Association between diabetes or antidiabetic therapy and lung cancer: A meta-analysis

Use of Antihyperglycemic Drugs and Risk of Cancer in Patients with Diabetes

PURPOSE OF REVIEW

Diabetes is associated with an increased risk for several types of cancer. Therefore, use of antihyperglycemic medications to lower blood glucose may modify cancer risk. Here we review available data on the link between the most common classes of antihyperglycemic agents and cancer risk among patients with diabetes.

RECENT FINDINGS

A database search was conducted between February 2022 and June 2022 on PubMed and Embase for systematic reviews and meta-analyses investigating the association between antihyperglycemic agents and risk of cancer. Use of biguanides such as metformin is associated with 20-30% lower risk for all cancer incidence, and somewhat greater benefit for cancer-related mortality. Alpha-glucosidase inhibitors, e.g., acarbose, have not been consistently associated with cancer. Similarly, no consistent effects have been reported for thiazolidinediones, but the relationship with cancer seems to depend on the type of drug, dose, and duration of treatment. Exposure to various types of incretin-based therapies (glucagon-like peptide-1 agonists and dipeptidyl peptidase-4 inhibitors) has not been found to significantly modify cancer risk. Inhibitors of sodium glucose cotransporter-2 may raise risk for bladder cancer and reduce risk for gastrointestinal cancer. Use of insulin and insulin analogs is associated with a significant increase in total cancer risk by almost 50% compared to other antihyperglycemic drugs. Likewise, insulin secretagogues like sulfonylureas have generally been linked to greater risk for cancer by ~ 20%, although these associations may be agent-specific and dose-dependent. Current evidence suggests that the risk of cancer associated with the use of antihyperglycemic medications among patients with diabetes depends on the class of drug and type of agent, dosage, and duration of treatment. More research is needed to delineate the mechanisms by which these agents affect the process of carcinogenesis.

Effect of Body Weight and Other Metabolic Factors on Risk of Non-Small Cell Lung Cancer among Veterans with HIV and a History of Smoking

Simple Summary

Among people living with HIV (PWH), there has been an increasing incidence of non-small cell lung cancer (NSCLC) and metabolic abnormalities, such as diabetes and high cholesterol, which affect the risk of NSCLC. In this article, we evaluate which metabolic risk factors increase the risk of NSCLC among PWH who smoke. Through a retrospective study that includes 33,351 veterans, we found that the risk of NSCLC was lower in well-controlled PWH (1.46 vs. 2.06/1000 patient/year [PY]). Metabolic factors associated with higher NSCLC risk included lower body weight at HIV diagnosis and a remote history of involuntary weight loss in PWH regardless of whether they had a well-controlled infection or not. Lower HDL and triglyceride levels increased the risk of NSCLC only in non-well-controlled smokers. Our results suggest these factors may be important to consider in targeting surveillance and for early identification of NSCLC in PWH smokers.

Abstract

Among people living with HIV (PWH), there has been an increasing incidence of non-small cell lung cancer (NSCLC) and metabolic abnormalities, including dyslipidemia, which can modulate NSCLC risk. In this article, we evaluate which metabolic risk factors are associated with incident risk among PWH who smoke. This is done through a retrospective cohort study, using data of HIV+ veterans who smoke from the nationwide Veterans Affairs (VA) healthcare system. Data on diagnostic codes, medication, and laboratory values of 33,351 veterans were obtained using the VA’s Corporate Data Warehouse and Central Cancer Registry. We calculated NSCLC incidence and utilized Cox regression to determine metabolic factors associated with NSCLC risk. HIV+ cohort was 97.4% male; median age = 47 years and 20,050 (60.1%) well-controlled (≥80% follow-up time undetectable viral load). Crude incidence rates were lower in well-controlled PWH (1.46 vs. 2.06/1000 PY). Metabolic factors associated with incident NSCLC risk included lower BMI at HIV diagnosis and cachexia history in both groups, while HDL and triglycerides were significant in non-well-controlled smokers only. Our findings that lower BMI at HIV diagnosis, history of cachexia among individuals with well-controlled HIV, and cachexia presence at diagnosis are associated with increased risk of developing NSCLC in PWH with a history of smoking have important implications.

Metabolic syndrome and the incidence of lung cancer: a meta-analysis of cohort studies

BACKGROUND

Metabolic syndrome (MetS) has been related to the pathogenesis of variety categories of cancers. This meta-analysis aimed to determine the association between MetS and the incidence of lung cancer.

METHODS

Relevant cohort studies were identified by search of PubMed, Embase, and Cochrane's Library databases. Cochrane's Q test and I2 statistic were used to analyze the heterogeneity. Random-effect model which incorporates the potential heterogeneity was used for the meta-analysis.

RESULTS

Five cohort studies with 188,970 participants were included. A total of 1,295 lung cancer cases occurred during follow-up. Meta-analyses showed that neither MetS defined by the revised NCEP-ATP III criteria (hazard ratio [HR]: 0.94, 95% confidence interval [CI]: 0.84 to 1.05, p = 0.25; I2 = 0) nor the IDF criteria (HR: 0.82, 95% CI: 0.61 to 1.11, p = 0.20; I2 = 0) was associated with an affected risk of lung cancer. Subgroup analyses showed consistent results in women and in men, in studies performed in Asian and non-Asian countries, and in prospective and retrospective cohorts (p all > 0.05). Meta-analysis limited to studies with the adjustment of smoking status also showed similar results (HR: 0.91, 95% CI: 0.80 to 1.05, p = 0.21; I2 = 0). No publication bias was detected based on the Egger regression test (p = 0.32).

CONCLUSIONS

Current evidence from cohort studies does not support that MetS is an independent risk factor for the incidence of lung cancer.

Diabetes and cancer: Pathophysiological fundamentals of a 'dangerous affair'

Diabetes and cancer are worldwide chronic diseases with a major impact on the quality and expectancy of life. Metabolic abnormalities observed during the onset and progression of diabetes may have a critical role on the initiation and progression of carcinogenesis. To date, there are no conclusive data on the mechanisms underlying the relationship between diabetes and any type of human cancer. However, recent evidence suggests that both hyperglycemia and hyperinsulinemia in diabetes could elicit cell damage responses, such as glucotoxicity, lipotoxicity and oxidative stress, which participate in the cell transformation process raising the risk of cancer development. In addition, clinical trials have revealed that several anti-diabetes therapies may potentially affect the risk of cancer though largely undefined mechanisms. In this review, we highlight epidemiological and pathophysiological aspects of diabetes, which may influence cancer initiation and progression.

Metformin and lung cancer risk in patients with type 2 diabetes mellitus

This study evaluated whether metformin might reduce lung cancer risk. The reimbursement database of the Taiwan's National Health Insurance was used. A sample of 15414 never users and 280159 ever users of metformin (original sample) and a 1:1 matched-pairs of ever and never users (n=15414 in each group, matched sample) were recruited from patients with newly diagnosed type 2 diabetes mellitus during 1999-2005. They were followed until December 31, 2011. Cox regression incorporated with the inverse probability of treatment weighting using propensity score was used to estimate hazard ratios. Results showed that the respective incidence of lung cancer in ever and never users was 173.36 and 292.65 per 100000 person-years in the original sample; and was 211.71 and 292.65, respectively, in the matched sample. The overall hazard ratios (95% confidence intervals) of 0.586 (0.509-0.674) in the original sample and 0.717 (0.584-0.881) in the matched sample suggested a significantly lower risk among metformin users. Hazard ratios comparing the first (<22.60 months), second (22.60-46.67 months) and third (>46.67 months) tertile of cumulative duration of metformin use to never users was 1.163 (1.005-1.348), 0.612 (0.526-0.711) and 0.176 (0.148-0.210), respectively, in the original sample; and was 1.465 (1.131-1.897), 0.758 (0.566-1.016) and 0.228 (1.460-0.357) in the respective tertile of the matched sample. Sensitivity analyses after excluding patients with certain risk factors of cancer and subgroup analyses supported a favorable effect of metformin. In conclusion, metformin use may reduce lung cancer risk in patients with type 2 diabetes mellitus.

Smoking, depression, and hospital costs of respiratory cancers: Examining race and sex variation

OBJECTIVE

The role of smoking and depression relative to hospital cost for lung cancer (LC) remains unknown.

METHODS

We extracted data on depression, smoking history, demographics, and hospital charges on patients with respiratory cancers (ICD-9 codes 161-163,165) from the 2008 Tennessee Hospital Discharge Data System. The sample (n=6,665) was mostly white (86%) and male (57). Age-adjusted rates were developed per CDC methodology, and hospital costs were compared for LC with vs. without depression and smoking.

RESULTS

Three findings (p<.001) emerged: (i) LC rate was higher among blacks than whites, and higher among males than females; (ii) While 66% of LC smoked (more males than females without racial variation), 24% had depression (more females and whites were depressed); (iii) The LC hospital cost was 54% higher compared to non-LC, and this cost doubled for LC with depression and smoking vs. those without such characteristics.

CONCLUSION

While LC is more prevalent among blacks and males, depression is higher among female and white patients. Since depression with higher costs existed among LC patients, our findings point to: (i) possibility of cost savings by diagnosing and treating depression among LC, and (ii) implementing proven smoking cessation programs to reduce LC morbidity and hospital costs.

Pharmacologic Therapy of Diabetes and Overall Cancer Risk and Mortality: A Meta-Analysis of 265 Studies

Different anti-diabetic medications (ADMs) may modify cancer risk and mortality in patients with diabetes. We conducted a systematic review and meta-analysis to estimate the magnitude of association and quality of supporting evidence for each ADM. A total of 265 studies (44 cohort studies, 39 case-control studies, and 182 randomized controlled trials (RCT)) were identified, involving approximately 7.6 million and 137,540 patients with diabetes for observational studies and RCTs, respectively. The risk of bias overall was moderate. Meta-analysis demonstrated that the use of metformin or thiazolidinediones was associated with a lower risk of cancer incidence (RR = 0.86, 95% CI 0.83-0.90, I² = 88.61%; RR = 0.93, 95% CI 0.91-0.96, I² = 0.00% respectively). On the other hand, insulin, sulfonylureas and alpha glucosidase inhibitor use was associated with an increased risk of cancer incidence (RR = 1.21, 95% CI 1.08-1.36, I² = 96.31%; RR = 1.20, 95% CI 1.13-1.27, I² = 95.02%; RR = 1.10, 95% CI 1.05-1.15, I² = 0.00% respectively). Use of other types of ADMs was not significantly associated with cancer risk. This study indicates that some ADMs may modify the risk of cancer in individuals with diabetes. Knowledge of this risk may affect the choice of ADM in individuals concerned about cancer or at increased risk for cancer.