Diabetes mellitus and risk of gastric cancer: a systematic review and meta-analysis of observational studies

α‑Fetoprotein‑positive hepatoid adenocarcinoma of the stomach and a new classification: A case report

α-Fetoprotein (AFP)-producing gastric carcinoma (AFPGC) is a rare subtype of gastric cancer (GC) with controversial classification methods. Hepatoid adenocarcinoma of the stomach (HAS) is another rare subtype of GC. Its definition intersects with that of AFPGC, but it is much rarer. The present report describes the case of an elderly patient with GC and AFPGC and HAS features in a serum test and pathology, respectively, and proposes a new classification of GC subtypes based on histological and AFP-producing features. A 75-year-old woman presented with a history of polydipsia and polyuria for over a decade and dizziness for 1 day. Serum AFP levels gradually elevated from 183.70 to 397.70 ng/ml in 1 month after the patient's first clinic visit. Subsequent pathological findings from endoscopic biopsy samples confirmed a hepatoid focus with positive immunohistochemical staining for AFP. The patient underwent a laparoscopic-assisted radical total gastrectomy and esophagojejunal Roux-en-Y anastomosis, and the serum AFP levels decreased to the normal range after the surgery. The present case indicates the diagnostic value of both the serum AFP level and pathological examinations in the diagnosis of AFPGC and HAS, and also highlights the contemporary circumstances of the vague classification based on different criteria for these two subtypes. Furthermore, the present report proposes a new classification considering both histological and AFP-producing features (using both serum biomarkers and immunohistochemistry tests) to cover all cases encompassed by AFPGC and HAS under all definition methods. This new method would give more precise diagnoses and add value to the subsequent treatment decision-making.

Cumulative exposure to impaired fasting glucose and gastrointestinal cancer risk: A nationwide cohort study

BACKGROUND

Impaired fasting glucose (IFG) is associated with the risk of various cancers, but the cumulative effect of IFG on gastrointestinal cancer risk remains unclear. This study evaluated the association between the cumulative exposure to IFG and gastrointestinal cancer risk.

METHODS

The authors extracted data from the Korean National Health Insurance Service and health examination data sets. Among individuals ≥40 years old who were free of diabetes or cancer, 1,430,054 who underwent national health examinations over 4 consecutive years from 2009 to 2012 were selected and followed up until gastrointestinal cancer diagnosis, death, or December 31, 2019. The IFG exposure score (range, 0-4) was based on the number of IFG diagnoses over 4 years.

RESULTS

The median follow-up duration was 6.4 years. Consistent normoglycemia for 4 years was found in 44.3% of the population, whereas 5.0% had persistent IFG and 50.7% had intermittent IFG. Compared to the group with an IFG exposure score of 0, groups with IFG exposure scores of 1, 2, 3, and 4 had a 5%, 8%, 9%, and 12% increased risk of gastrointestinal cancer, respectively (score 1: adjusted hazard ratio [aHR], 1.05; 95% confidence interval [CI], 1.01-1.08; score 2: aHR, 1.08; 95% CI, 1.04-1.12; score 3: aHR, 1.09; 95% CI, 1.05-1.14; score 4: aHR, 1.12; 95% CI, 1.06-1.19). Persistent IFG exposure was also associated with higher risks of individual cancer types (colorectum, stomach, pancreas, biliary tract, and esophagus).

CONCLUSIONS

Cumulative exposure to IFG is associated with an increased risk of developing gastrointestinal cancer, in a dose-dependent manner.

PLAIN LANGUAGE SUMMARY

Hyperglycemia, including both diabetes and prediabetes, has been associated with an increased risk of various cancers. However, the cumulative effect of impaired fasting glucose on the risk of developing gastrointestinal cancer remains unclear. A frequent diagnosis of impaired fasting glucose was dose-dependently associated with a higher risk of developing overall gastrointestinal cancer. Furthermore, risks of individual cancer types increased with persistent impaired fasting glucose. Early detection of hyperglycemia and strict glycemic control can lower the risk of gastrointestinal cancer by reducing hyperglycemic burden. Additionally, for some individuals, lifestyle changes such as managing metabolic syndrome or abstaining from alcohol may also be helpful.

Association between diabetes and cancer. Current mechanistic insights into the association and future challenges

Compelling pieces of epidemiological, clinical, and experimental research have demonstrated that Diabetes mellitus (DM) is a major risk factor associated with increased cancer incidence and mortality in many human neoplasms. In the pathophysiology context of DM, many of the main classical actors are relevant elements that can fuel the different steps of the carcinogenesis process. Hyperglycemia, hyperinsulinemia, metabolic inflammation, and dyslipidemia are among the classic contributors to this association. Furthermore, new emerging actors have received particular attention in the last few years, and compelling data support that the microbiome, the epigenetic changes, the reticulum endoplasmic stress, and the increased glycolytic influx also play important roles in promoting the development of many cancer types. The arsenal of glucose-lowering therapeutic agents used for treating diabetes is wide and diverse, and a growing body of data raised during the last two decades has tried to clarify the contribution of therapeutic agents to this association. However, this research area remains controversial, because some anti-diabetic drugs are now considered as either promotors or protecting elements. In the present review, we intend to highlight the compelling epidemiological shreds of evidence that support this association, as well as the mechanistic contributions of many of these potential pathological mechanisms, some controversial points as well as future challenges.

Body mass index and esophageal and gastric cancer: A pooled analysis of 10 population-based cohort studies in Japan

The effect of body mass index (BMI) on esophageal and gastric carcinogenesis might be heterogeneous, depending on subtype or subsite. However, findings from prospective evaluations of BMI associated with these cancers among Asian populations have been inconsistent and limited, especially for esophageal adenocarcinoma and gastric cardia cancer. We performed a pooled analysis of 10 population-based cohort studies to examine this association in 394,247 Japanese individuals. We used Cox proportional hazards regression to estimate study-specific hazard ratios (HRs) and 95% confidence intervals (CIs), then pooled these estimates to calculate summary HRs with a random effects model. During 5,750,107 person-years of follow-up, 1569 esophageal cancer (1038 squamous cell carcinoma and 86 adenocarcinoma) and 11,095 gastric (728 cardia and 5620 noncardia) cancer incident cases were identified. An inverse association was observed between BMI and esophageal squamous cell carcinoma (HR per 5-kg/m2 increase 0.57, 95% CI 0.50-0.65), whereas a positive association was seen in gastric cardia cancer (HR 1.15, 95% CI 1.00-1.32). A nonsignificant and significant positive association for overweight or obese (BMI ≥25 kg/m2 ) relative to BMI <25 kg/m2 was observed with esophageal adenocarcinoma (HR 1.32, 95% CI 0.80-2.17) and gastric cardia cancer (HR 1.24, 95% CI 1.05-1.46), respectively. No clear association with BMI was found for gastric noncardia cancer. This prospective study-the largest in an Asian country-provides a comprehensive quantitative estimate of the association of BMI with upper gastrointestinal cancer and confirms the subtype- or subsite-specific carcinogenic impact of BMI in a Japanese population.

Diabetes Mellitus as Cancer Risk: A 14-year, Cross-Sectional Analysis

Diabetes mellitus is widely thought to be a risk factors of cancers, but evidence of the association remains inconclusive, especially in Asian countries where few relevant studies have been conducted. Our study aimed to estimate overall and specific types of cancer risks among diabetes patients in Southern Thailand. Patients diagnosed with diabetes who visited the outpatient clinic of Songklanagarind Hospital during 2004 to 2018 were included. Newly diagnosed cancer patients were identified using the hospital-based cancer registry. Age-standardized incidence ratios (ASRs) and standardized incidence ratios (SIRs) were used to estimate and compare the cancer risks among diabetes patients and the general population in Southern Thailand. Of 29,314 diabetes patients identified during the study period, 1,113 patients had developed cancer. An increased risk for overall cancer was observed in both genders, with SIRs [95% CI] of 2.99 [2.65, 3.39] in men and 3.51 [3.12, 3.96] in women. Increases in the risk of several site-specific cancers including liver cancer, non-melanoma skin cancer, colon cancer and lung cancer in both sexes; prostate cancer, lymphoid leukemia, and multiple myeloma in men; and endometrial, breast, and thyroid cancer in women were observed. Our study found that diabetes generally increased the risk of both overall and site-specific cancers.

Epidemiology of Gastric Intestinal Metaplasia and Gastric Cancer

Gastric cancer remains one of the most common cancers globally. The pathogenesis of intestinal-type gastric cancer involves pre-malignant stages, including gastric intestinal metaplasia (GIM), the replacement of native gastric foveolar and/or glandular epithelium by intestinal-type epithelium. GIM prevalence is highly variable based on geography and race/ethnicity partly due to the varying prevalence of H. pylori, a potent risk factor. However, gastric cancer incidence does not mirror that of H. pylori, demonstrating a complex interaction between H. pylori and risk factors. We will discuss the epidemiology of GIM and gastric cancer, including incidence trends, risk factors, and implications for future management.

Oxidatively Damaged Nucleic Acid: Linking Diabetes and Cancer

Significance: Our current knowledge of the mechanism between diabetes and cancer is limited. Oxidatively damaged nucleic acid is considered a critical factor to explore the connections between these two diseases. Recent Advances: The link between diabetes mellitus and cancer has attracted increasing attention in recent years. Emerging evidence supports that oxidatively damaged nucleic acid caused by an imbalance between reactive oxygen species generation and elimination is a bridge connecting diabetes and cancer. 8-Oxo-7,8-dihydro-2'-deoxyguanosine and 8-oxo-7,8-dihydroguanosine assume important roles as biomarkers in assessing the relationship between oxidatively damaged nucleic acid and cancer. Critical Issues: The consequences of diabetes are extensive and may lead to the occurrence of cancer by influencing a combination of factors. At present, there is no direct evidence that diabetes causes cancer by affecting a single factor. Furthermore, the difficulty in controlling variables and differences in detection methods lead to poor reliability and repeatability of results, and there are no clear cutoff values for biomarkers to indicate cancer risk. Future Directions: A better understanding of connections as well as mechanisms between diabetes and cancer is still needed. Both diabetes and cancer are currently intractable diseases. Further exploration of the specific mechanism of oxidatively damaged nucleic acid in the connection between diabetes and cancer is urgently needed. In the future, it is necessary to further take oxidatively damaged nucleic acid as an entry point to provide new ideas for the diagnosis and treatment of diabetes and cancer. Experimental drugs targeting the repair process of oxidatively generated damage require an extensive preclinical evaluation and could ultimately provide new treatment strategies for these diseases. Antioxid. Redox Signal. 37, 1153-1167.

Systematic Review of the Role of Alpha-Protein Kinase 1 in Cancer and Cancer-Related Inflammatory Diseases

Simple Summary

Aside from the basic phosphorylation function of alpha-kinase 1 (ALPK1), little is known about its major functions. Researchers have used various forms of biotechnology and human, animal, and cellular models to better understand the relationship of ALPK1 with cancer and cancer-related inflammatory diseases. ALPK1 is involved in the progression of breast, lung, colorectal, oral, and skin cancer as well as lymphoblastic leukemia. ALPK1 has also been implicated in gout, diabetes, and chronic kidney disease, which are thought to be associated with breast, lung, colorectal, urinary tract, pancreatic, and endometrial cancers and lymphoblastic leukemia. ALPK1 upregulates inflammatory cytokines and chemokines during carcinogenesis. The major cytokine involved in carcinogenesis is TNF-α, which activates the NF-κB pathway, and similar inflammatory responses exist in gout, diabetes, and chronic kidney disease. ALPK1 regulates downstream inflammatory mechanisms that lead to cancer development through certain pathways and plays a key role in cancer initiation and metastasis.

Abstract

Background: Deregulation of conventional protein kinases is associated with the growth and development of cancer cells. Alpha-kinase 1 (ALPK1) belongs to a newly discovered family of serine/threonine protein kinases with no sequence homology to conventional protein kinases, and its function in cancer is poorly understood. Methods: In this systematic review, we searched for and analyzed studies linking ALPK1 to cancer development and progression. Results: Based on the current evidence obtained using human, animal, cellular, and tissue models, ALPK1 is located upstream and triggers cancer cell development and metastasis by regulating the inflammatory response through phosphorylation. Its mRNA and protein levels were found to correlate with advanced tumor size and lymph node metastasis, which occur from the cellular cytoplasm into the nucleus. ALPK1 is also strongly associated with gout, chronic kidney disease, and diabetes, which are considered as inflammatory diseases and associated with cancer. Conclusion: ALPK1 is an oncogene involved in carcinogenesis. Chronic inflammation is the common regulatory mechanism between cancer and these diseases. Future research should focus on identifying inhibitors of serine/threonine and ALPK1 at their phosphorylation sites, which would block various signal transductions and potentially offer kinase-targeted therapeutic agents for patients with cancer and inflammatory diseases.

Relationship between diabetes and risk of gastric cancer: A systematic review and meta-analysis of cohort studies

Patients with diabetes mellitus (DM) are at increased risk of developing several cancers; however, there is a lack of consensus on the relationship between gastric cancer (GC) and DM. This study aimed to explore the association between GC and DM based on the type and duration of DM. We searched nine databases from inception to December 1, 2021, and 40 cohort studies that evaluated the relationship between DM and the incidence of GC were included in this review. The summary relative ratios for the relationship of GC incidence with type 1 DM (T1DM) and type 2 DM (T2DM) were estimated using the fixed-effect and random-effect models, respectively. The risk of GC was 46% and 14% higher in individuals with T1DM and T2DM, respectively, than in those without diabetes. The risk of GC development in patients with diabetes showed a U-shape curve of change with DM duration. Our meta-analysis suggested that both T1DM and T2DM present a higher risk of GC development. The risk of GC may be influenced by the different time windows following the onset of diabetes. Future studies are required to explore the mechanism by which the duration of DM, antidiabetic medication use, and sex affect this association.

The association between diabetes and gastric cancer: results from the Stomach Cancer Pooling Project Consortium

BACKGROUND

Prior epidemiologic studies on the association between diabetes and gastric cancer risk provided inconclusive findings, while traditional, aggregate data meta-analyses were characterized by high between-study heterogeneity.

OBJECTIVE

To investigate the association between type 2 diabetes and gastric cancer using data from the 'Stomach Cancer Pooling (StoP) Project', an international consortium of more than 30 case-control and nested case-control studies, which is large and provides harmonized definition of participants' characteristics across individual studies. The data have the potential to minimize between-study heterogeneity and provide greater statistical power for subgroup analysis.

METHODS

We included 5592 gastric cancer cases and 12 477 controls from 14 studies from Europe, Asia, North America, and South America in a two-stage individual-participant data meta-analysis. Random-effect models were used to estimate summary odds ratios (ORs) and their corresponding 95% confidence intervals (CIs) by pooling study-specific ORs.

RESULTS

We did not find an overall association between diabetes and gastric cancer (pooled OR = 1.01, 95% CI, 0.94-1.07). However, the risk of cardia gastric cancer was significantly higher among individuals with type 2 diabetes (OR = 1.16, 95% CI, 1.02-1.33). There was no association between diabetes and gastric cancer risk in strata of Helicobacter pylori infection serostatus, age, sex, BMI, smoking status, alcohol consumption, fruit/vegetable intake, gastric cancer histologic type, and source of controls.

CONCLUSION

This study provides additional evidence that diabetes is unrelated to gastric cancer overall but may be associated with excess cardia gastric cancer risk.

Haemoglobin A1c and serum glucose levels and risk of gastric cancer: a systematic review and meta-analysis

Background

This systematic review and meta-analysis examined associations between serum levels of haemoglobin A1c (HbA1c) and glucose and the risk of gastric cancer.

Methods

MEDLINE, Embase, and Cochrane Library were searched for studies examining associations between serum levels of HbA1c or glucose and the risk of gastric cancer. Inclusion of studies, quality assessment, and data extraction were conducted independently by two authors. Pooled hazard ratios (HR) with 95% confidence intervals (CI) were synthesised using random-effects models. Cochran’s Q test and I² statistic were used to assess heterogeneity.

Results

Among 3473 identified studies, 12 were included. Of these, 5 studies examined HbA1c levels and 7 studies examined serum glucose levels. Serum HbA1c levels >6% were associated with an increased risk of gastric cancer (HR 1.36, 95% CI 1.06–1.74). When compared with the lowest glucose categories, the highest glucose categories were associated with a borderline increased risk of gastric cancer (HR 1.11, 95% CI 0.98–1.26). In subgroup analyses, studies that adjusted for Helicobacter pylori infection indicated stronger associations between elevated HbA1c levels and gastric cancer (HR 2.08, 95% CI 1.46–2.98) than those without such adjustment (HR 1.10, 95% CI 0.91–1.32).

Conclusions

Long-standing poor glycaemic control may increase the risk of gastric cancer.

Registration number

PROSPERO CRD42020157453.

Diabetes mellitus contribution to the remodeling of the tumor microenvironment in gastric cancer

Compelling pieces of evidence derived from both clinical and experimental research has demonstrated the crucial contribution of diabetes mellitus (DM) as a risk factor associated with increased cancer incidence and mortality in many human neoplasms, including gastric cancer (GC). DM is considered a systemic inflammatory disease and therefore, this inflammatory status may have profound effects on the tumor microenvironment (TME), particularly by driving many molecular mechanisms to generate a more aggressive TME. DM is an active driver in the modification of the behavior of many cell components of the TME as well as altering the mechanical properties of the extracellular matrix (ECM), leading to an increased ECM stiffening. Additionally, DM can alter many cellular signaling mechanisms and thus favoring tumor growth, invasion, and metastatic potential, as well as key elements in regulating cellular functions and cross-talks, such as the microRNAs network, the production, and cargo of exosomes, the metabolism of cell stroma and resistance to hypoxia. In the present review, we intend to highlight the mechanistic contributions of DM to the remodeling of TME in GC.

Association of Diabetes Mellitus and Alcohol Abuse with Cancer: Molecular Mechanisms and Clinical Significance

Diabetes mellitus (DM), one of the metabolic diseases which is characterized by sustained hyperglycemia, is a life-threatening disease. The global prevalence of DM is on the rise, mainly in low- and middle-income countries. Diabetes is a major cause of blindness, heart attacks, kidney failure, stroke, and lower limb amputation. Type 2 diabetes mellitus (T2DM) is a form of diabetes that is characterized by high blood sugar and insulin resistance. T2DM can be prevented or delayed by a healthy diet, regular physical activity, maintaining normal body weight, and avoiding alcohol and tobacco use. Ethanol and its metabolites can cause differentiation defects in stem cells and promote inflammatory injury and carcinogenesis in several tissues. Recent studies have suggested that diabetes can be treated, and its consequences can be avoided or delayed with proper management. DM has a greater risk for several cancers, such as breast, colorectal, endometrial, pancreatic, gallbladder, renal, and liver cancer. The incidence of cancer is significantly higher in patients with DM than in those without DM. In addition to DM, alcohol abuse is also a risk factor for many cancers. We present a review of the recent studies investigating the association of both DM and alcohol abuse with cancer incidence.

Insulin Resistance and Cancer: In Search for a Causal Link

Insulin resistance (IR) is a condition which refers to individuals whose cells and tissues become insensitive to the peptide hormone, insulin. Over the recent years, a wealth of data has made it clear that a synergistic relationship exists between IR, type 2 diabetes mellitus, and cancer. Although the underlying mechanism(s) for this association remain unclear, it is well established that hyperinsulinemia, a hallmark of IR, may play a role in tumorigenesis. On the other hand, IR is strongly associated with visceral adiposity dysfunction and systemic inflammation, two conditions which favor the establishment of a pro-tumorigenic environment. Similarly, epigenetic modifications, such as DNA methylation, histone modifications, and non-coding RNA, in IR states, have been often associated with tumorigenesis in numerous types of human cancer. In addition to these observations, it is also broadly accepted that gut microbiota may play an intriguing role in the development of IR-related diseases, including type 2 diabetes and cancer, whereas potential chemopreventive properties have been attributed to some of the most commonly used antidiabetic medications. Herein we provide a concise overview of the most recent literature in this field and discuss how different but interrelated molecular pathways may impact on tumor development.

The Relationship between Diabetes Mellitus and Gastric Cancer and the Potential Benefits of Metformin: An Extensive Review of the Literature

The objective of this review is to summarize the findings of published research that investigated the relationship between diabetes mellitus and gastric cancer (GCa) and the potential benefits of metformin on GCa. Related literature has been extensively reviewed, and findings from studies investigating the relationship between diabetes mellitus and GCa suggest that hyperglycemia, hyperinsulinemia and insulin resistance are closely related to the development of GCa. Although not supported by all, most observational studies suggest an increased risk of GCa in patients with type 2 diabetes mellitus, especially in women and in Asian populations. Incidence of second primary malignancy diagnosed after GCa is significantly higher in diabetes patients. Diabetes patients with GCa may have more complications after gastrectomy or chemotherapy and they may have a poorer prognosis than patients with GCa but without diabetes mellitus. However, glycemic control may improve in the diabetes patients with GCa after receiving gastrectomy, especially after procedures that bypass the duodenum and proximal jejunum, such as Roux-en-Y gastric bypass or Billroth II reconstruction. The potential links between diabetes mellitus and GCa may involve the interactions with shared risk factors (e.g., obesity, hyperglycemia, hyperinsulinemia, insulin resistance, high salt intake, smoking, etc.), Helicobacter pylori (HP) infection, medications (e.g., insulin, metformin, statins, aspirin, proton pump inhibitors, antibiotics, etc.) and comorbidities (e.g., hypertension, dyslipidemia, vascular complications, heart failure, renal failure, etc.). With regards to the potential benefits of metformin on GCa, results of most observational studies suggest a reduced risk of GCa associated with metformin use in patients with T2DM, which can be supported by evidence derived from many in vitro and animal studies. Metformin use may also reduce the risk of HP infection, an important risk factor of GCa. In patients with GCa, metformin users may have improved survival and reduced recurrence. More studies are required to clarify the pathological subtypes/anatomical sites of GCa associated with type 2 diabetes mellitus or prevented by metformin, to confirm whether GCa risk can also be increased in patients with type 1 diabetes mellitus and to explore the possible role of gastric microbiota in the development of GCa.

Chemopreventive Effect of Metformin on Gastric Cancer Development

Although Helicobacterpylori infection is the most important causative factor for gastric cancer (GC), H. pylori eradication alone does not completely eliminate the GC risk. In addition to H. pylori eradication, other risk factors for GC should be identified and targeted. Diabetes mellitus (DM) confers a 20% increased risk of GC, which could be mediated via several biological mechanisms including the stimulation of cell proliferation via hyperinsulinemia and increased insulin-growth factor production, the promotion of angiogenesis, and DNA damage. With a current global prevalence of 9.3% and a predicted rise to 10.2% by 2030, DM could contribute substantially to the burden of GC cases worldwide. Emerging evidence showed that metformin possesses chemopreventive effects via both direct (e.g., adenosine monophosphate-activated protein kinase activation and subsequent inhibition of the mammalian target of rapamycin pathway) and indirect (e.g., modulation of the interaction between tumor cells and their microenvironment and gut microbiota) pathways. A recent meta-analysis of observational studies showed that metformin use was associated with 24% lower GC risk. However, many available observational studies related to metformin effects suffered from biases including the failure to adjust for the H. pylori infection status and serial glycemic control and time-related biases. Future prospective studies addressing these pitfalls are needed.

Beneficial effects of proximal intestinal bypass reconstruction on glucose metabolism in a type 2 diabetes animal model: a possible reconstruction strategy for diabetic gastric cancer patients

Purpose

Proximal intestinal bypass (PIB), such as Billroth II or Roux-en-Y gastrojejunostomy after curative distal gastrectomy for gastric cancer induces beneficial effects on glycemic control in patients with type 2 diabetes. We aimed to characterize the long-term evolution of pancreatic beta cells and insulin signaling in target tissue after a PIB procedure.

Methods

Zucker diabetic fatty rats were randomly assigned to the PIB, sham-operated PIB pair-fed, and ad libitum fed groups. Oral glucose tolerance (GT) and plasma insulin levels were measured periodically at 16 weeks postoperatively. Histomorphometric analyses were performed to evaluate changes in islet architectures and intranuclear pancreatic duodenal homeobox 1 (PDX1) expression in beta cells. Insulin signaling changes in visceral adipocytes were measured by the phosphorylated Akt/Akt ratio.

Results

Contrary to the progressively deteriorating GT and plasma insulin levels in sham-operated animals, these were preserved in PIB animals (P < 0.01) at 16 weeks postoperatively. The proportion of the islets having asteroid-like expanding projection was higher in PIB animals than in sham-operated animals (P < 0.01). PIB animals had 3-fold wider fractional area of beta cells (P < 0.01) and 3-fold higher proportion of beta-cell nuclear PDX1 expression (P < 0.01) than sham-operated animals. PIB animals had significantly higher levels of Akt phosphorylation in the visceral adipocytes (P < 0.05). The PIB did not substantially affect weight and food intake postoperatively.

Conclusion

The PIB preserved the plasma insulin levels and the wider beta-cell area over time and facilitated insulin signaling in the visceral fats. It could be considered as a possible reconstruction strategy for diabetic gastric cancer patients.

Proteomics Analysis of Gastric Cancer Patients with Diabetes Mellitus

Proteomics is a powerful approach to study the molecular mechanisms of cancer. In this study, we aim to characterize the proteomic profile of gastric cancer (GC) in patients with diabetes mellitus (DM) type 2. Forty GC tissue samples including 19 cases from diabetic patients and 21 cases from individuals without diabetes (control group) were selected for the proteomics analysis. Gastric tissues were processed following the single-pot, solid-phase-enhanced sample preparation approach-SP3 and enzymatic digestion with trypsin. The resulting peptides were analyzed by LC-MS Liquid Chromatography-Mass Spectrometry (LC-MS). The comparison of protein expression levels between GC samples from diabetic and non-diabetic patients was performed by label-free quantification (LFQ). A total of 6599 protein groups were identified in the 40 samples. Thirty-seven proteins were differentially expressed among the two groups, with 16 upregulated and 21 downregulated in the diabetic cohort. Statistical overrepresentation tests were considered for different annotation sets including the Gene Ontology(GO), Kyoto Encyclopedia of Genes and Genomes (KEGG), Reactome, and Disease functional databases. Upregulated proteins in the GC samples from diabetic patients were particularly enriched in respiratory electron transport and alcohol metabolic biological processes, while downregulated proteins were associated with epithelial cancers, intestinal diseases, and cell-cell junction cellular components. Taken together, these results support the data already obtained by previous studies that associate diabetes with metabolic disorders and diabetes-associated diseases, such as Alzheimer's and Parkinson's, and also provide valuable insights into seven GC-associated protein targets, claudin-3, polymeric immunoglobulin receptor protein, cadherin-17, villin-1, transglutaminase-2, desmoglein-2, and mucin-13, which warrant further investigation.

Impact of diabetes on prognosis of gastric cancer patients performed with gastrectomy

OBJECTIVE

This study aimed to determine the impact of type 2 diabetes mellitus (T2DM) on clinical outcomes of gastric cancer (GC) patients and explore whether metformin use and good glycemic control could reverse it.

METHODS

Clinicopathologic data of consecutive GC patients who underwent gastrectomy at Nanfang Hospital between October 2004 and December 2015 were included. Propensity score matching (PSM) was performed to balance the important factors of the disease status between non-T2DM and T2DM group. The last follow-up time was January 2019.

RESULTS

A total of 1,692 eligible patients (1,621 non-T2DM vs. 71 T2DM) were included. After PSM, non-T2DM group (n=139) and T2DM group (n=71) were more balanced in baseline variables. The 5-year cancer-specific survival (CSS) rate in T2DM group (47.0%) was inferior to that in non-T2DM group (58.0%), but did not reach statistical significance [hazard ratio (HR)=1.319, 95% confidence interval (95% CI): 0.868-2.005, P=0.192]. While the 5-year progress-free survival (PFS) rate of T2DM group (40.6%) is significantly worse than that in non-T2DM group (56.3%) (HR=1.516, 95% CI: 1.004-2.290, P=0.045). Univariate and multivariate analyses showed that T2DM was an independent risk factor for PFS but not for CSS. In T2DM group, metformin use subgroup was associated with superior 5-year CSS and PFS in compared with non-metformin use subgroup, although the difference was not statistically significant (5-year CSS: 48.0%vs. 45.4%, HR=0.680, 95% CI: 0.352-1.313, P=0.246; 5-year PFS: 43.5%vs. 35.7%, HR=0.763, 95% CI: 0.400-1.454, P=0.406). The 5-year CSS rate was 47.5% in good glycemic control subgroup and 44.1% in poor glycemic control subgroup (HR=0.826, 95% CI: 0.398-1.713, P=0.605). And both two subgroups yielded a similar 5-year PFS rate (42.2%vs. 36.3%, HR=0.908, 95% CI: 0.441-1.871, P=0.792).

CONCLUSIONS

DM promoted disease progress of GC after gastrectomy but had not yet led to the significant discrepancy of CSS. For GC patients with T2DM, metformin use was associated with superior survival but without statistical significance, while better glycemic control could not improve the prognosis.

Evaluating the effect of diabetes on the prognosis of gastric cancer using a propensity score matching method

Background

Gastric cancer (GC) is one of the malignant tumors with high incidence in China. At present, the relationship between type 2 diabetes (T2DM) and the therapeutic effect of various malignant tumors has attracted more and more attention. This study aimed to investigate whether T2DM is a prognostic factor for patients with GC.

Methods

Patients who had GC and who were admitted to our hospital from November 2008 to December 2015 were included in the study. Among these patients, 84 patients GC complicated with T2DM (GC + T2DM) were enrolled in the observation group, and 215 patients with normal blood glucose were enrolled in the control group. Patients' general information was collected by referring to their electronic and paper medical records, and their living status was followed up by conducting a telephone survey, referring to their hospitalization record, and performing an outpatient review. A propensity score matching method was used to select a 1:1 matched control for each patient with GC and diabetes. An overall survival curve was established using the Kaplan-Meier method. The survival rate was compared via a log-rank test. A Cox proportional hazards regression model was used to the analyse single and multiple factors affecting patient outcomes.

Results

Before matching was conducted, the differences in gender, stage, treatment, and comorbidity were found to be statistically significant (P>0.05). After matching was completed, the clinical data and pathological differences between the two groups were not statistically significant (P<0.05). A histogram matching the pre- and post-propensity scores showed that the matching was successful. The results of the Cox regression model revealed that grouping, pathological type, and treatment were the independent risk factors of the survival of patients with GC. Survival analysis found that the 3-year, 5-year, and overall survival rates of the observation group were significantly lower than those of the control group (P<0.05).

Conclusions

T2DM plays an important role in the development of GC, and is a prognostic factor among patients with GC.

Association of Aspirin, Metformin, and Statin Use with Gastric Cancer Incidence and Mortality: A Nationwide Cohort Study

Anticancer effects of aspirin, metformin, and statins against gastric cancer, one of the most common cancers in the world, have been reported. This retrospective cohort study aimed to investigate independent associations of aspirin, metformin, and statin use with gastric cancer incidence and mortality after adjustment for concomitant use of other drugs, using pooled cohort data extracted from the Korean National Health Insurance claim database. Follow-up started on January 1, 2004 and ended at the date of gastric cancer diagnosis, death, or December 31, 2013. Exposures to drugs were defined as cumulative duration of use for aspirin and cumulative defined daily dose for metformin and statin, and were entered as time-dependent variables in Cox analysis models to avoid immortal time bias. Use of aspirin for longer than 182.5 and 547.5 days during 2-year interval was associated with reduced risks of gastric cancer incidence and mortality, respectively. Patients with diabetes were at higher risk of gastric cancer incidence and mortality than nondiabetic people, regardless of metformin treatment. However, metformin use among patients with diabetes was associated with a reduction in gastric cancer mortality in a dose-response manner. Statin use was also associated with a reduction of gastric cancer mortality in the general population, but not with gastric cancer incidence. In conclusion, long-term use of aspirin was independently associated with reduced incidence and mortality of gastric cancer in the general population, but metformin or statin use was only associated with a reduction of gastric cancer mortality in patients with diabetes and in the general population, respectively. PREVENTION RELEVANCE: Long-term use of aspirin was independently associated with reduced incidence and mortality of gastric cancer in the general population. Metformin or statin use, however, was only associated with a reduction of gastric cancer mortality in diabetic patients and in the general population in a dose-response manner, respectively.

Effect of diabetes mellitus on survival in patients with gallbladder Cancer: a systematic review and meta-analysis

Background

Increasing evidences indicated that diabetes might increase the incidence of gallbladder cancer. However, no sufficient data has ever clarified the impact of diabetes on the survival of patients with gallbladder cancer.

Methods

We comprehensively searched PubMed, Embase, and the Cochrane Library databases through July 2019 in order to find sufficient eligible researches. The pooled hazard risks (HRs) and relative risks (RRs) with 95% confidence intervals (CIs) were calculated with either fix-effects or random-effects model. Due to the low gallbladder cancer mortality in general population, the RRs and standard mortality ratios (SMRs) were considered the similar estimates of the HRs.

Results

Ten eligible studies were included in this meta-analysis. Analysis of eight cohorts found that diabetes was closely associated with the mortality of gallbladder cancer (HR = 1.10; 95% CI: 1.06–1.14; P < 0.00001). However, the mortality in male diabetes patients was not higher than female patients (RR = 1.08, 95%CI = 0.57–2.04, P = 0.80).

Conclusions

These findings indicated that diabetes patients had a higher mortality of gallbladder cancer compared with non-diabetes.

Impact of Metformin Use on Survival in Patients with Gastric Cancer and Diabetes Mellitus Following Gastrectomy

Studies have shown the anticancer effects of metformin in vitro. However, whether metformin can prevent cancer recurrence or prolong survival in patients with gastric cancer (GC) and diabetes mellitus (DM) post-gastrectomy remains unknown. We evaluated the beneficial effects of metformin in patients with GC and DM post-gastrectomy. We recruited 2400 patients with GC (1749 without DM, 651 with DM) who underwent surgery between 1997 and 2010. Patients with DM were stratified into metformin (group 1) and non-metformin (group 2) users. Their clinicopathological data were recorded prospectively, and demographics, recurrence-free survival (RFS), and cancer-specific survival (CSS) were compared. Tumour recurrence risk and cause of death were analysed between groups 1 and 2 among patients with DM stratified by tumour stage. We also compared RFS and overall survival among patients with and without DM. Tumour recurrence occurred in 201 patients with GC: 57 (25%) in group 1 and 144 (37%) in group 2. After adjusting for confounders, metformin significantly prolonged CSS (hazard ratio (HR) = 0.54, 95% confidence interval (CI) = 0.38-0.77) in patients with stage I-III GC and DM. In subgroup analysis, metformin users with stage III GC and DM had significantly prolonged CSS compared to non-metformin users (HR = 0.45, 95% CI = 0.30-0.68), with an insignificant difference in patients with stage I-II GC. Adjusted HRs for RFS and CSS were significantly lower in patients with stage I-III GC and DM than those in patients without DM (0.67 (95% CI = 0.54-0.92) and 0.62 (95% CI = 0.50-0.77), respectively), with an insignificant difference in patients with stage I GC. Metformin significantly reduces tumour recurrence risk and improves CSS in patients with stage III GC and DM post-gastrectomy. Further prospective studies may confirm the efficacy of metformin as an adjunctive treatment for advanced GC postoperatively.

Guidelines for endoscopic diagnosis of early gastric cancer

The Japan Gastroenterological Endoscopy Society developed the Guideline for Endoscopic Diagnosis of Early Gastric Cancer based on scientific methods. Endoscopy for the diagnosis of early gastric cancer has been acknowledged as a useful and highly precise examination, and its use has become increasingly more common in recent years. However, the level of evidence in this field is low, and it is often necessary to determine recommendations based on expert consensus only. This clinical practice guideline consists of the following sections to provide the current guideline: [I] Risk stratification of gastric cancer before endoscopic examination, [II] Detection of early gastric cancer, [III] Qualitative diagnosis of early gastric cancer, [IV] Diagnosis to choose the therapeutic strategy for gastric cancer, [V] Risk stratification after endoscopic examination, and [VI] Surveillance of early gastric cancer.

Diabetes, Glycated Hemoglobin, and Risk of Cancer in the UK Biobank Study

BACKGROUND

Evidence suggest that diabetes and glycated hemoglobin (HbA1c) levels are associated with cancer risk. However, previous studies have been limited variably by failure to adjust for cancer-specific risk factors (e.g., body mass index), inattention to diabetes duration and use of antidiabetic medications, and failure to stratify by obesity.

METHODS

We examined the association between diabetes, HbA1c, and cancer risk in the UK Biobank, using data from 476,517 participants (54% women), followed for an average period of 7.1 years. Diabetes was defined on the basis of baseline self-reported diagnosis of diabetes and/or use of diabetes medication, while HbA1c measured at baseline was categorized as low (<31 mmol/mol), normal (31-<39 mmol/mol), increased risk (39-<48 mmol/mol), and high risk for diabetes (≥48 mmol/mol). Multivariable Cox proportional hazards models were used to estimate the association of diabetes and cancer at different anatomical sites, with adjustment for cancer-specific risk factors.

RESULTS

Diabetes was associated with increased risk of cancers of the stomach, liver, bladder, endometrium, and lung among smokers, and with decreased risk of prostate cancer. Compared with the normal HbA1c category, the increased risk category was positively associated with risk of cancers of the colon, liver, bladder, and lung among smokers, and the high-risk category was associated with increased risk of cancers of the esophagus, liver, pancreas, and bladder, and with decreased risk of prostate cancer.

CONCLUSIONS

These results suggest that both diabetes and/or elevated HbA1c are associated with risk of cancer at several anatomic sites.

IMPACT

The associations of diabetes and HbA1c levels with cancer suggest their importance in cancer prevention.

The fasting blood glucose and long non-coding RNA SNHG8 predict poor prognosis in patients with gastric carcinoma after radical gastrectomy

This prospective study sought to evaluate the prediction of fasting blood glucose and long non-coding RNA (lncRNA) SNHG8 for the risk of gastric carcinoma mortality. A total of 217 gastric carcinoma patients underwent radical gastrectomy were included during 2012-16. The final follow-up was finished in January 2017. The aggregate hazard ratio(HR) demonstrated that poor prognosis of gastric carcinoma was associated with fasting blood glucose (HR= 1.29, P=0.037), SNHG8 expression(HR = 1.10, P= 0.009), positive distant metastasis(HR = 2.99, P= 0.020), EBV positive (HR = 3.40, P=0.002), and tumor size more than 5.0 cm (HR = 3.36, P= 0.005). In survival analysis, elevated fasting blood glucose (P =0.007) and high SNHG8 expression (P =0.007) were significantly associated with shorter survival times in gastric cancer. Significant multiplicative interaction was shown between fasting blood glucose and SNHG8 expression (chi-squared=7.81, P_{multiplicative} =0.005), without statistical additive interaction. Fasting blood glucose and SNHG8 expression could predict poor prognosis after radical gastrectomy. LncRNA SNHG8 could be applied as a novel epigenetic molecular target in gastric carcinoma.

Diabetes and cancer: A comprehensive review

Diabetes mellitus (DM) is a common worldwide endocrine disorder characterized by hyperglycemia resulting from defects in insulin secretion and insulin action or both. A number of clinical studies have investigated diabetes and its causal relation with neoplasm. Several epidemiological studies have found that diabetic patients have an increased risk of different types of cancers, for example liver, pancreas, gastric (stomach), colorectum, kidney, and breast, and it is predicted that hyperglycemic state observed in diabetic milieu enhances the cancer risk in prediabetic and diabetic individuals. To explore the strength of evidence and biases in the claimed associations between type 2 DM (T2DM) and risk of developing cancer, an umbrella review of the evidence across published meta-analyses or systematic reviews is performed. The concurrence of T2DM with the growing burden of cancer globally has generated interest in defining the epidemiological and biological relationships between these medical conditions. Through this review, it was found that diabetes could be related to cancer. Yet, the results from most of the studies are obscure and conflicting and need a robust research so that the link between diabetes and cancer could be firmly and impeccably documented.

British Society of Gastroenterology guidelines on the diagnosis and management of patients at risk of gastric adenocarcinoma

Gastric adenocarcinoma carries a poor prognosis, in part due to the late stage of diagnosis. Risk factors include Helicobacter pylori infection, family history of gastric cancer-in particular, hereditary diffuse gastric cancer and pernicious anaemia. The stages in the progression to cancer include chronic gastritis, gastric atrophy (GA), gastric intestinal metaplasia (GIM) and dysplasia. The key to early detection of cancer and improved survival is to non-invasively identify those at risk before endoscopy. However, although biomarkers may help in the detection of patients with chronic atrophic gastritis, there is insufficient evidence to support their use for population screening. High-quality endoscopy with full mucosal visualisation is an important part of improving early detection. Image-enhanced endoscopy combined with biopsy sampling for histopathology is the best approach to detect and accurately risk-stratify GA and GIM. Biopsies following the Sydney protocol from the antrum, incisura, lesser and greater curvature allow both diagnostic confirmation and risk stratification for progression to cancer. Ideally biopsies should be directed to areas of GA or GIM visualised by high-quality endoscopy. There is insufficient evidence to support screening in a low-risk population (undergoing routine diagnostic oesophagogastroduodenoscopy) such as the UK, but endoscopic surveillance every 3 years should be offered to patients with extensive GA or GIM. Endoscopic mucosal resection or endoscopic submucosal dissection of visible gastric dysplasia and early cancer has been shown to be efficacious with a high success rate and low rate of recurrence, providing that specific quality criteria are met.

Sex differences in the association between diabetes and risk of cardiovascular disease, cancer, and all-cause and cause-specific mortality: a systematic review and meta-analysis of 5,162,654 participants

BACKGROUND

Studies have suggested sex differences in the mortality rate associated with diabetes. We conducted a meta-analysis to estimate the relative effect of diabetes on the risk of all-cause, cancer, cardiovascular disease (CVD), infectious disease, and respiratory disease mortality in women compared with men.

METHODS

Studies published from their inception to April 1, 2018, identified through a systematic search of PubMed and EMBASE and review of references. We used the sex-specific RRs to derive the women-to-men ratio of RRs (RRR) and 95% CIs from each study. Subsequently, the RRR for each outcome was pooled with random-effects meta-analysis weighted by the inverse of the variances of the log RRRs.

RESULTS

Forty-nine studies with 86 prospective cohorts met the inclusion criteria and were eligible for analysis. The pooled women-to-men RRR showed a 13% greater risk of all-cause mortality associated with diabetes in women than in men (RRR 1.13, 95% CI 1.07 to 1.19; P < 0.001). The pooled multiple-adjusted RRR indicated a 30% significantly greater excess risk of CVD mortality in women with diabetes compared with men (RRR 1.30, 95% CI 1.13 to 1.49; P < 0.001). Compared with men with diabetes, women with diabetes had a 58% greater risk of coronary heart disease (CHD) mortality, but only an 8% greater risk of stroke mortality (RRR_CHD 1.58, 95% CI 1.32 to 1.90; P < 0.001; RRR_stroke 1.08, 95% CI 1.01 to 1.15; P < 0.001). However, no sex differences were observed in pooled results of populations with or without diabetes for all-cancer (RRR 1.02, 95% CI 0.98 to 1.06; P = 0.21), infectious (RRR 1.13, 95% CI 0.90 to 1.38; P = 0.33), and respiratory mortality (RRR 1.08, 95% CI 0.95 to 1.23; P = 0.26).

CONCLUSIONS

Compared with men with the same condition, women with diabetes have a 58% and 13% greater risk of CHD and all-cause mortality, respectively, although there was a significant heterogeneity between studies. This points to an urgent need to develop sex- and gender-specific risk assessment strategies and therapeutic interventions that target diabetes management in the context of CHD prevention.

Diabetes in the practice of otolaryngology

Diabetes mellitus is the most common endocrine disease, characterized by chronic hyperglycemia. The hyperglycemic milieu leads to endothelial injury in blood vessels of variant size, which results in microangiopathy and macroangiopathy (atherosclerosis). Consequential ischemia of nerves and hyperglycemia by itself lead to nerve degeneration and generalized neuropathy, affecting most often the sensory peripheral nerves and the autonomic nervous system. Auditory, vestibular and olfactory sensorium may be compromised by DM. People with DM have an increased susceptibility to infection, as a result of neutrophil dysfunction and impaired humoral immunity. Therefore DM predisposes to certain infectious diseases, such as fungal sinusitis or malignant otitis externa, which are rare in general population. Recovery from infections or from injuries may be compromised by coexisting DM. In this review we discuss complications of DM in the head and neck region. Otolaryngologists and general practitioners should be alert to specific conditions related to DM and be minded of the relevant complications and consequences.

Malignancy incidences by glycemic control among diabetic patients

BACKGROUND

The aim of this study was to evaluate the difference in malignancy incidence by evaluating time-dependent HbA1c levels among diabetic patients in a longitudinal study.

METHODS

We conducted a retrospective longitudinal study at large academic hospital, Tokyo, Japan, from 2006 to 2016. We included all diabetic patients who were 50 years or older and who underwent health check-ups at the Center for Preventive Medicine. Those patients with a prior history of malignancies were excluded. We categorized patients into five groups on the basis of HbA1c measurements: <5.4, 5.5-6.4, 6.5-7.4, 7.5-8.5, >8.5%. Our primary outcome was the development of any types of malignancy. Longitudinal analyses by a mixed effect model with time-dependent HbA1c levels were applied in order to take into account fluctuations in HbA1c levels within the same patient.

RESULTS

In total, 2729 participants were included in this study, where the mean age was 62.6 (standard deviation (s.d.): 7.8) and 2031 (74.4%) were male. The mean disease duration of diabetes was 7.6 (s.d.: 7.6) years, and 1688 (61.8%) were prescribed medications. Median follow-up was 1443.5 (interquartile range (IQR): 2508) days and 376 (13.8%) developed malignancies. Compared to the reference range of HbA1c (5.5-6.4%), the odds ratios for developing malignancies among the other HbA1c level groups were similar and not statistically different (OR: 0.98, 95% CI:0.31-3.15 (for HbA1c <5.4%); OR: 0.88, 95% CI: 0.69-1.12 (for HbA1c 6.5-7.4%); OR: 0.88, 95% CI: 0.64-1.22 (for HbA1c 7.5-8.4%); OR 1.07, 95% CI: 0.70-1.66 (for HbA1c >8.5%)).

CONCLUSION

In our study, there was no association between glycemic control and the development of future malignancies. Compared to very strictly controlled HbA1c levels, both excessive control and good or bad control had a statistically similar risk of developing malignancies.

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

AIMS/HYPOTHESIS

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

METHODS

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

RESULTS

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

CONCLUSIONS/INTERPRETATION

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

Epidemiological dimensions of the association between type 2 diabetes and cancer: A review of observational studies

Type 2 diabetes (T2D) is a major cause of complications and death in many countries. The possible causal relation between T2D and cancer has been the aim of many research investigations. In view of the importance of the topic we carried out a narrative review of observational studies to summarize the available evidence of the association between T2D and cancer. To deal with the problem of abundance of published studies, we reviewed up to December 2017, the literature of meta-analyses of observational studies first, then we reviewed cohort studies not reported in meta-analyses because of more recent publication. We found that the association of T2D with risk of colorectal cancer was robust, whereas the evidence of the associations with other cancer sites was lower. Some of the observed associations could be overestimated, due to publication bias, unmeasured confounders (such as obesity) and surveillance bias. In conclusion a probable causal association of T2D with risk of colorectal cancer was confirmed. A possible causal association with pancreatic, endometrial, hepatocellular and gallbladder carcinoma was also found. Substantial uncertainty exists for other cancer sites.

Metabolic Syndrome and the Risk of Gastrointestinal Cancer: a Case-Control Study

Background:

The metabolic syndrome and its concomitant complications are a major public health challenge worldwide. Growing evidence implies associations with cancer development and progression. Since there has been no report on this subject in South Khorasan, we studied metabolic syndrome components in gastrointestinal (GI) cancer patients for comparison with a control group in this province.

Materials and methods:

This case-control study was performed on 68 patients with histopathologically proven gastrointestinal cancers, referred to the oncology center in Birjand city (capital of South Khorasan province, Iran) in 2016-2017, and 100 control subjects without disease. Patients and control subjects completed a researcher-made questionnaire covering demographic characteristics, physical activities and food intake. Also, blood samples were obtained from both patients and control subjects after overnight fast. Anthropometric measurements of height, weight, body mass index, waist circumference and blood pressure were additionally performed.

Results:

Significant differences in the levels of blood glucose and serum HDL were noted between the two groups (P≤0.001). Also, the percentage of pre-diabetic and diabetic patients in the case group was higher than the control group (17.6 and 16.2% vs. 10.3 and 2.9%) (P=0.009). Multiple logistic regression showed that the risk of gastrointestinal cancer in people with high blood glucose was 3.35 times that in those with normal blood glucose (OR3.35, 95%CI,1.41-7.94; P=0.006), 2.37 times higher in subjects with lower HDL (OR 2.37, 95%CI,1.18-4.78), 10.4 times higher in overweight people (OR10.4, 95%CI,2.23-48.5) and 4.3 times higher in individuals with an opium addiction(OR4.3, 95%CI, 1.6-11.5) than those without. The mean consumption of fish (P=0.03) and vegetables and fruits (P=0.027) in the case group was significantly lower than in the control group.

Conclusion:

Emerging evidence indicates that the metabolic syndrome or its individual components may be important in the etiology and progression of GI cancer. Research to work toward preventing cancers should thus focus on nutritional and lifestyle modifications which may alleviate the metabolic syndrome.

Retrospective database analysis of cancer risk in patients with type 2 diabetes mellitus in China

OBJECTIVE

To investigate the association between type 2 diabetes (T2D) and the risk of overall cancer and site-specific cancers in a Chinese population.

RESEARCH DESIGN AND METHODS

Tianjin Urban Employee Basic Medical Insurance database (2003-2014) was used to identify patients with newly onset T2D in 2009, patients with prevalent T2D prior to 2009, and general individuals without T2D. Overall and site-specific cancer incidence rates and incidence rate ratios relative to general population were calculated for both incident and prevalent T2D cohorts. Multivariate Cox proportional hazards models adjusting for baseline characteristics and potential bias were conducted. Subgroup analyses based on gender and age were further conducted.

RESULTS

For the year 2009, 21,208 patients with onset T2D (mean age 58.8 years; 48.1% female), 28,248 patients with prevalent T2D (mean age 63.7 years; 50.2% female) and 744,339 general individuals (mean age 43.2 years; 47.7% female) were identified. Controlling for confounders, diabetic patients had an overall 56%-59% higher risk of developing cancer, among which the highest risks by site were liver (adjusted hazard ratio [aHR] = 1.80-2.48), colorectal (aHR = 2.41-2.69) and stomach (aHR = 2.02-2.51) cancers (all p < .05). Patients with prevalent T2D had increased cancer risk in the pancreas (aHR = 4.52, p < .001). Female diabetic patients had increased risk in the kidneys (aHR = 3.22-3.31, p < .01). Patients aged between 50 and 59 years had the highest relative risk (90% higher), while the relative risk was the lowest among patients ≥70 (45% higher).

CONCLUSION

Type 2 diabetes was associated with increased overall cancer risk led by liver, colorectal and stomach cancers. Patients with longer diabetes duration were associated with higher pancreatic cancer risk and female diabetic patients had a higher risk of kidney cancer.

Impact of type 2 diabetes mellitus on short-term and long-term outcomes of patients with esophageal squamous cell cancer undergoing resection: a propensity score analysis

Background

The association between type 2 diabetes mellitus (T2DM) and the risk of esophageal cancer remains unclear. The present study aimed to evaluate the impact of T2DM on short-term outcomes and long-term survival in patients with esophageal squamous cell cancer (ESCC).

Methods

The present retrospective study included 862 patients diagnosed with ESCC between January 2001 and December 2010. Among them, 280 patients had T2DM. A 1:1 propensity score-matched cohort consisting of 280 patients with and 280 without T2DM was selected from the 862 patients. The associations between T2DM and clinicopathologic characteristics were assessed using the χ² or Fisher’s exact test. Survival of ESCC patients with and without T2DM was calculated by using the Kaplan–Meier method and compared by using the Cox regression model between the two groups.

Results

The occurrence rate of anastomotic leakage was significantly higher in patients with T2DM than in those without T2DM (P < 0.001). In the subgroup with weight loss rate ≤ 5.05%, ESCC patients with T2DM had a significant longer overall survival than did those without T2DM (P = 0.003), whereas in the subgroup with weight loss rate > 5.05%, the patients without T2DM showed a longer survival (P = 0.001). Univariate and multivariate analysis results showed that T2DM was not an independent prognostic factor for patient survival.

Conclusions

Type 2 diabetes mellitus is not an independent prognostic factor in patients with ESCC. However, the combination of T2DM with severe weight loss would be a predictor of poor prognosis.

Sex Differences in the Burden and Complications of Diabetes

PURPOSE OF THE REVIEW

To review the latest evidence on sex differences in the burden and complications of diabetes and discuss the potential explanations for the sex differences described.

RECENT FINDINGS

Diabetes is a strong risk factor for vascular disease, with compelling evidence that the relative risks of vascular diseases conferred by diabetes are considerably greater in women than men. The mechanisms underpinning women's excess relative risk of vascular disease from diabetes are unknown. Sex differences in the health care provided for the prevention, management, and treatment of diabetes and its complications could contribute to women's greater excess relative risks of diabetes complications. However, since the excess risk of vascular disease is not seen for other major vascular risk factors, inherent biological factors may be more likely to be involved. In addition to other cardiometabolic pathways, the sex dimorphism in body composition and fat distribution may be particularly important in explaining women's greater excess risk of the vascular complications of diabetes. There is strong evidence to suggest that diabetes is a stronger risk factor for vascular disease in women than men. Although several mechanisms may be involved, further research is needed to provide new and deeper insights into the mechanisms underpinning sex differences in the association between diabetes and vascular diseases. Such research will inform patients, health care professionals, and policy makers to ensure that women are not disproportionately affected by diabetes, and will help to reduce the burden in both sexes.

Diabetes mellitus and the risk of gastric cancer: a meta-analysis of cohort studies

Studies examining the relationship between diabetes mellitus (DM) and the risk of gastric cancer incidence or gastric cancer mortality have produced inconsistent results. The purpose of this study was to evaluate the evidence regarding the relationship between DM and subsequent gastric cancer incidence or gastric cancer mortality risk on the basis of cohort studies. A systematic search of articles in PubMed, EmBase, the Cochrane Library, and reference lists was conducted to identify relevant literature. Twenty-two cohort studies reporting data on 8,559,861 participants were included in the study. Overall, participants with DM had little or no change in the risk of gastric cancer, or gastric cancer mortality. There was no evidence of difference in the RR for gastric cancer between men and women. Participants with DM had a non-significant trend towards an increased risk of gastric cancer mortality in men. There was no significant difference between men and women for this relationship. Finally, although subgroup analysis suggested DM was associated with a significant impact on gastric cancer incidence and gastric cancer mortality risk in several specific populations, a significance based on gender difference was not observed. In conclusion, DM might increase the risk of gastric cancer in men when the study used standard incidence/mortality ratio as effect estimate. Further, DM were associated with higher risk of gastric cancer mortality in men if the mean age at baseline less than 55.0 years, used RR or HR as effect estimate, the study adjusted smoking or not, and the study not adjusted alcohol drinking.

Obesity, Diabetes and Gastrointestinal Malignancy: The role of Metformin and other Anti-diabetic Therapy

The association between Diabetes and cancer has been known for decades with obesity and insulin resistance being postulated as the main underlying risk factors for both disorders. With rise of the epidemic of obesity in the USA and around the globe, there has been a rise in diabetes that is currently reaching epidemic proportions. Diabetes is known to be associated with increased risk of several types of malignancy including breast, cervical, pancreatic and colon cancer. In this review, we discuss the epidemic of obesity and its consequential epidemic of diabetes highlighting the pathophysiologic mechanisms of increased cancer in the diabetic population. We will then discuss the role of insulin therapy as well as, other antidiabetic medications, particularly metformin that has been to be associated with lower risk as well as better survival with GI malignancies based on several studies including a study that was recently published by our group.

Elevated O-GlcNAcylation stabilizes FOXM1 by its reduced degradation through GSK-3β inactivation in a human gastric carcinoma cell line, MKN45 cells

O-GlcNAcylation is a dynamic post-translational modification of cytonuclear proteins for intracellular signaling. Elevated O-GlcNAcylation is a general feature of cancer and contributes to cancer progression, and recent studies indicate the contribution to increasing incidence of various types of cancer in diabetic patients. However, the role of O-GlcNAcylation in tumor progression is not fully elucidated. Forkhead box M1 (FOXM1), a master mitotic transcription factor, has been implicated in all major hallmarks of cancer, and is wildly expressed in solid tumors. Given that FOXM1 expression was reported to be elevated in gastric cancer, we examined the effect of high glucose or an inhibitor of O-GlcNAc hydrolase, Thiamet G (TMG), on FOXM1 protein expression in a human gastric cancer cell line, MKN45 cells, and confirmed that FOXM1 protein level and the cell proliferation were upregulated. To investigate the molecular mechanisms by which FOXM1 protein expression is regulated by O-GlcNAcylation, the effect of high glucose and TMG on FOXM1 ubiquitination was examined in MKN45 cells. As a result, the ubiquitination and degradation of FOXM1 protein were both suppressed by high glucose and TMG treatment. However, the O-GlcNAcylation was not detected on FOXM1 but not on GSK-3β. High glucose and TMG treatment increased phospho-serine 9 GSK-3β, an inactive form, and the degradation of FOXM1 protein was suppressed by treatment of GSK-3β inhibitors in MKN45 cells. Taken together, we suggest that high glucose and elevated O-GlcNAcylation stabilize FOXM1 protein by its reduced degradation via GSK-3β inactivation in MKN45 cells, suggesting that the higher risk of gastric cancer in diabetic patients could be partially due to O-GlcNAcylation-mediated FOXM1 stabilization.

Improved glycemic control with proximal intestinal bypass and weight loss following gastrectomy in non-obese diabetic gastric cancer patients

PURPOSE

The aim of this study was to assess whether gastrectomy influences glycemic control in non-obese diabetic gastric cancer patients and to identify factors related to glucose metabolism after gastrectomy.

MATERIALS AND METHODS

We retrospectively analyzed changes in glucose metabolism in 238 non-obese (body mass index < 30 kg/m2) patients with type II diabetes who underwent distal gastrectomy with either gastroduodenostomy (n = 91) or gastrojejunostomy (n = 147) for stage I gastric cancer. We collected demographics, diabetes-related features, surgery-related features, and changes in glucose metabolism during follow-up. The effect of surgery on the course of diabetes was evaluated at different time points according to fasting blood glucose levels and use of diabetes-related medication.

RESULTS

Preoperatively, the mean body mass index was 24.3 ± 2.3. Weight, body mass index and fasting blood glucose of all patients were significantly lower compared to preoperative levels at all time points. Weight loss after 6 months and the percentage of patients whose weight loss ratio was higher than 10% after one year were greater in the gastrojejunostomy group than the gastroduodenostomy group. Overall, 88 (37%) patients showed improvement in their diabetes course at one month after surgery; 152 (64%) showed improvement after 2 years. Duration of diabetes, weight loss, and reconstruction type were associated with improvement in diabetes at different time points. At 6 months and thereafter, the percentage of patients with an improved diabetes course was highest in the gastrojejunostomy plus higher than 10% weight loss group.

CONCLUSIONS

Although weight loss may be associated with adverse effects of gastrectomy, postoperative weight loss in an acceptable range is a useful measure of the better glycemic control for the group of diabetic patients. Selecting gastrojejunostomy during gastrectomy and inducing acceptable weight loss after gastrectomy could be beneficial to the non-obese diabetic gastric cancer patients for improved glycemic control.

Diabetes mellitus and the risk of bladder cancer: A PRISMA-compliant meta-analysis of cohort studies

BACKGROUND

Epidemiologic studies have reported inconsistent results regarding the relationship between diabetes mellitus (DM) and the incidence of bladder cancer. This comprehensive systematic review and meta-analysis explored and evaluated this relationship in participants with different characteristics.

METHODS

Studies indexed in the PubMed, Embase, and the Cochrane Library databases that compared bladder cancer incidence mortality between DM and non-DM participants were included in the present study. The relative risks (RRs) of a random-effects model were used to assess these associations.

RESULTS

The final analysis included 21 cohort studies, involving a total of 13,505,643 participants. Overall, DM was associated with an increased risk of bladder cancer or cancer mortality when compared with non-DM participants (RR: 1.23; 95% confidence interval [CI]: 1.12-1.35; P < .001). Furthermore, DM had a harmful impact on subsequent bladder cancer risk in men compared with those without DM (RR: 1.23; 95% CI: 1.06-1.42; P = .005), whereas no significant relationship was observed between DM and bladder cancer in women (RR: 1.24; 95% CI: 0.95-1.61; P = .119). There was no significant gender difference for this relationship (ratio of RR: 0.99; 95% CI: 0.73-1.34; P = .958). In addition, cancer incidence (RR: 1.21; 95% CI: 1.09-1.35; P < .001) and cancer mortality (RR: 1.25; 1.17-1.35; P < .001) both increased in DM patients. Finally, smoking status and follow-up duration might also affect this relationship in men and women.

CONCLUSIONS

The findings of this study indicated that DM was associated with elevated bladder cancer or cancer mortality risk, especially in men. This relationship in women requires further exploration.

Enemies or weapons in hands: investigational anti-diabetic drug glibenclamide and cancer risk

Epidemiological evidence suggests that diabetes is associated with elevated cancer risk through the actions of hyperglycemia, hyperinsulinemia and chronic inflammation. Metformin, a first-line medication for type 2 diabetes mellitus, arouses growing concerns on its anti-cancer effect. However, data regarding the effect of glibenclamide on tumor growth and cancer risk are less consistent, which may be a potential anti-cancer drug. Areas covered: In this review, we clarified probable underlying mechanisms in preclinical studies and reviewed epidemiological evidence on glibenclamide's cancer risk in clinical studies. Glibenclamide inhibited carcinogenesis through ATP-binding cassette protein super-family and ATP-sensitive potassium channels, while majority of clinical researches reported an increased or non-significant elevated cancer risk of glibenclamide users compared with metformin users. Other sulfonylureas and diarylsulfonylureas were also briefly introduced. Expert opinion: The inconsistency between the results of studies was probably ascribed to undiscovered mechanisms, confounding factors, inconsistent comparators and publication bias. Existing clinical trials were prone to be afflicted by time-related bias including immortal time bias, time-window bias, and time-lag bias. Glibenclimiade could be a promising and well-tolerated anti-neoplastic drug targeting ATP-binding cassette protein super-family and KATP channels, but its efficacy still needs to be proven in well-designed long-term randomized controlled clinical trials.

Diabetic biomarkers and the risk of proximal or distal gastric cancer

BACKGROUND AND AIM

The role of diabetes mellitus as a risk factor for gastric cancer has been controversial. We studied the association between diabetic biomarkers and the risk of gastric cancer and whether these associations depend on cancer location.

METHODS

In this retrospective cohort study with subjects with negative initial esophagogastroduodenoscopy findings (n = 23 218) during a routine health checkup, we measured fasting glucose and insulin levels, calculated the homeostatic model assessment insulin resistance (HOMA-IR) values, and analyzed the risk of gastric cancer in relation to diabetic biomarker tertiles and the presence of diabetes mellitus.

RESULTS

The incidence rate of gastric cancer was 9.7 per 10 000 person-years during the mean 6.8-year follow up. Patients with diabetes, higher fasting glucose levels, or higher HOMA-IR levels were older; men, current smokers, and heavy alcohol consumers represented larger proportions of these groups. They also had high body mass index and hemoglobin A1c more often. In the multivariate-adjusted Cox regression analyses, the incidence of gastric cancer was not significantly associated with diabetes mellitus or higher diabetic biomarker levels. Compared with normal glucose levels, lower glucose levels were significantly associated with an increased risk of distal gastric cancer. The hazard ratio for fasting glucose level tertile 1 was 2.39 (95% confidence interval, 1.48-3.85) (reference, tertile 2). Lower glucose levels were not associated with a risk of proximal gastric cancer, compared with a normal glucose level.

CONCLUSIONS

Our findings suggest that fasting glucose levels have a different effect on distal and proximal gastric cancers.

New utility of an old marker: serum low-density lipoprotein predicts histopathological response of neoadjuvant chemotherapy in locally advanced gastric cancer

Background

Although the correlation between metabolic abnormality and gastric cancer has been extensively investigated, the question of whether metabolic parameters might influence the efficacy of chemotherapy in locally advanced gastric cancer is still unanswered. In our present study, we investigated the relationship between serum fasting glucose, lipid levels, and histopathological response of neoadjuvant chemotherapy (NAC) in locally advanced gastric cancers.

Patients and methods

A total of 128 patients were identified from a prospectively maintained database of patients with locally advanced gastric cancer who received NAC between July 2004 and December 2012. Histopathological response after NAC was analyzed according to Becker’s tumor-regression grade. Univariate analyses and multivariable regression analyses were performed to determine the correlation between tumor size, differentiation, fasting glucose, lipid levels, and tumor histopathological response after NAC.

Results

Univariate analysis revealed that low-density lipoprotein level and total cholesterol, as well as tumor size and differentiation, correlated significantly with histopathological response. Low-density lipoprotein levels and tumor size were found to be independent predictors for histopathological response, according to multivariable regression analyses.

Conclusion

In this observational, hypothesis-generating study, serum low-density lipoprotein measurement was found to be useful in predicting chemosensitivity to locally advanced gastric cancer patients undergoing NAC. Incorporation of serum low-density lipoprotein levels into individualized treatment protocols could be considered in clinical practice.

Cumulative Metformin Use and Its Impact on Survival in Gastric Cancer Patients After Gastrectomy

OBJECTIVE

The aim of this study was to evaluate the association between metformin and survival of gastric cancer (GC) patients.

BACKGROUND

Metformin has recently received attention as a potential anticancer treatment. However, no study has shown the survival benefit of metformin for GC patients.

METHODS

A total of 1974 GC patients who underwent curative gastrectomy were compared for survival according to groups; 132 diabetic patients treated with metformin, 194 diabetic patients without metformin, and 1648 non-diabetic patients.

RESULTS

During the median follow-up period of 6.2 years (interquartile range, 4.7-7.8 years), 381 patients (19.3%) died, including 302 (15.3%) who died from GC. The non-diabetic patients had significantly better recurrence-free survival (RFS; P < 0.0001), cancer-specific survival (CSS; P = 0.006), and overall survival (OS; P < 0.0001). However, the diabetic patients treated with metformin had a significantly better prognosis than those who were not (OS: hazard ratio [HR] = 0.584, 95% confidence interval [CI], 0.369-0.926; CSS: HR = 0.57, 95% CI, 0.334-0.975; RFS: HR = 0.633, 95% CI, 0.410-0.977), and metformin treatment prolonged survival in diabetic patients to a rate comparable to that in non-diabetic patients. In multivariable analysis using the Cox proportional hazard model with time-dependent covariates, each cumulative 6 months of metformin use was significantly associated with a decreased risk of recurrence, cancer-specific mortality, and all-cause mortality (RFS: HR = 0.864, 95% CI, 0.797-0.937; CSS: HR = 0.865, 95% CI, 0.782-0.958; OS: HR 0.870, 95% CI, 0.801-0.945).

CONCLUSIONS

The increased cumulative duration of metformin use decreased the recurrence, all-cause mortality, and cancer-specific mortality rates among GC patients with diabetes who underwent gastrectomy.

Cancer risk among patients with type 2 diabetes mellitus: a population-based prospective study in China

Evidence indicates an increased cancer risk among type 2 diabetes mellitus (T2DM) patients, yet studies in mainland China are scarce. Based on Diabetes Surveillance System linking to Cancer Surveillance System of Zhejiang Province in China, we explored the cancer risk among T2DM patients. Totally, 327,268 T2DM patients were identified and followed from January 1, 2007 to December 31, 2013. Standardized incidence ratios (SIRs) with 95% confidence intervals (CIs) were reported. Overall cancer risk was found significantly increased with an SIR of 1.15 (95% CI 1.12-1.19) and 1.25 (95% CI 1.21-1.30) in males and females, respectively. Regarding specific cancer sites, risks of liver, colon, rectum, pancreas, and kidney were significantly increased with SIRs of 1.26 (95% CI 1.16-1.36), 1.47 (95% CI 1.29-1.67), 1.25 (95% CI 1.09-1.43), 2.81 (95% CI 2.50-3.16) and 1.61 (95% CI 1.28-2.03) in males, 1.53 (95% CI 1.35-1.73), 1.33 (95% CI 1.15-1.54), 1.29 (95% CI 1.10-1.51), 3.62 (95% CI 3.20-4.09) and 1.71 (95% CI 1.28-2.29) in females, respectively. A significant increased SIR was noted for prostate (1.80, 95% CI 1.58-2.06). Significant increased SIRs for lung (1.32, 95% CI 1.20-1.44) and stomach (1.16, 95% CI 1.03-1.30) were observed in females. We suggested an increased cancer risk among T2DM patients.