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

Impact of diabetes on stage I lung cancer treatment patterns and prognosis in older adults: A population-based cohort study

Background

Diabetes is a common comorbidity in patients with early-stage non-small cell lung cancer (NSCLC), a growing population due to increased LC screening. However, it is unknown if diabetes is associated with less aggressive NSCLC treatment and worse NSCLC outcomes. This study aimed to investigate treatment patterns and outcomes of older patients with Stage I NSCLC and diabetes.

Methods

Using national cancer registry data linked to Medicare, we identified patients ≥65 years old with Stage I NSCLC. Patients were categorized as having no diabetes, diabetes without severe complications (DM-c), or diabetes with ≥1 severe complication (DM + c). We used multinomial logistic regression to assess the association of diabetes and NSCLC treatment. The association of diabetes category with NSCLC and non-NSCLC survival was analyzed with Fine-Grey competing-risks regression.

Results

In 25,358 patients (75% no diabetes, 12% DM-c and 13% had DM + c), adjusted analyses showed that DM-c and DM + c were associated with increased odds of receiving limited resection rather than lobectomy (odds ratio [OR]: 1.22, 95% confidence interval [CI]: 1.07-1.37 and OR 1.42, 95% CI 1.26-1.59, respectively). Competing risk regression showed diabetes was associated with increased risk of non-NSCLC death (DM-c hazard ratio [HR] 1.16, 95% CI: 1.08-1.25, DM + c HR 1.49, 95% CI: 1.40-1.59), but not NSCLC-specific death.

Conclusion

This study uncovers critical information on how diabetes is associated with less aggressive early-stage NSCLC care in older patients. This study also confirms that diabetes increases death from non-lung cancer causes and managing comorbidities is crucial to improving outcomes in older early-stage NSCLC survivors.

The quality of diabetes care among cancer survivors: a retrospective cohort study

BACKGROUND

As cancer survivorship continues to improve, management of co-morbid diabetes has become an increasingly important determinant of health outcomes for people with cancer. This study aimed to compare indicators of diabetes quality of care between people with diabetes and without a history of cancer.

METHODS

We used the Electronic Medical Record Administrative data Linked Database (EMRALD), a database of Ontario primary care EMR charts linked to administrative data, to identify people with diabetes and at least 1 year follow-up. Persons with a history of cancer were matched 1:2 on age, sex and diabetes duration to those without cancer. We compared recommended diabetes quality of care indicators between persons with and without cancer using a matched cohort analysis.

RESULTS

Among 229,627 people with diabetes, we identified 2275 people with cancer and 4550 matched controls; 86.5% had diabetes diagnosed after cancer. Compared to controls, cancer people with diabetes were significantly less likely to receive ACE inhibitors or angiotensin receptor blockers (OR 0.75 [95% CI 0.64-0.89]), receive statin therapy if age 50-80 years (OR 0.79 [95% CI 0.68-0.92]) and achieve an LDL cholesterol level <2.0 mmol/L (OR 0.82 [95% CI 0.74-0.91]). There were no differences in recommended clinical testing or achieving A1C and blood pressure targets between groups.

CONCLUSION

Cancer survivors with diabetes are less likely to receive recommended cardiovascular risk-reducing therapies compared to people with diabetes without cancer of similar age, sex and diabetes duration. Further studies are warranted to determine if these associations are linked to worse survival, cardiovascular outcomes and quality of life.

Determining the Impact of a Cancer Diagnosis on Diabetes Management: A Systematic Literature Review

OBJECTIVES

Cancer patients with comorbid diabetes have a 50% increased risk of all-cause mortality compared with cancer patients without diabetes. Less attention to diabetes management (glucose control, medication adherence, and diabetes self-management behaviors) during active cancer treatment is hypothesized as an explanation for worse outcomes among diabetic cancer patients. The objective of this systematic review is to determine and quantify how a cancer diagnosis impacts diabetes management.

METHODS

Quantitative and qualitative studies evaluating diabetes management among patients were identified by searching 4 databases: MEDLINE, EMBASE, The Cochrane Library, and Web of Science. Two independent reviewers extracted data and summarized results from eligible studies. Study quality was formally assessed.

RESULTS

Thirty-six studies met all inclusion criteria. We observed heterogeneity across studies in terms of study design, sample size, cancer site, type of diabetes management evaluated, and quality. Numerous articles discussed that overall, glucose control, medication adherence, and diabetes self-management behaviors declined following a cancer diagnosis. However, findings were inconsistent across studies.

CONCLUSIONS

Although the effects of a cancer diagnosis on diabetes management are mixed, when results across studies were synthesized together, diabetes management appeared to generally decline after a cancer diagnosis. Declines in diabetes management seem to be primarily due to shifts in the priority of care from diabetes management to cancer. A next critical step in this line of work is to identify patient and provider level predictors of better or worse diabetes management to design and test interventions aimed at improving effective diabetes management for cancer patients.

The Impact of Diabetes on Breast Cancer Treatments and Outcomes: A Population-Based Study

OBJECTIVE

Women with breast cancer and diabetes face worse outcomes than those with breast cancer without diabetes; however, the contribution of comorbidity to these disparities remains unclear. We evaluated the impact of diabetes on receipt of cancer treatments as well as mortality while accounting for other comorbidities.

RESEARCH DESIGN AND METHODS

Ontario administrative databases were used to compare the rate of receipt of breast cancer treatments between women with and without diabetes. We also performed adjusted cause-specific hazard models to account for comorbidities when evaluating differences in treatments received and mortality outcomes between the two groups.

RESULTS

Women with diabetes and stage III breast cancer were slightly less likely to receive chemotherapy (relative risk [RR] 0.93 [95% CI 0.89-0.97]), although this difference was not significant when we adjusted for comorbidities (adjusted hazard ratio [aHR] 1.03 [95% CI 0.93-1.13]). We saw similar trends for receipt of guideline-adherent radiotherapy (RR 0.97 [0.95-0.99], aHR 0.98 [0.94-1.02]). All-cause mortality was increased in women with diabetes after adjusting for comorbidities (aHR 1.16 [1.06-1.27]), but breast cancer-specific mortality was not increased overall. Women with a longer duration of diabetes and those with preexisting cardiovascular disease had increased all-cause and cancer-specific mortality.

CONCLUSIONS

Although cancer treatments received were similar between women with and without diabetes, breast cancer-specific mortality remains higher among women with diabetes who have longer diabetes duration or preexisting cardiovascular disease. This study uncovers new information about key risk factors for poorer prognosis in women with diabetes and breast cancer.

Low glycemic index diet, exercise and vitamin D to reduce breast cancer recurrence (DEDiCa): design of a clinical trial

BACKGROUND

Mechanisms influencing breast cancer (BC) development and recurrence include hyperglycemia, hyperinsulinemia, high insulin-like growth factor-1, high circulating estrogen, inflammation and impaired cellular differentiation/apoptosis. A lifestyle program that targets all the above mechanisms may be warranted. Low glycemic index (GI) foods produce lower post-prandial glucose and insulin responses and have been associated with lower BC risk. Moderate physical activity post-diagnosis reduces BC recurrence and mortality, partly explained by reduced insulin and estrogen levels. Vitamin D increases cell differentiation/apoptosis and high serum vitamin D levels improve BC survival. Yet no trial has evaluated the combined effect of a low GI diet, moderate physical activity and vitamin D supplementation on BC recurrence in the context of a Mediterranean lifestyle setting.

METHODS

Women (30-74 yr) who had undergone surgery for primary histologically confirmed BC (stages I-III) within the previous 12 months, in cancer centres in Italy, will be randomized to follow, for a maximum of 33 months, either a high intensity treatment (HIT) composed of low GI diet + exercise + vitamin D (60 ng/mL serum concentration) or a lower intensity treatment (LITE) with general advice to follow a healthy diet and exercise pattern + vitamin D to avoid insufficiency. Both interventions are on a background of a Mediterranean diet. Considering a 20% recurrence rate within 3 years for BC cases and a predicted rate of 10% in the HIT group, with power of 80% and two-sided alpha of 0.05, the subject number required will be 506 (n = 253 in each arm). Clinic visits will be scheduled every 3 months. Dietary and exercise counselling and vitamin D supplements will be given at each clinic visit when blood samples, anthropometric measures and 7-day food records will be collected.

DISCUSSION

DEDiCa study aims to reduce BC recurrence in women with BC using a lifestyle approach with additional vitamin D and to investigate possible cardio-metabolic benefits as well as epigenetic modifications according to lifestyle changes. Given the supporting evidence and safety of the components of our intervention we believe it is feasible and urgent to test it in cancer patients.

TRIAL REGISTRATION

May 11, 2016; NCT02786875 .

EUDRACT NUMBER

2015-005147-14.

Excess of health care use in general practice and of comorbid chronic conditions in cancer patients compared to controls

Background

The number of cancer patients and the number of patients surviving initial treatments is expected to rise. Traditionally, follow-up monitoring takes place in secondary care. The contribution of general practice is less visible and not clearly defined.

This study aimed to compare healthcare use in general practice of patients with cancer during the follow-up phase compared with patients without cancer. We also examined the influence of comorbid conditions on healthcare utilisation by these patients in general practice.

Methods

We compared health care use of N=8,703 cancer patients with an age and gender-matched control group of patients without cancer from the same practice. Data originate from the Netherlands Information Network of General Practice (LINH), a representative network consisting of 92 general practices with 350,000 enlisted patients. Health care utilisation was assessed using data on contacts with general practice, prescription and referral rates recorded between 1/1/2001 and 31/12/2007. The existence of additional comorbid chronic conditions (ICPC coded) was taken into account.

Results

Compared to matched controls, cancer patients had more contacts with their GP-practice (19.5 vs. 11.9, p<.01), more consultations with the GP (3.5 vs. 2.7, p<.01), more home visits (1.6 vs. 0.4, p<.01) and they got more medicines prescribed (18.7 vs. 11.6, p<.01) during the follow-up phase. Cancer patients more often had a chronic condition than their matched controls (52% vs. 44%, p<.01). Having a chronic condition increased health care use for both patients with and without cancer. Cancer patients with a comorbid condition had the highest health care use.

Conclusion

We found that cancer patients in the follow-up phase consulted general practice more often and suffered more often from comorbid chronic conditions, compared to patients without cancer. It is expected that the number of cancer patients will rise in the years to come and that primary health care professionals will be more involved in follow-up care. Care for comorbid chronic conditions, communication between specialists and GPs, and coordination of tasks then need special attention.