES This study examined the effect of metformin use on the prognosis of gastric cancer patients. MATERIALS AND METHODS The study population comprised 2187 patients who underwent curative gastrectomy for the treatment of gastric cancer. They were divided into 3 groups: metformin (n=103), non-metformin (n=139), and non-diabetes mellitus (DM) (n=1945) according to their history of type 2 DM and metformin use. Survival, disease recurrence, and the pathologic stage were analyzed. RESULTS Overall survival was better in the metformin group than in the non-DM group (P=0.005). Metformin use was an independent prognostic factor of overall survival, cancer recurrence, and peritoneal recurrence. An effect of metformin use was especially notable in patients with T4 or N0 disease. CONCLUSIONS Metformin improves the survival of patients with gastric cancer and type 2 DM.
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28
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The effect of metformin on gastric cancer in patients with type 2 diabetes: a systematic review and meta-analysis. Clin Transl Oncol 2020; 22:1580-1590. [PMID: 32060719 DOI: 10.1007/s12094-020-02304-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Accepted: 01/18/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Metformin, a drug widely used in the treatment of diabetes, has proven preventive and survival benefits for various malignancies. However, the effect of metformin on gastric cancer risk and survival rate in T2DM patients remains controversial. Therefore, we conducted a systematic review and meta-analysis to evaluate the effect of metformin on gastric cancer in T2DM patients. METHODS We searched PubMed, EMBASE, Medline and the Cochrane Library for related studies up to October 22, 2019. Pooled hazard ratios with 95% confidence intervals were calculated using random-effects model. Heterogeneity was assessed. All articles were evaluated by Newcastle-Ottawa Scale. RESULTS A total of 11 cohort studies met eligibility criteria and were included in the meta-analysis. The use of metformin was related to a significant 21% reduction in GC incidence (HR 0.790; 95% CI 0.624-1.001). Subgroup analysis showed that the use of metformin significantly reduced the risk of gastric cancer in T2DM patients in Asian populations, but not in western populations. In a pooled analysis of 3 studies, metformin use was associated with increased overall survival rate (HR 0.817; 95% CI 0.600-1.113) and cancer-specific survival rate (HR 0.824; 95% CI 0.614-1.106) of T2DM patients. CONCLUSIONS Metformin could reduce the risk of gastric cancer in T2DM patients, particularly in Asian populations. However, it is debatable whether metformin use can improve the prognosis of gastric cancer in T2DM patients.
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Chen X, Chen Y, Li T, Jun L, Lin T, Hu Y, Huang H, Chen H, Liu H, Li T, Li G, Yu J. Impact of diabetes on prognosis of gastric cancer patients performed with gastrectomy. Chin J Cancer Res 2020; 32:631-644. [PMID: 33223758 PMCID: PMC7666786 DOI: 10.21147/j.issn.1000-9604.2020.05.08] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Objective This study aimed to determine the impact of type 2 diabetes mellitus (T2DM) on clinical outcomes of gastric cancer (GC) patients and explore whether metformin use and good glycemic control could reverse it. Methods Clinicopathologic data of consecutive GC patients who underwent gastrectomy at Nanfang Hospital between October 2004 and December 2015 were included. Propensity score matching (PSM) was performed to balance the important factors of the disease status between non-T2DM and T2DM group. The last follow-up time was January 2019. Results A total of 1,692 eligible patients (1,621 non-T2DM vs. 71 T2DM) were included. After PSM, non-T2DM group (n=139) and T2DM group (n=71) were more balanced in baseline variables. The 5-year cancer-specific survival (CSS) rate in T2DM group (47.0%) was inferior to that in non-T2DM group (58.0%), but did not reach statistical significance [hazard ratio (HR)=1.319, 95% confidence interval (95% CI): 0.868−2.005, P=0.192]. While the 5-year progress-free survival (PFS) rate of T2DM group (40.6%) is significantly worse than that in non-T2DM group (56.3%) (HR=1.516, 95% CI: 1.004−2.290, P=0.045). Univariate and multivariate analyses showed that T2DM was an independent risk factor for PFS but not for CSS. In T2DM group, metformin use subgroup was associated with superior 5-year CSS and PFS in compared with non-metformin use subgroup, although the difference was not statistically significant (5-year CSS: 48.0%vs. 45.4%, HR=0.680, 95% CI: 0.352−1.313, P=0.246; 5-year PFS: 43.5%vs. 35.7%, HR=0.763, 95% CI: 0.400−1.454, P=0.406). The 5-year CSS rate was 47.5% in good glycemic control subgroup and 44.1% in poor glycemic control subgroup (HR=0.826, 95% CI: 0.398−1.713, P=0.605). And both two subgroups yielded a similar 5-year PFS rate (42.2%vs. 36.3%, HR=0.908, 95% CI: 0.441−1.871, P=0.792).
Conclusions DM promoted disease progress of GC after gastrectomy but had not yet led to the significant discrepancy of CSS. For GC patients with T2DM, metformin use was associated with superior survival but without statistical significance, while better glycemic control could not improve the prognosis.
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Affiliation(s)
- Xinhua Chen
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Yuehong Chen
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Tao Li
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Luo Jun
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Tian Lin
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Yanfeng Hu
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Huilin Huang
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Hao Chen
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Hao Liu
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Tuanjie Li
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Guoxin Li
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Jiang Yu
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
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30
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Dulskas A, Patasius A, Linkeviciute-Ulinskiene D, Zabuliene L, Smailyte G. A cohort study of antihyperglycemic medication exposure and survival in patients with gastric cancer. Aging (Albany NY) 2019; 11:7197-7205. [PMID: 31518336 PMCID: PMC6756873 DOI: 10.18632/aging.102245] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 08/22/2019] [Indexed: 12/14/2022]
Abstract
Objective: We aimed to estimate survival in gastric cancer patients with type 2 diabetes mellitus (T2DM) using different antihyperglycemic medication. Methods: Patients with gastric cancer and diabetes between 2003-2013 were identified form The Lithuanian Cancer Registry and The National Health Insurance Fund database. Cohort members were classified into five groups: four groups of T2DM patients according to treatment: metformin users; metformin and other medication users; sulphonylurea users; insulin and other medication users; and non-diabetic group. Kaplan-Meier survival analysis and Cox proportional hazards models were used to estimate gastric cancer-specific survival and overall survival. Results: 8423 patients met eligibility criteria. Survival analysis showed no differences in gastric cancer-specific survival between non-diabetic and diabetic patient groups. Better survival was observed in the groups of patients using antihyperglycemic medication combinations with metformin, metformin alone or insulin. Lowest survival was observed in diabetic patients who were sulphonylurea users. Survival analysis comparing overall survival between non-diabetic and diabetic patients (p = 0.89) showed no evidence of survival difference between groups and survival differences between antihyperglycemic medication user groups were of borderline significance (p = 0.052). Conclusions: Antihyperglycemic medication use was not associated with a significant effect on survival in patients with gastric cancer and T2DM.
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Affiliation(s)
- Audrius Dulskas
- Department of Abdominal and General Surgery and Oncology, National Cancer Institute, Vilnius LT-08406, Lithuania.,University of Applied Sciences, Faculty of Health Care, Vilnius ELT-08303, Lithuania.,Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius LT-03101, Lithuania
| | - Ausvydas Patasius
- Laboratory of Cancer Epidemiology, National Cancer Institute, Vilnius LT-08406, Lithuania.,Institute of Health Sciences, Faculty of Medicine, Vilnius University, Vilnius LT-03101, Lithuania
| | | | - Lina Zabuliene
- Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius LT-03101, Lithuania
| | - Giedre Smailyte
- Laboratory of Cancer Epidemiology, National Cancer Institute, Vilnius LT-08406, Lithuania.,Institute of Health Sciences, Faculty of Medicine, Vilnius University, Vilnius LT-03101, Lithuania
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31
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Li L, Jiang L, Wang Y, Zhao Y, Zhang XJ, Wu G, Zhou X, Sun J, Bai J, Ren B, Tian K, Xu Z, Xiao HL, Zhou Q, Han R, Chen H, Wang H, Yang Z, Gao C, Cai S, He Y. Combination of Metformin and Gefitinib as First-Line Therapy for Nondiabetic Advanced NSCLC Patients with EGFR Mutations: A Randomized, Double-Blind Phase II Trial. Clin Cancer Res 2019; 25:6967-6975. [PMID: 31413010 DOI: 10.1158/1078-0432.ccr-19-0437] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 06/13/2019] [Accepted: 08/09/2019] [Indexed: 11/16/2022]
Abstract
PURPOSE Preclinical and retrospective studies suggested a role for metformin in sensitizing patients who have diabetes with non-small cell lung cancer (NSCLC) to EGFR tyrosine kinase inhibitors (TKIs). We therefore examined its effects in combination with gefitinib in patients without diabetes harboring EGFR mutations (EGFRm). PATIENTS AND METHODS A total of 224 patients without diabetes with treatment-naïve stage IIIB-IV EGFRm NSCLC were randomly assigned in a 1:1 ratio to receive gefitinib plus either metformin or placebo. The primary endpoint was progression-free survival (PFS) rate at 1 year and secondary endpoints included overall survival (OS), PFS, objective response rate (ORR), and safety. Serum levels of IL6 were also examined in an exploratory analysis. RESULTS The median duration of follow-up was 19.15 months. The estimated 1-year PFS rates were 41.2% [95% confidence interval (CI), 30.0-52.2] with gefitinib plus metformin and 42.9% (95% CI, 32.6-52.7) with gefitinib plus placebo (P = 0.6268). Median PFS (10.3 months vs. 11.4 months) and median OS (22.0 months vs. 27.5 months) were numerically lower in the metformin group, while ORRs were similar between the two arms (66% vs. 66.7%). No significant treatment group differences were detected across all subgroups with respect to PFS, including those with elevated levels of IL6. Metformin combined with gefitinib resulted in a remarkably higher incidence of diarrhea compared with the control arm (78.38% vs. 43.24%). CONCLUSIONS Our study showed that addition of metformin resulted in nonsignificantly worse outcomes and increased toxicity and hence does not support its concurrent use with first-line EGFR-TKI therapy in patients without diabetes with EGFRm NSCLC.
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Affiliation(s)
- Li Li
- Department of Respiratory Medicine, Daping Hospital, Army Medical University, Chongqing, China
| | - Liyan Jiang
- Department of Pulmonary Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yubo Wang
- Department of Respiratory Medicine, Daping Hospital, Army Medical University, Chongqing, China
| | - Yizhuo Zhao
- Department of Pulmonary Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Xiao-Ju Zhang
- Department of Pulmonary Medicine, People's Hospital of Henan Province, Zhengzhou, China
| | - Guoming Wu
- Department of Respiratory Medicine and Respiratory Intensive Care Unit, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Xiangdong Zhou
- Department of Respiratory Medicine, Southwest Hospital, Army Medical University, Chongqing, China
| | - Jianguo Sun
- Cancer Institute, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Jun Bai
- Department of Medical Oncology, People's Hospital of Shanxi Province, Xi'an, China
| | - Biyong Ren
- Cancer Center, Chongqing Three Gorges Central Hospital, Chongqing, China
| | - Kun Tian
- Department of Respiratory Medicine, General Hospital of Chengdu Military Region of PLA, Chengdu, China
| | - Zhi Xu
- Department of Respiratory Medicine and Respiratory Intensive Care Unit, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Hua-Liang Xiao
- Department of Pathology, Daping Hospital, Army Medical University, Chongqing, China
| | - Qi Zhou
- Department of Oncology, Fuling Center Hospital, Chongqing, China
| | - Rui Han
- Department of Respiratory Medicine, Daping Hospital, Army Medical University, Chongqing, China
| | - Hengyi Chen
- Department of Respiratory Medicine, Daping Hospital, Army Medical University, Chongqing, China
| | - Haidong Wang
- Department of Thoracic Surgery, Southwest Hospital, Army Medical University, Chongqing, China
| | - Zhenzhou Yang
- Department of Oncology, Daping Hospital, Army Medical University, Chongqing, China
| | - Chan Gao
- The Medical Department, 3D Medicines Inc., Shanghai, P.R. China
| | - Shangli Cai
- The Medical Department, 3D Medicines Inc., Shanghai, P.R. China
| | - Yong He
- Department of Respiratory Medicine, Daping Hospital, Army Medical University, Chongqing, China.
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32
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Thakur S, Daley B, Klubo-Gwiezdzinska J. The role of an anti-diabetic drug metformin in the treatment of endocrine tumors. J Mol Endocrinol 2019; 63:R17-R35. [PMID: 31307011 PMCID: PMC6938582 DOI: 10.1530/jme-19-0083] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 07/15/2019] [Indexed: 12/15/2022]
Abstract
Incidence of endocrine cancers is rising every year. Over the last decade, evidence has accumulated that demonstrates the anti-cancer effects of an anti-diabetic drug, metformin, in endocrine malignancies. We performed a literature review utilizing the PubMed, Medline and clinicaltrials.gov databases using the keyword 'metformin' plus the following terms: 'thyroid cancer', 'thyroid nodules', 'parathyroid', 'hyperparathyroidism', 'adrenal adenoma', 'Cushing syndrome', 'hyperaldosteronism', 'adrenocortical cancer', 'neuroendocrine tumor (NET)', 'pancreatic NET (pNET)', 'carcinoid', 'pituitary adenoma', 'pituitary neuroendocrine tumor (PitNET)', 'prolactinoma', 'pheochromocytoma/paraganglioma'. We found 37 studies describing the preclinical and clinical role of metformin in endocrine tumors. The available epidemiological data show an association between exposure of metformin and lower incidence of thyroid cancer and pNETs in diabetic patients. Metformin treatment has been associated with better response to cancer therapy in thyroid cancer and pNETs. Preclinical evidence suggests that the primary direct mechanisms of metformin action include inhibition of mitochondrial oxidative phosphorylation via inhibition of both mitochondrial complex I and mitochondrial glycerophosphate dehydrogenase, leading to metabolic stress. Decreased ATP production leads to an activation of a cellular energy sensor, AMPK, and subsequent downregulation of mTOR signaling pathway, which is associated with decreased cellular proliferation. We also describe several AMPK-independent mechanisms of metformin action, as well as the indirect mechanisms targeting insulin resistance. Overall, repositioning of metformin has emerged as a promising strategy for adjuvant therapy of endocrine tumors. The mechanisms of synergy between metformin and other anti-cancer agents need to be elucidated further to guide well-designed prospective trials on combination therapies in endocrine malignancies.
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Affiliation(s)
- Shilpa Thakur
- Metabolic Disease Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Brianna Daley
- Metabolic Disease Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Joanna Klubo-Gwiezdzinska
- Metabolic Disease Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
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33
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Courtois S, Lehours P, Bessède E. The therapeutic potential of metformin in gastric cancer. Gastric Cancer 2019; 22:653-662. [PMID: 30900101 DOI: 10.1007/s10120-019-00952-w] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 03/11/2019] [Indexed: 02/07/2023]
Abstract
Metformin is a biguanide molecule used since 1957 to treat type 2 diabetes patients. In addition to its hypoglycemic effects, epidemiological studies have shown that metformin can be associated with a decrease in cancer development risk in diabetic populations. Thus, since 2005 this molecule is largely studied for its antitumoural properties in different types of cancer. The potential antitumoural effect of metformin in gastric cancer has been poorly studied. Here, we detailed the different described mechanisms implicated in the antitumoural effect of metformin in gastric cancer, from the signalling pathways to the functional effects on gastric cancer cell lines and gastric cancer stem cells.
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Affiliation(s)
- Sarah Courtois
- INSERM, Univ. Bordeaux, UMR1053 Bordeaux Research In Translational Oncology, BaRITOn, 33000, Bordeaux, France.
| | - Philippe Lehours
- INSERM, Univ. Bordeaux, UMR1053 Bordeaux Research In Translational Oncology, BaRITOn, 33000, Bordeaux, France.,French National Reference Center for Campylobacters and Helicobacters in Bordeaux (CNRCH), University Hospital of Bordeaux, Bordeaux, France
| | - Emilie Bessède
- INSERM, Univ. Bordeaux, UMR1053 Bordeaux Research In Translational Oncology, BaRITOn, 33000, Bordeaux, France.,French National Reference Center for Campylobacters and Helicobacters in Bordeaux (CNRCH), University Hospital of Bordeaux, Bordeaux, France
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34
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Baglia ML, Cui Y, Zheng T, Yang G, Li H, You M, Xu L, Murff H, Gao YT, Zheng W, Xiang YB, Shu XO. Diabetes Medication Use in Association with Survival among Patients of Breast, Colorectal, Lung, or Gastric Cancer. Cancer Res Treat 2019; 51:538-546. [PMID: 29986576 PMCID: PMC6473299 DOI: 10.4143/crt.2017.591] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 06/25/2018] [Indexed: 12/18/2022] Open
Abstract
PURPOSE Studies suggest that regular use of metformin may decrease cancer mortality. We investigated the association between diabetes medication use and cancer survival. MATERIALS AND METHODS The current study includes 633 breast, 890 colorectal, 824 lung, and 543 gastric cancer cases identified from participants of two population-based cohort studies in Shanghai. Information on diabetes medication use was obtained by linking to electronic medical records. The associations between diabetes medication use (metformin, sulfonylureas, and insulin) and overall and cancer-specific survival were evaluated using time-dependent Cox proportional hazards models. RESULTS After adjustment for clinical characteristics and treatment factors, use of metformin was associated with better overall survival among colorectal cancer patients (hazards ratio [HR], 0.55; 95% confidence interval [CI], 0.34 to 0.88) and for all four types of cancer combined (HR, 0.75; 95% CI, 0.57 to 0.98). Ever use of insulin was associated with worse survival for all cancer types combined (HR, 1.89; 95% CI, 1.57 to 2.29) and for the four cancer types individually. Similar associations were seen for diabetic patients. Sulfonylureas use was associated with worse overall survival for breast or gastric cancer (HR, 2.87; 95% CI, 1.22 to 6.80 and HR, 2.05; 95% CI, 1.09 to 3.84, respectively) among diabetic patients. Similar association patterns were observed between diabetes medication use and cancer-specific survival. CONCLUSION Metformin was associated with improved survival among colorectal cancer cases, while insulin use was associated with worse survival among patients of four major cancers. Further investigation on the topic is needed given the potential translational impact of these findings.
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Affiliation(s)
- Michelle L. Baglia
- Division of Epidemiology, Department of Medicine, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Yong Cui
- Division of Epidemiology, Department of Medicine, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Tao Zheng
- Tongren Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Gong Yang
- Division of Epidemiology, Department of Medicine, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Honglan Li
- Shanghai Cancer Institute, Shanghai Jiao Tong University, Shanghai, China
| | - Mingrong You
- Division of Epidemiology, Department of Medicine, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Liling Xu
- Tongren Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Harvey Murff
- Division of General Internal Medicine, Department of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Yu-Tang Gao
- Shanghai Cancer Institute, Shanghai Jiao Tong University, Shanghai, China
| | - Wei Zheng
- Division of Epidemiology, Department of Medicine, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Yong-Bing Xiang
- Shanghai Cancer Institute, Shanghai Jiao Tong University, Shanghai, China
| | - Xiao-Ou Shu
- Division of Epidemiology, Department of Medicine, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
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35
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Metformin causes cancer cell death through downregulation of p53-dependent differentiated embryo chondrocyte 1. J Biomed Sci 2018; 25:81. [PMID: 30442142 PMCID: PMC6238313 DOI: 10.1186/s12929-018-0478-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 10/18/2018] [Indexed: 12/27/2022] Open
Abstract
Background Metformin is the most commonly used first-line medicine for type II diabetes mellitus. Acting via AMP-activated protein kinase, it has been used for more than 60 years and has an outstanding safety record. Metformin also offers protection against cancer, but its precise mechanisms remain unclear. Methods We first examined the cytotoxic effects of metformin in the HeLa human cervical carcinoma and ZR-75-1 breast cancer cell lines using assays of cell viability, cleaved poly-ADP-ribose polymerase, and Annexin V-fluorescein isothiocyanate apoptosis, as well as flow cytometric analyses of the cell cycle profile and reactive oxygen species (ROS). We later clarified the effect of metformin on p53 protein stability using transient transfection and cycloheximide chase analyses. Results We observed that metformin represses cell cycle progression, thereby inducing subG1 populations, and had induced apoptosis through downregulation of p53 protein and a target gene, differentiated embryo chondrocyte 1 (DEC1). In addition, metformin increased intracellular ROS levels, but N-acetyl cysteine, a ROS scavenger, failed to suppress metformin-induced apoptosis. Further results showed that metformin disrupted the electron transport chain and collapsed the mitochondrial membrane potential, which may be the cause of the elevated ROS levels. Examination of the mechanisms underlying metformin-induced HeLa cell death revealed that reduced stability of p53 in metformin-treated cells leads to decreases in DEC1 and induction of apoptosis. Conclusion The involvement of DEC1 provides new insight into the positive or negative functional roles of p53 in the metformin-induced cytotoxicity in tumor cells.
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36
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Li P, Tong L, Song Y, Sun J, Shi J, Wu Z, Diao Y, Li Y, Wang Z. Long noncoding RNA H19 participates in metformin-mediated inhibition of gastric cancer cell invasion. J Cell Physiol 2018; 234:4515-4527. [PMID: 30192003 DOI: 10.1002/jcp.27269] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Accepted: 07/20/2018] [Indexed: 12/30/2022]
Abstract
Recent research suggests that the first-line oral antidiabetes drug metformin may prevent gastric cancer progression and improve prognosis. Many studies have also shown that long noncoding RNAs (lncRNAs) play important roles in many biological processes. Therefore, we aimed to explore whether lncRNAs participate in the mechanisms by which metformin affects gastric cancer cells. In the current study, we found that metformin significantly inhibited the cellular functions of gastric cancer cells through Cell Counting Kit-8 and invasion assays. We found that lncRNA H19 was greatly downregulated in gastric cancer cells treated with metformin using lncRNA microassays. Based on bioinformatics analyses of the Oncomine and The Cancer Genome Atlas databases, H19 is shown to be overexpressed in gastric cancer tissues, with increased expression of H19 relating to advanced pathological tumor stage and pathological tumor node metastasis stage, indicating that H19 may be associated with the invasive ability of gastric cancer. We knocked down H19 in AGS and SGC7901 cell lines and found that knocked-down H19 could decrease gastric cancer cell invasion and that metformin could not further decrease invasion after the knock down. Moreover, H19 depletion increased AMPK activation and decreased MMP9 expression, and metformin could not further activate AMPK or decrease MMP9 in H19 knocked-down gastric cancer cells. In summary, metformin has a profound antitumor effect on gastric cancer cells, and H19 is a key component in the process of metformin suppressing gastric cancer cell invasion.
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Affiliation(s)
- Peiwen Li
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, Shenyang, China.,Department of Thoracic Surgery, The First Hospital of China Medical University, Shenyang, China
| | - Linhao Tong
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, Shenyang, China
| | - Yongxi Song
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, Shenyang, China
| | - Jingxu Sun
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, Shenyang, China
| | - Jinxin Shi
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, Shenyang, China
| | - Zhonghua Wu
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, Shenyang, China
| | - Yao Diao
- Department of Nuclear Medicine, The First Hospital of China Medical University, Shenyang, China
| | - Yaming Li
- Department of Nuclear Medicine, The First Hospital of China Medical University, Shenyang, China
| | - Zhenning Wang
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, Shenyang, China
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Vicentini M, Ballotari P, Giorgi Rossi P, Venturelli F, Sacchettini C, Greci M, Mangone L, Pezzarossi A, Manicardi V. Effect of different glucose-lowering therapies on cancer incidence in type 2 diabetes: An observational population-based study. Diabetes Res Clin Pract 2018; 143:398-408. [PMID: 29807100 DOI: 10.1016/j.diabres.2018.04.036] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 04/04/2018] [Accepted: 04/18/2018] [Indexed: 01/30/2023]
Abstract
AIM To assess the effect of metformin on cancer incidence in type 2 diabetes (T2DM), considering possible interactions with other glucose-lowering drugs and diabetes duration. METHODS Study cohort included diabetes patients aged 20-84 on December 2009, still alive and resident in Reggio Emilia province as of December 2011. Drug exposure was assessed for 2009-2011; subjects taking metformin continuously, with or without other hypoglycaemic drugs, were compared to subjects on diet-only therapy. The cohort was followed up from 2012 to 2014 through the cancer registry. Age- and sex-adjusted incidence rate ratios (IRRs) were computed using Poisson regression models for all sites, lung, breast, liver, colorectal, prostate and pancreatic cancer. RESULTS The cohort includes 17,026 people with T2DM, 7460 taking metformin. 887 cancers occurred during follow-up, 348 among metformin users. Cancer risk was similar in T2DM patients using metformin and those on diet-only. The risk for prostate (IRR = 0.65; 95%CI:0.36; 1.17), liver (IRR = 0.82; 95%CI:0.36; 1.85) and breast (IRR = 0.77; 95%CI:0.43; 1.40) cancers only was slightly reduced; for lung (IRR = 1.52; 95%CI:0.92; 2.50), pancreas (IRR = 1.51; 95%CI:0.59:3.89) and colon-rectum (IRR = 1.71; 95%CI:0.94; 3.08) the risk was slightly increased. CONCLUSIONS There is no evidence of antitumor effect of metformin. A possible decrease only for breast, liver and prostate cancer, is compatible with random fluctuations.
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Affiliation(s)
- Massimo Vicentini
- Epidemiology Unit, Local Health Authority of Reggio Emilia-IRCCS, Reggio Emilia, Italy.
| | - Paola Ballotari
- Epidemiology Unit, Local Health Authority of Reggio Emilia-IRCCS, Reggio Emilia, Italy.
| | - Paolo Giorgi Rossi
- Epidemiology Unit, Local Health Authority of Reggio Emilia-IRCCS, Reggio Emilia, Italy.
| | - Francesco Venturelli
- Epidemiology Unit, Local Health Authority of Reggio Emilia-IRCCS, Reggio Emilia, Italy; Specialization School of Hygiene and Preventive Medicine, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy.
| | - Claudio Sacchettini
- Epidemiology Unit, Local Health Authority of Reggio Emilia-IRCCS, Reggio Emilia, Italy.
| | - Marina Greci
- Primary Health Care, Local Health Authority of Reggio Emilia-IRCCS, Reggio Emilia, Italy.
| | - Lucia Mangone
- Epidemiology Unit, Local Health Authority of Reggio Emilia-IRCCS, Reggio Emilia, Italy.
| | - Annamaria Pezzarossi
- Epidemiology Unit, Local Health Authority of Reggio Emilia-IRCCS, Reggio Emilia, Italy.
| | - Valeria Manicardi
- Department of Internal Medicine, Hospital of Montecchio, Local Health Authority of Reggio Emilia-IRCCS, Reggio Emilia, Italy.
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Impact of metformin on gastric adenocarcinoma survival: A Belgian population based study. Cancer Epidemiol 2018; 53:149-155. [PMID: 29453032 DOI: 10.1016/j.canep.2018.02.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 02/02/2018] [Accepted: 02/05/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND Preclinical studies have shown anticancer activities of metformin in gastric cancer and a recent epidemiological study showed a decrease in recurrence and mortality of gastric cancer in metformin users. This study aimed to assess the impact of metformin on gastric cancer survival in diabetic patients at a Belgian population level. METHODS We conducted an observational, population-based study by linking data of the Belgian Cancer Registry with medical claims data coming from the health insurance companies for patients diagnosed with stage I to III gastric adenocarcinoma between 2006 and 2012. Information on gastric cancer-specific deaths was retrieved from mortality records collected by regional governments. Time-dependent Cox regression models were used to calculate hazard ratios (HRs) and 95% confidence intervals (CI) for overall survival (OS) and cancer-specific mortality (CSS). RESULTS In our population of 371 patients, a reduction in all-cause mortality was observed in metformin users (adjusted HR = 0.73, 95% CI: [0.52; 1.01], p = 0.06) but not for cancer specific mortality (adjusted HR = 0.86, 95% CI: [0.56; 1.33], p = 0.50). Pre-diagnosis exposure to metformin was associated with a significant improvement in OS (adjusted HR = 0.75, 95% CI: [0.57; 0.98], p = 0.04) that was not significant for CSS (adjusted HR = 0.89, 95% CI: [0.62; 1.28], p = 0.52). Moreover, no dose-response relationship between metformin use and either all-cause or cancer-specific mortality was observed. CONCLUSION In the first population based study of metformin use in gastric cancer adenocarcinoma patients with previous diabetes, our findings suggest that metformin use might improve overall mortality. However, no such association was found for cancer-specific survival. Additional studies in other populations are required.
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Gyawali B, Pantziarka P, Crispino S, Bouche G. Does the oncology community have a rejection bias when it comes to repurposed drugs? Ecancermedicalscience 2018; 12:ed76. [PMID: 29456622 PMCID: PMC5813914 DOI: 10.3332/ecancer.2018.ed76] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Indexed: 12/18/2022] Open
Abstract
Among the various measures proposed to combat the challenge of financial toxicity in cancer care, an important strategy is the use of lower-priced drugs instead of expensive alternatives. However, the oncology community seems to either ignore or more readily reject cheaper drugs in cancer care compared to more expensive alternatives. In this commentary, we present three examples of lower-priced drugs rejected or ignored by the oncology community and contrast this with three expensive drugs where persistent optimism remained despite negative clinical trial results. We argue that all drugs be held to the same rigorous standards – this not only includes skepticism in the absence of sound evidence, but also the suspension of premature judgement as has happened in the cases of repurposed drugs.
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Affiliation(s)
- Bishal Gyawali
- Anticancer Fund, Boechoutlaan 221-1853, Strombeek-Bever, Belgium.,Department of Medical Oncology, Civil Service Hospital, Minbhawan Marg Min Bhawan, Kathmandu 44600, Nepal.,Institute of Cancer Policy, King's College London, Great Maze Pond Road, London SE1 9RT, UK
| | - Pan Pantziarka
- Anticancer Fund, Boechoutlaan 221-1853, Strombeek-Bever, Belgium.,The George Pantziarka TP53 Trust, London KT1 2JP, UK
| | - Sergio Crispino
- Anticancer Fund, Boechoutlaan 221-1853, Strombeek-Bever, Belgium
| | - Gauthier Bouche
- Anticancer Fund, Boechoutlaan 221-1853, Strombeek-Bever, Belgium
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40
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Li P, Zhang C, Gao P, Chen X, Ma B, Yu D, Song Y, Wang Z. Metformin use and its effect on gastric cancer in patients with type 2 diabetes: A systematic review of observational studies. Oncol Lett 2017; 15:1191-1199. [PMID: 29391902 DOI: 10.3892/ol.2017.7370] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Accepted: 08/23/2017] [Indexed: 02/06/2023] Open
Abstract
Increasing evidence suggests that metformin use is associated with a decreased risk of cancer. The traditional therapies for gastric cancer (GC) are gastrectomy and chemoradiotherapy; however, these therapies may cause certain adverse effects, which affect a patient's quality of life, and the overall survival rate is low. At present, little is known about whether the use of metformin decreases the risk of GC in patients with type 2 diabetes. Therefore, in the present study, a systematic review was performed to analyze the effect of metformin on GC. A literature search was conducted in PubMed, EMBASE, and the Cochrane Library databases for articles published up to June 30th, 2016. The studies that evaluated GC patients treated with metformin and compared them with GC patients treated with other antidiabetic drugs were reviewed. Eligible studies were evaluated using the Newcastle-Ottawa Scale. Adjusted hazard ratio and 95% confidence intervals were determined to evaluate the effect of metformin on GC. From the 422 articles evaluated, 5 studies involving a total of 1,804,479 patients met the inclusion criteria and were qualitatively analyzed. The quality of all selected articles was classified as moderate. These studies reported that the long-term use of metformin was associated with a lower risk of GC compared with the lack of use of metformin or the use of other hypoglycemic drugs. In GC patients with diabetes who were subjected to gastrectomy, the cumulative use of metformin reduced the rates of disease recurrence and of all-cause and cancer-specific mortality. Despite the limited number of studies on this subject, currently available evidence indicates that metformin is associated with a decreased risk of GC and improves survival in patients with type 2 diabetes. However, more well-designed trials are required to elucidate this association.
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Affiliation(s)
- Peiwen Li
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, Shenyang, Liaoning 110001, P.R. China
| | - Cong Zhang
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, Shenyang, Liaoning 110001, P.R. China
| | - Peng Gao
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, Shenyang, Liaoning 110001, P.R. China
| | - Xiaowan Chen
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, Shenyang, Liaoning 110001, P.R. China
| | - Bin Ma
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, Shenyang, Liaoning 110001, P.R. China
| | - Dehao Yu
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, Shenyang, Liaoning 110001, P.R. China
| | - Yongxi Song
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, Shenyang, Liaoning 110001, P.R. China
| | - Zhenning Wang
- Department of Surgical Oncology and General Surgery, The First Hospital of China Medical University, Shenyang, Liaoning 110001, P.R. China
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Joo MK, Park JJ, Chun HJ. Additional Benefits of Routine Drugs on Gastrointestinal Cancer: Statins, Metformin, and Proton Pump Inhibitors. Dig Dis 2017; 36:1-14. [PMID: 28881340 DOI: 10.1159/000480149] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 08/08/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Commonly used medications including statins, metformin, and proton pump inhibitors (PPIs) effectively reduce the risk of esophageal, gastric, and colorectal cancer (CRC). SUMMARY A number of observational studies and meta-analyses have shown that long-term statin use significantly reduces the incidence of gastrointestinal (GI) cancer. Moreover, statin use after GI cancer diagnosis has been significantly associated with better prognosis in large-scale cohort studies. Metformin was rigorously evaluated in a population-based study and meta-analysis, and was found to have an unexpected benefit in the prevention and prolonged survival of CRC patients with type 2 diabetes mellitus. In contrast, few studies have demonstrated the chemopreventive effect of metformin for esophageal and gastric cancer. Recent observational studies have demonstrated that PPIs effectively reduce the progression of nondysplastic Barrett's esophagus into esophageal adenocarcinoma in a dose-dependent manner. However, the association between chronic PPI use and CRC or gastric cancer risk is still controversial. It was expected that these 3 routinely used medicines would show a synergistic effect with conventional systemic chemotherapy in advanced GI cancers. However, recent phase III studies failed to show significantly better outcomes. Key Messages: Further studies are needed to identify "additional" anticancer effects of these commonly used medicines.
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Affiliation(s)
- Moon Kyung Joo
- Division of Gastroenterology, Department of Internal Medicine, Korea University College of Medicine Guro Hospital, Seoul, South Korea
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Metformin targets gastric cancer stem cells. Eur J Cancer 2017; 84:193-201. [PMID: 28822889 DOI: 10.1016/j.ejca.2017.07.020] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 07/14/2017] [Accepted: 07/18/2017] [Indexed: 02/06/2023]
Abstract
Gastric cancer is the third leading cause of cancer-related deaths worldwide and has still a poor prognosis. Therefore, new therapeutic strategies are needed: among them, targeting cancer stem cells (CSCs) could offer new opportunities. The aim of our study was to evaluate the anti-tumoural effect of metformin on gastric cancer in vitro and in vivo and especially, to determine whether this molecule could target the gastric CSCs. Metformin effects were evaluated on the proliferation and tumourigenic properties of the gastric CSCs from patient-derived primary tumour xenografts (PDXs) and cancer cell lines (MKN45, AGS and MKN74) in vitro in conventional 2 dimensional (2D) and in 3 dimensional (3D) culture systems, in which only CSCs are able to form tumourspheres and in mouse xenograft models in vivo. Metformin induced a cell cycle arrest, which decreased cell proliferation in the 2D cultures. In a 3D culture system, metformin decreased the number of tumourspheres, revealing its capacity to target the CSCs. This effect was confirmed by the study of the expression of CSC markers (CD44 and Sox2) and differentiation markers (Kruppel-like factor 4 and MUC5AC), which were decreased or increased in response to metformin, respectively. Finally, in vivo treatment of PDXs with metformin led to a tumour growth delay and decreased the self-renewal ability of the CSCs. These results suggest that the use of metformin could represent an efficient strategy to inhibit tumour growth by targeting gastric CSCs.
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43
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The effect of metformin on survival of patients with pancreatic cancer: a meta-analysis. Sci Rep 2017; 7:5825. [PMID: 28724893 PMCID: PMC5517652 DOI: 10.1038/s41598-017-06207-x] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 06/08/2017] [Indexed: 12/18/2022] Open
Abstract
We conducted a meta-analysis to analyse the effect of metformin on survival of pancreatic cancer patients at various stages. We performed a systematic search of PubMed, Embase, Cochrane, and Web of Science to identify all relevant studies. Summary hazard ratios (HR) of survival and 95% confidence intervals (95% CI) were calculated with a fixed or random effects model according to inter-study heterogeneity. Nine retrospective cohort studies and two randomized controlled trials (RCTs) were eligible. There was a significant improvement in survival (HR = 0.86, 95% CI 0.76–0.97; P < 0.05) in the metformin group compared with control. Subgroup analysis indicated that metformin improved survival in patients with resection (HR = 0.79, 95% CI 0.69–0.91; P < 0.05) and patients with locally advanced tumors (HR = 0.68, 95% CI 0.55–0.84; P < 0.05) but not in patients with metastatic tumors, even when RCT data were included (HR = 0.99, 95% CI 0.70–1.40; P > 0.05), or were excluded (HR = 0.89, 95% CI 0.61–1.31; P > 0.05). This meta-analysis indicated that the effect of metformin does correlate with tumor stage but should be prudently considered given the limited and variable studies performed to data.
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44
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Cao Y, Wang RH. Associations among Metabolism, Circadian Rhythm and Age-Associated Diseases. Aging Dis 2017; 8:314-333. [PMID: 28580187 PMCID: PMC5440111 DOI: 10.14336/ad.2016.1101] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 11/01/2016] [Indexed: 12/12/2022] Open
Abstract
Accumulating epidemiological studies have implicated a strong link between age associated metabolic diseases and cancer, though direct and irrefutable evidence is missing. In this review, we discuss the connection between Warburg effects and tumorigenesis, as well as adaptive responses to environment such as circadian rhythms on molecular pathways involved in metabolism. We also review the central role of the sirtuin family of proteins in physiological modulation of cellular processes and age-associated metabolic diseases. We also provide a macroscopic view of how the circadian rhythm affects metabolism and may be involved in cell metabolism reprogramming and cancer pathogenesis. The aberrations in metabolism and the circadian system may lead to age-associated diseases directly or through intermediates. These intermediates may be either mutated or reprogrammed, thus becoming responsible for chromatin modification and oncogene transcription. Integration of circadian rhythm and metabolic reprogramming in the holistic understanding of metabolic diseases and cancer may provide additional insights into human diseases.
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Affiliation(s)
- Yiwei Cao
- Faculty of Health Science, University of Macau, Macau, China
| | - Rui-Hong Wang
- Faculty of Health Science, University of Macau, Macau, China
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45
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Coyle C, Cafferty FH, Vale C, Langley RE. Metformin as an adjuvant treatment for cancer: a systematic review and meta-analysis. Ann Oncol 2016; 27:2184-2195. [PMID: 27681864 PMCID: PMC5178140 DOI: 10.1093/annonc/mdw410] [Citation(s) in RCA: 286] [Impact Index Per Article: 35.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 08/17/2016] [Accepted: 08/19/2016] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Metformin use has been associated with a reduced risk of developing cancer and an improvement in overall cancer survival rates in meta-analyses, but, to date, evidence to support the use of metformin as an adjuvant therapy in individual cancer types has not been presented. PATIENTS AND METHODS We systematically searched research databases, conference abstracts and trial registries for any studies reporting cancer outcomes for individual tumour types in metformin users compared with non-users, and extracted data on patients with early-stage cancer. Studies were assessed for design and quality, and a meta-analysis was conducted to quantify the adjuvant effect of metformin on recurrence-free survival (RFS), overall survival (OS) and cancer-specific survival (CSS), to inform future trial design. RESULTS Of 7670 articles screened, 27 eligible studies were identified comprising 24 178 participants, all enrolled in observational studies. In those with early-stage colorectal cancer, metformin use was associated with a significant benefit in all outcomes [RFS hazard ratio (HR) 0.63, 95% confidence interval (CI) 0.47-0.85; OS HR 0.69, CI 0.58-0.83; CSS HR 0.58, CI 0.39-0.86]. For men with early-stage prostate cancer, metformin was associated with significant, or borderline significant, benefits in all outcomes (RFS HR 0.83, CI 0.69-1.00; OS HR 0.82, CI 0.73-0.93; CSS HR 0.58, CI 0.37-0.93); however, there was significant heterogeneity between studies. The data suggest that prostate cancer patients treated with radical radiotherapy may benefit more from metformin (RFS HR 0.45, CI 0.29-0.70). In breast and urothelial cancer, no significant benefits were identified. Sufficient data were not available to conduct analyses on the impact of metformin dose and duration. CONCLUSIONS Our findings suggest that metformin could be a useful adjuvant agent, with the greatest benefits seen in colorectal and prostate cancer, particularly in those receiving radical radiotherapy, and randomised, controlled trials which investigate dose and duration, alongside efficacy, are advocated.
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Affiliation(s)
- C Coyle
- MRC Clinical Trials Unit at University College London, London, UK
| | - F H Cafferty
- MRC Clinical Trials Unit at University College London, London, UK
| | - C Vale
- MRC Clinical Trials Unit at University College London, London, UK
| | - R E Langley
- MRC Clinical Trials Unit at University College London, London, UK
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46
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Nimako GK, Wintrob ZAP, Sulik DA, Donato JL, Ceacareanu AC. Synergistic Benefit of Statin and Metformin in Gastrointestinal Malignancies. J Pharm Pract 2016; 30:185-194. [PMID: 26811340 DOI: 10.1177/0897190015627255] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To evaluate whether statin use influences gastrointestinal cancer prognosis in patients with diabetes mellitus (DM). METHODS We reviewed all DM patients diagnosed at Roswell Park Cancer Institute with emergent gastrointestinal malignancy (January 2003 to December 2010) (N = 222). Baseline demographic, clinical history, and cancer outcomes were documented. Overall survival (OS) and disease-free survival (DFS) comparisons across various treatment groups were assessed by Kaplan-Meier and Cox proportional hazards. RESULTS Use of statin, alone or in combination, was associated with improved OS and DFS (hazard ratio [HR] = 0.65, P = .06; HR = 0.60, P < .02). We report similar OS and DFS advantage among users of mono- or combined metformin therapy (HR = 0.55, P < .01; HR = 0.63, P < .02). Concomitant use of metformin and statin provided a synergistic OS and DFS benefit (HR = 0.42, P < .01; HR = 0.44, P < .01). Despite significant tobacco and alcohol use history, patients with upper gastrointestinal cancers derived enhanced cancer outcomes from this combination (HR = 0.34, P < .01; HR = 0.43, P < .02), while receiving a statin without metformin or metformin without a statin did not provide significant cancer-related benefits. CONCLUSION Use of statin and metformin provides a synergistic improvement in gastrointestinal malignancies outcomes.
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Affiliation(s)
- George K Nimako
- 1 Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, State University of New York at Buffalo, Buffalo, NY, USA.,2 Pharmacy Service, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Zachary A P Wintrob
- 1 Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, State University of New York at Buffalo, Buffalo, NY, USA.,2 Pharmacy Service, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Dmitriy A Sulik
- 1 Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, State University of New York at Buffalo, Buffalo, NY, USA
| | - Jennifer L Donato
- 1 Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, State University of New York at Buffalo, Buffalo, NY, USA
| | - Alice C Ceacareanu
- 1 Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, State University of New York at Buffalo, Buffalo, NY, USA.,2 Pharmacy Service, Roswell Park Cancer Institute, Buffalo, NY, USA
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47
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Yu G, Fang W, Xia T, Chen Y, Gao Y, Jiao X, Huang S, Wang J, Li Z, Xie K. Metformin potentiates rapamycin and cisplatin in gastric cancer in mice. Oncotarget 2016; 6:12748-62. [PMID: 25909163 PMCID: PMC4494971 DOI: 10.18632/oncotarget.3327] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2014] [Accepted: 02/09/2015] [Indexed: 12/22/2022] Open
Abstract
Here we showed that pAMPKα and PTEN were down-regulated and p-mTOR, p-S6, p-4EBP1, MMP7, and DCN1 were up-regulated in human gastric cancer tissue samples as compared to that in the noncancerous tissues. Metformin inhibited tumor growth in mice. Also it enhanced cisplatin- or rapamycin-induced reduction of tumor growth as compared with treatment of either drug alone. In addition to activation of AMPK and suppression of the mTOR pathway, a series of increased and decreased genes expression were induced by metformin, including PTEN, MMP7, and FN1. We suggest that metformin could potentially be used for the treatment of gastric cancer especially in combination with cisplatin or rapamycin.
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Affiliation(s)
- Guanzhen Yu
- Department of Medical Oncology, Changzheng Hospital, Shanghai 200070, China.,Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA
| | - Wenzheng Fang
- Department of Medical Oncology, Changzheng Hospital, Shanghai 200070, China.,Department of Oncology, Fuzhou General Hospital, Clinical Medical College of Fujian Medical University, Fuzhou, Fujian 350025, China
| | - Tian Xia
- Department of Gastroenterology, Changhai Hospital, Shanghai 200433, China.,Department of Gastroenterology, Hepatology & Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA
| | - Ying Chen
- Department of Pathology, Changhai Hospital, Shanghai 200433, China
| | - Yunshu Gao
- Department of Oncology, Qingdao, Shandong 266000, China
| | - Xiaodong Jiao
- Department of Medical Oncology, Changzheng Hospital, Shanghai 200070, China
| | - Suyun Huang
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA
| | - Jiejun Wang
- Department of Medical Oncology, Changzheng Hospital, Shanghai 200070, China
| | - Zhaosheng Li
- Department of Gastroenterology, Changhai Hospital, Shanghai 200433, China
| | - Keping Xie
- Department of Gastroenterology, Hepatology & Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA
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48
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Choi YY, Noh SH, Cheong JH. Molecular Dimensions of Gastric Cancer: Translational and Clinical Perspectives. J Pathol Transl Med 2015; 50:1-9. [PMID: 26498010 PMCID: PMC4734963 DOI: 10.4132/jptm.2015.09.10] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 09/09/2015] [Indexed: 12/13/2022] Open
Abstract
Gastric cancer is a global health burden and has the highest incidence in East Asia. This disease is complex in nature because it arises from multiple interactions of genetic, local environmental, and host factors, resulting in biological heterogeneity. This genetic intricacy converges on molecular characteristics reflecting the pathophysiology, tumor biology, and clinical outcome. Therefore, understanding the molecular characteristics at a genomic level is pivotal to improving the clinical care of patients with gastric cancer. A recent landmark study, The Cancer Genome Atlas (TCGA) project, showed the molecular landscape of gastric cancer through a comprehensive molecular evaluation of 295 primary gastric cancers. The proposed molecular classification divided gastric cancer into four subtypes: Epstein-Barr virus–positive, microsatellite unstable, genomic stable, and chromosomal instability. This information will be taken into account in future clinical trials and will be translated into clinical therapeutic decisions. To fully realize the clinical benefit, many challenges must be overcome. Rapid growth of high-throughput biology and functional validation of molecular targets will further deepen our knowledge of molecular dimensions of this cancer, allowing for personalized precision medicine.
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Affiliation(s)
- Yoon Young Choi
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Hoon Noh
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea ; Brain Korea 21 PLUS Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Jae-Ho Cheong
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea ; Brain Korea 21 PLUS Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea ; Department of Biochemistry and Molecular Biology, Yonsei University College of Medicine, Seoul, Korea
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49
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Coperchini F, Leporati P, Rotondi M, Chiovato L. Expanding the therapeutic spectrum of metformin: from diabetes to cancer. J Endocrinol Invest 2015; 38:1047-55. [PMID: 26233338 DOI: 10.1007/s40618-015-0370-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 07/23/2015] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Metformin, an oral hypoglycemic agent, was introduced in the clinical practice for the treatment of type 2 diabetes mellitus more than a half-century ago. Over the years, several studies demonstrated that diabetic patients treated with metformin have a lower incidence of cancer, raising the hypothesis that the spectrum of clinical applications of the drug could be expanded also to cancer therapy. Following these initial findings, a large number of studies were performed aimed at elucidating the effects of metformin on different types of tumor, at explaining its direct and indirect anti-cancer mechanisms and at identifying the molecular pathways targeted by the drug. Several clinical trials were also performed aimed at evaluating the potential anti-cancer effect of metformin among diabetic and non-diabetic patients affected by different types of cancer. While the results of several clinical studies are encouraging, a considerable number of other investigations do not support a role of metformin as an anti-cancer agent, and highlight variables possibly accounting for discrepancies. AIM We hereby review the results of in vitro and in vivo studies addressing the issue of the anti-cancer effects of metformin. CONCLUSIONS If in vitro data appear solid, the results provided by in vivo studies are somehow controversial. In this view, larger studies are needed to fully elucidate the role of metformin on cancer development and progression, as well as the specific clinical settings in which metformin could become an anti-cancer drug.
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Affiliation(s)
- F Coperchini
- Chair of Endocrinology, Unit of Internal Medicine and Endocrinology, Laboratory for Endocrine Disruptors, Fondazione Salvatore Maugeri I.R.C.C.S., University of Pavia, Via Maugeri 10, 27100, Pavia, Italy
| | - P Leporati
- Chair of Endocrinology, Unit of Internal Medicine and Endocrinology, Laboratory for Endocrine Disruptors, Fondazione Salvatore Maugeri I.R.C.C.S., University of Pavia, Via Maugeri 10, 27100, Pavia, Italy
| | - M Rotondi
- Chair of Endocrinology, Unit of Internal Medicine and Endocrinology, Laboratory for Endocrine Disruptors, Fondazione Salvatore Maugeri I.R.C.C.S., University of Pavia, Via Maugeri 10, 27100, Pavia, Italy
| | - L Chiovato
- Chair of Endocrinology, Unit of Internal Medicine and Endocrinology, Laboratory for Endocrine Disruptors, Fondazione Salvatore Maugeri I.R.C.C.S., University of Pavia, Via Maugeri 10, 27100, Pavia, Italy.
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50
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Choi Y, Kim TY, Oh DY, Lee KH, Han SW, Im SA, Kim TY, Bang YJ. The Impact of Diabetes Mellitus and Metformin Treatment on Survival of Patients with Advanced Pancreatic Cancer Undergoing Chemotherapy. Cancer Res Treat 2015; 48:171-9. [PMID: 25779362 PMCID: PMC4720092 DOI: 10.4143/crt.2014.292] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2014] [Accepted: 02/02/2015] [Indexed: 12/21/2022] Open
Abstract
PURPOSE A causal relationship between diabetes mellitus (DM) and pancreatic cancer is well established. However, in patients with advanced pancreatic cancer (APC) who receive palliative chemotherapy, the impact of DM on the prognosis of APC is unclear. MATERIALS AND METHODS We retrospectively enrolled APC patients who received palliative chemotherapy between 2003 and 2010. The patients were stratified according to the status of DM, in accordance with 2010 DM criteria (American Heart Association/American Diabetes Association). DM at least 2 years' duration prior to diagnosis of APC was defined as remote-onset DM (vs. recent-onset). RESULTS Of the 349 APC patients, 183 (52.4%) had DM. Among the patients with DM, 160 patients had DM at the time of diagnosis of APC (remote-onset, 87; recent-onset, 73) and the remaining 23 patients developed DM during treatment of APC. Ultimately, 73.2% of patients (134/183) with DM received antidiabetic medication, including metformin (56 patients, 41.8%), sulfonylurea (62, 45.5%), and insulin (43, 32.1%). In multivariate analysis, cancer extent (hazard ratio [HR], 1.792; 95% confidence interval [CI], 1.313 to 2.445; p < 0.001) showed association with decreased overall survival (OS), whereas a diagnosis of DM (HR, 0.788; 95% CI, 0.615 to 1.009; p=0.059) conferred positive tendency on the OS. Metformin treatment itself conferred better OS in comparison within DM patients (HR 0.693; 95% CI, 0.492 to 0.977; p=0.036) and even in all APC patients (adjusted HR, 0.697; 95% CI, 0.491 to 1.990; p=0.044). CONCLUSION For APC patients receiving palliative chemotherapy, metformin treatment is associated with longer OS. Patients with DM tend to survive longer than those without DM.
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Affiliation(s)
- Younak Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Tae-Yong Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea ; Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Do-Youn Oh
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea ; Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Kyung-Hun Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea ; Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Sae-Won Han
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea ; Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Seock-Ah Im
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea ; Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Tae-You Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea ; Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Yung-Jue Bang
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea ; Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
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