Kate McHenry BSN, RN3W Oncology Unit

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

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

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

Age Race/ethnicity Sex (men have a higher risk for both

cancer and diabetes) Obesity Physical activity Diet Alcohol Smoking

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.

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.

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)

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)

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%)

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

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

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

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

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

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

Hyperglycemia has been associated with increased hospital mortality in critically ill patients

New hyperglycemia in any serious ill patient results in poorer clinical outcomes

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

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

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