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Diabetes and Cancer The 2013-14 Diabetes Algorithm
• Daniel Einhorn
• President, American College of Endocrinology • Medical Director, Scripps Whittier Diabetes Institute
• Clinical Professor of Medicine, UCSD
Links to websites • Diabetes and Cancer Consensus
Statement: https://www.aace.com/files/position-statements/revised-with-appendix.pdf
• AACE Comprehensive Diabetes Management Algorithm
Consensus Statement: https://www.aace.com/files/algorithm-07-11-2013.pdf
• Algorithm slides:
https://www.aace.com/files/aace_algorithm_slides.pptx
Diabetes and Cancer
Consensus Conference Endocrine Practice
• Epidemiology of the associations among obesity, insulin resistance, diabetes, and cancer
• Biologic links between diabetes and cancer
• Do diabetes treatments influence risk of cancer or its prognosis?
Obesity is linked to specific cancers
• Every year 100,500 new cases of cancer are caused by Obesity:
• Breast, 33,000. • Endometrial, 20,700 • Kidney, 13,900 • Colorectal, 13,200 • Pancreas, 11,900. • Esophagus, 5,800. • Gallbladder, 2,000. American Institute for Cancer Research: Reported USA TODAY 11-5-09
Cancer Deaths Associated with Obesity
Calle EE et al. N Engl J Med. 2003;348:1625-1638. Copyright © 2013 AACE. May not be reprinted in any form without express written permission from AACE.
Fasting Plasma Triglycerides and Premenopausal Breast Cancer Risk
• premenopausal women scheduled for breast surgery • biopsies classified according to level of breast cancer risk (NP, PDWA, AH/C’s, IC) • monotonic increase fasting TG with increasing risk level • 102 NP, 102 IC (N0)
Breast Cancer Risk According to Plasma TG
Quintile TG (mg/ml) RR Breast Cancer * (95% CI)
1 0.34-0.62 1.0 2 0.63-0.78 0.75 (0.31-1.90) 3 0.79-0.95 1.13 (0.45-2.84) 4 0.96-1.23 1.64 (0.64-4.20) 5 1.24-2.61 2.48 (0.91-6.75)
* age, weight adjusted, p=0.007
Goodwin PJ et al. Nutrition and Cancer 1997
Fasting Insulin and Breast Cancer Risk
• Case-control design • 99 premenopausal T1-3, N0-1, M0 BC • 99 age-matched premenopausal controls with non-proliferative breast biopsies
Insulin Quintile
Level (pmol/L)
Odds Ratio (95% CI) for Breast Cancer (age, weight adjusted)
I ≤ 35 1.0
II >35 - ≤41 1.19 (0.49 – 2.89) III >41 - ≤47 1.33 (0.53 – 3.35) IV >47 - ≤58 1.19 (0.48 – 2.93)
V >58 - ≤180 3.72 (1.32 – 10.5)
Del Giudice ME. Breast Cancer Res Treat. 1998;47:110-120.
P (insulin) = 0.02 (2-tail)
Copyright © 2013 AACE. May not be reprinted in any form without express written permission from AACE.
Mathieu et al. Proc Assoc Am Physicians. 1997 ;109(6):565-71
Insulin Receptor Expression and Breast Cancer Survival
Renehan AG et al. Lancet. 2008;371:569-578.
BMI & Cancer Risk (men)
Copyright © 2013 AACE. May not be reprinted in any form without express written permission from AACE.
BMI & Cancer Risk (women)
Renehan AG et al. Lancet. 2008;371:569-578. Copyright © 2013 AACE. May not be reprinted in any form without express written permission from AACE.
BMI & risk of second primary cancer
Druesne-Pecollo N et al. Breast Cancer Res Treat. 2012;135:647-654. Copyright © 2013 AACE. May not be reprinted in any form without express written permission from AACE.
BMI (post-diagnosis) & breast cancer
Niraula S et al. Breast Cancer Res Treat. 2012;134:769-781.
Breast cancer-specific survival
Copyright © 2013 AACE. May not be reprinted in any form without express written permission from AACE.
Diabetes and Cancer Mortality • Post-operative cancer patients with T2DM have ~85% higher
overall mortality compared to patients without T2DM – adjusted for confounders the increased mortality is ~50%
Barone BB et al. Diabetes Care. 2010;33:931-939. Copyright © 2013 AACE. May not be reprinted in any form without express written permission from AACE.
Glycemia-cancer relationship: Men
Stocks T et al., PLoS Medicine 2009;6: e1000201
Glycemia-cancer relationship: Women
Stocks T et al., PLoS Medicine 2009;6: e1000201
MOLECULAR MECHANISMS
Copyright © 2013 AACE. May not be reprinted in any form without express written permission from AACE.
How Can the Metabolic Syndrome, Obesity, and Type 2 Diabetes Affect Cancer Development and
Metastases?
Hyperinsulinemia Hyperglycemia Hyperlipidemia
Nutrients IGF-I Leptin Adiponectin Cytokines Chemokines Estrogen
Obesity Diabetes
Cancer
LeRoith D. Presented at: AACE Annual Meeting; May 2013. Copyright © 2013 AACE. May not be reprinted in any form without express written permission from AACE.
Normal
Initiation
Promotion Progression
Promotion
Initiation
Normal
Multistage Carcinogenesis
Adapted from: Hursting SD et al. JNCI. 1999;91:215-225. Abel EL et al. Nat Protoc. 2009;4:1350-1362.
Loeb LA et al. Cancer Res. 2008;68:6863-6872.
Study Subject Estimated Lag Time Mice 20 to 50 weeks Humans 20 to 50 years
Copyright © 2013 AACE. May not be reprinted in any form without express written permission from AACE.
Cellular Requirements for Tumor Biosynthesis
• Tumor cells depend on multiple energy sources not just glucose • Genetic mutations and altered metabolism also support tumor growth
Vander Heiden MG et al. Science. 2009;324:1029-1033. Christofk HR et al. Nature. 2008;452:230-233.
Copyright © 2013 AACE. May not be reprinted in any form without express written permission from AACE.
Insulin resistance ↑ Insulin
Blood and tissue: ↓ IGFBP-1
−IGF-1/2 serum and/or tissue bioavailability
Mammary epithelium: ↑↑↑ IR ↑ IGF-IR ↑ IR/IGF-IR
↑ IGF
↓ Apoptosis ↑ Proliferation
↑ Tumor development
IGF-IR
IR
IR/IGF-IR hybrids
from Derek LeRoith
Obesity, Insulin, and IGF-1 • Increased BMI has been directly related to increased insulin and
free insulin-like growth factor-1 (IGF-1) levels.
Roberts DL et al. Annu Rev Med. 2010;61:301-316. Copyright © 2013 AACE. May not be reprinted in any form without express written permission from AACE.
Pathways Linking Obesity with Breast Cancer
Dannenberg A. Presented at: AACE Consensus Conference on Diabetes and Cancer; September 2012. Copyright © 2013 AACE. May not be reprinted in any form without express written permission from AACE.
Potential Mechanisms Linking Diabetes and Cancer
Macrophage infiltration of adipose tissue IL-6, IL1-beta
Calle EE et al. Nat Rev Cancer. 2004;4:579-591. Copyright © 2013 AACE. May not be reprinted in any form without express written permission from AACE.
Insulin, Insulin-like Growth Factors, and Receptors
LeRoith D. Presented at: AACE Consensus Conference on Diabetes and Cancer; September 2012.
Metabolic Effects Cell Survival,
Growth, Proliferation
IGF-I Insulin
Insulin Receptor-A
ß ß
α α
ß ß
α α
Insulin Receptor-B
IGF-I Receptor
ß ß
α α
High expression in fetal and neoplastic
tissues
IGF-2
Copyright © 2013 AACE. May not be reprinted in any form without express written permission from AACE.
Indirect Effects
↑IGF-1 ↓IGFBP-1/2 ↑Aromatase
↓SHBG ↑Estrogen
Obesity ↑Inflammatory Adipokines; TNF, IL-6 ↓Protective Adipokines; Adiponectin
↑Glucose ↑Free fatty acids ↑Amino acids
↓AMP-kinase
↑Protein translation mTOR/p70S6K
Figure 2B
Hyperinsulinemia and Cancer (Indirect Effects)
Fantus IG. Presented at: AACE Consensus Conference on Diabetes and Cancer; September 2012. Copyright © 2013 AACE. May not be reprinted in any form without express written permission from AACE.
DIABETES MANAGEMENT & CANCER RISK
Copyright © 2013 AACE. May not be reprinted in any form without express written permission from AACE.
Copyright © 2013 AACE. May not be reprinted in any form without express written permission from AACE.
Metformin Associated with Lower Cancer Risk in Type 2 Diabetes
Diabetes Care 33:322-326, 2010
Metformin Associated with Lower Cancer Risk in Type 2 Diabetes
Diabetes Care 33:322-326, 2010
Effect of Metformin in WHI • Women’s Health Initiative
– No diabetes 2,926 – Diabetes metformin 104 – Diabetes other tx 129
• Hazard Ratio adjusting for age, first-
degree relative with breast cancer, benign breast disease, age at menarche, age at menopause, parity, age at first birth, education, No. of months of breastfeeding, smoking, alcohol consumption, body mass index, physical activity, duration of use of estrogen alone, duration of use of estrogen plus progesterone, bilateral oophorectomy, mammogram within 2 years of baseline
P=0.04
Chlebowski et al. J Clin Oncol 2012;30:2844
Metformin: esophageal adenocarcinoma pathologic complete response
Skinner et al. Acta Oncologica, 2012
TZD, metformin: prostate ca survival
He et al. Ann Oncol 2011;22:2640-5
Insulin Therapy and Cancer
Copyright © 2013 AACE. May not be reprinted in any form without express written permission from AACE.
Malignant Neoplasm in Diabetic Patients with Different Insulin Doses (Glargine vs. Human Insulin)
• N=127,031 T1 and T2 insulin-treated patients. 95,804 human insulin, 23,855 glargine, followed up to 4.4 years (mean 1.6 years), cancer-free in preceding 3 years.
Hemkens LG et al. Diabetologia. 2009;52:1732-1744.
Incidence per 1,000 patient-years (95% CI)
<20 U/d 20-40 U/d >40 U/d Glargine 18.6 (16.5-20.7) 20.3 (17.9-22.9) 52.6 (42.9-63.8) Human Insulin 17.3 (16.1-18.6) 23.6 (22.3-25.0) 31.0 (29.6-32.3)
Note high rates of new cancer in the study Copyright © 2013 AACE. May not be reprinted in any form without express written permission from AACE.
ORIGIN Trial Results
Presented at: 72nd Scientific Sessions of the American Diabetes Association, 2012. Copyright © 2013 AACE. May not be reprinted in any form without express written permission from AACE.
The ORIGIN Trial: Lack of Association of Insulin Glargine with Malignancy
Insulin Control P-value Cancer death 3.0% 3.0% N.S. Breast cancer 0.4% 0.4% N.S. Lung cancer 1.3% 1.1% N.S. Colon cancer 1.2% 1.1% N.S. Prostate cancer 2.1% 2.2% N.S. Melanoma 0.2% 0.3% N.S. Other cancer 3.7% 3.9% N.S. Total cancers 8.9% 9.0% N.S.
ORIGIN Trial Investigators, Gerstein HC et al. N Engl J Med. 2012;367:319-328.
N.S., not significant
Copyright © 2013 AACE. May not be reprinted in any form without express written permission from AACE.
Meta-analysis: Insulin Glargine and Cancer Risk
• Findings from an European Medicines Agency (EMA)-commissioned database study indicate significantly decreased risk of all cancer and prostate cancer (glargine vs. non-glargine use).
Boyle P et al. Presented at: 72nd Session of the American Diabetes Association. 2012. Poster 1332-P.
Cancer Type Cancer Incidence Summary Relative Risk
(95% CI) All cancer 0.90 (0.82 – 0.99) Colorectal 0.84 (0.74 – 0.95) Breast 1.11 (1.00 – 1.22) Prostate 1.30 (1.00 – 1.28)
Copyright © 2013 AACE. May not be reprinted in any form without express written permission from AACE.
Meta-analysis: Insulin Glargine and Cancer Risk
• Data from the Inovalon MORE 2 registry and the Kaiser Permanente Northern California (KPNC) database showed no significant increased risk of all cancer incidence (glargine vs. NPH use)
Sturmer T et al. Diabetes Care. 2013 July 22 [Epub ahead of print]. Habel L. Presented at: 72nd Session of the American Diabetes Association. 2012. CT-SY13.
Database All Cancer Incidence Hazard Ratio (95% CI)
Inovalon MORE 2 Registry
1.12 (0.95 – 1.32)
KPNC 0.90 (0.90 – 1.00)
Copyright © 2013 AACE. May not be reprinted in any form without express written permission from AACE.
GLP-1 Agonists and Calcitonin
Bjerre Knudsen L et al. Endocrinology. 2010;151:1473-1486. Hegedüs L et al. J Clin Endocrinol Metab. 2011;96:853-860.
• Plasma calcitonin levels did not increase in patients with T2DM treated with liraglutide or comparator for two years in the Phase III LEAD-2 & -3 trials (Figures A, B, and C)
• Plasma calcitonin also did not increase in LEAD-6 (liraglutide vs. exenatide BID)
Copyright © 2013 AACE. May not be reprinted in any form without express written permission from AACE.
Thyroid Neoplasms in RCTs
• No great disparity in the incidence of thyroid neoplasms has been observed between GLP-1 receptor agonists and placebo or active comparator.
GLP-1 Agonist Treatment Group Incidence Rate Liraglutide Liraglutide 1.3 cases per 1000 patient-years
Placebo 1.0 cases per 1000 patient-years Exenatide BID Exenatide BID 0.3 cases per 100 patient-years
Comparator 0 cases per 100 patient-years
Novo Nordisk. VICTOZA (liraglutide) U.S. Prescribing Information, April 2012. MacConell L et al. Diabetes Metab Syndr Obes. 2012;5:29-41.
BID, twice daily; GLP, glucagon-like peptide; RCT, randomized controlled trial
Copyright © 2013 AACE. May not be reprinted in any form without express written permission from AACE.
GLP-1 agonists increase β-cell mass in rodents
Spranger J et al. Gastroenterology. 2011;141:20-23. Copyright © 2013 AACE. May not be reprinted in any form without express written permission from AACE.
Do TZDs bladder cancer?
Colmers et al. CMAJ 2012; 184:E675-E683
Pioglitazone studies Rosiglitazone studies
i3 Database Analysis of Bladder Cancer and Nine Other Cancers: Overall Conclusions
• In a US population of T2DM adults > 45 years from the i3 InVision health claims database, the risk of bladder cancer with PIO is similar to that with Insulin
• The risk of developing nine other common cancers (prostate,
female breast, lung, pancreatic, endometrial, non-Hodgkin’s lymphoma, colorectal, kidney and malignant melanoma) associated with the use of PIO is 22% lower than the risk associated with the use of Insulin.
• Although a large number of covariates was used in the
models, residual confounders may potentially remain.
Perez A, et al. Presented at: 72nd Scientific Sessions of the American Diabetes Association. Philadelphia, PA. June 8-12, 2012. Abstract 930-P.
Cancer reporting from clinical trials
• Analyses of individual trials – ORIGIN – ADVANCE – PROACTIVE – RECORD – ADOPT
• Metaanalyses – Rosiglitazone metaanalysis – Intensive treatment trials metaanalysis
• Sample size considerations
CLINICAL IMPLICATIONS OF CANCERS IN OBESE & DIABETIC PATIENTS
1. ANNUAL MAMMOGRAM AND RELATED BREAST SCREENING FOR BREAST CANCER BY AGE 40 2. PATIENTS WITH PCOS, MAY REQUIRE EARLIER CANCER SCREENING, PERHAPS AS SOON AS AGE 30 .
3. EARLIER SCREENING COLONOSCOPY SHOULD BE ENCOURAGED BY AGE 40. 4. REGULAR SKILLED SKIN EVALUATIONS
5. IN PATIENTS WITH MALIGNANCIES IN CERTAIN ORGANS, THOSE ANTI-DIABETIC AGENTS WHICH MAY BE ASSOCIATED WITH EXCESS MALIGNANCY RISK IN THOSE ORGANS SHOULD BE AVOIDED.
6. PATIENTS WITH DIABETES UNDERGOING TREATMENT FOR MALIGNANCIES SHOULD HAVE RIGOROUS DIABETES CONTROL. FOR PATIENTS IN-HOSPITAL, AGGRESSIVE GLYCEMIC MANAGEMENT HAS BEEN ASSOCIATED WITH IMPROVED OUTCOMES.
And There is Still More for 2014-15
• Cancer • Sleep apnea • Depression • Dental disease • Osteoporosis • Fatty Liver Disease • Dementia of Multiple Etiologies
Agenda
• Diabetes and Cancer
• New Diabetes Treatment Algorithm
• New Class of Diabetes Medication
The Role of SGLT-2 Inhibitors in the Management of Patients
with Type 2 Diabetes
January 10, 2013 FDA Advisory Committee Recommends Approval of Canagliflozin for Treatment of Adults with Type 2 Diabetes
http://pharmalive.com/News/index.cfm (accessed 1/14/2013)
SGLT-2 Inhibitor – kidney is target organ Renal glucose reabsorption
Glucose
Proximal tubule
S1 segment
SGLT2 ~90%
glucose reabsorption
SGLT-1 ~10%
glucose reabsorption
S3 segment
Collecting ducts
SGLT-2 Inhibitor – Mechanism of Action
Glucose
SGLT-2
Inhibitors
Glucosuria Loss
of calories
Qualities that Make these Clinically Attractive
• 1) one tablet • 2) once daily • 3) anytime (AM recommended) • 4) lower BG as well as any pill • 5) no hypoglycemia • 6) weight loss (3-5% body weight) • 7) blood pressure lowering • 8) non-insulin-dependent MOA • 9) minimal LDL and no TG elevation
Qualities that Make them Less Attractive
• 1) bladder and genital infections • 2) dehydration/hypotension • 3) need good renal function • 4) insurance hassles of being new • 5) the unknowns with a new med • 6) ? bladder cancer signal with dapa • 7) LDL elevation (2-3 mg/dl)
A1c Lowering: Canagliflozin vs Sitagliptin
*P˂.001 vs. placebo calculated using LS means Rosenstock J, et al. Abstract 77-OR. ADA 2010.
Metformin + Canagliflozin Dose-Ranging Study Mean Baseline
A1C (%) 7.71 8.01 7.81 7.57 7.70 7.71 7.62
*
*
*
* *
*
Weight Loss: Canagliflozin vs Sitagliptin
Metformin + Canagliflozin Dose-Ranging Study
*P˂.001 vs. placebo calculated using LS means Rosenstock J, et al. Abstract 77-OR. ADA 2010.
Mean Baseline Weight (kg)
* *
*
*
*
*
*
*
* *
*
*
85.5 87.5 87.7 87.7 87.8 86.3 87
Stenlöf et al, Diabetes Obes Metab. 2012 Dec 26. [Epub ahead of print]
Canagliflozin monotherapy vs Placebo in Patients with T2D – Effect on A1c
Stenlöf et al, Diabetes Obes Metab. 2012 Dec 26. [Epub ahead of print]
Canagliflozin monotherapy vs Placebo in Patients with T2D - % to goal and PPG
Stenlöf et al, Diabetes Obes Metab. 2012 Dec 26. [Epub ahead of print]
Canagliflozin monotherapy vs Placebo in Patients with T2D
Weight Change
Canagliflozin Trials • Symptomatic genital infections in 3-8% canagliflozin arms
– 2% placebo – 2% SITA
• Urinary tract infections in 3-9% canagliflozin arms
– 6% placebo – 2% SITA
• Hypoglycemia in 0-6% canagliflozin arms
– 2% placebo – 5% SITA
Rosenstock J, et al. Abstract 77-OR. ADA 2010.
Sodium–glucose cotransporter 2 (SGLT2) is the major cotransporter involved in reabsorption of filtered glucose in the tubular nephron of the kidney
Chronic hyperglycaemia in patients with diabetes mellitus might upregulate glucose reabsorption in the kidneys above normal levels
SGLT2 inhibitors lower the threshold for glycosuria by lowering the maximum transport capacity or, more likely, by reducing the affinity of the transporter for glucose without causing hypoglycaemia
SGLT2 inhibitors cause proximal diuresis and calorie leakage into the urine; therefore, the benefits of these agents could include blood pressure lowering and weight control
Increased risk of genitourinary infections is a consistent adverse effect of SGLT2 inhibitors
SUMMARY: SGLT2 INHIBITION IN DIABETES
Perspectives on SGLT2 Inhibition
• Concerns – Polyuria – Electrolyte disturbances – Bacterial urinary tract
infections – Fungal genital infections – Malignancies (?)
• Advantages – Improved glycemic
control – Weight loss (75g urine
glucose = 300kcal/d) – Low risk of hypoglycemia – Blood pressure lowering – One pill once daily
Summary of Diabetes Trifecta 2013 • Diabetes and Cancer
– Diabetes = more and worse cancer – Diabetes treatments likely don’t cause cancer
• New Diabetes Control Algorithm
– Incorporates pre-diabetes, obesity, and insulin – Prescriptive statemenst of what to use, when, and how
• New Class of Agents to Treat Diabetes
– Simple, effective, weight loss, no hypos, compatible – But new always brings hassles and risks – we’ll see