The management of diabetes in patients with advanced cancer

Diabetes and cancer co-management: patient-reported challenges, needs, and priorities

INTRODUCTION

Twenty percent of breast cancer survivors have co-occurring diabetes and face a 50% greater risk of 10-year mortality compared to survivors without diabetes. Individuals with cancer are often overwhelmed during cancer treatment and have less time for their diabetes, contributing to worse outcomes. We elicited perspectives of breast cancer survivors with diabetes regarding their specific needs for diabetes and cancer co-management.

METHODS

We conducted semi-structured interviews with women with breast cancer aged 40 + years at three New York City hospitals from May 2021 to March 2022. Eligible participants had type 2 diabetes or pre-diabetes. Interviews were audio-recorded, professionally transcribed, and coded by two independent reviewers.

RESULTS

We conducted interviews with 15 females with breast cancer of mean age 61.5 years (SD 7.2); 70% were Black, Hispanic, or Asian/Pacific Islander, and 20% had only a high school education. Most (73%) patients were insured by Medicaid or Medicare, and 73% underwent chemotherapy as part of their cancer care. Of the 15 participants, 60% reported that their glucose levels were of control during cancer treatment and nearly 50% reported glucose levels > 200 mg/dL. We identified distinct themes that reflect patient-reported challenges (worse glucose control after initiation of cancer treatment, lack of information on co-managing diabetes, negative psychosocial effects, burden of diabetes management during cancer care) and needs/priorities (designated provider to help, educational resources specific to diabetes and cancer, and individualized care plans).

CONCLUSIONS

Patients co-managing diabetes and cancer face challenges and have unmet needs that should be addressed to improve diabetes control during cancer treatment. Our findings can directly inform interventions aimed at improving glucose control in this population.

Deprescribing in Older Adults With Cancer and Limited Life Expectancy: An Integrative Review

Polypharmacy is common in older adults with cancer and deprescribing potentially inappropriate medications becomes very relevant when life expectancy decreases due to metastatic disease. Especially preventive medications may no longer be beneficial, because they may decrease quality of life and reduction in morbidity and mortality may be futile. Although deprescribing of preventive medication is common in the last period of life, it is still unusual during active cancer treatment for advanced disease, although life expectancy is often limited to less than 1 to 2 years in that stage. We performed a systematic search of the literature in Pubmed and Embase on the discontinuation of commonly utilized groups of preventive medication and evaluated the evidence of potential benefits and harms in patients aged 65 years or older with cancer and a limited life expectancy (LLE). From 21 included studies, it can be concluded that deprescribing lipid lowering drugs, antihypertensive drugs, osteoporosis drugs and antihyperglycemic drugs is feasible in a considerable part of patients with a LLE. Discontinuation may be performed safely, without the occurrence of serious adverse events or decrease of survival. The only study that addressed quality of life after deprescribing showed that discontinuation of statins improves quality of life in patients with a LLE. Recurrence of symptoms requiring reintroduction occurred in 0-13% of patients on antihyperglycemic treatment and 8-60% of patients using antihypertensive drugs. In order to reduce pill burden and futile treatment clinicians should discuss deprescribing of preventive medication with older patients with advanced cancer and a LLE.

Integrating Traditional and Complementary Medicine Recommendations into Clinical Practice Guidelines for People with Diabetes in Need of Palliative and End-of-Life Care: A Scoping Review

Objectives: This study was conducted before an evidence review on Traditional and Complementary Medicine (TCM) to update the clinical practice guidelines (CPGs): "Deciding palliative and end-of-life (P/EoL) care for people with diabetes." The aim was to frame the PICO (population/problems, interventions/comparisons, and outcomes), ascertain their importance, and identify other modifying factors for grading recommendations. Design: A systematic scoping review mapped information about diabetes P/EoL problems and outcomes, TCM use, provision, benefits and risks, and stakeholder preferences and values. Thirteen electronic databases were searched in 2017/18 until no new information was identified. Relevant data were extracted, rated for quality, directness, and relevance, and synthesized using triangulation methods. Excluded was diabetes prevention or treatment, as this is not an important P/EoL problem. Results: Of the 228 included articles, except for diabetes P/EoL problems, insufficient direct evidence led to data being extrapolated from either adults with diabetes or any P/EoL diagnosis. The findings affirmed that caring for people with diabetes in need of P/EoL care is complex due to multiple fluctuating needs that are influenced by the P/EoL trajectories (stable, unstable, deteriorating, terminal, or bereaved), multimorbidity, and difficult-to-manage chronic and acute problems. The only problem specific to diabetes P/EoL care, was unstable glycemia. Over 50 TCM interventions commonly used by patients and/or provided by services were identified, of which, many might simultaneously address multiple problems and 18 had been appraised in systematic reviews. Physical and psychologic symptom reliefs were most often evaluated; however, these were only one aspect of a "good death." Other important outcomes were the quality and location of care, personal agency, relationships, preparations for the dying process, spirituality, and affirmation of the whole person. Other important modifying factors included opportunity costs, affordability, availability, preferences, cultural appropriateness, and alignment with beliefs about the meaning of illness and death. Conclusions: There is a role for TCM in the multidisciplinary holistic P/EoL care of people with diabetes. Due to the paucity of evidence specific to this population, the generalizability of some of these results is broader and the updated CPG will also need to consider indirect evidence from other patient groups. Along with recommendations about indications for TCM use, the CGP should provide guidance on ceasing unnecessary interventions, reducing polypharmacy and managing unstable glycemia is required. Before ceasing a TCM, a broader risk-benefit analysis is recommended, as unlike many conventional therapies, there may be multiple benefits warranting its continuation.

The effect of diabetes mellitus on pharmacokinetics, pharmacodynamics and adverse drug reactions of anticancer drugs

Diabetes mellitus (DM) and cancer are global problems carrying huge human, social, and economic impact. Type 2 diabetes (T2DM) is associated with an increased risk for a number of cancers, including breast, pancreatic, and liver cancer. Moreover, adverse drug reactions are higher in paitents with cancer with T2DM compared to cancer patients without T2DM. Cellular mechanisms of hyperglycemia and chemotherapy efficacy may be different depending upon the particular cancer type and the condition of the patient. This review evaluates the effect of DM on the pharmacokinetic, pharmacodynamic, and adverse drug reactions of commonly used anticancer drugs such as cisplatin, methotrexate, paclitaxel, doxorubicin, and adriamycin in both clinical and animal models. A literature search was conducted in scientific databases including Web of Science, PubMed, Scopus, and Google Scholar including the relevant keywords. The results of the effectiveness of anticancer therapies in patients with DM are, however, inconsistent because DM can negatively impact multiple diverse entities including nerves and vascular structures, insulin-like growth factor 1, the function of the innate immune system, drug pharmacokinetics, the expression levels of hepatic CYP₄₅₀ , Mdr _1b and enzymes that then lead to drug toxicity. However, in a few circumstances, DM led to attenuation of the toxicity of anticancer drugs secondary to attenuation of the energy-dependent renal uptake process. Overall, the impact of DM on patients with cancer is variable because of the diverse types of cancers and the spectrum of anticancer drugs. With respect to the evidence for cancer involvement in DM pathophysiology and the response to anticancer treatment in patients with DM, many questions still remain and further clinical trials are needed.

Diabetologists and Oncologists attitudes towards treating diabetes in the oncologic patient: Insights from an exploratory survey

AIMS

Diabetes and cancer frequently coexist in the same subject, often having relevant effects on the management and prognosis of the oncologic patient. However, existing guidelines do not deal with many clinical issues in this setting appropriately. In evaluating the opinions of Diabetologists and Oncologists dealing with diabetes care in people with cancer, the Italian Association of Diabetologists (AMD) promoted a dedicated exploratory survey.

METHODS

The survey was carried out through the web or handily delivered printed copies between October 2014 and April 2015, in Italy. It was composed of 27 questions intended to gather information on the characteristics of participants and to examine their clinical habits in this context, and participation was totally free and anonymous.

RESULTS

A total of 252 physicians participated in the survey. Diabetologists accounted for 51.1% of respondents. According to survey results, in spite of the presence of diabetes (or diabetic complications) worsening the outcome of cancer treatments, the counseling or intervention of a Diabetologist was only required for less than two-thirds of hospitalized patients. For subjects with a life expectancy of months, 80% of specialists considered a glycemic target of 120-250 mg/dL optimal whereas Oncologists were more likely to consider a range of 180-360 mg/dL for patients with a shorter life expectancy. Furthermore, 1 participant out of 3 indicated 1-4 measurements/day as the most appropriate frequency for blood glucose monitoring including in the palliative setting. Insulin was the therapy of choice for the majority of respondents albeit with different routes of administration.

CONCLUSIONS

This survey provides interesting preliminary data that could help facilitate and optimize the management of patients with cancer and diabetes, promoting the delivery of an organic answer to fragmented assistance, to potentially inappropriate behaviors, and to a tailored therapy in a context of particular clinical fragility.

Adverse glycaemic effects of cancer therapy: indications for a rational approach to cancer patients with diabetes

Diabetes and cancer are common, chronic, and potentially fatal diseases that frequently co-exist. Observational studies have reported an increased risk of cancer in patients with diabetes. Furthermore, many patients with cancer already have diabetes, or develop hyperglycaemia as a consequence of the tumor or of cancer therapies, and coexisting diabetes confers a greater risk of mortality for many malignancies. Managing oncologic patients with diabetes is often complicated, since the co-existence of diabetes and cancer poses several complex clinical questions: what level of glycaemic control to achieve, which therapy to use, how to deal with glucocorticoid therapies and artificial nutrition, how diabetes complications can affect cancer management, which drug-drug interactions should be taken into account, or even how to manage diabetes at the end of life. In the clinical setting, both at hospital and at home, there are little agreed, evidence-based guidelines on the best management and criteria upon which clinical decisions should be based. A practical solution lies in the implementation of care networks based on communication and ongoing collaboration between Oncologists, Endocrinologists, and the nursing staff, with the patient at the centre of the care process. This manuscript aims to review the current evidence on the effect of cancer therapies on glucose metabolism and to address some of the more common challenges of diabetes treatment in patients with cancer.

Diabetes is an Important Risk Factor for Metastasis in Non- Muscle-Invasive Bladder Cancer

BACKGROUND

Epidemiological evidence indicates that individuals with diabetes mellitus (DM) may have a modestly increased risk of bladder cancer. In the present study, we aimed to show any association between DM and risk of metastasis in patients with non-muscle-invasive bladder cancer (NMIBC).

MATERIALS AND METHODS

We retrospectively analyzed 698 patients between January 2007 and December 2014 who were diagnosed with and underwent transurethral resection of bladder tumors (TUR-BT). Comparisons of means was conducted by independent samples t test, and relations between categorical variables were investigated by non-parametric chi- square test. A p value of 0.05 was accepted as statistically significant in comparisons.

RESULTS

We analyzed 418 patients with non muscle invasive bladder cancer. 123 of whom were diabetic and 295 non-diabetic. In diabetic patients, 13 were N1 stage and 11 M1 stage. When compared with non diabetic patients that was statistically significant (p<0.001). TNM stages were more advanced in diabetic patients (p<0.001), but concurrent CIS (p=0.1) and squamous metaplasia did not significantly differ between diabetic and non-diabetic cases (p=1).

CONCLUSIONS

Diabetic patients with non-muscle-invasive bladder cancer may suffer metastases earlier than expected although they are non invasive. Therefore such patients must be followed-up carefully and early cystectomy decision may be necessary. Further prospective studies with more patients are needed to confirm these findings.

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.

Diabetology and oncology meet in a network model: union is strength

Diabetes and cancer are increasingly common conditions, and the management of cancer patients with diabetes is often challenging. Diabetes in cancer patients poses several complex clinical issues, including which treatment is suitable to control hyperglycemia, how to better counteract glucocorticoid-induced hyperglycemia, and how to manage nutritional problems of cachectic patients and glucose variability linked to artificial nutrition. A key aspect to consider is the patients' position on the trajectory of the oncologic disease, both to establish which level of glycemic control should be pursued and to decide the most suitable antidiabetic treatment to recommend. Endocrinologists are rarely involved in the management of patients with advanced cancer. Furthermore, lack of guidelines results in a "trial-and-error" approach, often with suboptimal disease management. Lastly, cancer survivors represent a frequently underestimated category of patients at higher cardiometabolic risk. A practical solution for these challenges lies in the implementation of care networks based on a close partnership and ongoing communication between oncologists, endocrinologists, and nutritionists, placing the patient at the center of the care process. At the same time, universities and scientific societies should play a key role in promoting research into areas of intersection of oncology and endocrinology, in raising awareness of common possibilities of primary and secondary prevention of metabolic and oncologic diseases, as well as specific challenges of managing diabetes and cancer, and proper training of health workers, while also supporting the shared implementation of effective management strategies.

A Pilot Study Evaluating Steroid-Induced Diabetes after Antiemetic Dexamethasone Therapy in Chemotherapy-Treated Cancer Patients

Purpose

Dexamethasone is a mainstay antiemetic regimen for the prevention of chemotherapy-induced nausea and vomiting. The aim of this pilot study was to assess the incidence of and factors associated with steroid-induced diabetes in cancer patients receiving chemotherapy with dexamethasone as an antiemetic.

Materials and Methods

Non-diabetic patients with newly diagnosed gastrointestinal cancer who received at least three cycles of highly or moderately emetogenic chemotherapy with dexamethasone as an antiemetic were enrolled. Fasting plasma glucose levels, 2-hour postprandial glucose levels, and hemoglobin A_1C tests for the diagnosis of diabetes were performed before chemotherapy and at 3 and 6 months after the start of chemotherapy. The homeostasis model assessment of insulin resistance (HOMA-IR) was used as an index for measurement of insulin resistance, defined as a HOMA-IR ≥ 2.5.

Results

Between January 2012 and November 2013, 101 patients with no history of diabetes underwent laboratory tests for assessment of eligibility; 77 of these patients were included in the analysis. Forty-five patients (58.4%) were insulin resistant and 17 (22.1%) developed steroid-induced diabetes at 3 or 6 months after the first chemotherapy, which included dexamethasone as an antiemetic. Multivariate analysis showed significant association of the incidence of steroid-induced diabetes with the cumulative dose of dexamethasone (p=0.049).

Conclusion

We suggest that development of steroid-induced diabetes after antiemetic dexamethasone therapy occurs in approximately 20% of non-diabetic cancer patients; this is particularly significant for patients receiving high doses of dexamethasone.

Development of Gendine-Coated Cannula for Continuous Subcutaneous Insulin Infusion for Extended Use

Continuous subcutaneous insulin infusion (CSII) using pumps is a widely used method for insulin therapy in patients with diabetes mellitus. Among the major factors that usually lead to the discontinuation of CSII are CSII set-related issues, including infection at the infusion site. The American Diabetic Association currently recommends rotating sites every 2 to 3 days. This recommendation adds cost and creates inconvenience. Therefore, in order to prevent infections and extend the duration between insertion site changes, we developed a Teflon cannula coated with a combination of gentian violet and chlorhexidine (gendine) and tested its antimicrobial efficacy against different pathogens. The cannulas were coated with gendine on the exterior surface and dried. The efficacy and durability of gendine-coated cannulas were determined against methicillin-resistant Staphylococcus aureus, Staphylococcus epidermidis, methicillin-susceptible S. aureus, Streptococcus pyogenes, vancomycin-resistant enterococci, Escherichia coli, Pseudomonas aeruginosa, Candida albicans, and Candida glabrata using a biofilm colonization method. The cytotoxicity of gendine was assessed against mouse fibroblast cell lines. The gendine-coated cannulas showed complete prevention of biofilm colonization of all organisms tested for up to 2 weeks (P < 0.0001) compared to that with the uncoated control. A gendine-coated catheter against mouse fibroblast cells was shown to be noncytotoxic. Our in vitro results show that a novel gendine cannula is highly effective in completely inhibiting the biofilm of multidrug-resistant pathogens for up to 2 weeks and may have potential clinical applications, such as prolonged use, cost reduction, and lower infection rate.

Cancer risk and mortality in asthma patients: A Swedish national cohort study

BACKGROUND

Previous studies found an increased risk of cancer in hospitalized asthma patients, but it is not known whether patients from primary health care show a similar risk pattern. In addition, it is unclear whether the diagnosis of asthma can influence the prognosis of subsequent cancer.

METHODS

Asthma patients were identified from Swedish inpatient, outpatient, and primary health care registers, and were linked to the Swedish Cancer Registry to identify subsequent diagnoses of cancer. Standardized incidence ratios (SIRs) were used to examine the risk of cancer in asthma patients compared with subjects without asthma. In addition, we used Cox proportional hazards regression to estimate hazard ratios (HRs) for mortality in patients with both asthma and cancer.

RESULTS

A total of 10 649 cancers were diagnosed in patients with previous asthma, with a SIR of 1.19 (95% CI 1.17-1.21). A total of 15 cancer sites showed an increased incidence, whereas two cancer sites showed a decreased risk. Non-allergic asthma showed the highest risk of cancer (SIR = 1.25, 95% CI 1.18-1.32), followed by unspecified asthma (SIR = 1.22, 95% CI 1.19-1.25), status asthmaticus (SIR = 1.19, 95% CI 1.02-1.39), and allergic asthma (SIR = 1.14, 95% CI 1.06-1.22). The risk of cancer was similarly increased in asthma patients diagnosed in primary health care and those diagnosed in hospitals. Cancer patients with previous asthma had increased mortality, with a HR of 1.55 (95% CI 1.50-1.60). HRs ranged from 1.09 to 1.94 for different sites/types of cancer.

CONCLUSIONS

Patients with asthma, irrespective of whether they were treated in primary health care or hospitals, had an increased risk of cancer. In addition, cancer patients with previous asthma had a worse prognosis compared with those without asthma, suggesting that these patients may require a multidisciplinary approach to manage the comorbidity.

Aggravation of Fatigue by Steroid Therapy in Terminally Ill Patients With Cancer

Steroids are commonly used for fatigue relief in terminally ill cancer patients. However, steroid-induced adverse effects including depression, myopathy, and hyperglycemia may contribute to fatigue. We report our experiences with aggravation of fatigue with steroid use in three cases. Case 1 was a 65-year-old man with advanced gastric cancer. He was started on betamethasone (2 mg/d) for fatigue, but the fatigue worsened due to steroid-induced depression. Discontinuation of steroids and initiation of an antidepressant ameliorated the fatigue. Case 2 was a 68-year-old man with advanced lung cancer. He complained of fatigue. Betamethasone (1 mg/d) was started and alleviated the fatigue. However, when the betamethasone dose was increased to 2 mg/d, the fatigue, with muscle weakness and myalgia, worsened due to steroid-induced myopathy. We therefore switched from betamethasone (2 mg/d) to prednisolone (10 mg /d). The fatigue resolved and the patient returned to his previous condition. Case 3 was a 73-year-old man with recurrent bile duct cancer. He also had diabetes mellitus. He developed fatigue, anorexia and fever. We started betamethasone (1.5 mg/d) for these symptoms, but the fatigue and anorexia worsened due to steroid-induced hyperglycemia. Blood glucose rose to 532 mg/dL. Therefore, insulin therapy was started, and the dose of betamethasone was reduced to 0.5 mg/d. His glucose level decreased to less than 320 mg/dL and he recovered from the fatigue while achieving moderate oral intake. In conclusion, the possibility of steroid-induced secondary fatigue in terminally ill cancer patients should be taken into consideration.

Diabetes Management in End of Life

The increasing coexistence of cancer and diabetes within the elderly population requires specific palliative care skills on diabetes treatment. We report our experience of diabetes management in a palliative care setting. In our retrospective 3-year activity sample (n = 563), 27.2% of patients have a diagnosis of diabetes mellitus: 80% have cancer whereas 20% have a main diagnosis of other severe chronic diseases. As to the presence/absence of diabetes, no differences emerge in the examined clinical indicators and global survival, with the exception of body mass index and days of hospitalization. At lifetime analysis, Barthel index and palliative prognostic index are the only parameters significantly related to death. Even if diabetes seems not to modify the prognosis, it significantly influences the health care burden and the team engagement.

Information needs of family carers of people with diabetes at the end of life: a literature review

BACKGROUND

Recent research identified the issue that family carers of people with diabetes at the end of life (EOL) did not receive sufficient information to enable them to help their relative manage their diabetes at the EOL.

AIM

The aim of the current study was to undertake a literature review to identify the information needs of family carers of people with diabetes at the EOL.

METHOD

A comprehensive review of the literature was conducted by searching the following databases: CINAHL, PubMed, PsychInfo, Scopus, and SocINDEX. The grey literature was also searched for papers relevant to the aim. All study designs were included. A content analysis of relevant papers was undertaken to identify themes.

RESULTS

Sixteen of the more than 300 papers identified addressed the information needs of family carers of people with diabetes at the EOL and were included in the review. Five key themes were identified from the papers reviewed: (1) performing diabetes care tasks, (2) focus of care, (3) blood glucose management, (4) EOL stages, and (5) involving patients and family carers in decisions about diabetes care. Most of the 16 papers represented the views of health professionals and focused on the need to provide information about the medical aspects of diabetes management.

CONCLUSIONS

The review suggests further research is needed to identify the information needs of family carers of people with diabetes at the EOL to enable interventions to be developed to support the family carers and meet their unique information needs.

Cancer with diabetes: prevalence, metabolic control, and survival in an academic oncology practice

OBJECTIVE

To determine the prevalence of diabetes mellitus, glycemic control, and impact of diabetes on overall survival in an academic oncology practice.

METHODS

Data on cancer patients (1999 to 2008) were retrieved from the institutional cancer registry and linked to electronic files to obtain diabetes status and hemoglobin A1c (A1C) values within the first 6 months of cancer diagnosis. Overall survival by cancer type with and without diabetes was compared using Cox regression.

RESULTS

Excluding skin and hematologic malignancies, 15,951 cancer cases were identified. Overall diabetes prevalence was 6.8% (n = 1,090), declining over time (P<0.001). Diabetes was common among patients with pancreatic (9.8% [61 of 624]), colorectal (7.7% [89 of 1,151]), or bladder cancers (7.6% [68 of 899]). Patients with diabetes were older (mean age, 70 versus 66 years; P<0.001) and more likely to be male (66.3% [723 of 1,090] versus 60.2% [8,949 of 14,858]; P<0.001). The mean A1C among diabetic cancer patients was 6.8% and did not differ across cancer types (P = 0.80). Only 58.6% (331 of 565) of diabetic cancer patients had all A1C <7.0% during the first 6 months following cancer diagnosis. Pancreatic cancer patients with coexisting diabetes had better overall survival than pancreatic cancer patients without diabetes (hazard ratio, 0.60; 95% confidence interval 0.44 to 0.80; P<0.001). Conversely, diabetic prostate cancer patients had worse overall survival than prostate cancer patients without diabetes (hazard ratio, 1.36; 95% confidence interval 1.05 to 1.76; P = 0.02).

CONCLUSION

In this academic oncology practice, diabetes was common, glycemic control often was suboptimal, and survival varied by cancer type. Additional study is needed to optimize glucose management and investigate mechanisms underlying age, sex, and survival differences.

Developing clinical guidelines for end-of-life care: blending evidence and consensus

BACKGROUND

Developing clinical practice guidelines (CPGs) is challenging, particularly in areas that are difficult to research such as end-of-life care.

AIM

To describe the process that staff in a large regional health-care service in Victoria, Australia, used to develop CPGs for managing diabetes at the end of life.

METHOD

An interdisciplinary advisory group was appointed, a structured literature review undertaken, personal illness accounts sourced, and a guiding philosophy formulated. Individual interviews were conducted with people with diabetes and their carers. Formative and summative evaluation was undertaken.

RESULTS

No level I or II evidence was identified. The interviews yielded important information about how people wanted their diabetes managed. Formative evaluation enabled stakeholders to participate in developing the CPGs. The summative evaluation confirmed the CPGs are easy to use and appropriate to clinical staff.

CONCLUSIONS

The CPG development process yielded the best current evidence on which to base care plans and person-centred CPGs.

Diabetes and end of life: ethical and methodological issues in gathering evidence to guide care

INTRODUCTION

Providing palliative care for people with diabetes at the end of life is part of the chronic disease care trajectory, but end of life care is complex and the presence of diabetes further complicates management.

AIM

The aim of the paper is to discuss the ethical and methodological issues encountered when undertaking research to develop guidelines for managing diabetes at the end of life and the strategies used to address the issues.

METHOD

The issues emerged as we developed guidelines for managing diabetes at the end of life, which included conducting individual interviews with 14 people with diabetes requiring palliative care and 10 family members. A reflexive researcher journal was maintained throughout the guideline development process. The interview transcripts and researcher's journal were analysed to determine key methodological, ethical and researcher-related issues.

FINDINGS

Key themes were vulnerability of the sampling population, methodological issues included recruiting participants and ensuring rigor, ethical issues concerned benefit and risk, justice, autonomy, privacy, professional boundaries and informed consent. Researcher-related issues were identified such as managing participant distress and their own emotional distress. People were willing to discuss end of life diabetes management preferences.

CONCLUSIONS

Undertaking research with people at the end of life is complex because of their vulnerability and the ethical issues involved. However, the ethical principles of autonomy and justice apply and people should be given the relevant information and opportunity to decide whether to participate or not.

Risk of cancer in patients using glucose-lowering agents: a nationwide cohort study of 3.6 million people

OBJECTIVES

To study the association between exposures to glucose-lowering therapy and risk of cancer using the nationwide administrative registers in Denmark.

DESIGN

Nationwide cohort study.

SETTING

All hospitals in Denmark.

PARTICIPANTS

All individuals aged ≥35 years in 1998-2009 who were naive to glucose-lowering treatment and had no history of cancer. Primary measures outcomes: first cancer diagnosis between 1998 and 2009. The RR of cancer as dependent on exposure to individual glucose-lowering agents was assessed by multivariable Poisson regression models.

RESULTS

Of 159 894 patients that initiated treatment with glucose-lowering agents, 12 789 developed cancer, incidence rate 17.4/1000 person-years. Of the remaining 3 447 904 individuals not using glucose-lowering agents, 293 878 developed cancer, incidence rate 7.9/1000 person-years. Use of different types of glucose-lowering agents including human insulin, insulin analogues, as well as sulfonylureas were associated with a quantitatively similar and significantly increased RR of cancer of 1.2-1.3 compared with unexposed individuals after multivariable adjustment. For the majority of agents, the authors identified the highest RR of cancer during the first 30 treatment days with a subsequent decline of risk approaching the cancer risk of the background population only 6-12 months after initiation of treatments.

CONCLUSIONS

Use of most glucose-lowering agents including sulfonylureas was associated with a comparable increased risk of cancer shortly after initiation of treatment and subsequently a decline to the risk of the background population. This suggests that the relation is not causal.

The management of diabetes in terminal illness related to cancer

The management of diabetes during terminal illness is complex, with lack of agreement and consensus among physicians and multidisciplinary teams. Despite the plethora of guidelines available for the management of diabetes, there exists no agreed, evidence-based strategy for managing diabetes during terminal illness and at the end of life. A number of physiological factors may influence glycaemic control during terminal illness. These include anorexia, cachexia, malabsorption, renal and hepatic failure. Furthermore, controversy exists on the frequency of blood glucose monitoring, the optimum blood glucose range and how to achieve this. We review the factors influencing blood glucose during terminal illness and provide a suggested approach to managing patients with type 1 and type 2 diabetes during the early and late stages of terminal illness.

Survival of cancer in patients with rheumatoid arthritis: a follow-up study in Sweden of patients hospitalized with rheumatoid arthritis 1 year before diagnosis of cancer

OBJECTIVES

Patients diagnosed with RA have an increased risk of some cancers. However, limited data are available on the important issue of prognosis of RA patients with cancer.

METHODS

RA patients were identified from the Swedish Hospital Discharge Register by linkage to the Cancer Registry. Follow-up of patients was started from the date of diagnosis of cancer through year 2006. Hazard ratios (HRs) were calculated in cancer patients with RA compared with subjects without RA.

RESULTS

A total of 1,411,163 cancer patients were identified in the database, of whom 6309 had a previous hospitalization for RA. Compared with all cancer patients without RA, patients with RA had a worse prognosis, with an HR of 1.29 and 1.31 for cause-specific and overall survival, respectively. For specific cancer sites, skin and breast cancers and non-Hodgkin's lymphoma showed worst survival. Age stratification did not change the results.

CONCLUSION

Cancer patients with a previous hospitalization for RA had a worse prognosis for all and many site-specific cancers compared with patients without RA, independent of age at diagnosis and tumour staging. Improvement of survival for cancer patients with RA may require a multidisciplinary approach to accommodate the comorbidity.

Epidemiological aspects of neoplasms in diabetes

Glucose metabolism represents a complex system, and several components of the regulatory metabolic pathways may induce abnormalities in cellular growth and regulation. The strongest evidence of an association between glucose metabolism alterations and cancer derives from cohort studies, showing increased cancer incidence and mortality in the presence of diabetes. In particular, several studies clearly indicate an association between type 2 diabetes and the risk of colorectal, pancreatic, and breast cancer. An increased risk of liver, gastric, and endometrial malignancies has also been suggested. Type 1 diabetes is associated with an elevated risk of female reproductive organs and gastric cancers. The risk of malignancies is also increased at earlier stages of glucose metabolism abnormalities, with a linear relationship between cancer risk and plasma insulin levels, usually elevated in the presence of metabolic syndrome or diabetes. The prevalence of diabetes and obesity is rapidly increasing worldwide; if these conditions are associated even with a small increase in the risk of cancer, this will translate into important consequences for public health.

Association of diabetes duration and diabetes treatment with the risk of hepatocellular carcinoma

BACKGROUND

Despite the observed association between diabetes mellitus and hepatocellular carcinoma (HCC), little is known about the effect of diabetes duration before HCC diagnosis and whether some diabetes medications reduced the risk of HCC development. This objective of the current study was to determine the association between HCC risk and diabetes duration and type of diabetes treatment.

METHODS

A total of 420 patients with HCC and 1104 healthy controls were enrolled in an ongoing hospital-based case-control study. Multivariate logistic regression models were used to adjust for HCC risk factors.

RESULTS

The prevalence of diabetes mellitus was 33.3% in patients with HCC and 10.4% in the control group, yielding an adjusted odds ratio (AOR) of 4.2 (95% confidence interval [95% CI], 3.0-5.9). In 87% of cases, diabetes was present before the diagnosis of HCC, yielding an AOR of 4.4 (95% CI, 3.0-6.3). Compared with patients with a diabetes duration of 2 to 5 years, the estimated AORs for those with a diabetes duration of 6 to 10 years and those with a diabetes duration >10 years were 1.8 (95% CI, 0.8-4.1) and 2.2 (95% CI, 1.2-4.8), respectively. With respect to diabetes treatment, the AORs were 0.3 (95% CI, 0.2-0.6), 0.3 (95% CI, 0.1-0.7), 7.1 (95% CI, 2.9-16.9), 1.9 (95% CI, 0.8-4.6), and 7.8 (95% CI, 1.5-40.0) for those treated with biguanides, thiazolidinediones, sulfonylureas, insulin, and dietary control, respectively.

CONCLUSIONS

Diabetes appears to increase the risk of HCC, and such risk is correlated with a long duration of diabetes. Relying on dietary control and treatment with sulfonylureas or insulin were found to confer the highest magnitude of HCC risk, whereas treatment with biguanides or thiazolidinediones was associated with a 70% HCC risk reduction among diabetics.

Results of general internal medicine consultations for diabetes mellitus in 283 cancer patients

BACKGROUND

Diabetes is a major reason for patient referral to the General Internal Medicine (GIM) Department at M.D. Anderson Cancer Center. Previous studies of various factors that affect diabetes care have not focused on cancer patients. The objective of this study was to examine the level of diabetic care received by cancer patients.

METHODS

We conducted a retrospective chart review of 283 consecutive GIM patients with diabetes in the years 2000 to 2001. For each patient, data were collected about the cancer, diabetes-related history, and the general internist's recommendations for further diabetes care. Patients were stratified by whether their cancer was controlled (stable or in remission) or uncontrolled (being actively treated by an oncologist or said to be progressive). chi tests and t tests were used to compare means for controlled cancer and uncontrolled cancer patient groups, with a value of P < 0.05 being considered significant.

RESULTS

Patients with controlled cancer were more likely to have a lipid profile ordered (P < 0.001) or to be referred for diabetes-specific ophthalmology evaluation (P = 0.02). On logistic regression analysis, increasing patient age was associated with less frequent HgbA1c testing (P = 0.01), and both advanced age and uncontrolled cancer were associated with less lipid testing and ophthalmology referral.

CONCLUSIONS

Patients with uncontrolled advanced cancer were not as aggressively treated for diabetes, especially if they were elderly. Further work should evaluate whether the observed level of diabetes care was appropriate and could affect patient outcome.

Less aggressive treatment and worse overall survival in cancer patients with diabetes: a large population based analysis

The purpose of this study was to document the prevalence of diabetes among newly diagnosed cancer patients and to evaluate the influence of diabetes on stage at diagnosis, treatment and overall survival. We performed a population-based analyses of all 58,498 cancer patients newly diagnosed between 1995 and 2002 in the registration area of the Eindhoven Cancer Registry. Stage of cancer, cancer treatment and comorbidities were actively collected by hospital medical records review. Follow-up of all patients was completed until January 1, 2005. Nine percent of all cancer patients had diabetes at the time of cancer diagnosis. The prevalence of diabetes was highest among patients with cancer of the pancreas (19%), uterus (14%) and among young men with kidney cancer (8%). Colon, breast and ovarian cancer patients with diabetes were more often diagnosed with a higher tumour stage (p < 0.05). Patients with diabetes and cancer of the oesophagus, colon, breast and ovary were treated less aggressively compared to those without diabetes (p < 0.05). During the follow-up period 3,902 of 5,555 cancer patients with diabetes died and 29,909 of 52,943 cancer patients without diabetes died. For all cancers combined, in a multivariate cox-regression model, adjusting for age, gender, stage, treatment and cardiovascular disease, patients with diabetes experienced a significant increase in overall mortality (HR = 1.44, 95% CI 1.40-1.49), ranging however from 0 to 40% for different types of cancer, compared to those without diabetes. In conclusion, diabetic cancer patients frequently were treated less aggressively and had a worse prognosis compared to those without diabetes.

Diabetes management in patients receiving palliative care

A literature review revealed no evidence-based guidelines specific to managing diabetes in the context of palliative care. The purpose of the current project was to describe the management practices of doctors and nurses caring for people with diabetes and advanced disease. Palliative care doctors, palliative care nurses, endocrinologists, and diabetes nurse educators participated in this study. A two-phase project was undertaken: 1) two focus groups, and 2) a cross-sectional survey using a self-completed questionnaire. The focus group and questionnaire data identified that doctors and nurses used a range of practices and blood glucose testing frequencies to control blood glucose based on experience and not according to a robust evidence base. Implications for practice include the importance of collaboration between diabetes and palliative care specialists, and the need to develop clinical management guidelines.

Diabetes Management at the End of Life

Tight glycemic control has become the standard of care for prevention of the long-term side effects of diabetes mellitus. When individuals with diabetes approach the end of life from advanced cancer or another chronic illness, they often become anorexic. The result is an increased risk for hypoglycemic episodes. It is appropriate to shift the goal of therapy from tight control of blood sugar to maintaining comfort and enhancing quality of life.

[Management of diabetes during the last days of life: attitudes of consultant diabetologists and consultant palliative care physicians in the UK

Diabetes is an increasingly common condition and hence, managing dying patients with diabetes as a co-morbidity will become a frequent challenge. It is uncertain whether there is net beneficence in preventing hyperglycaemia in diabetic patients during the terminal phase or whether the distress involved in administering therapy and blood glucose monitoring may outweigh this ordeal. Since there is no available evidence upon which to base clinical decisions, a semi-structured questionnaire based around three clinical vignettes was sent to consultants in diabetes and palliative care in the UK. There was consensus of opinion from both groups of consultants that treatment and monitoring should be stopped in patients with type 2 diabetes, once in the terminal phase. There was less consensus regarding management of type 1 diabetes. Practical issues were raised by both groups of consultants and clinical guidelines are suggested.

Therapy insight: Influence of type 2 diabetes on the development, treatment and outcomes of cancer

Although type 2 diabetes and cancer are major health concerns among the adult population, few studies have directly addressed the relationship between the two, or the impact of diabetes on cancer outcomes. Diabetes and hyperglycemia are associated with an elevated risk of developing pancreatic, liver, colon, breast, and endometrial cancer. When treating cancer patients who have diabetes, clinicians must consider the cardiac, renal, and neurologic complications commonly associated with diabetes. Chemotherapeutic choices and, ultimately, the outcome for cancers may be affected by the avoidance of agents that have been shown to provide the best clinical response and survival in cancer patients without other disease complications. Evidence from population-based studies and clinical trials indicate that hyperglycemic and diabetic patients experience higher mortality and recurrence rates after diagnosis with, and treatment for, cancer. Evidence from the intensive care literature indicates that achieving glucose control leads to better clinical outcomes. If so, continued improvement of cancer outcomes may depend upon improved diabetes control. The association between diabetes and cancer is complex and warrants further study as the general population ages and the magnitude of both health problems continues to grow. Here we consider the influence of diabetes and hyperglycemia on the development, treatment, and long-term outcomes of cancer.

Managing diabetes mellitus in patients with advanced cancer: a case note audit and guidelines

Patients with advanced cancer and diabetes mellitus present a challenge to healthcare professionals. To establish how diabetes is currently being managed in these patients, we audited the care of patients who died in Cheltenham General Hospital over the previous 12 months with diagnoses of both diabetes mellitus and cancer. Management and monitoring of the diabetes was variable and there was little record of discussion between healthcare professionals and the patient or family regarding the diabetes. Thirty-two out of 42 patients continued to have blood sugar monitoring up to and including the day they died. We review the literature on this topic and suggest guidelines to help professionals to appropriately manage diabetes in the palliative setting at the end of life.

Methylglyoxal enhances cisplatin-induced cytotoxicity by activating protein kinase Cdelta

The cytotoxic side effects of anti-neoplastic drugs are increased in patients with either type 1 or type 2 diabetes mellitus by a mechanism that is not clearly defined. We report that the circulating glucose metabolite, methylglyoxal (MGO), enhances cisplatin-induced apoptosis by activating protein kinase Cdelta (PKCdelta). We found that treatment of myeloma cells with the antioxidant N-acetylcysteine completely blocked cisplatin-dependent intracellular GSH oxidation, reactive oxygen species (ROS) generation, poly(ADP-ribose) polymerase cleavage, and apoptosis. Importantly, co-treatment of cells with the reactive carbonyl MGO and cisplatin increased apoptosis by 90% over the expected additive effect of combined MGO and cisplatin treatment. This same synergism was also observed when ROS generation was examined. MGO and cisplatin increased PKCdelta activity by 4-fold, and this effect was blocked by the PKCdelta inhibitor rottlerin but not by NAC. Furthermore, rottlerin blocked combined MGO and cisplatin-induced ROS generation and apoptosis. Finally, MGO and cisplatin induced c-Abl activation and c-Abl:PKCdelta association. Rottlerin blocked c-Abl activation, but the c-Abl inhibitor STI-571 increased MGO and cisplatin-induced apoptosis by 50%. Taken together these data indicate that MGO synergistically enhances cisplatin-induced apoptosis through activation of PKCdelta and that PKCdelta is critical to both cell death and cell survival pathways. These findings suggest that in the patient with diabetes mellitus heightened oxidative stress can enhance the cytotoxicity of agents that induce DNA damage.