Risk of cancer in acromegaly patients: An updated meta-analysis and systematic review

Cost-effectiveness analysis of second-line medical therapies in acromegaly: a real-life study

Introduction

Acromegaly is an uncommon disease with important comorbidity and economic cost. Although the pharmacological cost of second-line treatment for refractory acromegaly has been theoretically analyzed, real-life studies are needed.

Objectives

To assess the use of pasireotide and pegvisomant in a third-level center under routine clinical practice.

Methods

Acromegaly patients that had been treated with pasireotide and/or pegvisomant were included in (A) a cross-sectional study (two years after starting these drugs) to analyze the cost of acromegaly, hormone replacement, and type 2 diabetes mellitus (T2DM) treatments, and the cost of surgery and radiotherapy; and (B) a retrospective cohorts study (May 2006-October 2024) to analyze efficacy, safety (adverse events, fasting glucose, glycated hemoglobin, and T2DM diagnosis), and dose evolution. Descriptive statistics were 10% trimmed means and standard deviation. Two-tailed hypothesis testing with Yuen's t and Fisher's test had a P < 0.05 significance.

Results

25 participants were included in the transversal study and 31 participants in the longitudinal study. A typical patient with a poorly granulated GH-producing adenoma underwent in-center surgery once and received radiotherapy. In the transversal study, total pharmacological cost was 34,139.29 (13,472.09) €/person/year, with 33,874.88 (13,468.36) €/person/year for second-line acromegaly drugs. Pasireotide displayed 9,423.26 €/person/year worth of savings (P = .12), reaching 30,415.98 €/person/year at high dose (P < 0.001). In the longitudinal study, pasireotide dose was reduced (P = .06) regardless of treatment modality. Pasireotide affected carbohydrate metabolism (P = .001), but the effect was generally mild.

Conclusions

Pasireotide was found to be a more cost-effective option in patients with first-line treatment failure.

Prospective, Longitudinal Study of Cancer Predictors and Rates in a New York City Cohort of 598 Patients With Acromegaly

CONTEXT

Long-term growth hormone/insulin-like growth factor-1 (GH/IGF-1) excess could increase the risk of cancer in acromegaly, but individual levels of these hormones do not relate to this risk.

OBJECTIVE

We newly investigated longitudinally-measured IGF-1 levels as a potential predictor of cancer in a large New York City acromegaly cohort.

METHODS

We conducted a prospective, longitudinal study of 598 acromegaly (309 men, 289 women) and 292 clinically nonfunctioning pituitary adenoma (CNFPA) (140 women, 152 men) patients from the same underlying population. GH and IGF-1 levels were measured longitudinally and outcomes were observed during long-term follow-up. Cumulative exposure to IGF-1 excess was tested as a predictor of cancer. We compared cancer prevalence in acromegaly and CNFPA cohorts and incidence in each to that expected from Surveillance, Epidemiology, and End Results (SEER) data.

RESULTS

Cancer prevalence by last follow-up was 22.6% in acromegaly and 12.7% in CNFPAs (odds ratio [OR] = 1.99 [95% CI, 1.34-2.97]) (P = .0005). Overall standardized incidence ratio for cancer was 1.78 (1.51-1.81) in the acromegaly and 1.26 (0.89-1.70) in the CNFPA cohorts. Cumulative exposure to IGF-1 excess, OR = 1.278 (1.060-1.541) (P = .01), years from acromegaly diagnosis to cancer or last follow-up, OR = 1.03 (1.004-1.057) (P = .024), and age at follow up, OR = 1.064 (1.047-1.082) (P < .001), were predictors of cancer.

CONCLUSION

Cancer risk is increased in acromegaly, but not in CNFPA patients. Cumulative exposure to IGF-1 excess is a predictor of cancer in acromegaly. Our data suggest that cancer risk in acromegaly relates to the degree and duration of IGF-1 excess and that full appreciation of this risk requires long-term follow up.

Ectopic GHRH production: revisiting a rare cause of acromegaly

Growth Hormone-Releasing Hormone (GHRH) is a hypothalamic hormone that stimulates GH secretion by the anterior pituitary gland. Ectopic production of GHRH by neuroendocrine tumors (NETs) is a rare cause of acromegaly, with some clinical and biochemical features indistinguishable from pituitary adenoma origin. Some clues for this diagnosis include pituitary MRI harboring hyperplasia, increased serum GHRH and extra-pituitary tumor detected in whole body scans. The preferable treatment, when possible, should be surgical resection of the NET. In cases with residual tumor, somatostatin analogs could be used as an alternative for adjuvant therapy for both tumoral and biochemical control of IGF-1. Life-long follow-up is needed as some patients may develop persistent pituitary hyperplasia or GH-adenomas due to prolonged GHRH exposure, with elevated IGF-1 levels even without NET recurrence. In such scenarios, medical therapy should be provided for hyperplasia cases and transsphenoidal surgery to patients with pituitary adenoma. If available, genetic test for MEN1 mutations should always be performed.

Growth Hormone Action as a Target in Cancer: Significance, Mechanisms, and Possible Therapies

Growth hormone (GH) is a pituitary-derived endocrine hormone required for normal postnatal growth and development. Hypo- or hypersecretion of endocrine GH results in 2 pathologic conditions, namely GH deficiency (GHD) and acromegaly. Additionally, GH is also produced in nonpituitary and tumoral tissues, where it acts rather as a cellular growth factor with an autocrine/paracrine mode of action. An increasingly persuasive and large body of evidence over the last 70 years concurs that GH action is implicit in escalating several cancer-associated events, locally and systemically. This pleiotropy of GH's effects is puzzling, but the association with cancer risk automatically raises a concern for patients with acromegaly and for individuals treated with GH. By careful assessment of the available knowledge on the fundamental concepts of cancer, suggestions from epidemiological and clinical studies, and the evidence from specific reports, in this review we aimed to help clarify the distinction of endocrine vs autocrine/paracrine GH in promoting cancer and to reconcile the discrepancies between experimental and clinical data. Along this discourse, we critically weigh the targetability of GH action in cancer-first by detailing the molecular mechanisms which posit GH as a critical node in tumor circuitry; and second, by enumerating the currently available therapeutic options targeting GH action. On the basis of our discussion, we infer that a targeted intervention on GH action in the appropriate patient population can benefit a sizable subset of current cancer prognoses.

Acromegaly: diagnostic challenges and individualized treatment

INTRODUCTION

Acromegaly is due in almost all cases to a GH-secreting pituitary tumor. GH and IGF-1 excesses lead to its multi-system clinical manifestations and comorbidities. Acromegaly is under-diagnosed and typically presents with advanced disease. When early or mild, clinical recognition and biochemical confirmation are especially challenging. Individualized treatment may optimize patient outcome.

AREAS COVERED

This review covers challenges to diagnosing acromegaly and reviews therapies for acromegaly with a focus on those aspects that can be individualized.

EXPERT OPINION

The first step in diagnosing acromegaly is recognizing it clinically. To improve this, increase awareness and education of the general population and healthcare professionals about the acromegaly phenotype is needed. Once suspected clinically, IGF-1 measurement is the initial step in making the biochemical diagnosis. GH may be < 1.0 µg/L after oral glucose suppression in early/mild cases. GH and IGF-1 should be considered in concert. Providers should be aware of conditions that can alter GH and IGF-1 levels and each assay's performance. An individualized treatment approach is best employed. Surgery is preferred as initial treatment and medical therapy as initial adjuvant therapy. In individualizing therapy, the advantages and disadvantages of each option and predictors of response to them should be considered.

Integration of big data analytics in the investigation of the relationship between acromegaly and cancer

OBJECTIVE

To evaluate the association between acromegaly and cancer and different types of cancer by using natural language processing systems and big data analytics.

MATERIAL AND METHODS

We conducted an observational, retrospective study utilizing data from the electronic health records (EHRs) of Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain. Information from the EHRs was extracted using artificial intelligence techniques and analyzed using Savana Manager 4.0 software.

RESULTS

Out of a total of 708,047 registered patients (54.7% females), 544 patients (0.08%; 330 women, 60.7%; mean age at diagnosis 53.0±15.8 yr) were diagnosed with acromegaly. The incidence of cancer was higher in patients with acromegaly vs those without this condition (7.7% vs 3.9%, p<0.001; OR, 2.047, 95%CI, 1.493-2.804). Male acromegalic patients had a higher prevalence of cancer vs females (57.1% vs 42.9%, p=0.012). A significantly higher prevalence of colorectal cancer (2.9% vs 1.4%, p=0.006), bladder cancer (1.1% vs 0.3%, p=0.005), and lymphoma (1.1% vs 0.3%, p=0.009) was observed in patients with acromegaly vs those without the condition. Acromegalic men had significantly higher prevalence rates of colorectal cancer (4.7% vs 1.3%, p=0.001), bladder cancer (2.8% vs 0.4%, p<0.001), breast cancer (0.9% vs 0.2%, p=0.042), gastric cancer (0.9% vs 0.1%, p=0.011), lymphoma (1.4% vs 0.3%, p=0.037), and liver cancer (0.9% vs 0.1%, p=0.012) vs non-acromegalic men. On the other hand, acromegalic women showed a higher prevalence of thyroid cancer (1.2% vs 0.4%, p=0.043) vs non-acromegalic women.

CONCLUSION

Our study, based on artificial intelligence techniques and analysis of real-world data and information, revealed a significant association between acromegaly and cancer in our hospital population, mainly acromegalic men, with a higher frequency of colorectal cancer, bladder cancer and lymphoma in particular.

Endogenous Cushing's syndrome and cancer risk

OBJECTIVE

Cancer incidence in patients with endogenous Cushing's syndrome (CS) has never been established. Here, we aimed to assess the cancer risk in patients with CS as compared with individually matched controls.

DESIGN

A nationwide retrospective matched cohort study of patients with endogenous CS diagnosed between 2000 and 2023 using the database of Clalit Health Services in Israel.

METHODS

Patients with adrenal carcinoma or ectopic CS were excluded. Patients with CS were matched in a 1:5 ratio, with controls individually matched for age, sex, socioeconomic status, and body mass index. The primary outcome was defined as the first diagnosis of any malignancy following a CS diagnosis. Risk of malignancy was calculated using the Cox proportional hazard model, with death as a competing event.

RESULTS

A total of 609 patients with CS and 3018 controls were included [mean age at diagnosis, 48.0 ± 17.2 years; 2371 (65.4%) women]. The median follow-up was 14.7 years (IQR, 9.9-20.2 years). Patients with CS had an increased cancer risk, with a hazard ratio (HR) of 1.78 (95% CI 1.44-2.20) compared with their matched controls. The risk of malignancy was elevated in patients with Cushing's disease (251 cases and 1246 controls; HR 1.65, 95% CI 1.15-2.36) and in patients with adrenal CS (200 cases and 991 controls; HR 2.36, 95% CI 1.70-3.29). The increased cancer risk in patients with CS persists after exclusion of thyroid malignancies.

CONCLUSION

Endogenous CS is associated with increased malignancy risk. These findings underscore the need for further research to establish recommendations for cancer screening in this population.

Risk of intracranial meningioma in patients with acromegaly: a systematic review

Acromegaly is a rare endocrine disorder caused by hypersecretion of growth hormone (GH) from a pituitary adenoma. Elevated GH levels stimulate excess production of insulin-like growth factor 1 (IGF-1) which leads to the insidious onset of clinical manifestations. The most common primary central nervous system (CNS) tumors, meningiomas originate from the arachnoid layer of the meninges and are typically benign and slow-growing. Meningiomas are over twice as common in women as in men, with age-adjusted incidence (per 100,000 individuals) of 10.66 and 4.75, respectively. Several reports describe co-occurrence of meningiomas and acromegaly. We aimed to determine whether patients with acromegaly are at elevated risk for meningioma. Investigation of the literature showed that co-occurrence of a pituitary adenoma and a meningioma is a rare phenomenon, and the majority of cases involve GH-secreting adenomas. To the best of our knowledge, a systematic review examining the association between meningiomas and elevated GH levels (due to GH-secreting adenomas in acromegaly or exposure to exogenous GH) has never been conducted. The nature of the observed coexistence between acromegaly and meningioma -whether it reflects causation or mere co-association -is unclear, as is the pathophysiologic etiology.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42022376998.

Acromegaly in humans and cats: Pathophysiological, clinical and management resemblances and differences

OBJECTIVE

Acromegaly is a disorder associated with excessive levels of growth hormone (GH) and insulin-like growth factor-1 (IGF-1). In general, GH/IGF-1 excess leads to morphologic craniofacial and acral changes as well as cardiometabolic complications, but the phenotypic changes and clinical presentation of acromegaly differ across species. Here, we review the pathophysiology, clinical presentation and management of acromegaly in humans and cats, and we provide a systematic comparison between this disease across these different species.

DESIGN

A comprehensive literature review of pathophysiology, clinical features, diagnosis and management of acromegaly in humans and in cats was performed.

RESULTS

Acromegaly is associated with prominent craniofacial changes in both species: frontal bossing, enlarged nose, ears and lips, and protuberant cheekbones are typically encountered in humans, whereas increased width of the head and skull enlargement are commonly found in cats. Malocclusion, prognathism, dental diastema and upper airway obstruction by soft tissue enlargement are reported in both species, as well as continuous growth and widening of extremities resulting in osteoarticular compromise. Increase of articular joint cartilage thickness, vertebral fractures and spine malalignment is more evident in humans, while arthropathy and spondylosis deformans may also occur in cats. Generalized organomegaly is equally observed in both species. Other similarities between humans and cats with acromegaly include heart failure, ventricular hypertrophy, diabetes mellitus, and an overall increased cardiometabolic risk. In GH-secreting pituitary tumours, local compressive effects and behavioral changes are mostly observed in humans, but also present in cats. Cutis verticis gyrata and skin tags are exclusively found in humans, while palmigrade/plantigrade stance may occur in some acromegalic cats. Serum IGF-1 is used for acromegaly diagnosis in both species, but an oral glucose tolerance test with GH measurement is only useful in humans, as glucose load does not inhibit GH secretion in cats. Imaging studies are regularly performed in both species after biochemical diagnosis of acromegaly. Hypophysectomy is the first line treatment for humans and cats, although not always available in veterinary medicine.

CONCLUSION

Acromegaly in humans and cats has substantial similarities, as a result of common pathophysiological mechanisms, however species-specific features may be found.

Changes in acromegaly comorbidities, treatment, and outcome over three decades: a nationwide cohort study

Objective

To study the time-dependent changes in disease features of Danish patients with acromegaly, including treatment modalities, biochemical outcome, and comorbidities, with a particular focus on cancer and mortality.

Methods

Pertinent acromegaly-related variables were collected from 739 patients diagnosed since 1990. Data are presented across three decades (1990-1999, 2000-2009, and 2010-2021) based on the year of diagnosis or treatment initiation.

Results

Adenoma size and insulin-like growth factor I (IGF-I) levels at diagnosis did not differ significantly between study periods. The risk of being diagnosed with diabetes, heart disease, sleep apnea, joint disease, and osteoporosis increased from the 1990s to the later decades, while the mortality risk declined to nearly half. The risk of cancer did not significantly change. Treatment changed toward the use of more medical therapy, and fewer patients underwent repeat surgeries or pituitary irradiation. A statistically significant increase in the proportion of patients achieving IGF-I normalization within 3-5 years was observed over time (69%, 83%, and 88%). The proportion of patients with three or more deficient pituitary hormones decreased significantly over time.

Conclusion

Modern medical treatment regimens of acromegaly as well as increased awareness and improved diagnostics for its comorbidities have led to better disease control, fewer patients with severe hypopituitarism, and declining mortality in the Danish cohort of acromegaly patients. The risk of cancer did not increase over the study period.