Diabetes mellitus among cancer survivors

Increased risks of type II diabetes among older Asian, Native Hawaiian, and Pacific Islander lung cancer survivors: a SEER-Medicare analysis

PURPOSE

Asian, Native Hawaiian, and Pacific Islanders (ANHPI) have a higher prevalence of type II diabetes compared to the non-Hispanic White (NHW) population. However, the incidence of type II diabetes among ANHPI lung cancer survivors is unknown. The aim of this study is to investigate the risk of newly diagnosed type II diabetes among older ANHPI lung cancer survivors compared to older NHW lung cancer survivors.

METHODS

We identified 3920 ANHPI and 11,760 NHW lung cancer survivors diagnosed from 2000 to 2017 from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. Cox proportional hazard models were used to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs) for the risk of type II diabetes, adjusting for potential confounding factors.

RESULTS

Older ANHPI lung cancer survivors had an increased risk of incident type II diabetes compared to older NHW lung cancer survivors > 1 year after cancer diagnosis. For specific ANHPI subgroups, increased risks of type II diabetes were observed among Asian Indian and Pakistani (HR, 5.14; 95% CI 2.10, 12.60) compared to NHW patients, followed by Native Hawaiian and Pacific Islander (NHPI) (HR, 4.38; 95% CI 1.22, 15.74), Vietnamese (HR, 2.32; 95% CI 1.29, 4.18), Korean (HR, 2.26; 95% CI 1.13, 4.54), Filipino (HR, 1.78; 95% CI 1.00, 3.16), and Chinese (HR, 1.75; 95% CI 1.10, 2.79) lung cancer survivors.

CONCLUSION

Older ANHPI lung cancer survivors had a higher risk of type II diabetes compared to older NHW lung cancer survivors. Further research is needed to examine the underlying causes of health disparities in diabetes risk among ANHPI lung cancer survivors.

IMPLICATIONS FOR CANCER SURVIVORS

These findings suggest that increasing surveillance on type II diabetes and monitoring body weight for older ANHPI lung cancer patients may be beneficial.

Diabetes and Cancer: Risk, Challenges, Management and Outcomes

BACKGROUND

Diabetes mellitus and cancer are commonly coexisting illnesses, and the global incidence and prevalence of both are rising. Cancer patients with diabetes face unique challenges. This review highlights the relationship between diabetes and cancer and various aspects of the management of diabetes in cancer patients.

METHODS

A literature search using keywords in PubMed was performed. Studies that were published in English prior to July 2021 were assessed and an overview of epidemiology, cancer risk, outcomes, treatment-related hyperglycemia and management of diabetes in cancer patients is provided.

RESULTS

Overall, 8-18% of cancer patients have diabetes as a comorbid medical condition. Diabetes is a risk factor for certain solid malignancies, such as pancreatic, liver, colon, breast, and endometrial cancer. Several novel targeted compounds and immunotherapies can cause hyperglycemia. Nevertheless, most patients undergoing cancer therapy can be managed with an appropriate glucose lowering agent without the need for discontinuation of cancer treatment. Evidence suggests that cancer patients with diabetes have higher cancer-related mortality; therefore, a multidisciplinary approach is important in the management of patients with diabetes and cancer for a better outcome.

CONCLUSIONS

Future studies are required to better understand the underlying mechanism between the risk of cancer and diabetes. Furthermore, high-quality prospective studies evaluating management of diabetes in cancer patients using innovative tools are needed. A patient-centered approach is important in cancer patients with diabetes to avoid adverse outcomes.

Comparison of Comorbid Conditions Between Cancer Survivors and Age-Matched Patients Without Cancer

Background

Cancer survivors suffer from many comorbid conditions even after the cure of their cancers beyond 5 years. We explored the differences in the association of comorbid conditions between the cancer survivors and patients without cancer.

Methods

Electronic medical records of 280 adult cancer survivors and 280 age-matched patients without cancer in our suburban internal medicine office were reviewed.

Results

Mean age of the cancer survivors was 72.5 ± 13.1 years, and the age of the patients without cancer was 72.5 ± 12.8 years. The number of male cancer survivors was significantly higher than the female cancer survivors (52.5% vs. 47.5%, P < 0.001). There were significantly more Caucasians and other races (majority Asians) in the cancer survivor group compared to the patients without cancer group (81.8% vs. 79.3% and 4.6% vs. 0.4%, respectively, P < 0.05); while there were significantly less African Americans and Hispanics in the cancer survivor group compared to the patients without cancer group (10.0% vs. 12.8% and 3.6% vs. 7.5%, respectively, P < 0.05). Hypertension (64.3%), hyperlipidemia (56.1%), osteoarthritis (34.3%), hypothyroidism (21.8%), diabetes mellitus (21.8%) and coronary artery disease (21.8%) were the most common comorbid conditions observed in the cancer survivors. Osteoarthritis was the only comorbid condition that was significantly less frequently associated with the cancer survivors compared to the patients without cancer (42.9%, P < 0.05). The frequencies of all other comorbid conditions were not significantly different between the two groups. The majority of our group of cancer survivors had one or more types of the top six cancers which include prostate cancer (30.7%), melanoma (13.9%), thyroid cancer (11.4%), colon cancer (11.1%), uterine cancer (11.1%) and urinary bladder cancer (11.1%); while only a few had cancer of the cervix (6.1%) or breast cancer (0.3%). Use of aspirin, statin, vitamin D, multivitamins, metformin and fish oil supplement in the cancer survivors was similar to the patients without cancer.

Conclusions

Hypertension, hyperlipidemia, osteoarthritis, hypothyroidism, diabetes mellitus and coronary artery disease are the most common associated comorbid conditions in the cancer survivors. Osteoarthritis is less frequently seen in the cancer survivors compared to the patients without cancer. The frequencies of other comorbid conditions are not significantly different between the two groups.

Obesity, physical activity, and dietary behaviors in an ethnically-diverse sample of cancer survivors with early onset disease

PURPOSE

To assess weight status, physical activity, and dietary behaviors in an ethnically-diverse sample of breast and colorectal cancer survivors with early onset disease (≤ 50 years).

METHODS

Breast and colorectal cancer survivors, diagnosed between 1999 and 2009 with early-stage cancer diagnosed by 50 years of age, were identified through a population-based cancer registry and surveyed. Descriptive and regression analyses were conducted to characterize the sample and identify correlates of lifestyle behaviors.

FINDINGS

The majority of participants (n = 156) were female (83%), insured (84%), and racial/ethnic minorities (29% Asian, 24% Latino, 15% African American). Participants' mean age at response was 50 years and mean time since diagnosis was 9 years. Over half of survivors were overweight or obese. Few participants reported engaging in regular physical activity (31%) and adhering to minimum guidelines for fruit and vegetable consumption (32%). A substantial proportion of survivors consumed fast food in the past week (75%) and nearly half (48%) reported daily consumption of sugar-sweetened beverages. Lower income was associated with inadequate fruit and vegetable intake. Fast food and sugar-sweetened beverage consumption was significantly higher among racial/ethnic minority survivors compared to non-Latino whites.

CONCLUSIONS

High prevalence of overweight and suboptimal adherence to recommended nutrition and physical activity behaviors were observed among cancer survivors with early onset disease. Cancer survivors diagnosed at a young age may benefit from targeted interventions to address overweight and suboptimal nutrition and physical activity.

Perceived barriers and preferred components for physical activity interventions in African-American survivors of breast or endometrial cancer with type 2 diabetes: the S.U.C.C.E.S.S. framework

PURPOSE

African-American (AA) female cancer survivors share a disproportionate burden of diabetes compared to their white counterparts. Our objectives were to explore the perspectives of AA survivors with type 2 diabetes on perceived barriers to physical activity (PA) and preferences for a PA intervention and develop a framework for a PA program after cancer treatment.

METHODS

Trained interviewers conducted semi-structured interviews with AA survivors of breast or endometrial cancer with diabetes (total n = 20; 16 breast, 4 endometrial). Thirteen open-ended questions were posed to stimulate discussions, which were audio recorded and transcribed verbatim. Two investigators independently reviewed transcriptions and extracted coded quotations to identify major themes.

RESULTS

Median age of participants was 63 years. Nine themes were identified that focused on post-treatment physical symptoms (e.g., lymphedema, bone/joint pain, depression symptoms and self-motivation as barriers to PA, exercise routines tailored to physical limitations and peer partners and program leaders who understand their emotional health needs). The S.U.C.C.E.S.S. framework summarizes the survivors' preferences for an effective lifestyle intervention: Support efforts to maintain PA, Understand physical and depression symptoms, Collaborate with multi-disciplinary provider, Coordinate in-person intervention activities, Encourage partnerships among survivors for comorbidity risk reduction, develop Sustainable coping strategies for side effects of treatment, and Share local community resources.

CONCLUSIONS

Survivors verbalized the need for a multi-disciplinary team to assist with their psychosocial needs and physical limitations to achieve their PA goals, as integrated into the S.U.C.C.E.S.S.

FRAMEWORK

IMPLICATIONS FOR CANCER SURVIVORS

The S.U.C.C.E.S.S. framework reflects the perspectives of survivors with type 2 diabetes and may help to inform post-treatment programs.

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.

Development and Evaluation of the Curriculum for BOLD (Bronx Oncology Living Daily) Healthy Living: a Diabetes Prevention and Control Program for Underserved Cancer Survivors

Underserved minority communities have few resources for addressing comorbidity risk reduction among long-term cancer survivors. To address this community need, we developed and piloted the Bronx Oncology Living Daily (BOLD) Healthy Living program, the first known diabetes prevention and control program to target cancer survivors and co-survivors in Bronx County, NY. The program aimed to facilitate lifestyle change and improve health-related quality of life (HRQoL) through weekly group nutrition education (60-90 min) and exercise (60 min) classes. We examined baseline characteristics of participants using simple descriptive statistics and evaluated program implementation and impact using the Reach, Efficacy, Adoption, Implementation and Maintenance (RE-AIM) framework. The curriculum, which drew from the social-ecological framework and motivational and cognitive behavioral strategies, consisted of 12 culturally and medically tailored modules with options for implementation as a 12- or 4-week program. Seven programs (four 12 weeks and three 4 weeks in length, respectively) were implemented at five community site locations. Sixty-six cancer survivors and 17 cancer co-survivors (mean age 60.5 ± 10.2 years) enrolled in one of the programs. Most participants were female (95.2 %) minority (55.4 % black, 26.5 % Hispanic/Latino) breast cancer survivors (75.7 %). Median program attendance was 62.5 % and did not significantly differ by program length; however, 67.3 % of participants achieved ≥60 % attendance among the 12-week programs, compared to 41.9 % among the 4-week programs, and this difference was statistically significant (p = 0.02). Overall, participants reported significant pre/post improvements in perceived health as good/excellent (66.0 to 75.5 %; p = 0.001) and borderline significant decreases in perceived pain as moderate/severe (45.5 to 38.2 %; p = 0.05). More than 90 % of participants reported that the program helped them to achieve their short-term goals, motivated them to engage in healthier behaviors, and felt that the nutrition and exercise classes were relevant to their needs. These results indicate that a short-term lifestyle intervention program for adult cancer survivors was acceptable in our community and motivated cancer survivors to improve their HRQoL. The curriculum can be used as a tool to facilitate development of similar programs in the future.

Are long-term cancer survivors and physicians discussing health promotion and healthy behaviors?

PURPOSE

This study aimed to (1) describe the proportion of survivors reporting that a physician discussed strategies to improve health and (2) identify which groups are more likely to report these discussions.

METHODS

Lung cancer and colorectal cancer (CRC) survivors (>5 years from diagnosis) (n = 874) completed questionnaires, including questions on whether, in the previous year, a physician discussed (1) strategies to improve health, (2) exercise, and (3) diet habits. Chi-square tests and logistic regression models were used to examine whether the likelihood of these discussions varied by demographic and clinical characteristics.

RESULTS

Fifty-nine percent reported that a physician discussed strategies to improve health and exercise, 44% reported discussions on diet, and 24% reported no discussions. Compared to their counterparts, survivors with lower education were less likely to report discussing all three areas, but survivors with diabetes were more likely. Survivors ≥ 65 years old were less likely to report discussing strategies to improve health and diet. Males and CRC survivors reported discussing diet more than their female and lung cancer counterparts, respectively.

CONCLUSION

The frequency of health promotion discussions varied across survivor characteristics. Discussions were more frequently reported by some groups, e.g., survivors with diabetes, or among individuals less likely to engage in healthy behaviors. In contrast, males and older and less educated survivors were less likely to have these discussions.

IMPLICATIONS FOR CANCER SURVIVORS

Decreasing physician barriers and encouraging patients to discuss health promotion, especially in the context of clinical care for older survivors and those with low education, is essential for promoting the overall well-being of cancer survivors.

A novel method for studying the temporal relationship between type 2 diabetes mellitus and cancer using the electronic medical record

Background

We developed an algorithm for the identification of patients with type 2 diabetes and ascertainment of the date of diabetes onset for examination of the temporal relationship between diabetes and cancer using data in the electronic medical record (EMR).

Methods

The Marshfield Clinic EMR was searched for patients who developed type 2 diabetes between January 1, 1995 and December 31, 2009 using a combination of diagnostic codes and laboratory data. Subjects without diabetes were also identified and matched to subjects with diabetes by age, gender, smoking history, residence, and date of diabetes onset/reference date.

Results

The final cohort consisted of 11,236 subjects with and 54,365 subjects without diabetes. Stringent requirements for laboratory values resulted in a decrease in the number of potential subjects by nearly 70%. Mean observation time in the EMR was similar for both groups with 13—14 years before and 5–7 years after the reference date. The two cohorts were largely similar except that BMI and frequency of healthcare encounters were greater in subjects with diabetes.

Conclusion

The cohort described here will be useful for the examination of the temporal relationship between diabetes and cancer and is unique in that it allows for determination of the date of diabetes onset with reasonable accuracy.

Co-morbidity and predictors of health status in older rural breast cancer survivors

Purpose

More than 66% of the 200,000 newly diagnosed annual breast cancers in the US occurs in women over 55 years. Treatment advances result in excellent survival, yet older breast cancer survivors with co-morbidity may live longer, but not better after cancer. Decline in physical function, increased social isolation, and diminished economic resources increase vulnerability among older women. Rural women represent an underserved population. The purpose is to examine associations between comorbidity and predictors of health status among older rural breast cancer survivors.

Methods

Baseline data of 331 BCS age 55–90 years enrolled in the Rural Breast Cancer Survivors Study. Four surveys were used for data collection. Self-reported prescription medications were used as proxy for co-morbidity. Bivariate tests of association and multivariable recursive partitioning techniques were used for analysis.

Results

Mean number of prescription medication categories reported was 3.68 (SD = 2.3; range = 0–12). Common prescription categories were: anti-hormonal, anti-hypertensive, and cholesterol- reducing agents. 69% was overweight or obese. BMI >31 was significantly associated with both poorer physical and mental health. Multivariate analyses indicated physical health status was predicted by BMI, comorbid conditions, social support, and adverse changes in economic lifestyle. The same variables, with the exception of BMI, were predictors of mental health status.

Conclusions

Assessing co-morbid conditions, mental health status, social support, and economic burden after breast cancer treatment may better inform cancer survivorship care and comprehensive geriatric assessment.

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.

Breast and prostate cancer survivors in a diabetic cohort: results from the Living with Diabetes Study

OBJECTIVE

Diabetes is more common in cancer survivors than in the general population. The objective of the present study was to determine cancer frequency in a cohort of patients with diabetes and to examine demographic, clinical, and quality of life differences between cancer survivors and their cancer-free peers to inform better individualized care.

METHODS

Self-reported survey data from 3,466 registrants with type 2 diabetes from Australia's National Diabetes Services Scheme (NDSS) were analyzed to compare relevant variables between cancer survivors and cancer-free patients. Analyses were focused on breast and prostate cancer to reflect the most common cancers in women and men, respectively.

RESULTS

Five percent of diabetic women reported a history of breast cancer and 4.2% of men reported a history of prostate cancer. Diabetic patients with a history of breast or prostate cancer were older at time of survey and diabetes diagnosis, less likely to report metformin use (women), and more likely to have two or more comorbidities than their cancer-free peers. More diabetic prostate cancer survivors also reported problems with mobility and performing usual tasks. However, cancer-free diabetic subjects reported a lower diabetes-dependent quality of life than diabetic cancer survivors. There was no association between cancer survivorship and duration of diabetes, indices of glycemic control, obesity, or diabetic complications.

CONCLUSIONS

Cancer survivors comprise a significant minority of diabetic patients that are particularly vulnerable and may benefit from interventions to increase screening and treatment of other comorbidities and promote a healthy lifestyle.

Diabetes mellitus and health-related quality of life in prostate cancer: 5-year results from the Prostate Cancer Outcomes Study

Study Type--Therapy (outcomes research) Level of Evidence 2b. What's known on the subject? and What does the study add? Comorbid diabetes can affect prostate cancer treatment decision-making and outcomes. Few longitudinal studies have investigated the effect of comorbid diabetes on general and cancer-specific health-related quality of life (HRQL) in prostate cancer. Our study found that men with prevalent diabetes (pre-prostate cancer diagnosis) generally had the poorest general HRQL, urinary control and sexual function scores over time, independent of treatment. Non-diabetic men had the best scores and men with incident diabetes (post-prostate cancer diagnosis) reported intermediate scores. OBJECTIVE • To investigate the association between prostate cancer, diabetes, and long-term general and cancer-specific health-related quality of life (HRQL) in a cohort of men with non-metastatic prostate cancer. PATIENTS AND METHODS • We used data from self-administered surveys to assess the HRQL of men with localized or locally advanced disease at 6 (baseline), 12, 24, and 60 months after initial diagnosis. • We examined changes in general and cancer-specific HRQL with repeated measures analyses using a mixed-model approach. RESULTS • In total, we evaluated 1811 men, including 13% with prevalent (pre-prostate cancer diagnosis) diabetes, 12% with incident (post-prostate cancer diagnosis) diabetes, and 75% who never reported being diagnosed with diabetes. • Generally, men with prevalent diabetes had the poorest scores on general HRQL and non-diabetic men the best scores, independent of treatment. • Similarly, men with prevalent diabetes had the lowest urinary control and sexual function scores over time, while men without diabetes had the highest scores. Men with incident diabetes reported intermediate scores. CONCLUSION • Prostate cancer survivors with comorbid diabetes have poorer general and cancer-specific HRQL than those without diabetes.

Skeletal sequelae of cancer and cancer treatment

INTRODUCTION

Survivors of cancer may experience lingering adverse skeletal effects such as osteoporosis and osteomalacia. Skeletal disorders are often associated with advancing age, but these effects can be exacerbated by exposure to cancer and its treatment. This review will explore the cancer and cancer treatment-related causes of skeletal disorders.

METHODS

We performed a comprehensive search, using various Internet-based medical search engines such as PubMed, Medline Plus, Scopus, and Google Scholar, for published articles on the skeletal effects of cancer and cancer therapies.

RESULTS

One-hundred-forty-two publications, including journal articles, books, and book chapters, met the inclusion criteria. They included case reports, literature reviews, systematic analyses, and cohort reports. Skeletal effects resulting from cancer and cancer therapies, including hypogonadism, androgen deprivation therapy, estrogen suppression, glucocorticoids/corticosteroids, methotrexate, megestrol acetate, platinum compounds, cyclophosphamide, doxorubicin, interferon-alpha, valproic acid, cyclosporine, vitamin A, NSAIDS, estramustine, ifosfamide, radiotherapy, and combined chemotherapeutic regimens, were identified and described. Skeletal effects of hyperparathyroidism, vitamin D deficiency, gastrectomy, hypophosphatemia, and hyperprolactinemia resulting from cancer therapies were also described.

DISCUSSION/CONCLUSIONS

The publications researched during this review both highlight and emphasize the association between cancer therapies, including chemotherapy and radiotherapy, and skeletal dysfunction.

IMPLICATIONS FOR CANCER SURVIVORS

These studies confirm that cancer survivors experience a more rapid acceleration of bone loss than their age-matched peers who were never diagnosed with cancer. Further studies are needed to better address the skeletal needs of cancer survivors.

Endocrine sequelae of cancer and cancer treatments

INTRODUCTION

Exposure to cancer and its treatments, including chemotherapy and radiotherapy, may result in late adverse effects including endocrine dysfunction. Endocrine disorders are the most commonly reported long-term complications of cancer treatment, especially by adult survivors of childhood cancers. This review will explore the endocrinologic adverse effects from non-endocrine cancer therapies.

METHODS

Searches including various Internet-based medical search engines such as PubMed, Medline Plus, and Google Scholar were conducted for published articles.

RESULTS

One hundred sixty-nine journal articles met the inclusion criteria. They included case reports, systematic analyses, and cohort reports. Endocrine disorders including hypothalamus dysfunction, hypopituitarism, syndrome of inappropriate anti-diuretic hormone secretion, diabetes insipidus, growth hormone disorders, hyperprolactinemia, gonadotropin deficiency, serum thyroid hormone-binding protein abnormalities, hypothyroidism, hyperthyroidism, hypomagnesium, hypocalcemia, hyperparathyroidism, hyperparathyroidism, adrenal dysfunction, gonadal dysfunction, hypertriglyceridemia, hypercholesterolemia, diabetes mellitus, and glycosuria were identified and their association with cancer therapies were outlined.

DISCUSSION/CONCLUSIONS

The journal articles have highlighted the association of cancer therapies, including chemotherapy and radiotherapy, with endocrine dysfunction. Some of the dysfunctions were more often experienced than others. Especially in patients treated with radiotherapy, some endocrinologic disorders were progressive in nature.

IMPLICATIONS FOR CANCER SURVIVORS

Recognition and awareness of endocrine sequelae of cancer treatments may permit for early detection and appropriate follow-up care for cancer survivors, thus improving their overall health and quality of life.