Secondary diabetes associated with 5-fluorouracil-based chemotherapy regimens in non-diabetic patients with colorectal cancer: results from a single-centre cohort study

Associations between Diabetes Mellitus and Selected Cancers

Cancer is one of the major causes of mortality and is the second leading cause of death. Diabetes mellitus is a serious and growing problem worldwide, and its prevalence continues to grow; it is the 12th leading cause of death. An association between diabetes mellitus and cancer has been suggested for more than 100 years. Diabetes is a common disease diagnosed among patients with cancer, and evidence indicates that approximately 8-18% of patients with cancer have diabetes, with investigations suggesting an association between diabetes and some particular cancers, increasing the risk for developing cancers such as pancreatic, liver, colon, breast, stomach, and a few others. Breast and colorectal cancers have increased from 20% to 30% and there is a 97% increased risk of intrahepatic cholangiocarcinoma or endometrial cancer. On the other hand, a number of cancers and cancer therapies increase the risk of diabetes mellitus. Complications due to diabetes in patients with cancer may influence the choice of cancer therapy. Unfortunately, the mechanisms of the associations between diabetes mellitus and cancer are still unknown. The aim of this review is to summarize the association of diabetes mellitus with selected cancers and update the evidence on the underlying mechanisms of this association.

The impact of surgery and oncological treatment on risk of type 2 diabetes onset in patients with colorectal cancer: nationwide cohort study in Denmark

Background

Comorbidity with type 2 diabetes (T2D) results in worsening of cancer-specific and overall prognosis in colorectal cancer (CRC) patients. The treatment of CRC per se may be diabetogenic. We assessed the impact of different types of surgical cancer resections and oncological treatment on risk of T2D development in CRC patients.

Methods

We developed a population-based cohort study including all Danish CRC patients, who had undergone CRC surgery between 2001 and 2018. Using nationwide register data, we identified and followed patients from date of surgery and until new onset of T2D, death, or end of follow-up.

Results

In total, 46,373 CRC patients were included and divided into six groups according to type of surgical resection: 10,566 Right-No-Chemo (23%), 4645 Right-Chemo (10%), 10,151 Left-No-Chemo (22%), 5257 Left-Chemo (11%), 9618 Rectal-No-Chemo (21%), and 6136 Rectal-Chemo (13%). During 245,466 person-years of follow-up, 2556 patients developed T2D. The incidence rate (IR) of T2D was highest in the Left-Chemo group 11.3 (95% CI: 10.4-12.2) per 1000 person-years and lowest in the Rectal-No-Chemo group 9.6 (95% CI: 8.8-10.4). Between-group unadjusted hazard ratio (HR) of developing T2D was similar and non-significant. In the adjusted analysis, Rectal-No-Chemo was associated with lower T2D risk (HR 0.86 [95% CI 0.75-0.98]) compared to Right-No-Chemo.For all six groups, an increased level of body mass index (BMI) resulted in a nearly twofold increased risk of developing T2D.

Conclusions

This study suggests that postoperative T2D screening should be prioritised in CRC survivors with overweight/obesity regardless of type of CRC treatment applied.

Funding

The Novo Nordisk Foundation (NNF17SA0031406); TrygFonden (101390; 20045; 125132).

Mitochondrial ALDH2 improves ß-cell survival and function against doxorubicin-induced apoptosis by targeting CK2 signaling

AIMS

The aim of this study was to better understand how the chemotherapy drug doxorubicin contributes to the development of β-cell dysfunction and to explore its relationship with mitochondrial aldehyde dehydrogenase-2 (ALDH2).

MATERIALS AND METHODS

In order to investigate this hypothesis, doxorubicin was administered to INS-1 cells, a rat insulinoma cell line, either with or without several target protein activators and inhibitors. ALDH2 activity was detected with a commercial kit and protein levels were determined with western blot. Mitochondrial ROS, membrane potential, and lipid ROS were determined by commercial fluorescent probes. The cell viability was measured by CCK-assay.

RESULTS

Exposure of INS-1 cells to doxorubicin decreased active insulin signaling resulting in elevated ALDH2 degradation, compared with control cells by the induction of acid sphingomyelinase mediated ceramide induction. Further, ceramide induction potentiated doxorubicin induced mitochondrial dysfunction. Treatment with the ALDH2 agonist, ALDA1, blocked doxorubicin-induced acid sphingomyelinase activation which significantly blocked ceramide induction and mitochondrial dysfunction mediated cell death. Treatment with the ALDH2 agonist, ALDA1, stimulated casein kinase-2 (CK2) mediated insulin signaling activation. CK2 silencing neutralized the function of ALDH2 in the doxorubicin treated INS-1 cells.

CONCLUSIONS

Mitochondrial ALDH2 activation could inhibit the progression of doxorubicin induced pancreatic β-cell dysfunction by inhibiting the acid sphingomyelinase induction of ceramide, by regulating the activation of CK2 signaling. Our research lays the foundation of ALDH2 activation as a therapeutic target for the precise treatment of chemotherapy drug induced β-cell dysfunction.

Drug-induced hyperglycemia and diabetes

BACKGROUND

Drug-induced hyperglycemia and diabetes have negative and potentially serious health consequences but can often be unnoticed.

METHODS

We reviewed the literature searching Medline database for articles addressing drug-induced hyperglycemia and diabetes up to January 31, 2023. We also selected drugs that could induce hyperglycemia or diabetes according official data from drug information databases Thériaque and Micromedex. For each selected drug or pharmacotherapeutic class, the mechanisms of action potentially involved were investigated. For drugs considered to be at risk of hyperglycemia or diabetes, disproportionality analyses were performed using data from the international pharmacovigilance database VigiBase. In order to detect new pharmacovigilance signals, additional disproportionality analyses were carried out for drug classes with more than 100 cases reported in VigiBase, but not found in the literature or official documents.

RESULTS

The main drug classes found to cause hyperglycemia are glucocorticoids, HMG-coA reductase inhibitors, thiazide diuretics, beta-blockers, antipsychotics, fluoroquinolones, antiretrovirals, antineoplastic agents and immunosuppressants. The main mechanisms involved are alterations in insulin secretion and sensitivity, direct cytotoxic effects on pancreatic cells and increases in glucose production. Pharmacovigilance signal were found for a majority of drugs or pharmacological classes identified as being at risk of diabetes or hyperglycemia. We identified new pharmacovigilance signals with drugs not known to be at risk according to the literature or official data: phosphodiesterase type 5 inhibitors, endothelin receptor antagonists, sodium oxybate, biphosphonates including alendronic acid, digoxin, sartans, linosipril, diltiazem, verapamil, and darbepoetin alpha. Further studies will be needed to confirm these signals.

CONCLUSIONS

The risks of induced hyperglycemia vary from one drug to another, and the underlying mechanisms are multiple and potentially complex. Clinicians need to be vigilant when using at-risk drugs in order to detect and manage these adverse drug reactions. However, it is to emphasize that the benefits of appropriately prescribed treatments most often outweigh their metabolic risks.

Clinically Approved Monoclonal Antibodies-based Immunotherapy: Association With Glycemic Control and Impact Role of Clinical Pharmacist for Cancer Patient Care

PURPOSE

Compared with more conventional, nonspecific therapy options, such as radiotherapy and chemotherapy, monoclonal antibodies (mAbs) constitute a crucial approach of cancer treatment. Multiple autoimmune diseases have been observed during treatment with mAb medications, including autoimmune diabetes mellitus (DM). This study provides a narrative review of clinically approved mAbs in cancer treatment and focuses on the development of hyperglycemia and DM arising from using these therapies. Furthermore, it highlights the critical role of oncology clinical pharmacists in the management of autoimmune DM and patient care while using these medications in an oncology setting.

METHODS

An extensive literature search was conducted using various sources of electronic databases, such as Scopus, Embase, Web of Science, and PubMed, and search engines, such as Google Scholar, for studies on mAb classification, types, mechanisms of action, pharmacokinetic properties, current clinical applications, and the associated common adverse effects with significant recommendations for patient care in an oncology setting, along with focusing on the proposed mechanisms and clinical studies that reported the association of DM after the use of these therapies.

FINDINGS

There are 4 types (murine, chimeric, humanized, and human) and 3 classes (unconjugated, conjugated, and bispecific) of mAbs with several mechanisms of action that can destroy cancer cells, including preventing tumor cell survival cascades, inhibiting tumor growth by interfering with tumor angiogenesis, evading programmed cell death, and bypassing immune checkpoints. However, multiple endocrinopathies, autoimmune diseases, and complications were reported from the use of these medications, including the development of autoimmune DM and diabetic ketoacidosis. These autoimmune disorders were reported most with the use of immune checkpoint inhibitors, including inhibitors of the programmed cell death protein 1 (nivolumab and pembrolizumab), its ligand (atezolizumab, avelumab, and durvalumab), and cytotoxic T-lymphocyte-associated protein 4 (ipilimumab).

IMPLICATIONS

mAbs are considered important approaches for the treatment of many cancer types. However, a high incidence of hyperglycemia, type 1 DM, and diabetic ketoacidosis is observed with the use of these medications, particularly immune checkpoint inhibitors. It is important for oncologic clinical pharmacists to be involved in addressing these autoimmune disorders from the use of these immunotherapies via the provision of patient education, medication adherence support, close monitoring, and follow-up, which will lead to better health-related outcomes and improved patient quality of life.

Diabetes management in cancer patients. An Italian Association of Medical Oncology, Italian Association of Medical Diabetologists, Italian Society of Diabetology, Italian Society of Endocrinology and Italian Society of Pharmacology multidisciplinary consensus position paper

Cancer management has significantly evolved in recent years, focusing on a multidisciplinary team approach to provide the best possible patient care and address the various comorbidities, toxicities, and complications that may arise during the patient's treatment journey. The co-occurrence of diabetes and cancer presents a significant challenge for health care professionals worldwide. Management of these conditions requires a holistic approach to improve patients' overall health, treatment outcomes, and quality of life, preventing diabetes complications and cancer treatment side-effects. In this article, a multidisciplinary panel of experts from different Italian scientific societies provide a critical overview of the co-management of cancer and diabetes, with an increasing focus on identifying a novel specialty field, 'diabeto-oncology', and suggest new co-management models of cancer patients with diabetes to improve their care. To better support cancer patients with diabetes and ensure high levels of coordinated care between oncologists and diabetologists, 'diabeto-oncology' could represent a new specialized field that combines specific expertise, skills, and training.

Prognostic Factors for Hyperglycemia in Patients Receiving Chemotherapy

BACKGROUND

Approximately 10% to 30% of patients who receive chemotherapy experience hyperglycemia, which can affect the adverse reactions and treatment efficacy of chemotherapy. However, there is a paucity of research to explore the factors affecting hyperglycemia and include them in nursing interventions.

OBJECTIVE

The aim of this study was to understand the prognostic factors of hyperglycemia in cancer patients on chemotherapy.

METHODS

This retrospective, descriptive study included 134 adult patients with cancer receiving chemotherapy at Keimyeng University Dongsan Hospital in Daegu between July 1, 2021, and March 31, 2022. Data were analyzed using frequency, percentage, average, and standard deviation statistics and compared by t test, χ2 test, and logistic regression analysis.

RESULTS

Logistic regression analysis revealed that sex (male) (95% confidence interval [CI], 7.24-745.49; odds ratio [OR], 73.48); education (95% CI, 4.02-201.59; OR, 28.46); exercise durations of 30 to 60 minutes (95% CI, 0.00-0.06; OR, 0.01), 60 to 90 minutes (95% CI, 0.00-0.05, OR = 0.01), and ≥90 minutes (95% CI, 0.00-0.42; OR, 0.03); exercise amount ≥ 2000 kcal/wk (95% CI, 0.01-0.77; OR, 0.06); and daily fat (95% CI, 1.02-1.14; OR, 1.08), protein (95% CI, 0.82-0.95; OR, 0.88), and seaweed (95% CI, 0.85-0.99; OR, 0.92) intake were significant predictors of hyperglycemia.

CONCLUSION

The prognostic factors of hyperglycemia should be included in nursing interventions to prevent and manage hyperglycemia, which in turn may help reduce adverse reactions related to chemotherapy and improve treatment efficacy.

IMPLICATIONS FOR PRACTICE

To prevent and manage hyperglycemia in patients on chemotherapy, prognostic factors, including exercise and protein, fat, and seaweed consumption, should be considered in nursing interventions. Particularly, in men and patients with low education levels who are at a high risk of hyperglycemia, nursing interventions for diet and exercise should be individualized.

New-Onset Diabetes after an Obesity-Related Cancer Diagnosis and Survival Outcomes in the Women's Health Initiative

BACKGROUND

Individuals diagnosed with an obesity-related cancer (ORC survivors) are at an elevated risk of incident diabetes compared with cancer-free individuals, but whether this confers survival disadvantage is unknown.

METHODS

We assessed the rate of incident diabetes in ORC survivors and evaluated the association of incident diabetes with all-cause and cancer-specific mortality among females with ORC in the Women's Health Initiative cohort (N = 14,651). Cox proportional hazards regression models stratified by exposure-risk periods (0-1, >1-3, >3-5, >5-7, and >7-10 years) from ORC diagnosis and time-varying exposure (diabetes) analyses were performed.

RESULTS

Among the ORC survivors, a total of 1.3% developed diabetes within ≤1 year of follow-up and 2.5%, 2.3%, 2.3%, and 3.6% at 1-3, 3-5, 5-7, and 7-10 years of follow-up, respectively, after an ORC diagnosis. The median survival for those diagnosed with diabetes within 1-year of cancer diagnosis and those with no diabetes diagnosis in that time frame was 8.8 [95% confidence interval (CI), 7.0-14.5) years and 16.6 (95% CI, 16.1-17.0) years, respectively. New-onset compared with no diabetes as a time-varying exposure was associated with higher risk of all-cause (HR, 1.27; 95% CI, 1.16-1.40) and cancer-specific (HR, 1.17; 95% CI, 0.99-1.38) mortality. When stratified by exposure-risk periods, incident diabetes in ≤1 year of follow-up was associated with higher all-cause (HR, 1.76; 95% CI, 1.40-2.20) and cancer-specific (HR0-1, 1.82; 95% CI, 1.28-2.57) mortality, compared with no diabetes diagnosis.

CONCLUSIONS

Incident diabetes was associated with worse cancer-specific and all-cause survival, particularly in the year after cancer diagnosis.

IMPACT

These findings draw attention to the importance of diabetes prevention efforts among cancer survivors to improve survival outcomes.

Repositioning of simvastatin for diabetic colon cancer: role of CDK4 inhibition and apoptosis

There is increased risk of colon cancer in both men and women having diabetes. The objective of the study was to evaluate the role of simvastatin in colon cancer associated with type 2 diabetes mellitus. Diabetes was induced by administering high fat diet with low dose streptozotocin model. 1,2 dimethylhydrazine (25 mg/kg, sc) was used for colon cancer induction. MTT assay, scratch assay, clonogenic assay and annexin V-FITC assay using flow cytometry were performed on HCT-15 cell line. Simvastatin controlled diabetes and colon cancer in animal models and reduced mRNA expression of CDK4 in colon tissues. In vitro studies revealed that simvastatin showed a decrease in cell viability and produced dose dependent decrease in clone formation. There was decrease in the rate of migration with increase in concentration of simvastatin in scratch assay. Moreover, simvastatin induced apoptosis as depicted from annexin V-FITC assay using flow cytometry as well as that revealed by tunnel assay. Our data suggest that simvastatin exhibits protective role in colon cancer associated with diabetes mellitus and acts possibly via down regulation of CDK4 and induction of apoptosis and hence can be considered for repositioning in diabetic colon cancer.

Analysis of the Incidence of Type 2 Diabetes, Requirement of Insulin Treatment, and Diabetes-Related Complications among Patients with Cancer

This retrospective nationwide population-based cohort study used a dataset collected from the Korean National Health Insurance Service. We evaluated incident type 2 diabetes, insulin requirements, and diabetes-associated complications during a 10-year follow-up period using the log-rank test and Cox proportional hazards regression models. In total, 8114 and 16,228 individuals with and without cancer, respectively, were enrolled. We found a higher incidence rate and an increased adjusted hazard ratio (HR) for new cases of type 2 diabetes in patients with cancer, compared with those without cancer. Additionally, patients with cancer had a higher risk of insulin requirement than patients without cancer (adjusted HR 1.43, 95% confidence interval [CI], 1.14-1.78). Although there was no significant association between diabetes-associated complications and overall cancer diagnosis, specific cancer types (pancreas, bladder, and prostate) showed an increased risk of subsequent diabetic nephropathy. Therefore, clinicians should closely monitor patients with cancer for the early detection of type 2 diabetes and related morbidities.

New onset of type 2 diabetes after colorectal cancer diagnosis: Results from three prospective US cohort studies, systematic review, and meta-analysis

BACKGROUND

Limited data indicate that patients with colorectal cancer (CRC) are at higher risk of developing type 2 diabetes (T2D). We prospectively examined the risk of T2D between individuals with and without CRC in three large cohorts and conducted a meta-analysis.

METHODS

We assessed the diagnosis of CRC and T2D among 111,485 women from the Nurses' Health Study, 112,958 women from the Nurses' Health Study II, and 46,581 men from the Health Professionals Follow-up Study. We used multivariable Cox regression with time-varying covariates to calculate the hazard ratio (HR) of T2D in relation to CRC diagnosis. We further performed a systematic review and meta-analysis of cohort studies.

FINDINGS

Up to 36 years of follow-up (6.9 million person-years), we documented 3402 incident CRC cases and 26,469 T2D cases. Compared to non-CRC individuals, those with CRC were more likely to develop T2D (multivariable-adjusted HR 1.20, 95% CI 1.05-1.38). The association was most evident for individuals with fewer risk factors for T2D. In the meta-analysis of seven cohort studies (1,061,744 participants), CRC was associated with higher T2D risk (meta-analysis HR 1.21, 95% CI 1.11-1.31, I² = 57.9%). By CRC duration, a statistically significant association was observed in the first 10 years but not after 10 years of CRC diagnosis (≤5 years, meta-analysis HR 1.32, 95% CI 1.27-1.36; 5.1-10 years, 1.14 [1.04-1.25]; >10 years, 1.14 [0.91-1.37]).

INTERPRETATION

CRC was associated with increased T2D risk, especially in the first ten years after CRC diagnosis. Our findings highlight the importance of T2D prevention for CRC survivorship care.

FUNDING

NHS cohort infrastructure grant (UM1 CA186107), NHS program project grant that funds cancer research (P01 CA87969), NHS II cohort infrastructure grant (U01 CA176726), HPFS cohort infrastructure grant (U01 CA167552) and the Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences (2021-I2M-1-010).

Rectal Cancer and Diabetes Relationship: An Evidence-Based Overview for Healthcare Providers

As the third most frequently diagnosed cancer through the worldwide, colorectal cancer (CRC) is the fourth leading cause and account for around 8% of all cancer-related death. Diabetes mellitus (DM) is a complex metabolic disorder characterized by chronic hyperglycemia and inflammation due to deficiency in insulin secretion or dysregulation of the insulin action pathway, which further leads to dysfunction and failure of multiple organs. Many advances have been made in the diagnosis and management of rectal cancer. Although colorectal cancer survival is severely dependent on the stage of disease at diagnosis, it might also be influenced by several risk factors. The relationship between colorectal cancer and diabetes is a complex one and can raise problems in both diagnosis and the management of patients with both conditions. Metabolic pathways of the type II diabetes, glucose intolerance and obesity can be considered as a link to rectal cancer. This article provides not just an overview of the epidemiology, diagnosis and management of CRC and DM, but also highlights of CRC and DM relationship.

Anti-programmed Cell Death Protein-1 Therapy in Intrahepatic Cholangiocarcinoma Induced Type 1 Diabetes: A Case Report and Literature Review

Immune checkpoint inhibitors, widely used in the treatment of malignancies, can improve the prognosis of patients, while it also can induce various immune-related adverse events, and type 1 diabetes induced by anti-programmed cell death protein-1 is a rare but severe complication. Here we reported a case of type 1 diabetes induced by anti-PD-1 which was to treat intrahepatic cholangiocarcinoma. The case was a 61-year-old female who developed diabetes and ketoacidosis symptoms at the 16th week after anti-PD-1 therapy. Her blood glucose was 30.32 mmol/L, HBA1c was 8.10%, and C-peptide was <0.10 ng/ml. The patient was diagnosed as fulminant type 1 diabetes mellitus complicated with ketoacidosis induced by anti-PD-1, and was treated with massive fluid rehydration, intravenous infusion of insulin and correction of acid-base electrolyte disorder. Hepatectomy was performed after stabilization, and the patient was treated with long-term insulin. Through the case report and literature review, this study aims to improve oncologists' understanding of anti-PD-1 induced type 1 diabetes, so as to make early diagnosis and treatment of the complications and ensure medical safety.

Capecitabine-induced severe diabetes and hypokalemia: a case report

Background

Capecitabine is widely used in chemotherapy for breast, colorectal, and gastric cancers. The frequent adverse reactions of capecitabine mainly include gastrointestinal side effects, anemia, and cardiovascular toxicity. Here, we report a rare case of severe hyperglycemia and hypokalemia during long-term treatment with capecitabine.

Case presentation

A 48-year-old Chinese female was hospitalized with the complaint of breathlessness and weakness after activity, for 1 month. Her past history is significant for a diagnosis of right-sided breast cancer 7 years ago. She underwent right mastectomy, following which capecitabine was started 1.5 years prior to the current admission as part of her primary treatment at the discovery of systemic osseous metastasis. Her fasting plasma glucose and hemoglobin A1c levels were quite normal 7 months ago but increased to 15.3 mmol/L and 11.2%, respectively, at the present admission. Her serum potassium level was as low as 2.5 mmol/L. Plasma autoantibodies related to islets and insulin were all negative. Capecitabine was discontinued, and an insulin pump and potassium supplement were given after admission. Her blood sugar and potassium levels returned to their normal ranges soon. Self-injection of insulin was withdrawn completely at 2 months after discharge, and no oral hypoglycemic agents were added. Her plasma glucose and electrolyte levels were at normal levels at her 1-year follow-up.

Conclusion

Glucose intolerance and hypokalemia may be rare but serious adverse effects during long-term chemotherapy with capecitabine.

A guideline for the outpatient management of glycaemic control in people with cancer

Individuals with cancer are at increased risk of developing new-onset diabetes mellitus and hyperglycaemia, and an estimated 20% of people with cancer already have an underlying diagnosis of diabetes mellitus. People with both cancer and diabetes may have an increased risk of toxicities, hospital admissions and morbidity, with hyperglycaemia potentially attenuating the efficacy of chemotherapy often secondary to dose reductions and early cessation. Numerous studies have demonstrated that hyperglycaemia is prognostic of worse overall survival and risk of cancer recurrence. These guidelines aim to provide the oncology/haemato-oncology and diabetes multidisciplinary teams with the tools to manage people with diabetes commencing anti-cancer/glucocorticoid therapy, as well as identifying individuals without a known diagnosis of diabetes who are at risk of developing hyperglycaemia and new-onset diabetes.

Current cancer therapies and their influence on glucose control

This review focuses on the development of hyperglycemia arising from widely used cancer therapies spanning four drug classes. These groups of medications were selected due to their significant association with new onset hyperglycemia, or of potentially severe clinical consequences when present. These classes include glucocorticoids that are frequently used in addition to chemotherapy treatments, and the antimetabolite class of 5-fluorouracil-related drugs. Both of these classes have been in use in cancer therapy since the 1950s. Also considered are the phosphatidyl inositol-3-kinase (PI3K)/AKT/mammalian target of rapamycin (mTOR)-inhibitors that provide cancer response advantages by disrupting cell growth, proliferation and survival signaling pathways, and have been in clinical use as early as 2007. The final class to be reviewed are the monoclonal antibodies selected to function as immune checkpoint inhibitors (ICIs). These were first used in 2011 for advanced melanoma and are rapidly becoming widely utilized in many solid tumors. For each drug class, the literature has been reviewed to answer relevant questions about these medications related specifically to the characteristics of the hyperglycemia that develops with use. The incidence of new glucose elevations in euglycemic individuals, as well as glycemic changes in those with established diabetes has been considered, as has the expected onset of hyperglycemia from their first use. This comparison emphasizes that some classes exhibit very immediate impacts on glucose levels, whereas other classes can have lengthy delays of up to 1 year. A comparison of the spectrum of severity of hyperglycemic consequences stresses that the appearance of diabetic ketoacidosis is rare for all classes except for the ICIs. There are distinct differences in the reversibility of glucose elevations after treatment is stopped, as the mTOR inhibitors and ICI classes have persistent hyperglycemia long term. These four highlighted drug categories differ in their underlying mechanisms driving hyperglycemia, with clinical presentations ranging from potent yet transient insulin resistant states [type 2 diabetes mellitus (T2DM) -like] to rare permanent insulin-deficient causes of hyperglycemia. Knowledge of the relative incidence of new onset hyperglycemia and the underlying causes are critical to appreciate how and when to best screen and treat patients taking any of these cancer drug therapies.

High glucose: an emerging association between diabetes mellitus and cancer progression

The association of cancer and diabetes mellitus (DM) has been studied for decades. Hyperglycemia and the imbalance of hormones are factors that contribute to the molecular link between DM and carcinogenesis and cancer progression. Hyperglycemia alone or in combination with hyperinsulinemia are key factors that promote cancer aggressiveness. Many preclinical studies suggest that high glucose induces abnormal energy metabolism and aggressive cancer via several mechanisms. As evidenced by clinical studies, hyperglycemia is associated with poor clinical outcomes in patients who have comorbid DM. The prognoses of cancer patients with DM are improved when their plasma glucose levels are controlled. This suggests that high glucose level maybe be involved in the molecular mechanism that causes the link between DM and cancer and may also be useful for prognosis of cancer progression. This review comprehensively summarizes the evidence from recent pre-clinical and clinical studies of the impact of hyperglycemia on cancer advancement as well as the underlying molecular mechanism for this impact. Awareness among clinicians of the association between hyperglycemia or DM and cancer progression may improve cancer treatment outcome in patients who have DM.

Incidence and disease course of new-onset diabetes mellitus in breast and colorectal cancer patients undergoing chemotherapy: A prospective multicenter cohort study

AIMS

To investigate the incidence of and risk factors for new-onset type 2 diabetes mellitus (DM) developed during chemotherapy that included steroids in cancer patients without DM.

METHODS

This multicenter, prospective, and observational cohort study enrolled 299 cancer patients without DM (aged > 18 years), planning 4-8 cycles of adjuvant chemotherapy. The endpoints were the incidence, remission rate, and independent determinants of new-onset DM during chemotherapy.

RESULTS

Between April 2015 and March 2018, 270 subjects with colorectal cancer or breast cancer (mean age, 51.0 years) completed the follow up (mean 39 months). Of whom, 17 subjects (6.3%) developed DM within a median time of 90 days (range, 17-359 days). Male sex (hazard ratio [HR], 15.839; 95% confidence interval [CI], 2.004-125.20) and impaired fasting glucose (IFG) at baseline (HR, 8.307; CI, 1.826-37.786) were independent risk factors. Six months after chemotherapy completion, 11/17 subjects (64.7%) experienced DM remission, associated with a significantly higher C-peptide level at baseline (C-peptide levels, 1.3 ng/mL in subjects with remission and 0.9 ng/mL in subjects without remission, age- and sex-adjusted P = 0.007).

CONCLUSIONS

DM incidence was 6.3% in patients who received chemotherapy with dexamethasone. Close monitoring for hyperglycemia is recommended, especially for men with IFG.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT03062072).

Causes of Death After Colorectal Cancer Diagnosis: A Population-Based Study

Background: Non-cancer causes of death in patients with colorectal cancer (CRC) have not received much attention until now. The purpose of the current study is to investigate the non-cancer causes of death in patients with CRC at different periods of latency.

Methods: Eligible patients with CRC were included from the Surveillance, Epidemiology, and End Results (SEER) database, and standardized mortality ratios (SMRs) were calculated using the SEER*Stat software 8.3.8.

Results: A total of 475,771 patients with CRC were included, of whom 230,841 patients died during the follow-up period. Within 5 years, CRC was the leading cause of death. Over time, non-cancer causes of death account for an increasing proportion. When followed up for more than 10 years, non-cancer deaths accounted for 71.9% of all deaths worldwide. Cardiovascular diseases were the most common causes of non-cancer deaths, accounting for 15.4% of the total mortality. Patients had a significantly higher risk of death from septicemia within the first year after diagnosis compared with the general population (SMR, 3.39; 95% CI, 3.11–3.69). Within 5–10 years after CRC diagnosis, patients had a significantly higher risk of death from diabetes mellitus (SMR, 1.27; 95% CI, 1.19–1.36). During the course of more than 10 years, patients with CRC had a significantly higher risk of death from atherosclerosis (SMR 1.47; 95% CI, 1.11–1.9).

Conclusions: Although CRC has always been the leading cause of death in patients with CRC, non-cancer causes of death should not be ignored. For patients with cancer, we should not only focus on anti-tumor therapies but also pay attention to the occurrence of other risks to prevent and manage them in advance.

Capecitabine-induced hyperosmolar hyperglycaemic state

An elderly woman with metastatic breast cancer was admitted with hyperglycaemic hyperosmolar state (HHS) and an elevated haemoglobin A1C. For 1 week, she had experienced confusion, nausea and frequent urination. Preceding this, she had completed seven cycles of capecitabine chemotherapy for her breast cancer. She did not have a history of diabetes prior to chemotherapy. Given the temporal dysglycaemia following the patient's chemotherapy regimen, capecitabine was thought to be a probable offending agent. The patient was acutely treated for HHS, and was discharged on a basal-bolus insulin regimen. Her capecitabine was held pending review with her oncology team. The patient was ultimately titrated down to basal insulin only by her family doctor. Given the common use of capecitabine, it is important to recognise the risk of hyperglycaemic and hyperglycaemic emergencies as potential adverse effects. This highlights the need to monitor blood glucose throughout treatment to prevent hyperglycaemic emergencies.

Type 2 diabetes and cancer: problems and suggestions for best patient management

Diabetes and cancer are widespread worldwide and the number of subjects presenting both diseases increased over the years. The management of cancer patients having diabetes represents a challenge not only because of the complexity and heterogeneity of these pathologies but also for the lack of standardised clinical guidelines. The diagnosis of cancer is traumatizing and monopolizes the attention of both patients and caregivers. Thus, pre-existent or new-onset diabetes can be overshadowed thus increasing the risk for short- and long-term adverse events. Moreover, drugs used for each disease can interfere with the clinical course of the concomitant disease, making challenging the management of these patients. Over the years, this issue has become more relevant because of the increased patients’ life expectancy due to the improved efficacy of diabetes and cancer therapies. The purpose of this review is to highlight what is known and what should be taken into consideration to optimise the clinical management of patients with diabetes and cancer. Due to the complexity of these diseases, a multidisciplinary, shared approach, including all the protagonists involved, is necessary to improve patients’ quality of life and lifespan.

Cancer Biology and Prevention in Diabetes

The available evidence suggests a complex relationship between diabetes and cancer. Epidemiological data suggest a positive correlation, however, in certain types of cancer, a more complex picture emerges, such as in some site-specific cancers being specific to type I diabetes but not to type II diabetes. Reports share common and differential mechanisms which affect the relationship between diabetes and cancer. We discuss the use of antidiabetic drugs in a wide range of cancer therapy and cancer therapeutics in the development of hyperglycemia, especially antineoplastic drugs which often induce hyperglycemia by targeting insulin/IGF-1 signaling. Similarly, dipeptidyl peptidase 4 (DPP-4), a well-known target in type II diabetes mellitus, has differential effects on cancer types. Past studies suggest a protective role of DPP-4 inhibitors, but recent studies show that DPP-4 inhibition induces cancer metastasis. Moreover, molecular pathological mechanisms of cancer in diabetes are currently largely unclear. The cancer-causing mechanisms in diabetes have been shown to be complex, including excessive ROS-formation, destruction of essential biomolecules, chronic inflammation, and impaired healing phenomena, collectively leading to carcinogenesis in diabetic conditions. Diabetes-associated epithelial-to-mesenchymal transition (EMT) and endothelial-to-mesenchymal transition (EndMT) contribute to cancer-associated fibroblast (CAF) formation in tumors, allowing the epithelium and endothelium to enable tumor cell extravasation. In this review, we discuss the risk of cancer associated with anti-diabetic therapies, including DPP-4 inhibitors and SGLT2 inhibitors, and the role of catechol-o-methyltransferase (COMT), AMPK, and cell-specific glucocorticoid receptors in cancer biology. We explore possible mechanistic links between diabetes and cancer biology and discuss new therapeutic approaches.

Diabetes: an Overview for Clinical Oncologists

Diabetes and cancer are common conditions highly prevalent in the general population. The co-existence of diabetes and cancer in a patient is therefore not unexpected. Diabetes increases the risk of mortality from cancer and morbidity from the treatment of cancer. Furthermore, many cancer chemotherapeutic regimens increase glucose levels, especially those involving glucocorticoids. Many clinical oncologists will deal with patients with diabetes in their clinical work, and some working knowledge of diabetes diagnosis and management is helpful when managing such patients. This overview aims to summarise the clinical diagnosis and management of diabetes, review the potential links between diabetes and cancer, and provide some practical guidance on the management of hyperglycaemia in patients undergoing cancer therapy.

The impact of colectomy on the risk of cardiovascular disease among patients without colorectal cancer

Cardiometabolic disorders were discussed and might be changed by microbiota in recent years. Since the colon acts as the primary reservoir of microbiota, we designed the present study to explore the association between colectomy and cardiovascular disease (CVD). We identified a total of 18,424 patients who underwent colectomy between 2000-2012 for reasons other than colorectal cancer from the National Health Insurance Research Database of Taiwan. Patients were matched with 18,424 patients without colectomy using a 1:1 propensity score by age, sex, and comorbidity. Cox proportional-hazards regression was used to assess the risk of CVD. Patients with colectomy were found to be at lower risk of CVD (hazard ratio [HR]: 0.95, 95% confidence interval [CI] = 0.90-0.99) than patients without colectomy. Stratified analysis according to the type of surgery revealed patients who underwent cecectomy and right hemicolectomy were at lower risk of CVD (cecectomy: adjusted HR [aHR] = 0.77, 95% CI = 0.64-0.94; right hemicolectomy: aHR = 0.88, 95% CI = 0.82-0.96). Patients who underwent left hemicolectomy were at higher risk of CVD (aHR = 1.19, 95% CI = 1.08-1.32). Our results indicate that the different colectomy procedures influence the risk for the CVD differently.

A simple screening score to predict diabetes in cancer patients: A Korean nationwide population-based cohort study

Many cancer patients develop diabetes, which may result in reduction of chemotherapy effectiveness and increased infection risk and cardiovascular mortality. Diabetes may also increase the risks of chemotherapy-related toxicity and post-operative mortality, or represent an obstacle to optimal cancer treatment. However, the clinical predictors of diabetes in cancer patients remain largely unknown. Therefore, the aim of our study was to evaluate the risk factors for developing diabetes and construct a nomogram to predict diabetes in cancer patients.We investigated patients from a national sample cohort obtained from the Korea National Health Insurance Service (KNHIS), which included 2% of the Korean population. Patients who had undergone routine medical evaluation by the KNHIS between 2004 and 2008 and been hospitalized due to cancer (ICD-10 codes C00-97) during the past 3 years were included. After excluding patients with type 2 diabetes and missing data, 10,899 patients were enrolled and followed-up until 2013. A total of 7630 (70%) patients were assigned as the training cohort and used to construct the nomogram which was based on a multivariable logistic regression model. The remaining patients (n = 3269) were used as the validation cohort.The incidence rate of diabetes was 12.1 per 1000 person-years over a mean follow-up of 6.6 ± 1.8 years. Significant risk factors for developing diabetes were age, sex, obesity, fasting plasma glucose, hypertension, and hypercholesterolmia. A nomogram was constructed using these variables and internally validated. The area under the curve was 0.70 (95% confidence interval, .666-.730, P < .0001) and the calibration plot showed agreement between the actual and nomogram-predicted diabetes probabilities.The nomogram developed in this study is easy to use and convenient for identifying cancer patients at high-risk for type 2 diabetes, enabling early type 2 diabetes screening and management.

Incidence of Diabetes After Cancer Development: A Korean National Cohort Study

Importance

Diabetes is an established risk factor for developing cancer. A limited body of evidence also suggests that cancer can increase the risk of developing new cases of diabetes, but the evidence is inconclusive.

Objective

To evaluate whether the development of cancer is associated with increasing risk of subsequent diabetes.

Design, Setting, and Participants

This cohort study included a nationally representative sample of the Korean general population observed for up to 10 years (January 1, 2003, to December 31, 2013). A total of 524 089 men and women 20 to 70 years of age without diabetes and with no history of cancer at baseline were included.

Exposures

Incident cancer (time-varying exposure).

Main Outcomes and Measures

Incident type 2 diabetes using insurance claim codes.

Results

During 3 492 935.6 person-years of follow-up (median follow-up, 7.0 years) in 494 189 individuals (50.0% female; mean [SD] age, 41.8 [12.5] years), 15 130 participants developed cancer and 26 610 participants developed diabetes. After adjustment for age, sex, precancer diabetes risk factors, metabolic factors, and comorbidities, the hazard ratio (HR) for diabetes associated with cancer development was 1.35 (95% CI, 1.26-1.45; P < .001). The excess risk for diabetes was highest in the first 2 years after cancer diagnosis, but it remained elevated throughout follow-up. By cancer type, development of pancreatic (HR, 5.15; 95% CI, 3.32-7.99), kidney (HR, 2.06; 95% CI, 1.34-3.16), liver (HR, 1.95; 95% CI, 1.50-2.54), gallbladder (HR, 1.79; 95% CI, 1.08-2.98), lung (HR, 1.74; 95% CI, 1.34-2.24), blood (HR, 1.61; 95% CI, 1.07-2.43), breast (HR, 1.60; 95% CI, 1.27-2.01), stomach (HR, 1.35; 95% CI, 1.16-1.58), and thyroid cancer (HR, 1.33; 95% CI, 1.12-1.59) was associated with a significantly increased risk of diabetes.

Conclusions and Relevance

In this large Korean cohort, cancer development increased the risk of subsequent diabetes. These data provide evidence that cancer is associated with an increased risk of diabetes in cancer survivors independent of traditional diabetes risk factors. Physicians should remember that patients with cancer develop other clinical problems, such as diabetes, with higher frequency than individuals without cancer, and should consider routine diabetes screening in these patients.

Challenges in the management of people with diabetes and cancer

Although micro- and macrovascular complications of diabetes are the most important cause of mortality and morbidity in people with diabetes, it is increasingly recognized that diabetes increases the risk of developing cancer. Diabetes and cancer commonly co-exist, and outcomes in people with both conditions are poorer than in those who have cancer but no diabetes. There is no randomized trial evidence that treating hyperglycaemia in people with cancer improves outcomes, but therapeutic nihilism should be avoided, and a personalized approach to managing hyperglycaemia in people with cancer is needed. This review aims to outline the link between diabetes therapies and cancer, and discuss the reasons why glucose should be actively managed people with both. In addition, we discuss clinical challenges in the management of hyperglycaemia in cancer, specifically in relation to glucocorticoids, enteral feeding and end-of-life care.

Repurposing of sodium valproate in colon cancer associated with diabetes mellitus: Role of HDAC inhibition

BACKGROUND AND PURPOSE

Diabetic patients are at greater risk for colon cancer. Histone deacetylases (HDACs) serve as common target for both. The key objective of the study was to evaluate the effect of sodium valproate in type 2 diabetes mellitus associated colon cancer.

EXPERIMENTAL APPROACH

High fat diet and streptozotocin were used to induce type 2 diabetes. Following this, after diabetes confirmation, colon cancer was induced using 1,2 dimethylhydrazine (25 mg/kg, s.c.) once weekly from 7th week to 20th weeks. Sodium valproate (200 mg/kg) treatment was given from 20th to 24th week. At the end of 24 weeks, several enzymatic and biochemical parameters, were estimated. MTT, clonogenic and scratch wound healing assay were carried out in HCT-15 cell line.

KEY RESULTS

Hyperglycemia, hyperinsulinemia, increase in cytokines (TNF-α and IL-1β) and carcinoembryonic antigen and presence of proliferating cells was seen in disease control animals which was prevented by sodium valproate treatment. Overexpression of relative HDAC2 mRNA levels was found in diseased control animals, which was reduced by sodium valproate treatment. IC₅₀ of sodium valproate was found to be 3.40 mM and 3.73 mM at 48 h and 72 h respectively on HCT-15 cell line. Sodium valproate also dose dependently prevented colony formation and cell migration.

CONCLUSION AND IMPLICATIONS

Sodium valproate can be considered for repurposing in colon cancer associated with diabetes mellitus.

Rosiglitazone diminishes the high-glucose-induced modulation of 5-fluorouracil cytotoxicity in colorectal cancer cells

Colorectal cancer (CRC) is the third most leading cause of morbidity and mortality throughout the world. 5-fluorouracil (5-FU), which is often administrated to disrupt carcinogenesis, was found to elevate blood glucose level among CRC patients. Thus, this study was conducted to evaluate the influence of rosiglitazone on antiproliferative effect of 5-FU using cellular model. Two human colonic carcinoma cell lines (HCT 116 and HT 29) were cultured in the presence of 5-FU, rosiglitazone or in combination under normal and high glucose concentration. The drug cytotoxicity was evaluated using the MTT assay whereas the assessment of cell cycle was carried out using the flow cytometry technique. Combination index (CI) method was used to determine the drug interaction between rosiglitazone and 5-FU. High glucose diminished the cytotoxic effect of 5-FU but at a high drug dosage, this effect could be overcome. Cell cycle analysis demonstrated that 5-FU and rosiglitazone caused G1-phase arrest and S-phase arrest, respectively. CI values indicated that rosiglitazone exerted synergistic effect on 5-FU regardless of glucose levels. This study is the first to demonstrate the influence of rosiglitazone on cytotoxicity of 5-FU under normal or high glucose level. Rosiglitazone may be a promising drug for enhancing the efficacy of 5-FU in the treatment of CRC associated with hyperglycemia.

dUTPase (DUT) Is Mutated in a Novel Monogenic Syndrome With Diabetes and Bone Marrow Failure

We describe a new syndrome characterized by early-onset diabetes associated with bone marrow failure, affecting mostly the erythrocytic lineage. Using whole-exome sequencing in a remotely consanguineous patient from a family with two affected siblings, we identified a single homozygous missense mutation (chr15.hg19:g.48,626,619A>G) located in the dUTPase (DUT) gene (National Center for Biotechnology Information Gene ID 1854), affecting both the mitochondrial (DUT-M p.Y142C) and the nuclear (DUT-N p.Y54C) isoforms. We found the same homozygous mutation in an unrelated consanguineous patient with diabetes and bone marrow aplasia from a family with two affected siblings, whereas none of the >60,000 subjects from the Exome Aggregation Consortium (ExAC) was homozygous for this mutation. This replicated observation probability was highly significant, thus confirming the role of this DUT mutation in this syndrome. DUT is a key enzyme for maintaining DNA integrity by preventing misincorporation of uracil into DNA, which results in DNA toxicity and cell death. We showed that DUT silencing in human and rat pancreatic β-cells results in apoptosis via the intrinsic cell death pathway. Our findings support the importance of tight control of DNA metabolism for β-cell integrity and warrant close metabolic monitoring of patients treated by drugs affecting dUTP balance.

Acute Hyperglycemia Associated with Anti-Cancer Medication

Hyperglycemia during chemotherapy occurs in approximately 10% to 30% of patients. Glucocorticoids and L-asparaginase are well known to cause acute hyperglycemia during chemotherapy. Long-term hyperglycemia is also frequently observed, especially in patients with hematologic malignancies treated with L-asparaginase-based regimens and total body irradiation. Glucocorticoid-induced hyperglycemia often develops because of increased insulin resistance, diminished insulin secretion, and exaggerated hepatic glucose output. Screening strategies for this condition include random glucose testing, hemoglobin A1c testing, oral glucose loading, and fasting plasma glucose screens. The management of hyperglycemia starts with insulin or sulfonylurea, depending on the type, dose, and delivery of the glucocorticoid formulation. Mammalian target of rapamycin (mTOR) inhibitors are associated with a high incidence of hyperglycemia, ranging from 13% to 50%. Immunotherapy, such as anti-programmed death 1 (PD-1) antibody treatment, induces hyperglycemia with a prevalence of 0.1%. The proposed mechanism of immunotherapy-induced hyperglycemia is an autoimmune process (insulitis). Withdrawal of the PD-1 inhibitor is the primary treatment for severe hyperglycemia. The efficacy of glucocorticoid therapy is not fully established and the decision to resume PD-1 inhibitor therapy depends on the severity of the hyperglycemia. Diabetic patients should achieve optimized glycemic control before initiating treatment, and glucose levels should be monitored periodically in patients initiating mTOR inhibitor or PD-1 inhibitor therapy. With regard to hyperglycemia caused by anti-cancer therapy, frequent monitoring and proper management are important for promoting the efficacy of anti-cancer therapy and improving patients' quality of life.

Doxorubicin caused severe hyperglycaemia and insulin resistance, mediated by inhibition in AMPk signalling in skeletal muscle

BACKGROUND

Cancer is considered the second leading cause of death in the world, and for the treatment of this disease, pharmacological intervention strategies are frequently based on chemotherapy. Doxorubicin (DOX) is one of the most widely used chemotherapeutic agents in clinical practice for treating a number of solid tumours. The treatment with DOX mimics some effects of cancer cachexia, such as anorexia, asthenia, decreases in fat and skeletal muscle mass and fatigue. We observed that treatment with DOX increased the systemic insulin resistance and caused a massive increase in glucose levels in serum. Skeletal muscle is a major tissue responsible for glucose uptake, and the positive role of AMPk protein (AMP-activated protein kinase) in GLUT-4 (Glucose Transporter type 4) translocation, is well established. With this, our aim was to assess the insulin sensitivity after treatment with DOX and involvement of AMPk signalling in skeletal muscle in this process.

METHODS

We used Wistar rats which received a single dose of doxorubicin (DOX group) or saline (CT group) intraperitoneally at a dose of 15 mg/kg b.w. The expression of proteins involved in insulin sensitivity, glucose uptake, inflammation, and activity of electron transport chain was assessed in extensor digitorum longus muscle, as well as the histological evaluation. In vitro assays were performed in L6 myocytes to assess glucose uptake after treatment with DOX. Agonist of AMPk [5-aminoimidazole-4-carboxamide (AICAR)] and the antioxidant n-acetyl cysteine were used in L6 cells to evaluate its effect on glucose uptake and cell viability.

RESULTS

The animals showed a significant insulin resistance, hyperglycaemia, and hyperinsulinemia. A decrease in the expression of AMKP and GLUT-4 was observed in the extensor digitorum longus muscle. Also in L6 cells, DOX leads to a decrease in glucose uptake, which is reversed with AICAR.

CONCLUSIONS

DOX leads to conditions similar to cachexia, with severe glucose intolerance both in vivo and in vitro. The decrease of AMPk activity of the protein is modulated negatively with DOX, and treatment with agonist of AMPk (AICAR) has proved to be a possible therapeutic target, which is able to recover glucose sensitivity in skeletal muscle.

Does the hospitalization after a cancer diagnosis modify adherence to process indicators of diabetes care quality?

AIMS

This study was designed to answer the question whether surgery due to newly diagnosed cancer may modify quality of diabetes' management, as suggested by current guidelines.

METHODS

Adherence to guideline composite indicator (GCI), a process indicator including one annual assessment of HbA1c and at least two among eye examination, serum lipids measurement and microalbuminuria, was evaluated between years 2011-2012 and 2014-2015 in 158,069 diabetic patients living in Tuscany, Italy, on 1 January 2011 and surviving on 31 December 2015, of whom 661 were hospitalized in index year 2013 for a surgery procedure due to a newly incident cancer. Difference in GCI modification (DELTA_GCI) of these patients was compared with that of diabetic people without cancer, strictly matched for main confounders by means of a propensity score.

RESULTS

In diabetic patients with cancer, GCI adherence increased by about 8 % between years 2011-2012 and 2014-2015. When compared with controls, DELTA_GCI increased by 6 % in cancer group compared with controls (p < 0.05), but any significance was lost after matching the groups by propensity score (3 %; p = NS).

CONCLUSIONS

Our study suggests that a hospitalization for a surgical procedure due to a newly diagnosed cancer does not influence the compliance to a quality process indicator of diabetes care such as GCI.

Mechanisms of Doxorubicin Toxicity in Pancreatic β-Cells

Exposure to chemotherapeutic agents has been linked to an increased risk of type 2 diabetes (T2D), a disease characterized by both the peripheral insulin resistance and impaired glucose-stimulated insulin secretion (GSIS) from pancreatic β-cells. Using the rat β-cell line INS-1 832/13 and isolated mouse pancreatic islets, we investigated the effect of the chemotherapeutic drug doxorubicin (Adriamycin) on pancreatic β-cell survival and function. Exposure of INS-1 832/13 cells to doxorubicin caused impairment of GSIS, cellular viability, an increase in cellular toxicity, as soon as 6 h post-exposure. Doxorubicin impaired plasma membrane electron transport (PMET), a pathway dependent on reduced equivalents NADH and NADPH, but failed to redox cycle in INS-1 832/13 cells and with their lysates. Although NADPH/NADP(+ )content was unaffected, NADH/NAD(+ )content decreased at 4 h post-exposure to doxorubicin, and was followed by a reduction in ATP content. Previous studies have demonstrated that doxorubicin functions as a topoisomerase II inhibitor via induction of DNA cross-linking, resulting in apoptosis. Doxorubicin induced the expression of mRNA for mdm2, cyclin G1, and fas whereas downregulating p53, and increased the melting temperature of genomic DNA, consistent with DNA damage and induction of apoptosis. Doxorubicin also induced caspase-3 and -7 activity in INS-1 832/13 cells and mouse islets; co-treatment with the pan-caspase inhibitor Z-VAD-FMK temporarily attenuated the doxorubicin-mediated loss of viability in INS-1 832/13 cells. Together, these data suggest that DNA damage, not H2O2 produced via redox cycling, is a major mechanism of doxorubicin toxicity in pancreatic β-cells.

From obesity to diabetes and cancer: epidemiological links and role of therapies

Increasing evidence suggests a complex relationship between obesity, diabetes and cancer. Here we review the evidence for the association between obesity and diabetes and a wide range of cancer types. In many cases the evidence for a positive association is strong, but for other cancer types a more complex picture emerges with some site-specific cancers associated with obesity but not to diabetes, and some associated with type I but not type II diabetes. The evidence therefore suggests the existence of cumulative common and differential mechanisms influencing the relationship between these diseases. Importantly, we highlight the influence of antidiabetics on cancer and antineoplastic agents on diabetes and in particular that antineoplastic targeting of insulin/IGF-1 signalling induces hyperglycaemia that often evolves to overt diabetes. Overall, a coincidence of diabetes and cancer worsens outcome and increases mortality. Future epidemiology should consider dose and time of exposure to both disease and treatment, and should classify cancers by their molecular signatures. Well-controlled studies on the development of diabetes upon cancer treatment are necessary and should identify the underlying mechanisms responsible for these reciprocal interactions. Given the global epidemic of diabetes, preventing both cancer occurrence in diabetics and the onset of diabetes in cancer patients will translate into a substantial socioeconomic benefit.

Changes of erythrocyte element status of colectomysed cancerous patients: Retrospective study

Nowadays it has been established that metals and metal-induced oxidative stress act on signal transduction pathways, and are in association with cancer growth and spreading as well as in neurodegenerative disorders. In cases of several neurodegenerative diseases metals, especially Al, can be considered as a risk factor. Frequency of chemotherapy-related cognitive impairment or "chemobrain" is mentioned to be significant in literature, although very little is known about the chemotherapy-caused chemobrain and its connection with metal homeostasis alteration. Dysregulation of metal homeostasis can be assumed as one of the key factors in the progression of neurodegeneration. Therefore we were interested in studying metal element status of 27 adult patients in 3 years after their colectomy, 22 outpatients and 10 healthy volunteers in both genders. Tumour markers, laboratory parameters and metal element concentrations were determined. We found significant difference among the Al concentrations in operated patients compared with controls. Redox active Fe and Cu levels were also elevated slightly in this patient group. P and S concentrations changed in different ways, and Ca levels were slightly lower, than in healthy controls. Because of all above mentioned, examination of metal homeostasis in cancerous patients is necessary to moderate the risk of chemobrain and other redox-related disorders.

A phase I trial of mFOLFOX6 combined with the oral PI3K inhibitor BKM120 in patients with advanced refractory solid tumors

PURPOSE

The oral PI3K inhibitor BKM120 has been reported as safe and well tolerated in early phase clinical trials of advanced cancer patients. We performed a phase I trial of BKM120 plus mFOLFOX6 (5-FU/LV + oxaliplatin), a common chemotherapeutic backbone in GI malignancies, to establish the maximum tolerated dose (MTD) and characterize the safety and tolerability of the combination.

METHODS

Patients with advanced solid tumors received oral BKM120 daily combined with standard doses of mFOLFOX6 every 2 weeks of a 28 day cycle. The study utilized a standard 3 + 3 dose escalation schema.

RESULTS

A total of 17 patients received treatment with BKM120, 13 of which were evaluate for dose limited toxicity (DLT). The most common tumor types were colorectal cancer, cholangiocarcinoma, pancreatic cancer and hepatocellular carcinoma. DLT included grade 3 hyperglycemia, grade 3 AST/ALT elevation, grade 4 neutropenia and grade 4 thrombocytopenia. A total of 76 % of patients experienced treatment related grade 3/4 adverse events (AEs), the most common of which were neutropenia, fatigue, leukopenia, hyperglycemia and thrombocytopenia. One patient demonstrated an unconfirmed partial response and three patients had stable disease.

DISCUSSION

The MTD of BKM120 in combination with standard doses of mFOLFOX6 was 40 mg daily, which is well below the 100 mg daily dose proven effective and tolerable both as a single agent and in combination with other chemotherapeutics. In addition, the regimen of BKM120 with mFOLFOX6 in patients with refractory solid tumors resulted in increased toxicity than would be expected from either the PI3K inhibitor or the chemotherapy backbone alone.

Predictors of diabetes self-management in older adults receiving chemotherapy

BACKGROUND

Cancer patients with diabetes have higher mortality rates and are more likely to develop infections, and be hospitalized during treatment. Hyperglycemia has been hypothesized as one of the factors associated with this increased risk. Diabetes self-management is one of the essential elements used by patients to maintain glucose levels.

OBJECTIVE

This exploratory study seeks to develop an understanding of the impact cancer treatment can have on overall diabetes self-management and how individual, clinical, and behavioral characteristics may influence or predict the level of diabetes self-management in adults who are undergoing chemotherapy for a solid tumor cancer.

METHODS

This study was conducted at 8 community-based cancer centers in Michigan and Ohio and used a written, self-administered survey at baseline and a phone survey 8 weeks later.

RESULTS

Diabetes self-management significantly decreased (P < .001), and the level of symptom severity significantly increased (P < .001) after patients were on chemotherapy for a minimum of 8 weeks. The level of symptom severity and diabetes self-efficacy were significantly predictive of the performance of diabetes self-management activities.

CONCLUSIONS

Chemotherapy and associated symptoms can have a negative impact on the performance of diabetes self-management activities in adults with both diabetes and cancer, increasing the risk for hyperglycemia and development of complications.

IMPLICATIONS FOR PRACTICE

Oncology nurses need to be aware of the impact cancer treatment can have on the performance of diabetes self-management activities in adults. Future research needs to test interventions that may assist patients with diabetes and cancer in managing both diseases.

Management of diabetes in patients with cancer

Diabetes is common amongst patients with cancer. The co-occurrence of diabetes and cancer may lead to poorer prognosis and complications in patients undergoing cancer therapy. There is no randomized trial evidence that treating hyperglycaemia in patients with cancer improves outcomes, and therefore a pragmatic approach to managing hyperglycaemic in such patients is required. We discuss the management of hyperglycaemia in relation to cancer chemotherapy, glucocorticoids and enteral feeding. We also discuss management of glucose in diabetic patients with cancer approaching end of life care.

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

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

Diabetes and cancer: two diseases with obesity as a common risk factor

There is a growing body of evidence to support a connection between diabetes (predominantly type 2), obesity and cancer. Multiple meta-analyses of epidemiological data show that people with diabetes are at increased risk of developing many different types of cancers, along with an increased risk of cancer mortality. Several pathophysiological mechanisms for this relationship have been postulated, including insulin resistance and hyperinsulinaemia, enhanced inflammatory processes, dysregulation of sex hormone production and hyperglycaemia. In addition to these potential mechanisms, a number of common risk factors, including obesity, may be behind the association between diabetes and cancer. Indeed, obesity is associated with an increased risk of cancer and diabetes. Abdominal adiposity has been shown to play a role in creating a systemic pro-inflammatory environment, which could result in the development of both diabetes and cancer. Here, we examine the relationship between diabetes, obesity and cancer, and investigate the potential underlying causes of increased cancer risk in individuals with diabetes. Current treatment recommendations for reducing the overall disease burden are also explored and possible areas for future research are considered.

Management of colorectal cancer and diabetes

Colorectal cancer is associated with diabetes mellitus and both of these common conditions are often managed together by a surgeon. The surgical focus is usually upon cancer treatment rather than diabetes management. The relationship between colorectal cancer and diabetes is a complex one and can raise problems in both diagnosis and the management of patients with both conditions. This literature review explores the relationship between diabetes, diabetic treatment and colorectal cancer and addresses the issues that arise in diagnosing and treating this patient group. By highlighting these difficulties, this review aims to improve understanding and to provide clearer insight into both surgical and non-surgical management.

A comprehensive metabolic evaluation reveals impaired glucose metabolism and dyslipidemia in breast cancer patients early in the disease trajectory

BACKGROUND & AIMS

Weight gain in breast cancer patients during treatment is prevalent; the metabolic implications of this weight gain are poorly understood. We aimed to characterize glucose metabolism in breast cancer patients near the initiation of chemotherapy.

METHODS

Stage I-II breast cancer patients (n = 8) were evaluated near the initiation of chemotherapy and compared with a group of age- and body mass index-matched, as well as a group of young healthy, non-malignant females. Fasting blood samples (analyzed for lipids and cytokines) were taken and an oral glucose tolerance test was performed. Body composition, waist circumference, diet, cardiovascular fitness and muscle strength were evaluated.

RESULTS

Breast cancer patients were abdominally obese (mean ± SD: 94.6 ± 14.0 cm), overweight (28.8 ± 6.0 kg/m(2)) and dyslipidemic (triacylglycerides: 1.84 ± 1.17 mM; high-density lipoprotein cholesterol: 1.08 ± 0.23 mM). Compared to non-malignant matched females, fasting glucose and insulin concentrations were similar but fasting c-peptide was greater in patients (2.6 ± 1.2 ng/mL vs. 1.9 ± 0.8 ng/mL, p = 0.005). Glucose was elevated to a greater extent in patients during the oral glucose tolerance test compared with all non-malignant females. During the glucose tolerance test, c-peptide, but not insulin, remained elevated in patients compared with all non-malignant females. No differences in body composition, serum cytokines, nutrition or exercise capacity between patients and matched, non-malignant females emerged.

CONCLUSIONS

Breast cancer patients present with unhealthy metabolic features early in the disease trajectory. Future investigations need to examine the underlying mechanisms and the potential longitudinal changes following chemotherapy.

Severe hyperglycemia immediately after allogeneic hematopoietic stem-cell transplantation is predictive of acute graft-versus-host disease

Stress hyperglycemia and acute graft-versus-host disease (GVHD), the major early complication of hematopoietic stem cell transplantation (HSCT), are both associated with excessive release of inflammatory cytokines. We investigated whether new-onset hyperglycemia immediately after HSCT predicts acute GVHD. We studied nondiabetic adult recipients of human leukocyte antigen-matched HSCT (peripheral blood stem cells) for acute leukemia. Using mean morning serum glucose on Days 1-10, we classified hyperglycemia as: mild (6.11-8.33 mmol/L), moderate (8.34-9.98), and severe (minimum of 9.99). Subjects who were GVHD-free on Day 10 were followed during Days 11-100 for grades II-IV acute GVHD or competing event. Evaluation utilized cumulative incidence-based proportional hazards regression. Subjects (n = 328) were age 18-74, median of 49 years. Per body mass index (BMI)--25.0 % were obese (BMI, 30-48), 33.8 % overweight (25 to <30), 30.8 % normal weight (21 to <25), and 10.4 % lean (18 to <21). Mild, moderate, or severe hyperglycemia occurred during Days 1-10 in 50.0, 21.3, and 16.8 % of subjects, respectively. Cumulative incidence on Day 100 was 44.8 (±2.8) % acute GVHD and 7.9 (±1.5) % competing event. Among normal-to-overweight subjects (n = 212), severe hyperglycemia developed in 14.2 % (n = 30) and more than doubled the risk of acute GVHD (hazards ratio, 2.71; 95 % CI, 1.58-4.65--adjusted for donor/recipient characteristics, prophylactic regimen, and mucositis). In contrast, among obese subjects (n = 82), severe hyperglycemia developed in 30.5 % (n = 25) but did not significantly affect risk of GVHD. (No lean subjects (n = 34) developed severe hyperglycemia.) Hyperglycemia that was less than severe had an effect indistinguishable from normoglycemia. In nondiabetic patients, severe hyperglycemia immediately after allogeneic HSCT indicates increased likelihood of acute GVHD. This association is absent in obese patients, who may be primed by obesity-induced inflammation to develop severe hyperglycemia even without experiencing the cytokine storm that is essential to GVHD pathogenesis.