Is diabetes mellitus a risk factor for pancreatic cancer?

Surgical management of pancreatic cancer in Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia: a 5 years retrospective descriptive study

INTRODUCTION

The incidence of Pancreatic cancer is different in different parts of the world. It is a cancer with the worst prognosis of all malignancies. Pancreatic cancer is predominantly a disease of an older population. There are different environmental (modifiable) and non-modifiable risk factors associated with the development of pancreatic cancer. At present, surgical resection is the only potential cure for pancreatic cancer. However, as only 10-20% of the patients have resectable disease at the time of diagnosis. The morbidities associated with surgeries for pancreatic cancers remain high though the post-operative mortality has shown significant reduction in the past few decades. So far, no study has been conducted to investigate pancreatic cancer in Ethiopia.

OBJECTIVES

To assess the clinico-pathologic profile, associated factors, surgical management and short-term outcome of patients with pancreatic cancer in Tikur Anbessa Specialized hospital.

METHODS

A 5 years retrospective hospital-based cross-sectional study was conducted on 52 patients operated with the diagnosis of pancreatic cancer with either curative or palliative intents. The study period was from April 2016 to July 2021. The data collected includes demographic profile, associated risk factors and comorbidities, clinical presentations, biochemical parameters, pathologic features of the tumors as well as type of treatment offered and short term treatment outcome. The data was analyzed using SPSS version 25.

RESULT

The mean and median age of patients was 54.1 and 54.5% respectively. Males constitute about 52% the patients. 21% of the patients have potential risk factors; whereas only 10 (19.2%) of the patients had medical comorbidities. Median duration of symptoms at diagnosis was 12 weeks. Abdominal pain (88.5%) was the most common presenting symptom followed by anorexia (80.8%) and significant weight loss (78.8%), while 71.2% of the patients have jaundice. On clinical evaluation, 69.2% were jaundiced, while 34.6% had a palpable gallbladder. More than two third of patients presented with advanced disease. 76.9% of the tumors are located in the head of pancreas. More than three quarters (77%) of the surgeries performed were palliative. Postoperative morbidity and mortality were 19.2% and 3.8% respectively.

CONCLUSION

Age at first diagnosis of pancreatic cancer is relatively earlier in our setup. Most patients present with advanced condition, only amenable for palliative measures. The post-operative morbidity and mortality are more or less comparable with similar studies. The need for adjuvant therapy in pancreatic cancer should be emphasized.

Diabetes mellitus type 2 drives metabolic reprogramming to promote pancreatic cancer growth

Background

Diabetes mellitus type 2 (DM2) is a modifiable risk factor associated with pancreatic carcinogenesis and tumor progression on the basis of epidemiology studies, but the biological mechanisms are not completely understood. The purpose of this study is to demonstrate direct evidence for the mechanisms mediating these epidemiologic phenomena. Our hypothesis is that DM2 accelerates pancreatic cancer growth and that metformin treatment has a beneficial impact.

Methods

To determine the effect of glucose and insulin in pancreatic cancer proliferation, we used conditioned media to mimic DM2 conditions. Also, we studied the effect of anti-diabetic drugs, particularly metformin and rosiglitazone on pancreatic cancer growth. We established orthotopic/syngeneic (Lepr^db/db) mouse cancer models to evaluate the effect of diabetes on pancreatic tumor growth and aggressiveness.

Results

Our results showed that diabetes promotes pancreatic tumor growth. Furthermore, enhanced tumor growth and aggressiveness (e.g. epithelial–mesenchymal transition) can be explained by functional transcriptomic and metabolomic changes in the mice with diabetes, namely via activation of the AKT/mTOR pathway. Metformin treatment suppressed the diabetes-induced AKT/mTOR pathway activation and tumor growth. The metabolic profile determined by mass spectrum showed important changes of metabolites in the pancreatic cancer derived from diabetic mice treated with metformin.

Conclusions

Diabetes mellitus type 2 has critical effects that promote pancreatic cancer progression via transcriptomic and metabolomic changes. Our animal models provide strong evidence for the causal relationship between diabetes and accelerated pancreatic cancers. This study sheds a new insight into the effects of metformin and its potential as part of therapeutic interventions for pancreatic cancer in diabetic patients.

Epidemiology of Pancreatic Cancer: Global Trends, Etiology and Risk Factors

Pancreatic cancer is the seventh leading cause of cancer-related deaths worldwide. However, its toll is higher in more developed countries. Reasons for vast differences in mortality rates of pancreatic cancer are not completely clear yet, but it may be due to lack of appropriate diagnosis, treatment and cataloging of cancer cases. Because patients seldom exhibit symptoms until an advanced stage of the disease, pancreatic cancer remains one of the most lethal malignant neoplasms that caused 432,242 new deaths in 2018 (GLOBOCAN 2018 estimates). Globally, 458,918 new cases of pancreatic cancer have been reported in 2018, and 355,317 new cases are estimated to occur until 2040. Despite advancements in the detection and management of pancreatic cancer, the 5-year survival rate still stands at 9% only. To date, the causes of pancreatic carcinoma are still insufficiently known, although certain risk factors have been identified, such as tobacco smoking, diabetes mellitus, obesity, dietary factors, alcohol abuse, age, ethnicity, family history and genetic factors, Helicobacter pylori infection, non-O blood group and chronic pancreatitis. In general population, screening of large groups is not considered useful to detect the disease at its early stage, although newer techniques and the screening of tightly targeted groups (especially of those with family history), are being evaluated. Primary prevention is considered of utmost importance. Up-to-date statistics on pancreatic cancer occurrence and outcome along with a better understanding of the etiology and identifying the causative risk factors are essential for the primary prevention of this disease.

Epidemiological bases and molecular mechanisms linking obesity, diabetes, and cancer

The association between diabetes and cancer was hypothesized almost one century ago. Today, a vast number of epidemiological studies support that obese and diabetic populations are more likely to experience tissue-specific cancers, but the underlying molecular mechanisms remain unknown. Obesity, diabetes, and cancer share many hormonal, immune, and metabolic changes that may account for the relationship between diabetes and cancer. In addition, antidiabetic treatments may have an impact on the occurrence and course of some cancers. Moreover, some anticancer treatments may induce diabetes. These observations aroused a great controversy because of the ethical implications and the associated commercial interests. We report an epidemiological update from a mechanistic perspective that suggests the existence of many common and differential individual mechanisms linking obesity and type 1 and 2 diabetes mellitus to certain cancers. The challenge today is to identify the molecular links responsible for this association. Classification of cancers by their molecular signatures may facilitate future mechanistic and epidemiological studies.

Diagnostic value of selected markers and apoptotic pathways for pancreatic cancer

Pancreatic cancer occupies the fourth place as a cause of death from cancer, and the mortality rate is similar to the number of newly detected cases. Due to the late diagnosis, only 5-6% of patients with pancreatic cancer survive for five years. Given that early diagnosis is critical for improving patients' survival rates, there is an urgent need for the discovery and validation of new biomarkers with sufficient sensitivity and specificity to help diagnose pancreatic cancer early. Detection of serum tumor markers (CA19-9, CEA, CA125 and CA242) is conducive to the early diagnosis of pancreatic cancer. The combination of miR-16, miR-196a and CA19-9 plasma level was more effective, especially in early tumor screening. Furthermore, recent studies reported that mainly miR-21, miR-155 and miR-196 were dysregulated in IPMN (intraductal papillary mucinous neoplasms) and PanIN (pancreatic intraepithelial neoplasia) lesions, suggesting their usefulness as early biomarkers of these diseases. The reduced rate of apoptosis plays a crucial role in carcinogenesis, and it is one of the most important characteristics acquired by pancreatic cancer cells, which protects them from attack by the immune system and reduces the effectiveness of pharmacological treatment. This review summarizes the data concerning the clinical utility of selected biomarkers in pancreatic cancer patients. The review mainly focuses on the genetic aspects of signaling pathway disorders associated with apoptosis in the pathogenesis and diagnosis of pancreatic cancer.

Pancreatic Cancer Incidence and Lethality Rates in Brazil: An Ecological Study

OBJECTIVES

To describe incidence and lethality time trends rates of pancreatic cancer (PC) in Brazil.

METHODS

Data from Brazilian Health National Public System (SUS) were retrospectively collected with regard to PC from January 2005 to December 2012. Pancreatic cancer incidence and lethality rates were estimated from SUS hospitalizations and in-hospital PC deaths and adjusted to total available hospital beds.

RESULTS

From 2005 to 2012, a total of 36,332 admissions for PC were registered in Brazil. Pancreatic cancer incidence nearly doubled from 2.4/100,000 to 4.5/100,000, particularly among patients older than 70 years, whereas no difference in sex was noted. The greatest incidence rates increase (+109%) occurred in the northeast, a less developed region that has recently achieved significant economic advances. Dynamic changes were observed, notably a shift to increasing PC incidence in rural areas. Lethality rates increased from mean 25% to 27%, the highest rates registered in those 70 years or older.

CONCLUSIONS

Overall increase trends in PC incidence and lethality were observed. Pancreatic cancer remains an urban disease in Brazil, the highest incidence found in the most developed regions as in large metropolitan integrated municipalities. Improvement in diagnosis, notification quality, a rapidly aging population, and a great demographic dynamism could in part explain this fact.

Insulin resistance is associated with the aggressiveness of pancreatic ductal carcinoma

AIMS

To study whether insulin resistance accelerates the development and/or the progression of pancreatic adenocarcinoma (PDAC), we hypothesized that patients with insulin resistance, compared with those without insulin resistance, show: (1) a younger age and more advanced PDAC stage at diagnosis and (2) a shorter disease-free and overall survival after PDAC diagnosis.

METHODS

Prospective observational study of patients admitted to a referral center for pancreatic disease. Insulin resistance was defined as a HOMA-IR value greater than the 66th percentile value of the patients included in this study. Survival was estimated according to Kaplan-Meier and by Cox regression.

RESULTS

Of 296 patients with PDAC, 99 (33 %) met criteria for being classified as insulin resistant at diagnosis. Median follow-up time after diagnosis was 5.27 ± 0.23 years. Patients with insulin resistance received a diagnosis of PDAC at a similar age compared to patients without insulin resistance (67.1 ± 9 vs. 66.8 ± 10 years, p = 0.68), but were more likely to have a cancer stage ≥3 (23.2 vs. 14.2 %, p = 0.053) and a residual disease after surgery (R1 56.4 vs. 38 %; p = 0.007). The median overall survival was 1.3 ± 0.14 and 1.79 ± 0.11 years for the patients with and without insulin resistance, respectively (p = 0.016). Results did not change when patients with diabetes at PDAC diagnosis were excluded from the analysis. Multivariate analysis showed that insulin resistance was independently associated with overall survival.

CONCLUSIONS

Insulin resistance is associated with the aggressiveness of PDAC.

Effect of Diabetes on Survival after Resection of Pancreatic Adenocarcinoma. A Prospective, Observational Study

AIM

To investigate the effect of diabetes mellitus (DM) on disease-free and overall post-resection survival of patients with pancreatic ductal adenocarcinoma (PDAC).

METHODS

Prospective observational study on patients admitted for pancreatic disease from January 2008 to October 2012. DM was classified as recent-onset (<48 months before PDAC diagnosis), longstanding (≥48 months before PDAC) or new onset (after surgery).

RESULTS

Of 296 patients, 140 had a diagnosis of DM prior to surgery (26 longstanding, 99 recent-onset, 15 with unknown duration). Median follow-up time was 5.4 ± 0.22 years. Patients with recent onset DM had poorer postoperative survival than patients without DM: disease-free survival and overall survival were 1.14±0.13 years and 1.52±0.12 years in recent onset DM, versus 1.3±0.15 years and 1.87±0.15 years in non-diabetic patients (p = 0.013 and p = 0.025, respectively). Longstanding DM and postoperative new onset DM had no impact on prognosis. Compared to cases without DM, patients with recent onset DM were more likely to have residual disease after surgery and to develop liver metastases during follow-up. Multivariate analysis confirmed recent onset DM was independently associated with PDAC relapse (hazard ratio 1.45 [1.06-1.99]).

CONCLUSION

Preoperative recent onset DM has an impact on survival after the resection of PDAC.

VNN1, a potential biomarker for pancreatic cancer-associated new-onset diabetes, aggravates paraneoplastic islet dysfunction by increasing oxidative stress

In our previous clinical microarray analysis, we were the first to report on Vanin-1 (VNN1) as a novel clinically derived biomarker of pancreatic cancer-associated new-onset diabetes (PCAND). The functional mechanisms of VNN1 in the pathogenesis of PCAND, however, are not completely understood. In the present study, we further extend our previous clinical study to include laboratory research. The functions and mechanisms of neoplastic overexpressed VNN1 in PCAND have been explored using a co-culture model. Furthermore, the serum concentrations and discrimination power of downstream molecules of VNN1 were tested in a PCAND cohort. Pancreatic ductal adenocarcinoma (PDA) overexpressed VNN1 further aggravates paraneoplastic islet dysfunction; decreases in GSH/PPAR-γ concentrations and increases in ROS/cysteamine might be primary cause of this effect. Clinical serum analyses revealed that the expression profiles of these molecules were aberrant in the PCAND group. Our results further demonstrated that PCAND is a type of paraneoplastic diabetes. As the only clinically derived biomarker for PCAND screening available today, the biological role of VNN1 in triggering oxidative stress within the pancreatic microenvironment is important. The molecules downstream of VNN1 are also potential biomarkers for PCAND screening.

Type 2 diabetes mellitus and risk of gallbladder cancer: a systematic review and meta-analysis of observational studies

AIMS

Increasing evidence suggests that a history of type 2 diabetes mellitus (type 2 DM) may be involved in the development of various sites of cancer. However, the association with risk of gallbladder cancer remains unclear.

METHODS

We identified studies by a literature search of MEDLINE and EMBASE through 31 August 2014 and by searching the reference lists of pertinent articles. All data were independently extracted by two investigators using a standardized data abstraction tool. Summary relative risks (SRRs) with 95% confidence intervals (CIs) were calculated with a random effects model.

RESULTS

A total of 20 studies (eight case-control studies and 12 cohort studies) were included in this meta-analysis. Analysis of these 20 studies found that compared with non-diabetic individuals, diabetic individuals had an increased risk of gallbladder cancer (SRR = 1.56, 95% CI: 1.36-1.79). There was evidence of moderate heterogeneity among these studies (p = 0.010 and I(2)  = 43.5%). This increased risk relationship is independent of smoking, body mass index and a history of gallstones. However, whether or not controlled for, alcohol use may be one of the potential confounders that significantly affect the association between type 2 DM and the risk of gallbladder cancer. Diabetic women and men had a similarly increased risk of gallbladder cancer associated with type 2 DM.

CONCLUSIONS

These findings of this systematic review indicate that compared with non-diabetic individuals, both men and women with type 2 DM had an increased risk of gallbladder cancer. Copyright © 2015 John Wiley & Sons, Ltd.

Risk Factors for Pancreatic Cancer in China: A Multicenter Case-Control Study

Background

Despite having one of the highest mortality rates of all cancers, the risk factors of pancreatic cancer remain unclear. We assessed risk factors of pancreatic cancer in China.

Methods

A case-control study design was conducted using data from four hospital-based cancer registries (Henan Provincial Cancer Hospital, Beijing Cancer Hospital, Hebei Provincial Cancer Hospital, and Cancer Hospital of Chinese Academy of Medical Sciences). Controls were equally matched and selected from family members of non-pancreatic cancer patients in the same hospitals. Face-to-face interviews were conducted by trained staff using questionnaires. Conditional logistic regression models were used to assess odd ratios (ORs) and 95% confident intervals (CIs).

Results

Among 646 recruited participants, 323 were pancreatic cancer patients and 323 were controls. Multivariate logistic analysis suggested that pancreatic cancer family history (adjusted OR 1.23; 95% CI, 1.11–3.70), obesity (adjusted OR 1.77; 95% CI, 1.22–2.57), diabetes (adjusted OR 2.96; 95% CI, 1.48–5.92) and smoking (adjusted OR 1.78; 95% CI, 1.02–3.10) were risk factors for pancreatic cancer, but that drinking tea (adjusted OR 0.49; 95% CI, 0.25–0.84) was associated with reduced risk of pancreatic cancer.

Conclusions

Cigarette smoking, family history, obesity, and diabetes are risk factors of pancreatic cancer, which is important information for designing early intervention and preventive strategies for pancreatic cancer and may be beneficial to pancreatic cancer control in China.

Quantification of diabetes comorbidity risks across life using nation-wide big claims data

Despite substantial progress in the study of diabetes, important questions remain about its comorbidities and clinical heterogeneity. To explore these issues, we develop a framework allowing for the first time to quantify nation-wide risks and their age- and sex-dependence for each diabetic comorbidity, and whether the association may be consequential or causal, in a sample of almost two million patients. This study is equivalent to nearly 40,000 single clinical measurements. We confirm the highly controversial relation of increased risk for Parkinson's disease in diabetics, using a 10 times larger cohort than previous studies on this relation. Detection of type 1 diabetes leads detection of depressions, whereas there is a strong comorbidity relation between type 2 diabetes and schizophrenia, suggesting similar pathogenic or medication-related mechanisms. We find significant sex differences in the progression of, for instance, sleep disorders and congestive heart failure in diabetic patients. Hypertension is a highly sex-sensitive comorbidity with females being at lower risk during fertile age, but at higher risk otherwise. These results may be useful to improve screening practices in the general population. Clinical management of diabetes must address age- and sex-dependence of multiple comorbid conditions.

Pancreatic cancer-improved care achievable

Pancreatic adenocarcinoma is one of the most aggressive cancers, and the decline in mortality observed in most other cancer diseases, has so far not taken place in pancreatic cancer. Complete tumor resection is a requirement for potential cure, and the reorganization of care in the direction of high patient-volume centers, offering multimodal treatment, has improved survival and Quality of Life. Also the rates and severity grade of complications are improving in high-volume pancreatic centers. One of the major problems worldwide is underutilization of surgery in resectable pancreatic cancer. Suboptimal investigation, follow up and oncological treatment outside specialized centers are additional key problems. New chemotherapeutic regimens like FOLFIRINOX have improved survival in patients with metastatic disease, and different adjuvant treatment options result in well documented survival benefit. Neoadjuvant treatment is highly relevant, but needs further evaluation. Also adjuvant immunotherapy, in the form of vaccination with synthetic K-Ras-peptides, has been shown to produce long term immunological memory in cytotoxic T-cells in long term survivors. Improvement in clinical outcome is already achievable and further progress is expected in the near future for patients treated with curative as well as palliative intention.