Claire F. Snyder

Long-term All-Cause Mortality in Cancer Patients With Preexisting Diabetes Mellitus: A Systematic Review and Meta-analysis

CONTEXT Diabetes mellitus appears to be a risk factor for some cancers, but the effect of preexisting diabetes on all-cause mortality in newly diagnosed cancer patients is less clear. OBJECTIVE To perform a systematic review and meta-analysis comparing overall survival in cancer patients with and without preexisting diabetes. DATA SOURCES We searched MEDLINE and EMBASE through May 15, 2008, including references of qualifying articles. STUDY SELECTION English-language, original investigations in humans with at least 3 months of follow-up were included. Titles, abstracts, and articles were reviewed by at least 2 independent readers. Of 7858 titles identified in our original search, 48 articles met our criteria. DATA EXTRACTION One reviewer performed a full abstraction and other reviewers verified accuracy. We contacted authors and obtained additional information for 3 articles with insufficient reported data. RESULTS Studies reporting cumulative survival rates were summarized qualitatively. Studies reporting Cox proportional hazard ratios (HRs) or Poisson relative risks were combined in a meta-analysis. A random-effects model meta-analysis of 23 articles showed that diabetes was associated with an increased mortality HR of 1.41 (95% confidence interval [CI], 1.28-1.55) compared with normoglycemic individuals across all cancer types. Subgroup analyses by type of cancer showed increased risk for cancers of the endometrium (HR, 1.76; 95% CI, 1.34-2.31), breast (HR, 1.61; 95% CI, 1.46-1.78), and colorectum (HR, 1.32; 95% CI, 1.24-1.41). CONCLUSIONS Patients diagnosed with cancer who have preexisting diabetes are at increased risk for long-term, all-cause mortality compared with those without diabetes.

Diabetes Mellitus and Breast Cancer Outcomes: A Systematic Review and Meta-Analysis

PURPOSE The goal of this study was to perform a systematic review and meta-analysis to examine the effect of pre-existing diabetes on breast cancer-related outcomes. METHODS We searched EMBASE and MEDLINE databases from inception through July 1, 2009, using search terms related to diabetes mellitus, cancer, and prognostic outcome. Studies were included if they reported a prognostic outcome by diabetes status, evaluated a cancer population, and contained original data published in the English language. We performed a meta-analysis of pre-existing diabetes and its effect on all-cause mortality in patients with breast cancer and qualitatively summarized other prognostic outcomes. RESULTS Of 8,828 titles identified, eight articles met inclusion/exclusion criteria and described outcomes in patients with breast cancer and diabetes. Pre-existing diabetes was significantly associated with all-cause mortality in six of seven studies. In a meta-analysis, patients with breast cancer and diabetes had a significantly higher all-cause mortality risk (pooled hazard ratio [HR], 1.49; 95% CI, 1.35 to 1.65) compared with their nondiabetic counterparts. Three of four studies found pre-existing diabetes to be associated with more advanced stage at presentation. Diabetes was also associated with altered regimens for breast cancer treatment and increased toxicity from chemotherapy. CONCLUSION Compared with their nondiabetic counterparts, patients with breast cancer and pre-existing diabetes have a greater risk of death and tend to present at later stages and receive altered treatment regimens. Studies are needed to investigate pathophysiologic interactions between diabetes and breast cancer and determine whether improvements in diabetes care can reduce mortality in patients with breast cancer.

Postoperative Mortality in Cancer Patients With Preexisting Diabetes Systematic review and meta-analysis

OBJECTIVE Diabetes appears to increase risk for some cancers, but the association between preexisting diabetes and postoperative mortality in cancer patients is less clear. Our objective was to systematically review postoperative mortality in cancer patients with and without preexisting diabetes and summarize results using meta-analysis. RSEARCH DESIGN AND METHODS We searched the Medical Literature Analysis and Retrieval System Online (MEDLINE) and Excerpta Medica Database (EMBASE) for articles published on or before 1 July 2009, including references of qualifying articles. We included English language investigations of short-term postoperative mortality after initial cancer treatment. Titles, abstracts, and articles were reviewed by at least two independent readers. Study population and design, results, and quality components were abstracted with standard protocols by one reviewer and checked for accuracy by additional reviewers. RESULTS Of 8,828 titles identified in our original search, 20 articles met inclusion criteria for qualitative systematic review. Of these, 15 reported sufficient information to be combined in meta-analysis. Preexisting diabetes was associated with increased odds of postoperative mortality across all cancer types (OR = 1.85 [95% CI 1.40–2.45]). The risk associated with preexisting diabetes was attenuated but remained significant when we restricted the meta-analysis to models that controlled for confounders (1.51 [1.13–2.02]) or when we accounted for publication bias using the trim and fill method (1.52 [1.13–2.04]). CONCLUSIONS Compared with their nondiabetic counterparts, cancer patients with preexisting diabetes are ∼50% more likely to die after surgery. Future research should investigate physiologic pathways to mortality risk and determine whether improvements in perioperative diabetes care can reduce postoperative mortality.

Does pre-existing diabetes affect prostate cancer prognosis? A systematic review.

To summarize the influence of pre-existing diabetes on mortality and morbidity in men with prostate cancer. We searched MEDLINE and EMBASE from inception through 1 October 2008. Search terms were related to diabetes, cancer and prognosis. Studies were included if they reported an original data analysis of prostate cancer prognosis, compared outcomes between men with and without diabetes and were in English. Titles, abstracts and articles were reviewed independently by two authors. Conflicts were settled by consensus or third review. We abstracted data on study design, analytic methods, outcomes and quality. We summarized mortality and morbidity outcomes qualitatively and conducted a preliminary meta-analysis to quantify the risk of long-term (>3 months), overall mortality. In total, 11 articles were included in the review. Overall, one of four studies found increased prostate cancer mortality, one of two studies found increased nonprostate cancer mortality and one study found increased 30-day mortality. Data from four studies could be included in a preliminary meta-analysis for long-term, overall mortality and produced a pooled hazard ratio of 1.57 (95% CI: 1.12–2.20). Diabetes was also associated with receiving radiation therapy, complication rates, recurrence and treatment failure. Our analysis suggests that pre-existing diabetes affects the treatment and outcomes of men with prostate cancer.

The role of informatics in promoting patient-centered care

Patient-centered care is an important aspect of high-quality care. Health informatics, particularly advances in technology, has the potential to facilitate, or detract from, patient-centered cancer care. Informatics can provide a mechanism for patients to provide their clinician(s) with critical information and to share information with family, friends, and other patients. This information may enable patients to exert greater control over their own care. Clinicians may use information systems (e.g., electronic medical records) to coordinate care and share information with other clinicians. Patients and clinicians may use communication tools and information resources to interact with one another in new ways. Caution in using new information resources is warranted to avoid reliance on biased or inappropriate data, and clinicians may need to direct patients to appropriate information resources. Perhaps the greatest challenge for both patients and providers is identifying information that is high quality and that enhances (and does not impede) their interactions.

How does initial treatment choice affect short-term and long-term costs for clinically localized prostate cancer?

Data regarding costs of prostate cancer treatment are scarce. This study investigates how initial treatment choice affects short‐term and long‐term costs.

Coordination of care in breast cancer survivors: an overview.

The number of breast cancer survivors in the United States is increasing. With longer survival, there has been an increase in the complexity and duration of posttreatment care. Multidisciplinary care teams are needed to participate across the broad spectrum of issues that breast cancer survivors face. In this setting, the need for well-established patterns of communication between care providers is increasingly apparent. We have created a multidisciplinary approach to the management of breast cancer survivors to improve communication and education between providers and patients. This approach could be extended to the care and management of survivors of other types of cancer.

Crossover from one aromatase inhibitor (AI) to another in the Exemestane and Letrozole Pharmacogenetics (ELPh) trial.

158 Background: Tolerance of AI therapy can be poor due to treatment-emergent toxicities and can lead to early discontinuation (non-persistence). Patients often switch from one AI to another when toxicities develop; however, limited prospective data exist on patients who switch AI. Here we describe the effect of switching from E to L or L to E on tolerance of and persistence with therapy. METHODS Postmenopausal women initiating AI therapy were enrolled on the ELPh trial and randomized to E or L. Those that stopped their AI for self-reported intolerance were offered crossover to alternate AI after a 2-6 week washout. Kaplan-Meier estimates of proportions on AI after 1, 3, and 6 months were assessed during 1st and 2nd AI. Associations between time on 2ndAI and clinicopathologic factors were analyzed using univariable Cox proportional hazards model. To evaluate effect of crossover on patient-reported outcomes, multiple questionnaires, including a pain visual analog scale (VAS), were assessed serially. RESULTS 83 women, mean age 60 years, 45% prior chemotherapy, and 31% with prior tamoxifen use, participated in the crossover protocol. 71% reported improvement in symptoms a mean 4.72 weeks after discontinuing 1st AI therapy. Median time on 1st AI was 6.8 months (95% CI 5.8-9 months), and on 2nd AI was 11.5 months (6.9-24.2). The probability of persistence at 1, 3, and 6 months for the 1st AI was 94%, 76%, and 55% and for the 2nd AI was 89%, 73%, and 62%, respectively. There was no significant association between duration on 2nd AI and 1st AI (L vs. E), duration on 1st AI, age, body mass index, or prior therapies. The change in pain VAS from baseline to 1 or 3 months was not significantly different during treatment with the 1st or 2ndAI. CONCLUSIONS Although all AI medications have similar mechanisms of activity, nearly two-thirds of patients who are intolerant of one AI are able to maintain therapy for at least 6 months following switch to 2nd AI. Switching is a reasonable approach for women who cannot tolerate 1st AI that may improve persistence with therapy. The mechanisms for intrapatient variation in tolerance warrant further study. CLINICAL TRIAL INFORMATION NCT00228956.

Making it work: Breast cancer survivorship care at Johns Hopkins.

61 Background: Breast cancer survivor numbers are increasing due to population aging and improved treatment outcomes but many of their long-term health care needs are unmet. Integrated follow-up care strategies that enhance care coordination, education, and access to survivorship resources are needed to provide patients with evidence-based care that addresses medical and psychosocial needs after cancer treatment. METHODS In 2008, we established the Johns Hopkins Breast Cancer Survivorship Program with representation from the Schools of Nursing, Public Health, and Medicine to address the needs of patients completing initial cancer treatment and transitioning to long-term follow-up. Patient educational resources were created within an interactive website ( http://bit.ly/hZfzFi ) including > 35 patient/provider educational video clips, blogs and social media. Activities including provider educational events, educational folders, and trainee curriculum additions have been ongoing. Starting May 2011, Hopkins patients were offered a one-time transition visit with a nurse practitioner focusing on individualized treatment summary/survivorship care plan activities (e.g., cancer screening/surveillance, medical intervention, psychosocial support, and care coordination with non-cancer providers). RESULTS Our website is averaging 3,000 hits monthly. We have participated in 22 provider/trainee formal educational presentations. In the pilot phase of these transition visits (n=40), age/race breakdown of participants were representative of our breast cancer population (median age 51, range 34-69; 17% African Americans). Our post-visit survey (n=37), 97% found the survivorship visit beneficial and all reported that this one-time consultation helped with transitioning away from treatment. CONCLUSIONS A multidisciplinary patient-centered approach to breast cancer survivorship allowed us to develop comprehensive clinical and educational service models to benefit patients and their cancer/non-cancer providers. This program aims to enhance education, overcome the fragmentation of the health care system, and improve overall health and wellness of breast cancer survivors as they transition to long-term survivorship.