Diabetes and Cancer: A parallel diagnosis

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Diabetes and Cancer A parallel diagnosis

• Kate McHenry BSN, RN
• 3W Oncology Unit

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To Be Discussed

• Overview of diabetes, cancer, and interactions
  between the two
• Increased risk of certain cancers with the
  comorbid condition of diabetes
• Glucose control in the management of diabetes in
  patients with cancer
• Cancer treatment and side effects in patient with
  diabetes

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Diabetes and cancer are two of the top three
killers in the United States
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DIABETES

• 8 of the U.S. population (or 25.8 million
  people) have diabetes
• One in three people born in the U.S. in 2000 are
  projected to develop diabetes at some point in
  their lifetime

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CANCER

• One in four deaths in the U.S. is caused by
  cancer
• Most common and fatal cancers in men include
  prostate, lung, bronchus, colorectal
• Most common and fatal cancers in women include
  lung, breast, colorectal
• The GOOD NEWS the number of people becoming
  long-term survivors is increasing
• The BAD NEWS a greater number of patients will
  have to face the challenge of living with both
  cancer and diabetes

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Is there really a link between diabetes and
cancer?
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Risk factors in cancer and diabetes

• Age
• Race/ethnicity
• Sex (men have a higher risk for both cancer and
  diabetes)
• Obesity
• Physical activity
• Diet
• Alcohol
• Smoking

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Diabetes causes cancer?

• Many cells in the body have surface receptors for
  insulin and insulin-like growth factors that have
  been shown in lab tests to stimulate the growth
  and metastasis of cancer cells.
• About half of Type 2 diabetes and all Type 1's
  take insulin daily, and their blood-insulin
  levels spike higher than normal.
• Diabetic patients also have episodes of higher
  than normal blood sugar, which may promote cell
  cancer growth.

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Cancer Survival
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Hyperglycemia causes increased risk for
infection, and higher rates of cancer recurrence
and mortality
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• Diabetics are twice as likely to get cancer of
  the liver, pancreas and uterine lining. Their
  risk of colon, breast, and bladder cancer is 20
  to 50 percent higher than non-diabetics'.
• There doesn't seem to be any higher risk for
  other cancers, such as lung cancer.
• The risk of prostate cancer is actually lower
  among diabetics.

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Colorectal Cancer

• Elevated postprandial insulin have shown to
  increase colorectal cancer risk (Meyerhardt et
  al, 2003)
• Several studies show that patients with diabetes
  and stage II and III colon cancer had
  significantly higher rates of overall mortality
• Patients with diabetes often have delayed stool
  transit and gastrointestinal abnormalities, which
  are associated with colorectal cancer (Will et
  al, 1998)

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Breast Cancer

• Women with the highest fasting insulin levels had
  two-fold increased risk of distant cancer
  recurrence and three-fold increased risk of death
  compared to those with lower insulin levels
  (Coughlin et al, 2004, Goodwin et al, 2002)

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• In a study (Weiser, et al 2004), the complete
  remission duration, survival, and
  treatment-related complications were compared in
  patients with and without hyperglycemia
• Patients with hyperglycemia had shorter complete
  remission (24 versus 52 months)
• Shorter median survival (29 versus 88 months)
• More likely to develop a complicated infection
  (39 versus 25)

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So is there a link between cancer and diabetes?

• Yes and No
• Studies remain inconclusive on the connection
• A link appears to be more prevalent between
  diabetes and certain cancers, i.e. breast and
  colon
• There appears to be enough of a connection to
  warrant consideration when treating a patient
  with this dual diagnosis

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Caring for patients with both diabetes and cancer
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Complications from elevated blood glucose

• Macrovascular injury to the large blood vessels
  of the heart and brain, most commonly occur in
  coronary arteries and large vessels of the legs
  CAD, atherosclerosis
• Microvascular injury to capillaries throughout
  the body, to organs such as the eyes and kidneys,
  retinopathy, nephropathy
• Neurologic neuropathy

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Patients with diabetes and chemotherapy treatments

• Pre-existing renal, cardiac, or neuropathic
  complications
• Chemotherapy agents exacerbate these
  complications
• Cisplatin causes renal insufficiency
• Anthracyclines cause cardiotoxicity
• Cisplatin, pacitaxel, vincristine are neurotoxic
• Many of these side effects are permanent and
  irreversible, and diabetics have underlying
  predisposition

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Hyperglycemia and Cancer Treatment
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Chemotherapy

• Chemotherapy is the leading treatment option
  available for cancer
• Chemotherapy can alter glucose metabolism
  Androgen suppression therapy, used in patients
  with prostate cancer, affects insulin resistance
  and increase diabetes or hyperglycemia

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• Supportive medications, high-dose steroids,
  elevated blood glucose
• Steroids induce a hypermetabolic state by
  decreasing glucose uptake, increased hepatic
  glucose production, and inhibiting insulin
  release
• So, glucocorticoids increase postprandial
  hyperglycemia, and fasting hyperglycemia
• Induction of chemotherapy treatment is often
  preceded with steroid therapy, this can cause a
  patient already predisposed to diabetes to
  progress to type 2

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Managing hyperglycemia in patients on
glucocorticoids

• Patients with pre-existing diabetes may be kept
  on their oral hypoglycemic agents and monitored
  carefully. However, these agents are usually
  inadequate for managing hyperglycemia
• These patients may require two to three times
  their usual dose(s) of insulin.
• Insulin is the preferred drug for managing
  steroid-induced or exacerbated hyperglycemia in
  patients with known diabetes. Many patients will
  require basal and prandial bolus insulins to
  attain adequate glycemic control

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• Hyperglycemia has been associated with increased
  hospital mortality in critically ill patients
• New hyperglycemia in any serious ill patient
  results in poorer clinical outcomes

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Nausea and Vomiting

• Nausea and vomiting are common adverse reactions
  to chemotherapy
• Patients with diabetes should be assessed
  frequently for nausea and vomiting, hydration
  status, ability to eat and drink, and level of
  glycemic control

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Conclusions

• Both diabetes and cancer are complex diseases
  that require careful management
• When a patient is diagnosed with both diseases,
  there may be a connection, and patient care
  becomes even more complicated
• A well developed understanding of both diseases,
  and the possible connections between the two, can
  lead to better patient care and better
  potentially patient outcomes

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• Center for Disease Control and Prevention CDC,
  2011
• December 2011, Volume 15, Number 6, Clinical
  Journal of Oncology Nursing
• Clinical Journal of Oncology Nursing, Volume 13,
  Number 2, Diabetes Management and Self-Care
  Education
• Diabetes and Cancer A Consensus Report 2010
  American Diabetes Association and the American
  Cancer Society
• Diabetes Spectrum, Volume 19, Number 3, 2006
  Clinical Challenges in Caring for Patients with
  Diabetes and Cancer