Diabetes in relation to breast cancer relapse and all-cause mortality in elderly breast cancer patients: a FOCUS study analysis

Prognostic value of metformin in cancers: An updated meta-analysis based on 80 cohort studies

BACKGROUND

Experiments have shown that metformin can inhibit cancer cell growth, but clinical observations have been inconsistent, so we pooled the currently available data to evaluate the impact of metformin on cancer survival and progression.

METHODS

PubMed, web of science, Embase, and Cochrane databases were searched. Pooled hazard ratios (HRs) were identified using a random-effects model to estimate the strength of the association between metformin and survival and progression in cancer patients.

RESULTS

We incorporated 80 articles published from all databases which satisfied the inclusion criterion. It showed that metformin was associated with better overall survival (hazard ratio [HR] = 0. 81; 95% confidence interval [CI]: [0.77-0.85]) and cancer-specific survival (HR = 0.79; 95% CI: [0.73-0.86]), and metformin was associated with progression-free survival (HR = 0.76; 95% CI: [0.66-0.87]). In patients with diabetes mellitus, the HR of overall survival was 0.79(95% CI: [0.75-0.83]), progression-free survival was 0.72(95% CI: [0.60-0.85]), and the cancer-specific survival was 0.76(95% CI: [0.68-0.86]). It was proposed that metformin can improve the prognosis of cancer patients with diabetes mellitus.

CONCLUSION

Based on cohort studies, metformin therapy has potential survival benefits for patients with malignancy, especially with the greatest benefits seen in breast cancer on overall survival, progression-free survival, and cancer-specific survival. And metformin also showed potential benefits in cancer-specific survival in colorectal and prostate cancer.

Cancer and diabetes co-occurrence: A national study with 44 million person-years of follow-up

The number of new cases of cancer is increasing each year, and rates of diabetes mellitus are also increasing dramatically over time. It is not an unusual occurrence for an individual to have both cancer and diabetes at the same time, given they are both individually common, and that one condition can increase the risk of the other. In this manuscript, we use national-level diabetes (Virtual Diabetes Register) and cancer (New Zealand Cancer Registry) data on nearly five million individuals over 44 million person-years of follow-up to examine the occurrence of cancer amongst a national prevalent cohort of patients with diabetes. We completed this analysis separately by cancer for the 24 most commonly diagnosed cancers in Aotearoa New Zealand, and then compared the occurrence of cancer among those with diabetes to those without diabetes. We found that the rate of cancer was highest amongst those with diabetes for 21 of the 24 most common cancers diagnosed over our study period, with excess risk among those with diabetes ranging between 11% (non-Hodgkin's lymphoma) and 236% (liver cancer). The cancers with the greatest difference in incidence between those with diabetes and those without diabetes tended to be within the endocrine or gastrointestinal system, and/or had a strong relationship with obesity. However, in an absolute sense, due to the volume of breast, colorectal and lung cancers, prevention of the more modest excess cancer risk among those with diabetes (16%, 22% and 48%, respectively) would lead to a substantial overall reduction in the total burden of cancer in the population. Our findings reinforce the fact that diabetes prevention activities are also cancer prevention activities, and must therefore be prioritised and resourced in tandem.

Effect of concomitant statin treatment in postmenopausal patients with hormone receptor-positive early-stage breast cancer receiving adjuvant denosumab or placebo: a post hoc analysis of ABCSG-18

Background

Statins are cholesterol-lowering drugs prescribed for the prevention and treatment of cardiovascular disease. Moreover, statins may possess anticancer properties and interact with receptor activator of nuclear factor κB ligand expression. We aimed at evaluating a hypothetical synergistic effect of statins with denosumab in early-stage breast cancer (BC) patients from the Austrian Breast and Colorectal Cancer Study Group (ABCSG) trial 18.

Patients and methods

ABCSG-18 (NCT00556374) is a prospective, randomized, double-blind, phase III study; postmenopausal patients with hormone receptor-positive BC receiving a nonsteroidal aromatase inhibitor were randomly assigned to denosumab or placebo. In this post hoc analysis, we investigated the effects of concomitant statin therapy on recurrence risk (RR) of BC, fracture risk and bone mineral density (BMD).

Results

In the study population (n = 3420), statin therapy (n = 824) was associated with worse disease-free survival (DFS) [hazard ratio (HR) 1.35, 95% confidence interval (CI) 1.04-1.75; P = 0.023]. While no significant effect of lipophilic statins (n = 710) on RR was observed (HR 1.30, 95% CI 0.99-1.72; P = 0.062), patients on hydrophilic statins (n = 87) had worse DFS compared with patients not receiving any statins (HR 2.00, 95% CI 1.09-3.66; P = 0.026). This finding was mainly driven by the effect of hydrophilic statins on DFS in the denosumab arm (HR 2.63, 95% CI 1.21-5.68; P = 0.014). However, this effect subsided after correction for confounders in the sensitivity analysis. No association between statin use and fracture risk or osteoporosis was observed.

Conclusion

According to this analysis, hydrophilic statins showed a detrimental effect on DFS in the main model, which was attenuated after correction for confounders. Our data need to be interpreted with caution due to their retrospective nature and the low number of patients receiving hydrophilic statins.

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Statin co-medication was initially associated with a worse DFS in hormone receptor-positive early-stage BC patients.

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This effect was mainly driven by patients on hydrophilic statins.

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However, this effect subsided after correction for confounders in the sensitivity analysis.

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No association between statin use and fracture risk or osteoporosis was observed.

Differences in treatment and survival of older patients with operable breast cancer between the United Kingdom and the Netherlands – A comparison of two national prospective longitudinal multi-centre cohort studies

Background

Previous studies have shown that survival outcomes for older patients with breast cancer vary substantially across Europe, with worse survival reported in the United Kingdom. It has been hypothesised that these differences in survival outcomes could be related to treatment variation.

Objectives

We aimed to compare patient and tumour characteristics, treatment selection and survival outcomes between two large prospective cohorts of older patients with operable breast cancer from the United Kingdom (UK) and The Netherlands.

Methods

Women diagnosed with operable breast cancer aged ≥70 years were included. A baseline comprehensive geriatric assessment was performed in both cohorts, with data collected on age, comorbidities, cognition, nutritional and functional status. Baseline tumour characteristics and treatment type were collected. Univariable and multivariable Cox regression models were used to compare overall survival between the cohorts.

Results

3262 patients from the UK Age Gap cohort and 618 patients from the Dutch Climb cohort were included, with median ages of 77.0 (IQR: 72.0–81.0) and 75.0 (IQR: 72.0–81.0) years, respectively. The cohorts were generally comparable, with slight differences in rates of comorbidity and frailty. Median follow-up for overall survival was 4.1 years (IQR 2.9–5.4) in Age Gap and 4.3 years (IQR 2.9–5.5) in Climb. In Age Gap, both the rates of primary endocrine therapy and adjuvant hormonal therapy after surgery were approximately twice those in Climb (16.6% versus 7.3%, p < 0.001 for primary endocrine therapy, and 62.2% versus 38.8%, p < 0.001 for adjuvant hormonal therapy). There was no evidence of a difference in overall survival between the cohorts (adjusted HR 0.94, 95% CI 0.74–1.17, p = 0.568).

Conclusions

In contrast to previous studies, this comparison of two large national prospective longitudinal multi-centre cohort studies demonstrated comparable survival outcomes between older patients with breast cancer treated in the UK and The Netherlands, despite differences in treatment allocation.

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No survival difference between UK and Netherlands for older breast cancer patients.

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Similar patient and tumour characteristics seen in both cohorts.

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Higher rates of mastectomy for older breast cancer patients in Netherlands.

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Higher rates of adjuvant therapies for older breast cancer patients in UK.

Development and validation of the PORTRET tool to predict recurrence, overall survival, and other-cause mortality in older patients with breast cancer in the Netherlands: a population-based study

BACKGROUND

Current prediction tools for breast cancer outcomes are not tailored to the older patient, in whom competing risk strongly influences treatment effects. We aimed to develop and validate a prediction tool for 5-year recurrence, overall mortality, and other-cause mortality for older patients (aged ≥65 years) with early invasive breast cancer and to estimate individualised expected benefits of adjuvant systemic treatment.

METHODS

We selected surgically treated patients with early invasive breast cancer (stage I-III) aged 65 years or older from the population-based FOCUS cohort in the Netherlands. We developed prediction models for 5-year recurrence, overall mortality, and other-cause mortality using cause-specific Cox proportional hazard models. External validation was performed in a Dutch Cancer registry cohort. Performance was evaluated with discrimination accuracy and calibration plots.

FINDINGS

We included 2744 female patients in the development cohort and 13631 female patients in the validation cohort. Median age was 74·8 years (range 65-98) in the development cohort and 76·0 years (70-101) in the validation cohort. 5-year follow-up was complete for more than 99% of all patients. We observed 343 and 1462 recurrences, and 831 and 3594 deaths, of which 586 and 2565 were without recurrence, in the development and validation cohort, respectively. The area under the receiver-operating-characteristic curve at 5 years in the external dataset was 0·76 (95% CI 0·75-0·76) for overall mortality, 0·76 (0·76-0·77) for recurrence, and 0·75 (0·74-0·75) for other-cause mortality.

INTERPRETATION

The PORTRET tool can accurately predict 5-year recurrence, overall mortality, and other-cause mortality in older patients with breast cancer. The tool can support shared decision making, especially since it provides individualised estimated benefits of adjuvant treatment.

FUNDING

Dutch Cancer Foundation and ZonMw.

Metformin improves the outcomes in Chinese invasive breast cancer patients with type 2 diabetes mellitus

Early reports indicate that metformin, a clinical drug administered to treat type 2 diabetes mellitus (T2DM), was found to be associated with a better prognosis of cancer. The objective of this study was retrospectively analyzed the effect of metformin on the outcomes of Chinese breast cancer patients with T2DM. A total of 3757 primary invasive breast cancer patients who underwent surgery from January 2010 to December 2013 were enrolled. According to the medication treatment, all the patients were divided as non-diabetes group, metformin group and insulin group. The follow-up data for disease-free survival (DFS) and overall survival (OS) were obtained from 3553 patients (median follow up of 85 months) and estimated with the Kaplan–Meier method followed by a log-rank test. Multivariate Cox proportional hazards regression model was applied. The results showed that there was a significant survival difference among non-diabetes group, metformin group and insulin group, 5-year DFS was 85.8%, 96.1%, 73.0%, and 5-year OS was 87.3%, 97.1%, 73.3% respectively (P < 0.05). Prognostic analysis showed metformin was significantly associated with better DFS and OS. Our results suggested that metformin may have a good effect on the survival of invasive breast cancer patients with T2DM.

Type 2 diabetes, breast cancer specific and overall mortality: Associations by metformin use and modification by race, body mass, and estrogen receptor status

INTRODUCTION

While type 2 diabetes (T2D) has been associated with increased all-cause mortality among women diagnosed with breast cancer (BC), the association between T2D and breast cancer-specific (BCS) mortality is unresolved. The goal of this study was to examine the association between T2D and BCS mortality and examine the influence of metformin treatment on mortality rates.

METHODS

A retrospective cohort study was conducted between 2002 and 2008 at Emory University Hospitals among non-Hispanic black and white women who had confirmed diagnosis of stage I-III BC and known diabetes status (T2D: n = 73; non-T2D: n = 514). Cox proportional hazard models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI).

RESULTS

Compared to non-T2D patients, T2D women had almost a 2-fold increase in BCS mortality after adjusting for covariates (HR = 2.01; 95%CI = 1.02-3.98). Though attenuated, the increased hazard of death was also observed for all-cause mortality (HR = 1.74; 95%CI = 1.06-2.87). T2D patients who were not on metformin had substantially higher hazard of BCS mortality compared to non-diabetic patients (HR = 4.54; 95%CI = 1.98-10.44), whereas the association among T2D patients treated with metformin was weak (HR = 1.20; 95%CI = 0.36-3.97) and included the null.

CONCLUSIONS

Among women with BC, T2D is associated with increased BCS mortality. Metformin treatment for T2D during the initial diagnosis of BC may improve outcomes.

Pre- and Post-diagnosis Diabetes as a Risk Factor for All-Cause and Cancer-Specific Mortality in Breast, Prostate, and Colorectal Cancer Survivors: a Prospective Cohort Study

Objective: The relationship between diabetes and all- and cause-specific mortality in individuals with common cancers (breast, colorectal, and prostate) remains both under-researched and poorly understood. Methods: Cancer survivors (N = 37,993) from the National Health Interview Survey with linked data retrieved from the National Death Index served as our study participants. Cox proportional-hazards models were used to assess associations between pre- and post-diabetes and all-cause and cause-specific mortality. Results: Over a median follow-up period of 13 years, 2,350 all-cause, 698 cancer, and 506 CVD deaths occurred. Among all cancer survivors, patients with diabetes had greater risk of: all-cause mortality [hazard ratio (HR) 1.35, 95% CI = 1.27-1.43], cancer-specific mortality (HR: 1.14, 95% CI = 1.03-1.27), CVD mortality (HR: 1.36, 95% CI = 1.18-1.55), diabetes related mortality (HR: 17.18, 95% CI = 11.51-25.64), and kidney disease mortality (HR: 2.51, 95% CI = 1.65-3.82), compared with individuals without diabetes. The risk of all-cause mortality was also higher amongst those with diabetes and specific types of cancer: breast cancer (HR: 1.28, 95% CI = 1.12-1.48), prostate cancer (HR: 1.20, 95% CI = 1.03-1.39), and colorectal cancer (HR: 1.29, 95% CI = 1.10-1.50). Diabetes increased the risk of cancer-specific mortality among colorectal cancer survivors (HR: 1.36, 95% CI = 1.04-1.78) compared to those without diabetes. Diabetes was associated with higher risk of diabetes-related mortality when compared to non-diabetic breast (HR: 9.20, 95% CI = 3.60-23.53), prostate (HR: 18.36, 95% CI = 6.01-56.11), and colorectal cancer survivors (HR: 12.18, 95% CI = 4.17-35.58). Both pre- and post-diagnosis diabetes increased the risk of all-cause mortality among all cancer survivors. Cancer survivors with diabetes had similar risk of all-cause and CVD mortality during the second 5 years of diabetes and above 10 years of diabetes as compared to non-diabetic patients. Conclusions: Diabetes increased the risk of all-cause mortality among breast, prostate, and colorectal cancer survivors, not for pre- or post-diagnosis diabetes. Greater attention on diabetes management is warranted in cancer survivors with diabetes.

The added value of fasting blood glucose to serum squamous cell carcinoma antigen for predicting oncological outcomes in cervical cancer patients receiving neoadjuvant chemotherapy followed by radical hysterectomy

Objective

To determine the combination of fasting blood glucose (FBG) with squamous cell carcinoma antigen (SCCA) assessments in the prediction of tumor responses to chemotherapy and pretreatment prognostication among patients receiving neoadjuvant chemotherapy (NACT) for locally advanced cervical cancer (LACC).

Methods

Data of 347 LACC patients were retrospectively reviewed. Receiver operating characteristic (ROC) curves were constructed, and areas under the curves (AUCs) were compared to evaluate the ability to predict complete response (CR) following NACT. Patients were stratified into groups with low and high levels of SCCA and FBG and combined into low‐ or high‐SCCA and low‐ or high‐FBG groups. Cox regression analysis was performed to identify determinants of recurrence‐free survival (RFS) and overall survival (OS).

Results

The AUCs were 0.70, 0.68, and 0.66 for SCCA, FBG, and a combination of SCCA and FBG for predicting CR following NACT, respectively; however, the differences among AUCs were not significant (P = .496). Pretreatment SCCA and FBG levels were identified as independent predictors of RFS and OS. The high‐SCCA/high‐FBG group showed significantly worse prognosis than the low‐SCCA/low‐FBG group. After adjusting for other variables, high‐SCCA/high‐FBG remained independently associated with an increased risk of tumor recurrence and death.

Conclusion

SCCA, FBG, and a combination of SCCA and FBG could acceptably predict CR following NACT. Pretreatment SCCA and FBG levels were independent prognostic factors. The combination of SCCA and FBG levels refined the prognostic stratification of LACC patients, which allowed the group of patients with the highest risk of recurrence and death to be identified.

Differential Mortality and the Excess Rates of Hip Fracture Associated With Type 2 Diabetes: Accounting for Competing Risks in Fracture Prediction Matters

Type 2 diabetes (T2DM) is associated with a reduced life expectancy. The latest published evidence suggests an increased risk of fractures among T2DM patients. We conducted a population-based cohort study to determine the impact of mortality as a competing risk in the study of the association between T2DM and hip fracture rates. Participants were all diagnosed T2DM patients registered in the Sistema de Información para el Desarrollo de la Investigación en Atención Primaria (SIDIAP) database aged 65 years and older; up to two non-T2DM were matched by age, sex, and primary care facility. We used Cox regression models to estimate cause-specific hazard ratio (HR) of death or hip fracture according to T2DM status. Fine and Gray models were then fitted to estimate the subhazard ratio (SHR) of hip fracture while accounting for competing risk with death and to estimate the probability of hip fracture within 5 years. A total of 55,891 T2DM and 103,093 matched non-T2DM patients were observed for a median of 8 years. Mortality was 48.8 per 1000 person years (py) in T2DM, and 33.8 per 1000 py in non-T2DM; hip fracture rates were 6.0 per 1000 py and 4.9 per 1000 py, respectively. Cox models confirmed a significant association for death and hip fracture: HR 1.51 (95% CI, 1.48 to 1.55), and HR 1.32 (95% CI, 1.24 to 1.40), respectively. Accounting for death as a competing event (Fine-Gray models), the association between T2DM and hip fracture risk remained statistically significant (SHR 1.15; 95% CI, 1.09 to 1.21) and the probability of a hip fracture within 5 years was 2.3% for TD2M and 1.9% for non-TD2M patients compared to 2.6% and 2.1% respectively using Kaplan-Meier (KM) estimates. T2DM patients have a 50% increased mortality and, after adjusting for differential survival at 5 years, a 21% increased incidence of hip fracture when compared to matched non-T2DM. Failing to account for differential mortality leads to an overestimation of fracture risk. © 2018 American Society for Bone and Mineral Research.

Influence of the time interval from diagnosis to treatment on survival for early-stage liver cancer

Objectives

Liver cancer is the fifth most common cancer in men and the ninth most common cancer in women, and the WHO expects that there will be 1,341,344 cases in 2034 worldwide. Liver cancer also has the second-highest cancer death rate, accounting for 7% of all cancers. The study is going to explore the relationship between time interval from diagnosis to treatment and survival status of early-stage liver cancer patients.

Materials and methods

This is a retrospective cohort study using the national database from Taiwan. The datasets include the Taiwan Cancer Registry Database (TCR), the National Health Insurance Research Database (NHIRD), and the National Registry of Deaths. The target population for the study was patients newly diagnosed with stage I and stage II liver cancer between the years 2004 and 2010. Total of 26,038 cases were included in the study. Except descriptive analysis, the relationship between patient characteristics and the time interval from diagnosis to treatment was examined by chi-square tests. In addition, modified Cox proportional hazard models were used to analyze the hazard ratio of patient death with various treatment delay durations.

Results

There were 20,430 patients (78.46%) who received treatment less than 30 days after diagnosis, while 2,674 patients (10.27%) received treatment between 31 and 60 days after diagnosis, and 2,068 patients (7.94%) received treatment between 61 and 180 days after diagnosis, and 866 patients (3.33%) who received treatment 181 days after diagnosis. Those treated more than 181 days and 61–180 days after diagnosis had a 1.68-fold increased risk of death (95% confidence interval: 1.50–1.88) and a 1.39-fold increased risk of death (95% confidence interval: 1.31–1.17), respectively. Being male, being elderly, having a higher CCI level, and being treated in a hospital with a low service volume were factors associated with a poorer prognosis.

Conclusion

Overall, this study utilized a national cohort to conclude that for early-stage liver cancer patients, a longer the time interval from diagnosis to treatment results in a lower survival rate.

Impact of diabetes mellitus on the risk and survival of nasopharyngeal carcinoma: a meta-analysis

Background

Diabetes mellitus (DM) has been identified to be both a risk factor and a prognostic factor in a variety of malignancies, but its association with the risk and outcome of nasopharyngeal carcinoma (NPC) is still unclear. To elucidate this issue, we systematically reviewed the evidence concerning the association between DM status and NPC.

Materials and methods

We identified studies by a literature search of PubMed, Embase, and ISI Web of Knowledge through May 31, 2017, and by searching the reference lists of pertinent articles. Odds ratios (ORs) and hazard ratios (HRs) with 95% CIs were used to estimate the effect size. Heterogeneity across studies was evaluated by the Cochran’s Q and I² statistics.

Results

A total of nine studies were included. Four studies with a total sample size of 221,611 reported the effect of DM on NPC risk, and the other five studies with a sample size of 9,442 reported the impact of DM on survival in NPC patients. All included studies were retrospective, and mostly conducted in Asian populations. Meanwhile, condition of metformin usage was not considered in all studies. A pooled OR of 0.65 (95% CI: 0.43–0.98, P=0.04) revealed an inverse association between DM and NPC. Additionally, pooled analyses of studies investigating the prognosis value of DM revealed that preexisting DM had no effect on overall survival (HR =1.17, 95% CI: 0.94–1.46, P=0.16), local recurrence-free survival (HR =1.16, 95% CI: 0.80–1.67, P=0.44), and distant metastasis-free survival (HR =1.14, 95% CI: 0.92–1.40, P=0.22).

Conclusion

Our results suggested that DM patients might have decreased NPC risk, and have little impact on prognosis of NPC patients. This conclusion should be limited to Asian population. Our results also suggest that more attention should be paid to metformin medication in further studies in order to clarify whether the effects of DM on NPC risk and prognosis are influenced by the anticancer effect of metformin.

Fasting Blood Glucose Level in Locally Advanced Non-Small Cell Lung Cancer: a New Prognostic Factor?

Hyperglycemia may lead to proliferation, invasion, apoptosis inhibition, migration, and eventually metastasis of cancer cells by several mechanisms. In this study, the effect of hyperglycemia on overall survival (OS), disease-free survival (DFS), and locoregional recurrence (LRR) was investigated in NSCLC. One stage IIIA-IIIB NSCLC patient treated with chemoradiotherapy between 2010 and 2015 was enrolled. Fasting blood glucose (FBG) levels were recorded in pre-treatment, treatment, and post-treatment periods. Median age was 54 years (51-62). Fifty-two patients had squamous cell carcinoma (SCC); 19 had adenocarcinoma. Median follow-up was 19 (11-30), median survival was 19 (13-24), and DFS was 9 (7-11) months. Diabetic patients had shorter survival than non-diabetics 12 (95%CI, 10-14) vs. 25 months (95%CI,18-32), p = 0.005. Number of patients with LRR was also higher in diabetics compared to non-diabetics (8/12 vs. 11/37, p = 0.039). OS was shorter in patients with hyperglycemic-FBG and diabetic-FBG levels in pre-treatment period (log-rank p = 0.03 and 0.023, respectively). Diabetic-FBG level in pre-treatment period was found to be the only independent risk factor for survival. In subgroup analysis, these differences were apparent in SCC (log-rank p = 0.009 for hyperglicemic, log-rank p = 0.017 for diabetic-FBG). LRR was 68% in patients with diabetic-FBG, 36.5% in patients with non-diabetic-FBG in post-treatment period (p = 0.015). Patients with LRR had significantly higher median FBG value in post-treatment period compared to non-relapsing patients, 138 mg/dL (119-228) and 111 mg/dL (99-164), respectively (p = 0.022). The patients with hyperglycemic and diabetic-FBG levels in pre-treatment period had shorter survival compared to normoglycemic ones. The patients with diabetic-FBG level in post-treatment period had higher LRR, and relapsing patients had higher FBG levels in post-treatment period.

Cognitive Functioning, Health Screening Behaviors and Desire to Improve One's Health in Diabetic versus Healthy Older Women

AIMS

To attempt to fill a gap in the literature on diabetic versus healthy older women on desire to improve one's health, health screening behaviors, and cognitive health.

STUDY DESIGN

Between-subjects design.

PLACE AND DURATION OF STUDY

Department of Psychology, California State University Northridge, between July 2013 and June 2015.

METHODOLOGY

In this preliminary study, we compared 30 diabetic older women to 42 healthy older women (i.e., respondents who reported having no physical illnesses and not taking any medications) on: desire to improve their health (hypothesized as being higher in the diabetes group), receiving mammograms and regular health screenings (analyzed without any hypotheses, due to the lack of evidence on this topic), as well as cognitive functioning (hypothesized as lower in the diabetes group, based on prior research findings). Participants (N=72, mean age=69.29, SD=6.579, age range=50-90) were multiethnic, non-institutionalized women over the age of 50 residing in Los Angeles County who completed our research packet. The latter contained the first author's demographics list and her original structured interview protocol on older women's health, as well as the well-known Mini-Cog.

RESULTS

The results of an Analysis of Variance (ANOVA) showed that, as hypothesized, diabetic women desired to improve their health more than the women in the control group [F (1,70)=11.87, p<.05, η2 =.15]. Additionally, upon implementing Chi-square analyses, we discovered that diabetic respondents were significantly more likely to receive mammograms [X2 (1)=5.87, p<.05] and general health screenings [X2 (1)=4.51, p<.05] than healthy women. Moreover, in contrast with prior literature's findings, cognitive health in the diabetic group obtained marginal significance in an ANOVA as being better than the cognitive health of the control group [F(1,68)=3.30, p=.06, η2 =.05].

CONCLUSION

We have established a significant relationship between diabetes and a) desire to improve one's health and b) health screening behaviors, as well as c) cognitive impairment (at a marginally significant level) among diabetic versus healthy women. This has important clinical and public health implications. Although the findings of prior research suggest that diabetic older women often experience impaired cognitive performance compared to healthy older women, our marginally significant results showed that the opposite is true, at least in our ethnically diverse sample of modest size. Moreover, we found that diabetic older women desired to improve their health significantly more than healthy women and pursued cancer screenings and general health screenings more than their healthy counterpart. The limited size of our sample does not allow for generalizations of our findings. Additional research with larger samples is definitely needed to investigate these topics further.

Breast cancer recurrence after reoperation for surgical bleeding

BACKGROUND

Bleeding activates platelets that can bind tumour cells, potentially promoting metastatic growth in patients with cancer. This study investigated whether reoperation for postoperative bleeding is associated with breast cancer recurrence.

METHODS

Using the Danish Breast Cancer Group database and the Danish National Patient Register (DNPR), a cohort of women with incident stage I-III breast cancer, who underwent breast-conserving surgery or mastectomy during 1996-2008 was identified. Information on reoperation for bleeding within 14 days of the primary surgery was retrieved from the DNPR. Follow-up began 14 days after primary surgery and continued until breast cancer recurrence, death, emigration, 10 years of follow-up, or 1 January 2013. Incidence rates of breast cancer recurrence were calculated and Cox regression models were used to quantify the association between reoperation and recurrence, adjusting for potential confounders. Crude and adjusted hazard ratios according to site of recurrence were calculated.

RESULTS

Among 30 711 patients (205 926 person-years of follow-up), 767 patients had at least one reoperation within 14 days of primary surgery, and 4769 patients developed breast cancer recurrence. Median follow-up was 7·0 years. The incidence of recurrence was 24·0 (95 per cent c.i. 20·2 to 28·6) per 1000 person-years for reoperated patients and 23·1 (22·5 to 23·8) per 1000 person-years for non-reoperated patients. The overall adjusted hazard ratio was 1·06 (95 per cent c.i. 0·89 to 1·26). The estimates did not vary by site of breast cancer recurrence.

CONCLUSION

In this large cohort study, there was no evidence of an association between reoperation for bleeding and breast cancer recurrence.

Diabetes mellitus and prognosis in women with breast cancer: A systematic review and meta-analysis

BACKGROUND

Diabetes mellitus is associated with an increased risk of breast cancer, but studies of the effects of diabetes on the prognosis of women with breast cancer have yielded inconsistent findings. The present meta-analysis aimed to investigate the impact of preexisting diabetes on the prognosis in terms of overall survival (OS), disease-free survival (DFS), and relapse-free period (RFP) in women with breast cancer.

METHODS

We searched the Embase and PubMed databases until June 2016 for cohort or case-control studies assessing the impact of diabetes on the prognosis of women with breast cancer. The pooled multivariate adjusted hazard ratio (HR) and their 95% confidence intervals (CIs) for OS, DFS, and RFP were used to analyze the impact of diabetes on the prognosis of breast cancer patients.

RESULTS

Seventeen studies involving 48,315 women with breast cancer met our predefined inclusion criteria. Meta-analysis showed that the pooled adjusted HR was 1.51 (95% CI 1.34-1.70) for OS and 1.28 (95% CI 1.09-1.50) for DFS in breast cancer patients with diabetes compared to those without diabetes. However, RFP did not differ significantly between patients with and without diabetes (HR 1.42; 95% CI 0.90-2.23).

CONCLUSIONS

The present meta-analysis suggests that preexisting diabetes is independently associated with poor OS and DFS in female breast cancer patients. However, the impact of diabetes on RFP should be further verified. More prospective studies are warranted to investigate whether appropriate glycemic control with modification of antihyperglycemic agents can improve the prognosis of female breast cancer patients with diabetes.

Impact of Hyperglycemia on Outcomes among Patients Receiving Neoadjuvant Chemotherapy for Bulky Early Stage Cervical Cancer

Background

The impact of hyperglycemia on survival of patients undergoing neoadjuvant chemotherapy (NACT) for bulky early stage cervical cancer (BESCC) has not been explored.

Method

Records of patients who received NACT and radical hysterectomy in our institution between January 2005 and June 2010 were reviewed.

Results

In total, 347 patients were included. The median follow-up time was 37 months (range: 4–65). Patients with hyperglycemia (fasting blood glucose ≥ 100 mg/dl) had shorter recurrence-free survival (RFS) (univariate hazard ratio [HR] = 1.95, 95% confidence interval [CI] [1.16, 3.28], P = 0.010) and cancer-specific survival (CSS) (univariate HR = 2.24, 95% CI [1.33, 3.78], P = 0.002) compared with those with euglycemia (fasting blood glucose <100 mg/dl). In multivariate analysis, positive surgical margins, parametrium invasion, node metastasis, hyperglycemia and complete response to NACT independently predicted recurrence and cancer-specific death. To further validate the prognostic value of hyperglycemia, we conducted a subgroup analysis based on patient baseline characteristics and prognostic effect of hyperglycemia remained significant in all subgroups. On multivariable logistic regression analysis, euglycemia before NACT, squamous cell tumor and pre-treatment squamous cell carcinoma antigen levels < 3.5 ng/ml were identified as independent predictors of complete response after NACT.

Conclusions

FBG ≥100 mg/dl is a negative prognostic predictor for cervical cancer patients receiving NACT for BESCC. Patients with hyperglycemia are less likely to achieve complete response after NACT. Our findings underscore the clinical utility of hyperglycemia screening of for cervical cancer patients.

[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.

The impact of comorbidity on cancer and its treatment

Answer questions and earn CME/CNE Comorbidity is common among cancer patients and, with an aging population, is becoming more so. Comorbidity potentially affects the development, stage at diagnosis, treatment, and outcomes of people with cancer. Despite the intimate relationship between comorbidity and cancer, there is limited consensus on how to record, interpret, or manage comorbidity in the context of cancer, with the result that patients who have comorbidity are less likely to receive treatment with curative intent. Evidence in this area is lacking because of the frequent exclusion of patients with comorbidity from randomized controlled trials. There is evidence that some patients with comorbidity have potentially curative treatment unnecessarily modified, compromising optimal care. Patients with comorbidity have poorer survival, poorer quality of life, and higher health care costs. Strategies to address these issues include improving the evidence base for patients with comorbidity, further development of clinical tools to assist decision making, improved integration and coordination of care, and skill development for clinicians. CA Cancer J Clin 2016;66:337-350. © 2016 American Cancer Society.

Metformin use and gynecological cancers: A novel treatment option emerging from drug repositioning

Metformin exerts antitumor effects mainly through AMP-activated protein kinase [AMPK] activation and phosphatidylinositol 3-kinase [PI3K]-Akt-mammalian target of rapamycin [mTOR] inhibition. This drug leads to activation of the cellular energy-sensing liver kinase B1 [LKB1]/AMPK pathway. LKB1 is implicated as a tumor suppressor gene in molecular pathogenesis of different malignancies. AMPK is a serine/threonine protein kinase that acts as an ultra-sensitive cellular energy sensor maintaining the energy balance within the cell. AMPK activation inhibits mRNA translation and proliferation in cancer cells via down-regulation of PI3K/Akt/mTOR pathway. Moreover, metformin decreases the production of insulin, insulin-like growth factor, inflammatory cytokines and vascular endothelial growth factor, and therefore it exerts anti-mitotic, anti-inflammatory and anti-angiogenetic effects. Recent in vitro and experimental data suggest that metformin electively targets cancer stem cells, and acts together with chemotherapy to block tumor growth in different cancers. Several epidemiological studies and meta-analysis have shown that metformin use is associated with decreased cancer risk and/or reduced cancer mortality for different malignancies. The present review analyzes the recent biological and clinical data suggesting a possible growth-static effect of metformin also in gynecological cancers. The large majority of available clinical data on the anti-cancer potential of metformin are based on observational studies. Therefore long-term phase II-III clinical trials are strongly warranted to further investigate metformin activity in gynecological cancers.

Serum glucose and hemoglobin A1C levels at cancer diagnosis and disease outcome

BACKGROUND

Despite the lack of scientific data, many cancer patients hold the belief that glucose 'feeds' cancer and might affect disease outcome. We aimed to evaluate associations between glucose, hemoglobin A1C (HbA1C), and survival among individuals with diabetes and diabetes associated cancers.

METHODS

Five retrospective cohort studies were conducted in a large population-representative database. The study population included all patients with diabetes and an incident diagnosis of colorectal, breast, bladder, pancreatic and prostate cancers. Exposure of interest was serum glucose or HbA1C levels within 6 months prior to cancer diagnosis. Cox regression model was used to calculate hazard-ratio (HR) and 95% confidence-interval (CI) for overall survival. Analyses were adjusted for cancer-specific confounders. A subgroup analysis was performed among insulin-treated patients.

RESULTS

Study cohorts included 7916 individuals with incident cancers and concurrent diabetes. There was no association between HbA1C levels and overall survival in colorectal (HR 1.00, 95% CI 0.95-1.06), breast (HR 1.03, 95% CI 0.95-1.11), bladder (HR 0.94, 95% CI 0.86-1.01), pancreatic (HR 0.98, 95% CI 0.94-1.02), or prostate (HR 1.02, 95% CI 0.96-1.08) cancers. Among diabetes patients treated with insulin, there was increased survival with increasing serum glucose, most prominent for bladder cancer (HR 0.91, 95% CI 0.84-0.99, per 1 mmol/l increase).

CONCLUSIONS

Higher glucose and HbA1C levels in diabetes patients with incident cancer are not associated with worse overall survival following cancer diagnosis. Among insulin-treated patients, higher glucose levels may be associated with improved survival.

Prognostic value of Diabetes in Patients with Nasopharyngeal Carcinoma Treated with Intensity-Modulated Radiation Therapy

The prognostic value of diabetes remains unknown in nasopharyngeal carcinoma (NPC) treated with intensity-modulated radiation therapy (IMRT). We retrospectively reviewed medical records of 1489 patients with non-metastatic, histologically-proven NPC treated using IMRT. 81/1489 (5.4%) patients were diabetic, 168/1489 (11.3%) were prediabetic, and 1240/1489 (83.3%) were normoglycemic. The 4-year disease-free survival (DFS), overall survival (OS), loco-regional relapse-free survival (LRRFS) and distant metastasis-free survival (DMFS) rates were 77.1% vs. 82.4% (P = 0.358), 85.8% vs. 91.0% (P = 0.123), 90.9% vs. 91.7% (P = 0.884), and 85.5% vs. 89.2% (P = 0.445) for diabetic vs. normoglycemic patients, and 82.4% vs. 82.4% (P = 0.993), 88.7% vs. 91.0% (P = 0.285), 90.6% vs. 91.7% (P = 0.832) and 91.5% vs. 89.2% (P = 0.594) for preidabetic vs. normoglycemic patients. Multivariate analysis did not established diabetes as poor prognostic factors in NPC patients treated with IMRT (P = 0.332 for DFS, P = 0.944 for OS, P = 0.977 for LRRFS, P = 0.157 for DMFS), however, triglycerides and low density lipoprotein cholesterol were independent prognostic factors. In conclusion, diabetes does not appear to be a prognostic factor in NPC patients treated with IMRT, and attention should be paid to hyperglycemia-associated hyperlipaemia.

Determinants of mortality in patients with type 2 diabetes: a review

We aimed to review and summarize the evidence from accomplished trials analyzing factors influencing mortality in patients with T2DM and to provide some recommendations for targets and treatment in the European region. The following databases were searched for relevant trials: PubMed and the Cochrane Library. Of 3.806 citations, 134 trials met our inclusion criteria.

RESULTS

The reduction in lifetime for 65 + -years-old patients having less than 10 years T2DM amounts to 1.8 years. Having T2DM for more than 10 years lifetime will be reduced by 2.7 years. However, the lifetime shortening factor of T2DM will even be stronger for 40 + -years-old patients at onset. Males will lose 11.6 years of life and 18.6 QUALYs. T2DM among females will reduce life by 14 QUALYs by 22 years. From a statistical point of view, the highest mortality rate will occur in an over 55-years-old European smoking and non-compliant diabetic woman with alcohol abuse living in a rural area with a low level of education and a low socio-economic status. Furthermore, other co-morbidities such as cardiovascular diseases, gout, and depression affect mortality. Additionally, mortality will increase with a BMI over 35 and also with a BMI under 20-25. This refers to the obesity paradox indicating a higher mortality rate among normal weight patients with T2DM compared to overweight patients with T2DM. HbA1c-levels between 6.5 % and 7 % are associated with the lowest impact on mortality.

Validity of the online PREDICT tool in older patients with breast cancer: a population-based study

Background:

Predicting breast cancer outcome in older patients is challenging, as it has been shown that the available tools are not accurate in older patients. The PREDICT tool may serve as an alternative tool, as it was developed in a cohort that included almost 1800 women aged 65 years or over. The aim of this study was to assess the validity of the online PREDICT tool in a population-based cohort of unselected older patients with breast cancer.

Methods:

Patients were included from the population-based FOCUS-cohort. Observed 5- and 10-year overall survival were estimated using the Kaplan–Meier method, and compared with predicted outcomes. Calibration was tested by composing calibration plots and Poisson Regression. Discriminatory accuracy was assessed by composing receiver-operator-curves and corresponding c-indices.

Results:

In all 2012 included patients, observed and predicted overall survival differed by 1.7%, 95% confidence interval (CI)=−0.3–3.7, for 5-year overall survival, and 4.5%, 95% CI=2.3–6.6, for 10-year overall survival. Poisson regression showed that 5-year overall survival did not significantly differ from the ideal line (standardised mortality ratio (SMR)=1.07, 95% CI=0.98–1.16, P=0.133), but 10-year overall survival was significantly different from the perfect calibration (SMR=1.12, 95% CI=1.05–1.20, P=0.0004). The c-index for 5-year overall survival was 0.73, 95% CI=0.70–0.75, and 0.74, 95% CI=0.72–0.76, for 10-year overall survival.

Conclusions:

PREDICT can accurately predict 5-year overall survival in older patients with breast cancer. Ten-year predicted overall survival was, however, slightly overestimated.

The influence of insulin-like Growth Factor-1-Receptor expression and endocrine treatment on clinical outcome of postmenopausal hormone receptor positive breast cancer patients: A Dutch TEAM substudy analysis

BACKGROUND

Signaling via the Insulin-like Growth Factor type 1 Receptor (IGF1R) plays a crucial role in cancer development. In breast cancer (BC), IGF1R and estrogen receptor expression are correlated. In this current study we explored the hypothesis that postmenopausal hormone receptor positive (HR+ve) BC patients with high IGF1R tumor expression still have estrogen driven IGF1R stimulated tumor growth when treated with tamoxifen, resulting in detrimental clinical outcome compared to patients treated with exemestane. Additionally, we assessed the added value of metformin as this drug may lower IGF1R stimulation.

METHODS

Of 2,446 Dutch TEAM patients, randomized to either exemestane for 5 years or sequential treatment (tamoxifen for 2-3 years followed by exemestane for another 3-2 years) tumor tissue microarray sections were immunohistochemically stained for IGF1R. Overall Survival (OS), Breast Cancer specific Survival (BCSS) and Relapse-Free Survival (RFS) were assessed in patient subgroups with low and high IGF1R expression, and in patients with or without metformin use.

RESULTS

High IGF1R tumor expression was significantly associated with exemestane therapy for RFS (Hazard Ratio (HR) 0.74, 95% Confidence Interval (CI) 0.58-0.95, p = 0.02). In addition, the combination of metformin with exemestane resulted in improved efficacy, yielding a 5-yrs RFS of 95% (HR 0.32, 95% CI 0.10-1.00, p = 0.02, compared to sequential treatment). No relation was observed in tumors with low IGF-1R expression.

CONCLUSION

This study suggests IGF1R as a potential biomarker of improved clinical outcome in HR+ve BC patients treated with exemestane. Adding metformin to exemestane treatment may add to this effect.

Recent advances in the use of metformin: can treating diabetes prevent breast cancer?

There is substantial epidemiological evidence pointing to an increased incidence of breast cancer and morbidity in obese, prediabetic, and diabetic patients. In vitro studies strongly support metformin, a diabetic medication, in breast cancer therapy. Although metformin has been heralded as an exciting new breast cancer treatment, the principal consideration is whether metformin can be used as a generic treatment for all breast cancer types. Importantly, will metformin be useful as an inexpensive therapy for patients with comorbidity of diabetes and breast cancer? In general, meta-analyses of clinical trial data from retrospective studies in which metformin treatment has been used for patients with diabetes and breast cancer have a positive trend; nevertheless, the supporting clinical data outcomes remain inconclusive. The heterogeneity of breast cancer, confounded by comorbidity of disease in the elderly population, makes it difficult to determine the actual benefits of metformin therapy. Despite the questionable evidence available from observational clinical studies and meta-analyses, randomized phases I-III clinical trials are ongoing to test the efficacy of metformin for breast cancer. This special issue review will focus on recent research, highlighting in vitro research and retrospective observational clinical studies and current clinical trials on metformin action in breast cancer.

Convergence and divergence of genetic and modular networks between diabetes and breast cancer

Diabetes mellitus (DM) and breast cancer (BC) can simultaneously occur in the same patient populations, but the molecular relationship between them remains unknown. In this study, we constructed genetic networks and used modularized analysis approaches to investigate the multi-dimensional characteristics of two diseases and one disease subtype. A text search engine (Agilent Literature Search 2.71) and MCODE software were applied to validate potential subnetworks and to divide the modules, respectively. A total of 793 DM-related genes, 386 type 2 diabetes (T2DM) genes and 873 BC-related genes were identified from the Online Mendelian Inheritance in Man database. For DM and BC, a total of 99 overlapping genes, 9 modules, 29 biological processes and 7 pathways were identified. Meanwhile, for T2DM and BC, 56 overlapping genes, 5 modules, 20 biological processes and 12 pathways were identified. Based on the Gene Ontology functional enrichment analysis of the top 10 non-overlapping modules of the two diseases, 10 biological functions and 5 pathways overlapped between them. The glycosphingolipid and lysosome pathways verified molecular mechanisms of cell death related to both DM and BC. We also identified new biological functions of dopamine receptors and four signalling pathways (Parkinson's disease, Alzheimer's disease, Huntington's disease and long-term depression) related to both diseases; these warrant further investigation. Our results illustrate the landscape of the novel molecular substructures between DM and BC, which may support a new model for complex disease classification and rational therapies for multiple diseases.

The morbidity and associated risk factors of cancer in chronic liver disease patients with diabetes mellitus: a multicenter field survey

BACKGROUND AND AIMS

Diabetes mellitus is associated with various cancers; however, little is known of the relationship between cancer and diabetes in chronic liver disease (CLD) patients. The aim of this study is to investigate the morbidity and associated factors of cancer, including the use of anti-diabetics, in CLD patients with diabetes.

PATIENTS AND METHODS

We performed a multicenter survey in 2012 and 478 CLD patients with diabetes were enrolled (age 64.3 ± 12.1 years, female/male 187/291). A frequency analysis of cancer and antidiabetic use was performed. Independent factors for cancer were analyzed using logistic regression and decision-tree analysis.

RESULTS

The morbidity of cancer was 33.3%. Hepatocellular carcinoma (HCC) and extra-hepatic cancer were diagnosed in 24.7 and 11.3% of enrolled patients, respectively. The frequency of antidiabetic use was 66.5%. Of prescribed antidiabetics, 39% were dipeptidyl-peptidase 4 inhibitors; however, their use was not significantly associated with cancer. In contrast, the use of exogenous insulin (OR 2.21; 95% CI 1.16-4.21, P = 0.0165) and sulfonylurea (OR 2.08; 95% CI 1.05-3.97, P = 0.0353) were independently associated with HCC and extra-hepatic cancer, respectively. In decision-tree analysis, exogenous insulin and sulfonylurea were also identified as a divergence factor for HCC and extra-hepatic cancer, respectively.

CONCLUSIONS

We found a high morbidity of not only HCC, but also extra-hepatic cancer in CLD patients with diabetes. We also showed a possible association between the use of antidiabetics and the morbidity of cancer. Thus, a large-scale cohort study is needed to establish a therapeutic strategy for diabetes to suppress carcinogenesis in CLD patients.

Diabetes and other comorbidities in breast cancer survival by race/ethnicity: the California Breast Cancer Survivorship Consortium (CBCSC)

BACKGROUND

The role of comorbidities in survival of patients with breast cancer has not been well studied, particularly in non-white populations.

METHODS

We investigated the association of specific comorbidities with mortality in a multiethnic cohort of 8,952 breast cancer cases within the California Breast Cancer Survivorship Consortium (CBCSC), which pooled questionnaire and cancer registry data from five California-based studies. In total, 2,187 deaths (1,122 from breast cancer) were observed through December 31, 2010. Using multivariable Cox proportional hazards regression, we estimated HRs and 95% confidence intervals (CI) for overall and breast cancer-specific mortality associated with previous cancer, diabetes, high blood pressure (HBP), and myocardial infarction.

RESULTS

Risk of breast cancer-specific mortality increased among breast cancer cases with a history of diabetes (HR, 1.48; 95% CI, 1.18-1.87) or myocardial infarction (HR, 1.94; 95% CI, 1.27-2.97). Risk patterns were similar across race/ethnicity (non-Latina white, Latina, African American, and Asian American), body size, menopausal status, and stage at diagnosis. In subgroup analyses, risk of breast cancer-specific mortality was significantly elevated among cases with diabetes who received neither radiotherapy nor chemotherapy (HR, 2.11; 95% CI, 1.32-3.36); no increased risk was observed among those who received both treatments (HR, 1.13; 95% CI, 0.70-1.84; P(interaction) = 0.03). A similar pattern was found for myocardial infarction by radiotherapy and chemotherapy (P(interaction) = 0.09).

CONCLUSION

These results may inform future treatment guidelines for patients with breast cancer with a history of diabetes or myocardial infarction.

IMPACT

Given the growing number of breast cancer survivors worldwide, we need to better understand how comorbidities may adversely affect treatment decisions and ultimately outcome.

Metabolic syndrome and outcomes following early-stage breast cancer

The prevalence of risk factors contributing to metabolic syndrome (MetS) is increasing, and numerous components of MetS are associated with increased primary breast cancer (BC) risk. However, less is known about the relationship of MetS to BC outcomes. The aim of this study was to evaluate whether MetS, characterized by increased weight, hypertension, low HDL-cholesterol, high triglycerides, and diabetes or impaired glucose tolerance, is associated with risk of second breast cancer events (SBCE) and BC-specific mortality. Retrospective cohort study of women diagnosed with incident early-stage (I-II) BC between 1990 and 2008, enrolled in an integrated health plan. Outcomes of interest were SBCE, defined as recurrence or second primary BC, and BC-specific mortality. We used multivariable Cox proportional hazards models to estimate adjusted hazard ratios (HR) and 95% confidence intervals (CI) for time-varying exposure to MetS components while accounting for potential confounders and competing risks. Among 4,216 women in the cohort, 26% had ≥3 MetS components and 13% developed SBCE during median follow-up of 6.3 years. Compared to women with no MetS components, presence of MetS (≥3 components) was associated with increased risk of SBCE (HR = 1.50, 95% CI 1.08-2.07) and BC-specific mortality (HR = 1.65, 95% CI 1.02-2.69). Of the individual components, only increased weight was associated with increased risk of SBCE (HR = 1.26, 95% CI 1.06-1.49). MetS is associated with modestly increased risk of SBCE and BC-specific mortality. Given the growing population of BC survivors, further research in larger and more diverse populations is warranted.

Diabetes, prediabetes and the survival of nasopharyngeal carcinoma: a study of 5,860 patients

BACKGROUND

The incidence of diabetes is increasing. But the impact of diabetes and prediabetes on survival of patients with nasopharyngeal carcinoma (NPC) has received little evaluation.

METHODS

In a cohort of 5,860 patients, we compared the disease specific survival (DSS), locoregional relapse-free survival (LRFS) and distant metastasis-free survival (DMFS) of patients with diabetes, prediabetes and normoglycemia defined by pretreatment fasting plasma glucose (FPG) using Kaplan-Meier method, log-rank test and Cox proportional hazards model.

RESULTS

Comparing to normoglycemic patients, the diabetic and the prediabetic were generally older, fatter, had hypertension, heart diseases and hyperlipaemia and usually received radiotherapy alone. But both the diabetic and the prediabetic had similar DSS, LRFS and DMFS to normoglycemic patients, even adjusting for such important factors as age, gender, smoking, drinking, hypertension, heart diseases, body mass index, hyperlipaemia, titer of VCA-IgA and EA-IgA, pathology, T-stage, N-stage, chemotherapy and radiotherapy (P>0.05 for all). Additionally, the findings remained unchanged in sensitivity analysis by excluding patients with known diabetes history and in subgroups of the various factors.

CONCLUSIONS

The diabetic and prediabetic NPC patients had similar survival to normoglycemic NPC patients. These data, in the largest reported cohort, are the first to evaluate the association between diabetes, prediabetes and the survival in NPC. The findings are relevant to patient management and provided evidence of the effect on this disease exerted by comorbidities.

Comorbidity, chemotherapy toxicity, and outcomes among older women receiving adjuvant chemotherapy for breast cancer on a clinical trial: CALGB 49907 and CALGB 361004 (alliance)

PURPOSE

We evaluated associations among comorbidity, toxicity, time to relapse (TTR), and overall survival (OS) in older women with early-stage breast cancer receiving adjuvant chemotherapy.

METHODS

Cancer and Leukemia Group B 49907 (Alliance) randomly assigned women ≥ 65 years old with stages I-III breast cancer to standard adjuvant chemotherapy or capecitabine. We reviewed data from 329 women who participated in the quality of life companion study CALGB 70103 and completed the Physical Health Subscale of the Older American Resources and Services Questionnaire. This questionnaire captures data on 14 comorbid conditions and the degree to which each interferes with daily activities. A comorbidity burden score was computed by multiplying the total number of conditions by each condition's level of interference with function. Outcomes were grade 3 to 5 toxicity, TTR, and OS. Logistic regression was used to evaluate associations between comorbidity and toxicity, and Cox proportional hazards models for TTR and survival.

RESULTS

Number of comorbidities ranged from 0 to 10 (median 2); the comorbidity burden score ranged from 0 to 25 (median 3). The most common conditions were arthritis (58%) and hypertension (55%). Comorbidity was associated with shorter OS, but not with toxicity or TTR. The hazard of death increased by 18% for each comorbidity (hazard ratio [HR] = 1.18, 95% CI = 1.06 to 1.33) after adjusting for age, tumor size, treatment, node and receptor status. Comorbidity burden score was similarly associated with OS (HR = 1.08; 95% CI, 1.03 to 1.14).

CONCLUSIONS

Among older women enrolled onto a clinical trial, comorbidity was associated with shorter OS, but not toxicity or relapse.

Assessment of tumor characteristics and factors affecting survival in patients with primary metastatic breast carcinoma: a Multicenter Study of the Anatolian Society of Medical Oncology

Primary metastatic breast cancer (PMBC) comprises 3-10% of all BCs. PMBC is a heterogeneous disease. To date, little is known about the tumor characteristics, treatment results, and overall survival (OS) of patients with PMBC. Patients were considered to have PMBC if distant metastasis was evident within 3 months of the initial diagnosis of BC. Between September 2007 and April 2013, 466 PMBC patients were included in this study and analyzed retrospectively. The median age of the patients was 50 (18-90) years. Bone/soft tissue metastases were more frequent in the hormone receptor (HR)(+) human epidermal growth factor receptor (HER)2(-) group compared with the HR(-)HER2(-) and HR(-)HER2(+) groups (p < 0.001), whereas visceral organ metastasis was more frequent in the HR(-)HER2(-) and HR(-)HER2(+) groups (p < 0.001). The OS was affected by Eastern Cooperative Oncology Group performance status, tumor histology, receptor status, and the site of metastasis (p < 0.001, p < 0.001, p < 0.001, and p = 0.011, respectively). According to the first-line systemic treatment choices of the patients, the longest median OS was observed in the HR(+)HER2(+) group who received hormonotherapy combined with trastuzumab after chemotherapy (86 months, 95% CI 23.8-148.1) and the shortest median OS was observed in the HR(-)HER2(-) group who received chemotherapy only (24 months, 95% CI 17.9-30.0) (p < 0.001). Bisphosphonate therapy or radiotherapy had no significant effect on OS (p = 0.733, 0.603). In multivariate analysis, hormonotherapy, chemotherapy + trastuzumab, trastuzumab + hormonotherapy following chemotherapy, and surgery were the most important prognostic factors for OS, respectively (p < 0.001, p = 0.025, p = 0.027, p = 0.029). The general characteristics of the primary tumor are important for the prognosis and survival of patients with PMBC. Interestingly, patients who underwent primary breast tumor surgery, even those at the metastatic stage upon admission, had the longest survival.