Incidence and predictors of all-cause and site-specific cancer in type 2 diabetes: the Fremantle Diabetes Study

The impact of diabetes status on total and site-specific cancer risk in the elderly population: A nationwide cohort study

AIMS

We aimed to evaluate the association of prediabetes, diabetes, and diabetes duration with risk of total and site-specific cancer in the Korean population aged 65 years and above.

METHODS

This study included 1,232,173 subjects aged ≥ 65 years who underwent a general health screening program. Diabetes status was categorized as normal glucose tolerance, impaired fasting glucose, new-onset diabetes, diabetes duration of < 5 years, and diabetes duration of ≥ 5 years. Cox proportional hazards models were used to investigate the association of diabetes status with cancer risk.

RESULTS

The risk of total cancer increased as diabetes status worsened, as did the risks of liver, biliary, and pancreatic cancer. Risks of liver, biliary, and pancreatic cancer were significantly higher in subjects aged 65-74 years than in those aged ≥ 75 years. The relationship of diabetes status with overall cancer incidence was found to significantly interact with sex. Among subjects with diabetes, the risks of liver and lung cancer were significantly higher in men than in women regardless of diabetes duration.

CONCLUSIONS

Diabetes status is associated with increased risk of cancer in the elderly. There are age and sex differences in the risk of total and site-specific cancers, including liver, biliary, and pancreatic cancer. This study highlights the importance of cancer screening for elderly subjects with diabetes.

Effect of adipose tissue quantity and dysfunction on the risk of cancer in individuals with and without type 2 diabetes

OBJECTIVE

To determine the role of waist circumference and metabolic dysfunction in the risk of cancer in individuals with type 2 diabetes (T2D) and to compare this to individuals without T2D.

METHODS

Individuals with (n = 1925) and without T2D (n = 10,204) were included from the UCC-SMART cohort. Incident cancer diagnoses were obtained by linkage with the Netherlands Cancer Registry. Metabolic dysfunction was defined as ≥ 3 adapted NCEP ATP-III metabolic syndrome criteria. The effects of waist circumference and metabolic dysfunction on cancer were assessed using Cox proportional hazards models, adjusted for confounders.

RESULTS

During a median follow-up of 8.3 years (IQR 4.2-13.1), 1740 individuals were diagnosed with cancer. Incidence rates of total cancer were 19.3 and 15.5/1000 person-years for individuals with and without T2D, respectively. In individuals without T2D, a higher waist circumference was associated with an increased risk of colorectal (per standard deviation: HR 1.23; 95%CI 1.03-1.46), urinary tract (HR 1.28; 95%CI 1.05-1.56) and total cancer (HR 1.06; 95%CI 1.02-1.13). Metabolic dysfunction was related to an increased risk of colorectal (HR 1.35; 95%CI 1.01-1.82), lung (HR 1.37; 95%CI 1.07-1.75) and total cancer (HR 1.13; 95%CI 1.01-1.25) in individuals without T2D. In individuals with T2D, no significant associations were found.

CONCLUSION

Incidence rates of cancer are higher among individuals with T2D. However, higher waist circumference and metabolic dysfunction are only associated with an increased cancer risk in patients without T2D. These findings provide novel insights into the role of metabolic dysfunction in the occurrence of cancer.

Targeting lipid metabolism in metastatic prostate cancer

Despite key advances in the treatment of prostate cancer (PCa), a proportion of men have de novo resistance, and all will develop resistance to current therapeutics over time. Aberrant lipid metabolism has long been associated with prostate carcinogenesis and progression, but more recently there has been an explosion of preclinical and clinical data which is informing new clinical trials. This review explores the epidemiological links between obesity and metabolic syndrome and PCa, the evidence for altered circulating lipids in PCa and their potential role as biomarkers, as well as novel therapeutic strategies for targeting lipids in men with PCa, including therapies widely used in cardiovascular disease such as statins, metformin and lifestyle modification, as well as novel targeted agents such as sphingosine kinase inhibitors, DES1 inhibitors and agents targeting FASN and beta oxidation.

Smoking and diabetes interplay: A comprehensive review and joint statement

Evidence shows that smoking increases the risk of pre-diabetes and diabetes in the general population. Among persons with diabetes, smoking has been found to increase the risk of all-cause mortality and aggravate chronic diabetic complications and glycemic control. The current paper, which is a joint position statement by the French-Speaking Society on Tobacco (Société Francophone de Tabacologie) and the French-Speaking Society of Diabetes (Société Francophone du Diabète), summarizes the data available on the association between smoking and diabetes and on the impact of smoking and smoking cessation among individuals with type 1, type 2, and gestational diabetes mellitus. It also provides evidence-based information about the pharmacological and behavioral strategies for smoking cessation in these patients.

The relationship between pancreatic cancer and type 2 diabetes: the Fremantle Diabetes Study Phase I

Pancreatic cancer incidence was double (incidence rate ratio 2.06) in community-based adults with (n = 1291) versus without (n = 5158) type 2 diabetes followed for up to 25 years in the Fremantle Diabetes Study Phase 1. Sustained higher fasting plasma glucose reflecting insulin resistance and fewer comorbidities were statistically significant risk factors in the cohort with diabetes. Past pancreatitis was an aetiologically significant determinant in the cohort as a whole.

A Comprehensive Systematic Review of Data Linkage Publications on Diabetes in Australia

Aims

Our study aimed to identify the common themes, knowledge gaps and to evaluate the quality of data linkage research on diabetes in Australia.

Methods

This systematic review was developed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (the PRISMA Statement). Six biomedical databases and the Australian Population Health Research Network (PHRN) website were searched. A narrative synthesis was conducted to comprehensively identify the common themes and knowledge gaps. The guidelines for studies involving data linkage were used to appraise methodological quality of included studies.

Results

After screening and hand-searching, 118 studies were included in the final analysis. Data linkage publications confirmed negative health outcomes in people with diabetes, reported risk factors for diabetes and its complications, and found an inverse association between primary care use and hospitalization. Linked data were used to validate data sources and diabetes instruments. There were limited publications investigating healthcare expenditure and adverse drug reactions (ADRs) in people with diabetes. Regarding methodological assessment, important information about the linkage performed was under-reported in included studies.

Conclusions

In the future, more up to date data linkage research addressing costs of diabetes and its complications in a contemporary Australian setting, as well as research assessing ADRs of recently approved antidiabetic medications, are required.

Diabetes and pancreatic cancer: Exploring the two-way traffic

Pancreatic cancer (PC) is often associated with a poor prognosis. Long-standing diabetes mellitus is considered as an important risk factor for its development. This risk can be modified by the use of certain antidiabetic medications. On the other hand, new-onset diabetes can signal towards an underlying PC in the elderly population. Recently, several attempts have been made to develop an effective clinical tool for PC screening using a combination of history of new-onset diabetes and several other clinical and biochemical markers. On the contrary, diabetes affects the survival after treatment for PC. We describe this intimate and complex two-way relationship of diabetes and PC in this review by exploring the underlying pathogenesis.

Temporal Trends in Cardiovascular Complications in People With or Without Type 2 Diabetes: The Fremantle Diabetes Study

CONTEXT

There is evidence that diabetes-related complications are declining but most data sources have limitations.

OBJECTIVE

To characterize temporal changes in incidence rates (IRs) of chronic complications and mortality in well-characterized, community-based Australians.

DESIGN

Longitudinal observational study.

SETTING

Urban population.

PARTICIPANTS

Participants with type 2 diabetes from the Fremantle Diabetes Study phases I (FDS1; n = 1291 recruited 1993-1996) and II (FDS2; n = 1509 recruited 2008-2011) age-, sex,- and ZIP code-matched 1:4 to people without diabetes.

MAIN OUTCOME MEASURES

First hospitalizations for/with myocardial infarction (MI), stroke, heart failure (HF), lower extremity amputation, and cardiovascular disease (CVD) and all-cause mortality. Five-year IRs, IR ratios for those with versus without diabetes in FDS1 and FDS2, and IR differences (IRDs), were calculated.

RESULTS

The 13,995 participants had a mean age of 64.8 years and 50.4% were males. There were lower IR ratios for MI, stroke, HF, and CVD death in FDS2 versus FDS1. IRDs for people with versus without type 2 diabetes had reduced by >50% between phases for MI, stroke, HF, lower extremity amputation, and CVD death, with no change in IRD for all-cause mortality. Within the pooled type 2 diabetes cohort, FDS2 versus FDS1 participation was an independent inverse predictor of stroke, HF, CVD death, and all-cause mortality after adjustment in Cox proportional hazards models.

CONCLUSIONS

Cardiovascular outcomes in Australians have improved since the 1990s, especially in type 2 diabetes. The difference in all-cause mortality between those with and without type 2 diabetes has persisted despite longer survival.

Association of type 2 diabetes mellitus and antidiabetic medication with risk of prostate cancer: a population-based case-control study

BACKGROUND

Prostate cancer (PCa) and type 2 diabetes mellitus (T2DM) are prevalent conditions that often occur concomitantly. However, many aspects of the impact of T2DM, particularly the duration of T2DM and antidiabetic medications, on PCa risk are poorly understood.

METHODS

To assess the association of duration of T2DM and antidiabetic medication with PCa risk, we designed a matched case-control study, including 31,415 men with PCa and 154,812 PCa-free men in Prostate Cancer data Base Sweden (PCBaSe) 4.1.

RESULTS

Overall, a decreased risk of PCa was observed for men with T2DM (odds ratio (OR): 0.81, 95% confidence interval (CI): 0.78-0.84), as compared to men without T2DM. The decreased risk of PCa was consistently showed across duration of T2DM. With respect to use of antidiabetic drugs, this inverse association with duration was also found for all medications types, as compared to men without T2DM, including insulin, metformin and sulphonylurea (SU) (e.g. 3- < 5 yr insulin OR:0.69, 95%CI:0.60-0.80; 3- < 5 yr metformin OR: 0.82, 95%CI: 0.74-0.91; 3- < 5 yr SU OR: 0.72, 95%CI: 0.62-0.83). When stratifying by PCa risk categories, this decreased risk was most evident for diagnosis of low and intermediate-risk PCa (low-risk OR: 0.65, 95%CI: 0.66-0.70, intermediate-risk OR: 0.80, 95%CI: 0.75-0.85).

CONCLUSIONS

The study showed an inverse association between pre-existing T2DM and PCa across different durations of T2DM and all types of T2DM medication received. This inverse association was most evident for low- and intermediate-risk PCa, suggesting that whilst T2DM and its medication may protect some men from developing PCa, the relationship warrants further study.

Site-specific cancer risk in patients with type 2 diabetes: a nationwide population-based cohort study in Korea

BACKGROUND/AIMS

We aimed to evaluate site-specific cancer risk in diabetic patients and to investigate causal and temporal relationships by analyzing organ-specific cancer risk according to the duration of diabetes.

METHODS

Using a database provided by the Korean National Health Insurance Service, we conducted a retrospective, population-based cohort study of adults aged ≥ 30 years from January 2005 to December 2013. To verify the possibility of detection bias or reverse causation, we compared hazard ratios (HRs) for each cancer according to the following duration of diabetes: less than 6 months, 6 months to 3 years, and more than 3 years.

RESULTS

The incidence of overall cancer per 1,000 person-years was higher in patients with diabetes than in those without diabetes (20.36 vs. 10.83). The overall cancer risk according to the duration of diabetes was the highest within the first 6 months after diagnosis (HR, 2.03; 95% confidence interval [CI], 1.99 to 2.07), and the HR decreased with the duration of diabetes, ranging from 1.19 (95% CI, 1.18 to 1.21) between 6 months and 3 years to 1.12 (95% CI, 1.11 to 1.13) after 3 years. Both overall cancer risk and HR remained significantly higher in patients with diabetes than in those without diabetes. The risk for prostate cancer was higher in men with diabetes than in those without diabetes (HR, 1.12; 95% CI, 1.10 to 1.14). In women, the risk for endometrial cancer was significantly higher in patients with diabetes than in those without diabetes throughout the duration of diabetes.

CONCLUSION

The risk for stomach, colorectum, liver, pancreas, and kidney cancer appeared to be higher in patients with diabetes than in those without diabetes regardless of the sex or duration of diabetes.

The effect of metformin therapy on incidence and prognosis in prostate cancer: A systematic review and meta-analysis

The relationship between metformin and prostate cancer (PCa) remains controversial. To clarify this association, the PubMed, Embase and Cochrane library databases were systematically searched from their inception dates to May 23, 2018, using the keywords “metformin” and “prostate cancer” to identify the related studies. The results included incidence, overall survival (OS), PCa-specific survival (CSS) and recurrence-free survival (RFS), which were measured as hazard ratios (HR) with a 95% confidence interval (95% CI) using Review Manager 5.3 software. A total of 30 cohort studies, including 1,660,795 patients were included in this study. Our study revealed that metformin treatment improves OS, CSS and RFS in PCa (HR = 0.72, 95% CI: 0.59–0.88, P = 0.001; HR = 0.78, 95% CI: 0.64–0.94, P = 0.009; and HR = 0.60, 95% CI: 0.42–0.87 P = 0.006, respectively) compared with non-metformin treatment. However, metformin usage did not reduce the incidence of PCa (HR = 0.86, 95% CI: 0.55–1.34, P = 0.51). In conclusion, compared with non-metformin treatment, metformin therapy can significantly improve OS, CSS and RFS in PCa patients. No association was noted between metformin therapy and PCa incidence. This study indicates a useful direction for the clinical treatment of PCa.

Sex differences in the association between diabetes and cancer: a systematic review and meta-analysis of 121 cohorts including 20 million individuals and one million events

AIMS/HYPOTHESIS

Diabetes has been shown to be a risk factor for some cancers. Whether diabetes confers the same excess risk of cancer, overall and by site, in women and men is unknown.

METHODS

A systematic search was performed in PubMed for cohort studies published up to December 2016. Selected studies reported sex-specific relative risk (RR) estimates for the association between diabetes and cancer adjusted at least for age in both sexes. Random-effects meta-analyses with inverse-variance weighting were used to obtain pooled sex-specific RRs and women-to-men ratios of RRs (RRRs) for all-site and site-specific cancers.

RESULTS

Data on all-site cancer events (incident or fatal only) were available from 121 cohorts (19,239,302 individuals; 1,082,592 events). The pooled adjusted RR for all-site cancer associated with diabetes was 1.27 (95% CI 1.21, 1.32) in women and 1.19 (1.13, 1.25) in men. Women with diabetes had ~6% greater risk compared with men with diabetes (the pooled RRR was 1.06, 95% CI 1.03, 1.09). Corresponding pooled RRRs were 1.10 (1.07, 1.13) for all-site cancer incidence and 1.03 (0.99, 1.06) for all-site cancer mortality. Diabetes also conferred a significantly greater RR in women than men for oral, stomach and kidney cancer, and for leukaemia, but a lower RR for liver cancer.

CONCLUSIONS/INTERPRETATION

Diabetes is a risk factor for all-site cancer for both women and men, but the excess risk of cancer associated with diabetes is slightly greater for women than men. The direction and magnitude of sex differences varies by location of the cancer.

A systematic review of the literature exploring the interplay between prostate cancer and type two diabetes mellitus

Prostate cancer (PCa) and type two diabetes mellitus (T2DM) are both increasing prevalent conditions and often occur concurrently. However, the relationship between the two is more complex than just two prevalent conditions co-existing. This review systematically explores the literature around the interplay between the two conditions. It covers the impact of pre-existing T2DM on PCa incidence, grade and stage, as well as exploring the impact of T2DM on PCa outcomes and mortality and the interaction between T2DM and PCa treatments.

Metformin, Asian ethnicity and risk of prostate cancer in type 2 diabetes: a systematic review and meta-analysis

Background

Metformin is associated with a reduced risk of some cancers but its effect on prostate cancer is unclear. Some studies suggest only Asians derive this benefit. Therefore, we undertook a systematic review with particular attention to ethnicity.

Methods

Medline, Embase, Scopus, Web of Science, and EBM Reviews were searched from inception to 2015. Two reviewers identified and abstracted articles. Studies were pooled using random effects model and stratified by Western- vs Asian-based populations.

Results

We identified 482 studies; 26 underwent full review. Of Western-based studies (n = 23), two were randomized trials and 21 were observational studies. All Asian-based studies (n = 3) were observational. There were 1,572,307 patients, 1,171,643 Western vs 400,664 Asian. Across all studies there was no association between metformin and prostate cancer (RR: 1.01, 95%CI: 0.86-1.18, I²: 97%), with similar findings in Western-based trials (RR: 1.38, 95%CI: 0.72-2.64 I²: 15%) and observational studies (RR: 1.03 95%CI: 0.94-1.13, I²: 88%). Asian-based studies suggested a non-significant reduction (RR: 0.75, 95%CI: 0.42-1.34, I²: 90%), although these results were highly influenced by one study of almost 400,000 patients (propensity-adjusted RR: 0.47 95%CI 0.45-0.49). Removing this influential study yielded an estimate more congruent with Western-based studies (RR: 0.98 95%CI:0.71-1.36, I²: 0%).

Conclusion

There is likely no association between metformin and risk of prostate cancer, in either Western-based or Asian-based populations after removing a highly influential Asian-based study.

Electronic supplementary material

The online version of this article (10.1186/s12885-017-3934-9) contains supplementary material, which is available to authorized users.

Calcium channel blockers and breast cancer incidence: An updated systematic review and meta-analysis of the evidence

Controversy exists regarding the potential association between taking calcium channel blockers (CCBs) and the development of breast cancer. As a positive association would have important public health implications due to the widespread use of CCBs, this study aimed to incorporate new evidence to determine whether an association is likely to exist. We searched MEDLINE, EMBASE and the Cochrane Library to 28 June 2016 for relevant literature. References and citing articles were checked and authors contacted as necessary. Two authors independently selected articles and extracted data. Twenty-nine studies were reviewed; 26 were non-randomised studies (NRS). Meta-analysis of study data where adjustment for 'confounding by indication' was judged to be present suggests that an association, if any, is likely to be modest in magnitude (pooled odds/risk ratio 1.09 (95% confidence interval (CI) 1.03-1.15, I²=0%, 8 sub-studies; pooled hazard ratio 0.99 (95% CI 0.94-1.03, I²=35%, 9 sub-studies)). There are credible study data showing an increased relative risk with long-term use of CCBs, but the results of our meta-analysis and of meta-regression of log relative risk against minimum follow-up time are mixed. The current summative evidence does not support a clear association between taking CCBs and developing breast cancer. However, uncertainty remains, especially for long-term use and any association might not be uniform between different populations and/or breast cancer sub-types. We thus recommend further NRS in settings where CCB use is highly prevalent and population-based cancer, prescription and health-registries exist, to resolve this continuing uncertainty. PROSPERO, CRD42015026712.

[Breast cancer and diabetes mellitus: Complex interactions]

The aim of this literature review was to quantify the incidence and mortality of breast cancer for women treated for a diabetes mellitus and to analyze the complex relationship between these two common diseases.

METHODS

The articles analyzed were extracted from the PubMed database from 2000 to 2015. A total of 22 case/control studies or cohorts were retained, allowing the realization of a meta-analysis.

RESULTS

The incidence of breast cancer for women with diabetes is significantly increased for cohorts (RR=1.32; 95% CI: 1.06 to 1.65) and not significantly for case/control studies (RR=1.46; 95% CI: 0.99 to 2.26). Overall, mortality of women with breast cancer is significantly increased for diabetic patients compared with non-diabetic patients (RR=1.53; 95% CI: 1.23 to 1.90). The links between diabetes and breast cancer are explained by common risk factors (overweight/obesity, qualitative and quantitative dietary errors, physical inactivity), biological changes and the impact of some anti-diabetic treatments or hormonotherapy.

CONCLUSION

Physicians facing a diabetic patient treated for breast cancer have a role in choosing the best anti-diabetic treatment and implementing lifestyle modifications. Diabetic women without breast cancer should participate in organized breast screening programs and have an annual breast clinical examination.

miRNA-30e regulates abnormal differentiation of small intestinal epithelial cells in diabetic mice by downregulating Dll4 expression

OBJECTIVES

Depression of the Notch/Hes1 pathway has been reported to play a role in abnormal differentiation of intestinal epithelial cells (IECs) in diabetes mellitus (DM). However, the mechanism by which this pathway influences IEC differentiation has remained unclear. In this study, we have investigated the role of microRNAs (miRNAs) in regulating the Notch/Hes1 pathway in IECs of DM mice.

MATERIALS AND METHODS

Integrated comparative miRNA microarray technology was used to determine the expression profile of miRNAs in IECs of DM mice. After bioinformatic analysis, an miRNA with altered expression levels, miRNA-30e, was identified as a candidate for regulating the Notch pathway in DM. A luciferase reporter assay confirmed that miRNA-30e targeted 3'-UTR of the Notch gene. The role of miRNA-30e in regulating Notch signalling was then explored by up- and downregulating its expression in vitro and in vivo.

RESULTS

Abnormal differentiation of IECs in DM mice was associated with reduced activity of the Dll4/NICD/Hes1 signal pathway. Based on bioinformatic analyses, increased expression of miRNA-30e was identified as a potential candidate for regulating Notch signalling. miRNA-30e targeted the 3'-UTR of Dll4 and downregulated Dll4 expression in primary IECs and IEC-6 cells. Exogenous miRNA-30e reduced activity of the Dll4/NICD/Hes1 pathway, and induced abnormal differentiation of IECs in normal mice. Conversely, treatment with miRNA-30e antagonist upregu-lated activity of the Dll4/NICD/Hes1 pathway in vivo, and normalized IEC differentiation in DM mice.

CONCLUSIONS

Increased levels of miRNA-30e downregulated activity of the Dll4/NICD/Hes1 signalling pathway by targeting the 3'-UTR of Dll4, which contributed to abnormal differentiation in small intestinal epithelia of DM mice.

Pre-existing type 2 diabetes mellitus is an independent risk factor for mortality and progression in patients with renal cell carcinoma

Malignancies are one of the main causes of mortality in diabetic patients; however, to date, very limited data have been reported on the specific influence of type 2 diabetes mellitus (T2DM) on the survival of patients with renal cell carcinoma (RCC). In the present long-term retrospective study, we investigated whether T2DM may influence the overall survival (OS), cancer-specific survival (CSS), and progression-free survival (PFS) in patients with surgically treated RCC. Medical records of 924 patients treated by radical or partial nephrectomy for sporadic, unilateral RCC were reviewed. Patients with type-1 DM and with T2 DM receiving insulin treatment were excluded. Survival estimates were calculated according to the Kaplan-Meier method and compared with the log-rank test. Univariate and multivariate analyses were performed using the Cox regression model.Of the 924 RCC patients, 152 (16.5%) had T2DM. Mean follow-up was 68.5 months. Mean OS was 41.3 and 96.3 months in T2DM and non-T2DM patients, respectively (P < 0.0001).The estimated CSS rates at 1, 3, and 5 years in T2DM versus non-T2DM patients were 63.4% versus 76.7%, 30.4% versus 56.6%, and 16.3% versus 48.6%, respectively (P = 0.001). Mean PFS was significantly lower (31.5 vs 96.3 months; P < 0.0001) in the T2DM group. At multivariate analysis, T2DM was an independent adverse prognostic factor for OS (hazard ratio [HR]  = 3.44; 95% confidence interval [CI]:2.40-4.92), CSS (HR = 6.39; 95% CI: 3.78-10.79), and PFS (HR = 4.71; 95% CI: 3.11-7.15). In conclusion, our findings suggest that patients with RCC and pre-existing T2DM have a shorter OS, increased risk of recurrence, and higher risk for kidney cancer mortality than those without diabetes.

Incidence and precipitants of hospitalization for pancreatitis in people with diabetes: the Fremantle Diabetes Study

AIMS

To determine the relative risk of pancreatitis in diabetes, and to establish whether diabetes-related as well as recognized risk factors contribute.

METHODS

We studied 1426 participants [mean (SD) age 62.1 (13.3) years, 49.6% male, 90.9% type 2 diabetes, median (interquartile range) diabetes duration 4.0 (1.0-10.0) years] from the community-based Fremantle Diabetes Study Phase I and 5663 matched residents without diabetes from the same geographical area. Pancreatitis hospitalizations between 1982 and 2010 were ascertained using validated data linkage. For Fremantle Diabetes Study Phase I participants, chart review provided data on the likely causes of pancreatitis.

RESULTS

A total of 21 Fremantle Diabetes Study Phase I participants (1.5%) were hospitalized for pancreatitis before study entry vs 29 (0.5%) of contemporaneous residents without diabetes. During a mean (SD) of 12.1 (5.4) years of follow-up from entry, 22 (1.6%) Fremantle Diabetes Study Phase I participants were hospitalized for a first-ever episode of pancreatitis on 37 occasions (1.31/1000 person-years) compared with 58 (1.0%) residents without diabetes on 81 occasions during a mean (SD) 13.6 (4.8) years (0.75/1000 person-years). The age- and sex-adjusted hazard ratio (95% CI) for first-ever pancreatitis hospitalization in Fremantle Diabetes Study Phase I participants was 1.73 (1.06-2.83; P=0.029). Chart review of 17 of the 22 Fremantle Diabetes Study Phase I participants (77%) with incident pancreatitis and available case notes revealed that four (24%) presented without objective evidence of pancreatitis, seven (41%) presented with cholelithiasis, three (18%) with excessive alcohol consumption, two (12%) as a complication of elective endoscopic retrograde cholangiopancreatography, and one (6%) with hypertriglyceridaemia.

CONCLUSION

Consistent with previously published data, the risk of pancreatitis was higher in community-dwelling Fremantle Diabetes Study Phase I participants but conventional precipitants accounted for confirmed cases. These data question whether diabetes-specific risk factors cause or contribute to pancreatitis.

Metformin and cancer risk and mortality: a systematic review and meta-analysis taking into account biases and confounders

Treatment of diabetics with metformin is associated with decreased breast cancer risk in observational studies, but it remains unclear if this drug has clinical antineoplastic activity. In a recent presurgical trial, we found a heterogeneous effect of metformin on breast cancer proliferation (ki-67) depending upon insulin resistance (HOMA index). Here, we determined the associations of additional serum biomarkers of insulin resistance, tumor subtype, and drug concentration with ki-67 response to metformin. Two-hundred non-diabetic women were randomly allocated to metformin (850 mg/bid) or placebo for 4 weeks prior to breast cancer surgery. The ki-67 response to metformin was assessed comparing data obtained from baseline biopsy (ki-67 and tumor subtype) and serum markers (HOMA index, C-peptide, IGF-I, IGFBP-1, IGFBP-3, free IGF-I, hs-CRP, adiponectin) with the same measurements at definitive surgery. For patients with a blood sample taken within 24 h from last drug intake, metformin level was measured. Compared with placebo, metformin significantly decreased ki-67 in women with HOMA > 2.8, those in the lowest IGFBP-1 quintile, those in the highest IGFBP-3 quartile, those with low free IGF-I, those in the top hs-CRP tertile, and those with HER2-positive tumors. In women with HOMA index > 2.8, drug levels were positively correlated with the ki-67 decrease, whereas no trend was noted in women with HOMA < 2.8 (p-interaction = 0.07). At conventional antidiabetic doses, the effect of metformin on tumor ki-67 of non-diabetic breast cancer patients varies with host and tumor characteristics. These findings are relevant to design breast cancer prevention and treatment trials with metformin.

Metformin and cancer risk and mortality: a systematic review and meta-analysis taking into account biases and confounders

Previous meta-analyses have shown that the antidiabetic agent metformin is associated with reduced cancer incidence and mortality. However, this effect has not been consistently demonstrated in animal models and recent epidemiologic studies. We performed a meta-analysis with a focus on confounders and biases, including body mass index (BMI), study type, and time-related biases. We identified 71 articles published between January 1, 1966, and May 31, 2013, through Pubmed, ISI Web of Science (Science Citation Index Expanded), Embase, and the Cochrane library that were related to metformin and cancer incidence or mortality. Study characteristics and outcomes were abstracted for each study that met inclusion criteria. We included estimates from 47 independent studies and 65,540 cancer cases in patients with diabetes. Overall cancer incidence was reduced by 31% [summary relative risk (SRR), 0.69; 95% confidence interval (CI), 0.52-0.90], although between-study heterogeneity was considerable (I(2) = 88%). Cancer mortality was reduced by 34% (SRR, 0.66; 95% CI, 0.54-0.81; I(2) = 21%). BMI-adjusted studies and studies without time-related biases also showed significant reduction in cancer incidence (SRR, 0.82; 95% CI, 0.70-0.96 with I(2) = 76% and SRR, 0.90; 95% CI, 0.89-0.91 with I(2) = 56%, respectively), albeit with lesser magnitude (18% and 10% reduction, respectively). However, studies of cancer mortality and individual organ sites did not consistently show significant reductions across all types of analyses. Although these associations may not be causal, our results show that metformin may reduce cancer incidence and mortality in patients with diabetes However, the reduction seems to be of modest magnitude and not affecting all populations equally. Clinical trials are needed to determine if these observations apply to nondiabetic populations and to specific organ sites.

Abnormal differentiation of intestinal epithelium and intestinal barrier dysfunction in diabetic mice associated with depressed Notch/NICD transduction in Notch/Hes1 signal pathway

Proliferative change and intestinal barrier dysfunction in intestinal mucosa of diabetes have been described, but the differentiation characteristics of intestinal epithelial cells (IECs) and the mechanisms in the IECs development remain unclear. To explore the intestinal epithelial constitution patterns and barrier function, the diabetic mouse model was induced by streptozotocin. Tight junctions between IECs were significantly damaged and the serum level of D-lactate was raised in diabetic mice (P < 0.05). The expression of Zo1 and Ocln in the small intestine of diabetic mice were lower, while the markers for absorptive cell (SI) and Paneth cell (Lyz1) were significantly higher than in control mice (P < 0.05). The expression of Msi1, Notch1, and Dll1 in small intestine gradually increased throughout the course of hyperglycemia in diabetic mice (P < 0.05). However, the expression of NICD, RBP-jκ, Math1, and Hes1 had a reverse trend compared with Msi1 and Notch1. Intestinal absorptive cells and Paneth cells had a high proliferation rate in diabetic mice. However, the intestinal barrier dysfunction associated with the decreased expressions of Zo1 and Ocln was detected throughout hyperglycemia. In conclusion, downregulation of Notch/Hes1 signal pathway caused by depressed Notch/NICD transduction is associated with the abnormal differentiation of IECs and intestinal barrier dysfunction in diabetic mice.

Incidence and predictors of hospitalization for tendon rupture in type 2 diabetes: the Fremantle diabetes study

AIMS

To determine the incidence and predictors of tendon ruptures requiring hospitalization of representative patients with type 2 diabetes.

METHODS

A total of 1296 patients from the longitudinal observational Fremantle Diabetes Study, Phase I, and 5159 de-identified age- and sex-matched control subjects without diabetes from the same urban area were studied. The patients' mean (sd) age was 64.0 (11.3) years and 48.6% of them were male. Their median (interquartile range) diabetes duration was 4.0 (1.0-9.0) years. The main outcome assessed was any tendon rupture requiring hospitalization in the Fremantle Diabetes Study subjects and the matched control subjects. Independent predictors of spontaneous ruptures in the patients from the Fremantle Diabetes Study were assessed using Cox proportional hazards modelling.

RESULTS

The incidence rate ratio for any tendon rupture requiring hospitalization in patients vs control subjects was 1.44 (95% CI 1.10-1.87; P = 0.005). Independent predictors of spontaneous ruptures in patients were BMI [hazard ratio 1.05 (95% CI 1.002-1.10] for 1 kg/m2 increase; P = 0.010] and alcohol consumption [hazard ratio 1.52 (95% CI 1.11-2.09) for √1 standard drink/day increase; P = 0.010]. Adjustment of the incidence rate ratio for overall rupture requiring hospitalization for these variables using the BMI and alcohol consumption data from the contemporary Australian general population suggested it could be as high as 1.84.

CONCLUSIONS

There is a greater risk of tendon rupture requiring hospitalization in people with type 2 diabetes. Alcohol consumption and adiposity are potentially modifiable risk factors of spontaneous ruptures in patients with diabetes.

Association of diabetes mellitus and pancreatic adenocarcinoma: a meta-analysis of 88 studies

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC) is often diagnosed at an advanced, incurable stage. Previous epidemiological data suggests that diabetes mellitus (DM) is a risk factor for PDAC, which may be important in early detection. However, the strength of this association needs to be determined, taking into account a number of recently published studies.

METHODS

A systematic review of the association between DM and PDAC was undertaken by searching electronic databases and journal references from 1973 to 2013. Summary estimates were obtained separately for case-control and cohort studies by means of a 'random effects' approach. Data pertaining to the DM was recorded and plotted at both an individual and study level, with the relative risks (RR) pooled separately to determine the relationship of DM duration and PDAC.

RESULTS

A total of 88 independent studies, including 50 cohort and 39 case-control studies were examined. The overall summary-combined RR was 1.97 (95 % CI 1.78-2.18) with marked heterogeneity that could not be clearly attributed to any subgroup analyses. The risk of PDAC was greatest early after the diagnosis of DM but remained elevated long after the diagnosis. The individual-level RR ranged from 6.69 at less than 1 year to 1.36 at 10 years.

CONCLUSION

The results demonstrate a strong association between PDAC and recently diagnosed DM, which may be attributed to a paraneoplastic effect. However, the presence of diabetes also remains a modest risk factor for the development of PDAC long-term. Selective screening of patients with new-onset DM for PDAC needs to be considered.

Incidence and predictors of hospitalization for bacterial infection in community-based patients with type 2 diabetes: the fremantle diabetes study

Background

The few studies that have examined the relationship between diabetes and bacterial infections have utilized administrative databases and/or have had limited/incomplete data including recognized infection risk factors. The aim of this study was to determine the incidence and associates of bacterial infection severe enough to require hospitalization in well-characterized community-based patients with type 2 diabetes.

Methods and Findings

We studied a cohort of 1,294 patients (mean±SD age 64.1±11.3 years) from the longitudinal observational Fremantle Diabetes Study Phase I (FDS1) and 5,156 age-, gender- and zip-code-matched non-diabetic controls. The main outcome measure was incident hospitalization for bacterial infection as principal diagnosis between 1993 and 2010. We also examined differences in statin use in 52 FDS1 pairs hospitalized with pneumonia (cases) or a contemporaneous non-infection-related cause (controls). During 12.0±5.4 years of follow-up, 251 (19.4%) patients were hospitalized on 368 occasions for infection (23.7/1,000 patient-years). This was more than double the rate in matched controls (incident rate ratio (IRR) (95% CI), 2.13 (1.88–2.42), P<0.001). IRRs for pneumonia, cellulitis, and septicemia/bacteremia were 1.86 (1.55–2.21), 2.45 (1.92–3.12), and 2.08 (1.41–3.04), respectively (P<0.001). Among the diabetic patients, older age, male sex, prior recent infection-related hospitalization, obesity, albuminuria, retinopathy and Aboriginal ethnicity were baseline variables independently associated with risk of first hospitalization with any infection (P≤0.005). After adjustment for these variables, baseline statin treatment was not significant (hazard ratio (95% CI), 0.70 (0.39–1.25), P = 0.22). Statin use at hospitalization for pneumonia among the case-control pairs was similar (23.1% vs. 13.5%, P = 0.27).

Conclusions

The risk of severe infection is increased among type 2 diabetic patients and is not reduced by statin therapy. There are a number of other easily-accessible sociodemographic and clinical variables that could be used to optimize infection-related education, prevention and management in type 2 diabetes.

Type 2 diabetes mellitus, oral diabetic medications, insulin therapy, and overall breast cancer risk

Breast cancer is among the most common cancers worldwide. Diabetes is an important chronic health problem associated with insulin resistance, increased insulin level, changes in growth hormones and factors, and activation of mitogen-activating protein kinase (MAPK) pathways, leading to an increased breast cancer risk. This paper looked at the epidemiologic studies of the association between type 2 diabetes and risk of breast cancer and its effect on overall cancer-specific survival. The combined evidence overall supported a modest association between type 2 diabetes and the risk of breast cancer, which was found to be more prevalent among postmenopausal women. Effect of oral diabetics and insulin therapy on breast cancer risk was also evaluated. It was found that metformin and thiazolidinones tended to have a protective role. Metformin therapy trials for its use as an adjuvant for breast cancer treatment are still ongoing. Sulfonylurea and insulin therapy were found to be mildly associated with increased overall cancers. No evidence or studies evaluated the association of DPPIV inhibitors and GLP 1 agonists with breast cancer risk because of their recent introduction into the management of diabetes.