An Elevated HbA1c Level Is Associated With Short-Term Adverse Outcomes in Patients With Gastrointestinal Cancer and Type 2 Diabetes Mellitus

Influence of Diabetes Mellitus on Oncological Outcomes for Patients Living With Cancer

PURPOSE

The purpose of this meta-analysis was to examine the association between preexisting diabetes in persons living with cancer on diabetes and oncology-related health outcomes. Understanding this association is of priority because the incidence of both cancer and diabetes mellitus is increasing worldwide.

METHODS

A comprehensive review of the literature was conducted in collaboration with an expert health sciences librarian. Two authors independently conducted the screening, data collection, and extraction processes. The risk of bias was assessed using several tools, depending on the study design. Relative risks with 95% confidence intervals were calculated. The alpha threshold was 0.05. All analyses were performed using R statistical software (Metaphor and Demeter packages).

RESULTS

A total of 45 studies met the selection criteria, but 23 were excluded from the synthesis because they did not have the ranked outcome or correct comparison (persons with and without diabetes), totaling 22 studies included in the meta-analysis. In comparison to participants without preexisting diabetes, participants with preexisting diabetes and cancer were found to have a significantly higher risk of infection and cardiovascular, neurological, gastrointestinal, hepatic, and renal complications. Concurrent preexisting diabetes and cancer were also associated with increased health care service utilization and length of hospital stay.

CONCLUSION

The findings from this review highlight the importance of optimal concurrent management of both diseases by overcoming the compartmentalization of medical specializations through (1) integrated, multidisciplinary, shared, and coordinated clinical care pathways between oncology and diabetes health care providers/teams and (2) the continued development of evidence-based clinical guidelines.

Analysis of the Incidence of Type 2 Diabetes, Requirement of Insulin Treatment, and Diabetes-Related Complications among Patients with Cancer

This retrospective nationwide population-based cohort study used a dataset collected from the Korean National Health Insurance Service. We evaluated incident type 2 diabetes, insulin requirements, and diabetes-associated complications during a 10-year follow-up period using the log-rank test and Cox proportional hazards regression models. In total, 8114 and 16,228 individuals with and without cancer, respectively, were enrolled. We found a higher incidence rate and an increased adjusted hazard ratio (HR) for new cases of type 2 diabetes in patients with cancer, compared with those without cancer. Additionally, patients with cancer had a higher risk of insulin requirement than patients without cancer (adjusted HR 1.43, 95% confidence interval [CI], 1.14-1.78). Although there was no significant association between diabetes-associated complications and overall cancer diagnosis, specific cancer types (pancreas, bladder, and prostate) showed an increased risk of subsequent diabetic nephropathy. Therefore, clinicians should closely monitor patients with cancer for the early detection of type 2 diabetes and related morbidities.

Association of Glycosylated Hemoglobin Level and Cancer-Related Mortality in Patients without Diabetes

BACKGROUND

Previous studies have reported that abnormal glucose metabolism is associated with poor cancer outcomes. Glycated hemoglobin A1c (HbA1c) is an important indicator of glucose metabolism. This study aimed to investigate the relationship between nondiabetic HbA1c levels and cancer-related mortality.

METHODS

This was a retrospective cohort study of Koreans who attended an annual or biennial health checkup program. The study group was categorized based on the quintile of HbA1c level (Q1, 3.0-5.1%; Q2, 5.2-5.3%; Q3, 5.4%; Q4, 5.5-5.6%, Q5, 5.7-6.4%). Cancer-related mortality was determined using the mortality data from the Korea National Statistical Office. Participants with an established diagnosis of diabetes or cancer were excluded. Cancer-related mortality was assessed depending on each HbA1c level with adjustment for factors that could influence mortality.

RESULTS

A total of 589,457 participants were included in this study. During a median follow-up duration of 6.99 years, 1712 cancer-related deaths were reported. The risk of cancer-related mortality was significantly higher in the Q5 group (hazard ratio (HR) 1.23, range 1.02-1.47 in model 1; HR 1.25, range 1.04-1.50 in model 2). HbA1c levels were linearly associated with cancer-related deaths (Ptrend = 0.021 in model 1; 0.013 in model 2). HbA1c level and colorectal, stomach, and lung cancer mortality exhibited a positive relationship, whereas liver cancer-related mortality showed an inverse relationship with HbA1c level (Ptrend = 0.001).

CONCLUSIONS

Our study showed that abnormal glucose metabolism is significantly associated with cancer-related mortality, and its relationship varies with each type of cancer.

The impact of preoperative glycated hemoglobin (HbA1c) on postoperative complications after elective major abdominal surgery: a meta-analysis

Background

Diabetes is a risk factor for postoperative complications. Previous meta-analyses have shown that elevated glycated hemoglobin (HbA1c) levels are associated with postoperative complications in various surgical populations. However, this is the first meta-analysis to investigate the association between preoperative HbA1c levels and postoperative complications in patients undergoing elective major abdominal surgery.

Methods

PRISMA guidelines were adhered to for this study. Six databases were searched up to April 1, 2020. Primary studies investigating the effect of HbA1c levels on postoperative complications after elective major abdominal surgery were included. Risk of bias and quality of evidence assessments were performed. Data were pooled using a random effects model. Meta-regression was performed to evaluate different HbA1c cut-off values.

Results

Twelve observational studies (25,036 patients) were included. Most studies received a ‘good’ and ‘moderate quality’ score using the NOS and GRADE, respectively. Patients with a high HbA1c had a greater risk of anastomotic leaks (odds ratio [OR]: 2.80, 95% CI [1.63, 4.83], P < 0.001), wound infections (OR: 1.21, 95% CI [1.08, 1.36], P = 0.001), major complications defined as Clavien-Dindo [CD] 3–5 (OR: 2.16, 95% CI [1.54, 3.01], P < 0.001), and overall complications defined as CD 1–5 (OR: 2.12, 95% CI [1.48, 3.04], P < 0.001).

Conclusions

An HbA1c between 6% and 7% is associated with higher risks of anastomotic leaks, wound infections, major complications, and overall postoperative complications. Therefore, guidelines with an HbA1c threshold > 7% may be putting pre-optimized patients at risk. Future randomized controlled trials are needed to explore causation before policy changes are made.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Self-Care Adherence And Barriers To Good Glycaemic Control In Nepalese Type 2 Diabetes Mellitus Patients: A Hospital-Based Cross-Sectional Study

PURPOSE

The patient believes in adherence to medication rather than to self-care adherence and lifestyle changes for the management of diabetes. This study was carried out to establish the association of self-care adherence and their barriers in poor glycemic control in our diabetic population.

PATIENTS AND METHODS

This cross-sectional study was conducted among 480 already diagnosed diabetes outpatients attended in our two hospitals. Glycaemic control was defined by levels of HbA1c. Socio-demographic data, lifestyle variables and anthropometric measurements were recorded using a standard questionnaire. Fasting blood glucose, HbA1c and lipid profiles were estimated using the manufacturer's guideline. Student's t-test and one-way ANOVA were used for comparison between different groups and the correlation was established by Spearman correlation. Risk factors associated with poor glycaemic control were verified by logistic regression analysis.

RESULTS

The mean HbA1c of the study population was 7.4±1.3% and 65.4% had poor glycaemic control with mean 8.0±1.1%. Higher HbA1c levels were significantly associated with duration of diabetes, a number of drugs used, patient-physician relationship and knowledge about diabetes. The poor glycaemic control was significantly associated with low adherence of following the meal plan, regular medication and regular exercising (p<0.001). Among all the barriers, a too busy schedule for following the meal plan, taking medications and exercising regularly was significantly correlated with HbA1c levels. Multivariable logistic regression analysis showed irregular meal plan (OR=5.27), irregular exercise (OR=2.25), number of medication used (OR= 0.19) and lesser extent patient-physician relationship (OR=2.68) were independent risk factors for poor glycaemic control.

CONCLUSION

The poor glycaemic control was associated with poor adherence to self-care adherence and their barriers in our diabetic population. Integrated knowledge on diabetes management should be targeted to improve glycaemic control in our communities.