Diabetes, diabetes treatment and breast cancer prognosis A Prospective Study of the Associations Between Treated Diabetes and Cancer Outcomes Intensive glucose control and risk of cancer in patients with type 2 diabetes Diabetes and mortality in men with locally advanced prostate cancer: RTOG 92-02. Diabetes is associated with increased perioperative mortality but equivalent long-term outcome after hepatic resection for colorectal cancer Associations of type 2 diabetes and diabetes treatment with breast cancer risk and mortality: a population-based cohort study among British women Time-varying incidence of cancer after the onset of type 2 diabetes: evidence of potential detection bias The Clinical Significance of an Elevated Postoperative Glucose Value in Nondiabetic Patients after Colorectal Surgery: Evidence for the Need for Tight Glucose Control? Prospective study of adult onset diabetes mellitus (type 2) and risk of colorectal cancer in women. Diabetes and pancreatic cancer survival: a prospective cohort-based study Type 2 diabetes and subsequent incidence of breast cancer in the Nurses' Health Study. Five-year outcomes of patients with type 2 diabetes who underwent laparoscopic adjustable gastric banding. Diabetes and endometrial cancer in the Iowa women's health study. Intensive Intraoperative Insulin Therapy versus Conventional Glucose Management during Cardiac Surgery Diabetes mellitus as a predictor of cancer mortality in a large cohort of US adults. Type 2 diabetes mellitus and medications for type 2 diabetes mellitus are associated with risk for and mortality from cancer in a German primary care cohort. Associations of mortality and diabetes complications in patients with type 1 and type 2 diabetes: early treatment diabetic retinopathy study report no. 27.
The objectives of this study are to assess the impact of pre-existing diabetes and diabetes treatment on breast cancer prognosis . 8,108 women with central ly confirmed invasive breast cancer in the Women ’s Health Initiative diagnosed between 1998 and 2013 were followed through the date of death or September 20 , 2013 . Information on diabetes and diabetes therapy were obtained via self-report and face-to-face review of current medication containers , respectively . Cox proportional hazard regression was used to estimate adjusted relative hazard ratios for overall mortality . The proportional subdistribution hazard model was used to estimate hazard ratios for breast cancer-specific mortality . Compared with women without diabetes , women with diabetes had significantly increased risk of overall mortality ( HR 1.26 95 % CI 1.06–1.48 ) , especially among those who took insulin or had longer duration of diabetes . However , diabetes was not associated with increased risk of breast cancer-specific mortality , regardless of type of treatment and duration of diabetes , despite the significant association of diabetes with unfavorable tumor characteristics . Our large prospect i ve cohort study provides additional evidence that pre-existing diabetes increases risk of total mortality among women with breast cancer . The increased total mortality associated with diabetes was mainly driven by increased risk of dying from diseases other than breast cancer . Thus , the continuum of care for breast cancer patients with diabetes should include careful attention to CVD risk factors and other non-cancer conditions OBJECTIVE To quantify the association of treated diabetes with cancer incidence and cancer mortality as well as cancer case fatality and all-cause mortality in adults who subsequently develop cancer and to calculate attributable fractions due to diabetes on various cancer outcomes . RESEARCH DESIGN AND METHODS Prospect i ve data on 599 diabetic and 17,681 nondiabetic adults from the CLUE II ( Give Us a Clue to Cancer and Heart Disease ) cohort in Washington County , Maryl and , were analyzed . Diabetes was defined by self-reported use of diabetes medications at baseline . Cancer incidence was ascertained using county and state cancer registries .  Mortality data were obtained from death certificates . RESULTS From 1989 to 2006 , 116 diabetic and 2,365 nondiabetic adults developed cancer , corresponding to age-adjusted incidence of 13.25 and 10.58 per 1,000 person-years , respectively . Adjusting for age , sex , education , BMI , smoking , hypertension treatment , and high cholesterol treatment using Cox proportional hazards regression , diabetes was associated with a higher risk of incident cancer ( hazard ratio 1.22 [ 95 % CI 0.98–1.53 ] ) and cancer mortality ( 1.36 [ 1.02–1.81 ] ) . In individuals who developed cancer , adults with diabetes had a higher risk of cancer case fatality ( 1.34 [ 1.002–1.79 ] ) and all-cause mortality ( 1.61 [ 1.29–2.01 ] ) . For colorectal , breast , and prostate cancers , the attributable fractions result ing from diabetes were larger for cancer fatality and mortality than cancer incidence . CONCLUSIONS In this prospect i ve cohort , diabetes appears to exert a greater influence downstream on the risk of mortality in people with cancer than on upstream risk of incident cancer Aims /hypothesisType 2 diabetes has been associated with an increased risk of cancer . This study examines the effect of more vs less intensive glucose control on the risk of cancer in patients with type 2 diabetes . Methods All 11,140 participants from the Action in Diabetes and Vascular Disease : Preterax and Diamicron-MR Controlled Evaluation ( ADVANCE ) trial ( Clinical Trials.gov NCT00145925 ) were studied . Cancer incidence and cancer mortality was compared in groups r and omised to intensive or st and ard glucose control . Information on events during follow-up was obtained from serious adverse event reports and death certificates . HRs ( 95 % CI ) were calculated for all cancers , all solid cancers , cancer deaths and site-specific cancers . Results After a median follow-up of 5 years , 363 and 337 cancer events were reported in the intensive and st and ard control groups , respectively ( incidence 1.39/100 person-years [ PY ] and 1.28/100 PY ; HR 1.08 [ 95 % CI 0.93–1.26 ] ) . The incidences of all solid cancers and cancer deaths were 1.25/100 PY and 0.15/100 PY in the intensive group and 1.15/100 PY and 0.13/100 PY in the st and ard group ( HR 1.09 [ 95 % CI 0.93–1.27 ] for solid cancers , and 1.17 [ 0.75–1.84 ] for cancer death ) . Across all the major organ systems studied , no significant differences in the cancer incidences were observed in the intensive and st and ard control groups . Conclusions /interpretationsMore intensive glucose control achieved with a regimen that included greater use of gliclazide , insulin , metformin and other agents , did not affect the risk of cancer events or death in patients with type 2 diabetes PURPOSE Diabetes is associated with lower risk of prostate cancer . Most men with diabetes are obese , and obesity is associated with greater prostate cancer mortality . Whether diabetes influences outcomes after prostate cancer diagnosis is unknown . PATIENTS AND METHODS We assessed the relationship between prevalent diabetes and mortality using data from Radiation Therapy Oncology Group Protocol 92 - 02 , a large r and omized trial of men ( N = 1,554 ) treated with radiation therapy and short-term versus long-term adjuvant goserelin for locally advanced prostate cancer . Regression and proportional hazard models were performed to evaluate relationships between prevalent diabetes and all-cause mortality , prostate cancer mortality , and non-prostate cancer mortality . Covariates included age , race , tumor stage , Gleason score , prostate-specific antigen , weight , and treatment arm . RESULTS There were a total of 765 deaths ; 210 ( 27 % ) were attributed to prostate cancer . In univariate analyses , prevalent diabetes was associated with greater all-cause mortality and non-prostate cancer mortality but not prostate cancer mortality . After controlling for other covariates , prevalent diabetes remained significantly associated with greater all-cause mortality and non-prostate cancer mortality ( hazard ratio [ HR ] = 2.12 ; 95 % CI , 1.69 to 2.66 ; P < .0001 ) but not prostate cancer mortality ( HR = 0.80 ; 95 % CI , 0.51 to 1.25 ; P = .34 ) . In contrast , weight was associated with greater prostate cancer mortality ( HR = 1.77 ; 95 % CI , 1.22 to 2.55 ; P = .002 ) but not all-cause or non-prostate cancer mortality . CONCLUSION Weight but not prevalent diabetes is associated with greater prostate cancer mortality in men receiving combined modality treatment for locally advanced disease . These observations suggest that the association between obesity and greater prostate cancer mortality is mediated by mechanism(s ) other than the characteristic metabolic alterations of diabetes Diabetes is associated with alterations in liver metabolism and immune response that may influence post-operative recovery and long-term survival after hepatectomy for cancer . Patients with type I or type II diabetes mellitus su bmi tted to a potentially curative hepatic resection for metastatic colorectal cancer were identified from the prospect i ve data base , and compared with patients with hepatic colorectal metastases su bmi tted to resection during the same time interval , but without diabetes mellitus . Data on operative morbidity and mortality and long-term survival were analyzed . Between December 1990 and July 1999 , a total of 727 patients underwent hepatic resection , 61 of whom ( 8.1 % ) had type I and type II diabetes mellitus .  Operative mortality in the diabetic patients was significantly greater than in nondiabetic patients ( 8 % vs. 2 % , P < 0.02 ) . Among patients with diabetes mellitus , four of the five perioperative deaths were due to liver failure after major hepatic resection ( lobectomy or greater ) . All four of these patients had significant parenchymal abnormality ( three with steatosis ) . Long-term survival was identical to that in nondiabetic control subjects . We conclude that the presence of diabetes is associated with a higher incidence of perioperative mortality . In patients with diabetes mellitus and parenchymal steatosis , major hepatic resection should be undertaken with caution Purpose There is great interest in whether type 2 diabetes and its treatments alter breast cancer risk and prognosis , but previous studies are inconclusive . We conducted a cohort study within the UK General Practice Research Data base to investigate associations of type 2 diabetes and patterns of diabetes treatment with breast cancer risk and all-cause mortality . Methods We identified 52,657 women with type 2 diabetes , diagnosed between 1987 and 2007 , and 30,210 r and omly selected women without diabetes . We performed a time-dependent analysis using Cox proportional hazards models . Results Diabetes was associated with a 29 % increased overall breast cancer risk ( 95 % CI : 1.16–1.44 ) , but the association markedly attenuated when adjusted for age , period of cohort entry , region , and body mass index ( BMI ) ( HR : 1.12 ; 95 % CI : 0.98–1.29 ) . Women with breast cancer and pre-existing diabetes had a 49 % ( 95 % CI : 1.17–1.88 ) increased all-cause mortality risk compared with women with breast cancer but without diabetes , after controlling for age , period , region , BMI , smoking , alcohol , and deprivation . Compared with sulfonylurea , we found weak evidence that metformin monotherapy ( HR : 1.04 ; 95 % CI : 0.79–1.37 ) and insulin ( HR : 1.33 ; 95 % CI : 0.63–2.83 ) modified breast cancer risk among women with diabetes . Conclusions We found weak evidence that diabetes is associated with a small increased risk of breast cancer . Among treated women , there is no evidence that anti-diabetes treatments modify the risk of developing breast cancer , with wide confidence intervals indicating imprecise effect estimates . Women with breast cancer and diabetes , however , had an increased all-cause mortality risk highlighting the potential importance of maintaining adequate glycemic control alongside anti-cancer treatments and subsequent follow-up Aims /hypothesisDespite the vast body of epidemiological literature on the risk of  cancer in people with diabetes , few studies have examined the pattern of cancer risk during different time windows following diabetes onset . The objective of the study was to examine the risks of site-specific cancer in people with incident type 2 diabetes during different time windows following diabetes onset . Methods This was a population -based retrospective cohort study . The study period was 1 April 1994 to 31 March 2006 ; censoring occurred at 31 March 2006 , at death or on departure from British Columbia , Canada . Using linked health data bases , we identified incident cohorts with and without diabetes , who were matched by age , sex and index year . Following a minimum 2-year cancer washout period , first site-specific cancers were identified prospect ively in both cohorts . Results Within 3 months following diabetes onset , participants with diabetes had significantly increased risks of colorectal , lung , liver , cervical , endometrial , ovarian , pancreatic and prostate cancers . After the initial 3-month period , the risks for colorectal ( HR 1.15 , 95 % CI 1.05 , 1.25 ) , liver ( HR 2.53 , 95 % CI 1.93 , 3.31 ) and endometrial ( HR 1.58 , 95 % CI 1.28 , 1.94 ) cancers remained significantly elevated compared with those without diabetes . The diabetes cohort remained at increased risk of pancreatic cancer in later years , but followed a different pattern : HR 3.71 at 3 months–1 year , 2.94 at 1–2 years , 1.78 at 2–3 years and 1.65 at 3–10 years ( p value for all < 0.01 ) . After an initial period of elevated risk , men with type 2 diabetes subsequently had a decreased risk of prostate cancer ( HR 0.82 , 95 % CI 0.76 , 0.88 ) . Conclusions /interpretationPeople with type 2 diabetes are at increased risk of select cancers ; this risk is particularly elevated at the time of diabetes onset , which is likely to be due to increased ascertainment Objectives : To evaluate the significance of hyperglycemia in patients without a preoperative diagnosis of diabetes undergoing elective colorectal surgery . Methods : Preoperative and all postoperative blood glucose measurements were retrieved for 2628 consecutive patients undergoing elective colorectal resection within 2 years at 1 center . Nondiabetic patients were identified as those without a preoperative diagnosis of diabetes and /or based on HbA1C levels . The association between any elevated postoperative r and om glucose value ( hyperglycemia : > 125 mg/dL ) and level of elevation ( > 125 mg/dL or > 200 mg/dL ) within 72 hours of surgery in nondiabetic patients with 30-day mortality and infectious and noninfectious complications was assessed . Results : Evaluation of 16,404 postoperative glucose measurements for all 2447 nondiabetic patients who underwent surgery in 2010 and 2011 revealed that 66.7 % patients experienced hyperglycemia . Degree of hyperglycemia correlated with increasing American Society of Anesthesiologists class and surgical severity ( blood loss ) . Hyperglycemia was associated with infectious and noninfectious complications and mortality , the rates of these complications increasing parallel to the degree of hyperglycemia . Hyperglycemia was independently associated with septic complications ( P = 0.024 ) . Conclusions : Postoperative hyperglycemia is frequent after elective colorectal surgery in nondiabetic patients . Even a single postoperative elevated glucose value is adversely associated with morbidity and mortality ; this risk is related to the degree of glucose elevation . These findings strongly support monitoring of glucose values and early consideration of management strategies for glycemic control after surgery even in nondiabetic patients BACKGROUND The remarkable similarity of lifestyle and environmental risk factors for type 2 ( non-insulin-dependent ) diabetes mellitus and colon cancer has led to the hypothesis that diabetes may increase the risk of this cancer . We prospect ively examined the relationship between diabetes and risk of colorectal cancer in a cohort of 118403 women aged 30 through 55 years who were without previously diagnosed cancer at baseline in 1976 . METHODS The women , who were enrolled in the Nurses ' Health Study , were assessed for history of diabetes at baseline and during follow-up by use of biennial question naires . Self-reported diabetes was vali date d by information obtained from a supplemental question naire on symptoms and treatment and was confirmed by medical record review in a sample of the participants . Incident cases of colorectal cancer were ascertained through medical record review . All reported P values are two-sided . RESULTS During 18 years of follow-up ( 201061 person-years ) , we documented 892 new cases of colorectal cancer . After adjustment for age , body mass index ( weight in kg/height in m2 ) , physical activity , and other covariates , relative risks ( RRs ) were 1.43 ( 95 % confidence interval [ CI ] = 1.10 - 1.87 ; P = .009 ) for colorectal cancer , 1.49 ( 95 % CI = 1.09 - 2.06 ; P = .01 ) for colon cancer , 1.11 ( 95 % CI = 0.56 - 2.21 ; P = .76 ) for rectal cancer , 1.56 ( 95 % CI = 1.07 - 2.28 ; P = .02 ) for advanced colorectal cancer , and 2.39 ( 95 % CI = 1.46 - 3.92 ; P = .0005 ) for fatal colorectal cancer . CONCLUSION Our data provide support for the hypothesis that diabetes is associated with an increased risk of colorectal cancer in women Background : Diabetes is a risk factor for pancreatic cancer but its association with survival from pancreatic cancer is poorly understood . Our objective was to investigate the association of diabetes with survival among pancreatic cancer patients in a prospect i ve cohort-based study where diabetes history was ascertained before pancreatic cancer diagnosis . Methods : We evaluated survival by baseline ( 1993–2001 ) self-reported diabetes history ( n=62 ) among 504 participants that developed exocrine pancreatic cancer within the Prostate , Lung , Colorectal , and Ovarian ( PLCO ) Cancer Screening Trial .  Hazard ratios ( HRs ) and 95 % confidence intervals ( CIs ) for mortality were estimated using Cox proportional hazards model , adjusted for age , sex , body mass index , race , smoking , and tumour stage ( local , locally advanced , and metastatic ) . Results : The multivariable-adjusted HR for mortality comparing participants with diabetes to those without was 1.52 ( 95 % CI=1.14–2.04 , P-value < 0.01 ) . After excluding those diagnosed with pancreatic cancer within 3 years of study enrolment , HR for mortality among those with diabetes was 1.45 ( 95 % CI=1.06–2.00 , P-value=0.02 ) . Conclusions : Using prospect ively collected data , our findings indicate that diabetes is associated with worse survival among patients with pancreatic cancer OBJECTIVE Hyperinsulinemia may promote mammary carcinogenesis . Insulin resistance has been linked to an increased risk of breast cancer and is also characteristic of type 2 diabetes . We prospect ively evaluated the association between type 2 diabetes and invasive breast cancer incidence in the Nurses ' Health Study . RESEARCH DESIGN AND METHODS A total of 116,488 female nurses who were 30 - 55 years old and free of cancer in 1976 were followed through 1996 for the occurrence of type 2 diabetes and through 1998 for incident invasive breast cancer , verified by medical records and pathology reports . RESULTS During 2.3 million person-years of follow-up , we identified 6,220 women with type 2 diabetes and 5,189 incident cases of invasive breast cancer . Women with type 2 diabetes had a modestly elevated incidence of breast cancer ( hazard ratio [ HR ] = 1.17 ; 95 % CI 1.01 - 1.35 ) compared with women without diabetes , independent of age , obesity , family history of breast cancer , history of benign breast disease , reproductive factors , physical activity , and alcohol consumption . This association was apparent among postmenopausal women ( 1.16 ; 0.98 - 1.62 ) but not premenopausal women ( 0.83 ; 0.48 - 1.42 ) . The association was predominant among women with estrogen receptor-positive breast cancer ( 1.22 ; 1.01 - 1.47 ) . CONCLUSIONS Women with type 2 diabetes may have a slightly increased risk of breast cancer BACKGROUND Evidence of the positive effects of gastric b and ing on patients with diabetes has continued to increase . The long-term follow-up of such patients , however , has been limited . The purpose of the present study was to provide the long-term outcomes of patients with diabetes undergoing laparoscopic adjustable gastric b and ing at our institution . METHODS From January 2002 through June 2004 , 102 patients with type 2 diabetes mellitus underwent laparoscopic adjustable gastric b and ing .  The study parameters included preoperative age , gender , race , body mass index , duration of diabetes before surgery , fasting glucose level , hemoglobin A1c ( HbA1c ) , and medications used . Preoperative data from all patients were collected prospect ively and entered into an institutional review board-approved data base . Beginning in 2008 , efforts were made to collect the 5-year follow-up data . RESULTS Of the 102 patients , 7 were excluded because they had not reached the 5-year follow-up point ( 2 patients had had the b and removed early and 5 patients had died ; 2 of cancer and 3 of unknown causes ) , leaving 95 patients for the present study . The mean preoperative age was 49.3 years ( range 21.3 - 68.4 ) . The mean preoperative body mass index was 46.3 kg/m(2 ) ( range 35.1 - 71.9 ) and had decreased to 35.0 kg/m(2 ) ( range 21.1 - 53.7 ) by 5 years of follow-up , yielding a mean percentage of excess weight loss of 48.3 % . The mean duration of the diabetes diagnosis before surgery was 6.5 years . Of 94 patients , 83 ( 88.3 % ) were taking medications preoperatively , with 14.9 % overall taking insulin . At 5 years postoperatively , 33 ( 46.5 % ) of 71 patients were taking medications , with 8.5 % taking insulin . The mean fasting preoperative glucose level was 146.0 mg/dL. The glucose level had decreased to 118.5 mg/dL at 5 years postoperatively ( P = .004 ) . The mean HbA1c level was 7.53 preoperatively in 72 patients and was 6.58 at 5 years postoperatively in 64 patients ( P < .001 ) . Overall , diabetes had resolved ( no medication requirement , with HbA1c < 6 and /or glucose < 100 mg/dL ) in 23 ( 39.7 % ) of 58 patients and had improved ( use of fewer medications and /or fasting glucose levels of 100 - 125 mg/dL ) in 41 ( 71.9 % ) of 57 patients . The combined improvement/remission rate was 80 % ( 64 of 80 patients ) . CONCLUSION Our data have demonstrated that laparoscopic adjustable gastric b and ing results in a substantial sustained positive effect on diabetes in morbidly obese patients , with a significant reduction in HbA1c and an 80 % overall rate of improvement/remission Diabetes has been associated with increased risk of  endometrial cancer  in some epidemiological studies . Body mass index ( BMI ) and other measures of obesity have been associated positively with both diabetes and endometrial cancer . It is not clear whether or not the association of diabetes with endometrial cancer is explained entirely by obesity . Thus , we sought to test the hypothesis that diabetes is not associated with endometrial cancer independent of obesity . We examined the association between  self-reported diabetes  ( onset at > 30 years of age ) and incident endometrial cancer in a prospect i ve cohort study of 24,664 postmenopausal women in Iowa . Over 12 years of follow-up , 346 cases occurred among the cohort at risk . Data were analyzed using proportional hazards regression models . Diabetes was analyzed as reported at baseline and as a time-dependent variable using information obtained during follow-up . After adjustment for BMI , waist : hip ratio , and other covariates , the relative risk ( RR ) for women with diabetes versus women without diabetes was 1.43 [ 95 % confidence interval ( CI ) , 0.98 - 2.1 ] . The diabetes association was confined to women in the upper two BMI quintiles ( RR , 1.47 ; 95 % CI , 0.98 - 2.20 ) , but a formal test of interaction was not statistically significant . Analyses that included diabetes ascertained at baseline and at follow-up gave similar results ; the diabetes-associated RR in the higher BMI strata was 1.64 ( 95 % CI , 1.16 - 2.31 ) . We conclude that after adjustment for other risk factors , diabetes is associated with a modestly increased risk for endometrial cancer among women in this cohort Context Intensive insulin therapy used to maintain normoglycemia during intensive care after cardiac surgery improves perioperative outcomes . Its effect during cardiac surgery is unknown . Contributions The authors r and omly assigned 400 cardiac surgical patients to tight glycemic control ( blood glucose level , 4.4 to 5.6 mmol/L [ 80 to 100 mg/dL ] ) during surgery or usual intraoperative care . All patients received tight glycemic control in the cardiac intensive care unit . The groups had the same risk for perioperative adverse events ( risk ratio , 1.0 [ 95 % CI , 0.8 to 1.2 ] ) . The intensive treatment group had more strokes ( 8 vs. 1 ) and more deaths ( 4 vs. 0 ) than the conventional treatment group . Caution The authors performed the study at a single center . Implication s Maintaining normoglycemia during cardiac surgery does not improve outcomes and might worsen them . The Editors Hyperglycemia occurs frequently in patients with and without diabetes during cardiac surgery , especially during cardiopulmonary bypass surgery ( 1 , 2 ) . In a study by Van den Berghe and colleagues ( 3 ) , intensive insulin therapy after surgery reduced morbidity and death in critically ill patients , most of whom underwent cardiac surgery . As a result , professional organizations have recommended rigorous glycemic control in hospitalized patients ( 4 ) and strict glycemic control is now routine practice during the postoperative period in cardiac surgical patients . However , no consensus exists on the optimal management of intraoperative hyperglycemia in cardiac surgical patients because of the lack of evidence from r and omized trials . Research ers are increasingly extrapolating evidence from studies that assess the role of strict postoperative glycemic control in critically ill patients to advocate for intravenous insulin therapy for patients in the operating room ( 3 , 57 ) . Evidence , strictly from observational studies , suggests that tight intraoperative glycemic control may reduce postoperative complications ( 810 ) . We recently reported , in a retrospective , observational study of 409 cardiac surgical patients , that intraoperative hyperglycemia was an independent risk factor for perioperative complications , including death , after adjustment for postoperative glucose concentrations . Each 1.1-mmol/L ( 20 mg/dL ) increase in glucose concentration greater than 5.6 mmol/L ( > 100 mg/dL ) during surgery was associated with a 34 % increase in the likelihood of postoperative complications ( 8) . An association between intraoperative hyperglycemia and adverse outcomes based on observational studies does not prove causality . Because hyperglycemia can adversely affect immunity , wound healing , and vascular function , the concept that normoglycemia be maintained during the relatively brief duration of cardiac surgery seems plausible ( 1116 ) . On the other h and , the degree of intraoperative hyperglycemia may merely reflect the severity of underlying stress . If so , prevention of hyperglycemia might not reduce perioperative complications , and the risks and costs of intensive intraoperative glycemic management may outweigh the benefits . Simple , safe , and effective insulin infusion algorithms that achieve rigorous intraoperative glycemic control are lacking . To address these questions , we conducted a r and omized , controlled trial at 1 center to determine whether maintenance of near normoglycemia during cardiac surgery by using intraoperative intravenous insulin infusion reduced perioperative death and morbidity when added to rigorous postoperative glycemic control . Methods Design Overview This was a r and omized , open-label , controlled trial with blinded assessment . We r and omly assigned patients to receive intensive insulin therapy to maintain intraoperative glucose levels between 4.4 ( 80 mg/dL ) and 5.6 mmol/L ( 100 mg/dL ) or conventional treatment . By design , both groups were postoperatively treated with strict glycemic control to ensure that the observed difference in outcome could be attributed to the effects of intraoperative glycemic control . Setting We performed the study at St. Marys Hospital , Rochester , Minnesota , which is a tertiary care teaching hospital with 1157 beds and an average of more than 41000 admissions per year . Participants Adults undergoing elective cardiac surgery between July 2004 and April 2005 were eligible for enrollment in our study . We excluded patients who had off-pump cardiopulmonary bypass procedures . The Mayo Foundation Institutional Review Board , Rochester , Minnesota , approved the protocol . R and omization and Interventions Before we enrolled patients in our r and omized trial , we enrolled 20 patients in a 2-week pilot trial to ensure that the anesthesiologists in the operating room and the nursing staff in the intensive care units ( ICUs ) had adequate experience with the study insulin infusion algorithm . The 20 patients received intensive insulin therapy during surgery and for 24 hours after surgery . The pilot period data allowed us to modify the grade d insulin infusion to achieve desired glucose concentration goals . We built safety features into our infusion protocol to minimize hypoglycemia . We discontinued the infusion when glucose levels were less than 4.4 mmol/L ( < 80 mg/dL ) and initiated dextrose infusion . When glucose levels decreased to less than 3.3 mmol/L ( < 60 mg/dL ) , we treated hypoglycemia according to a st and ardized hypoglycemia protocol . Per protocol , patients treated in the pilot phase were not included in the analyzed cohort . Study coordinators obtained written informed consent from all patients who met eligibility criteria . We r and omly assigned patients to receive intensive or conventional intraoperative insulin therapy . R and omization was computer-generated with permuted blocks of 4 , with stratification according to surgeon , surgical procedure ( coronary artery bypass grafting [ CABG ] with or without other procedures and no CABG ) , and diabetes . The r and omization assignments were concealed in opaque , sealed , tamper-proof envelopes that were opened sequentially by study personnel after participants signed the patient consent form . We could not possibly know , before obtaining consent , the few patients who would not have intraoperative hyperglycemia ( glucose concentration of 5.6 mmol/L or more [ 100 mg/dL ] ) . Therefore , per protocol , patients who gave consent were r and omly assigned , and those whose glucose levels were less than 5.6 mmol/L ( < 100 mg/dL ) during surgery were not included in the final analyses . Intraoperative Period Intensive Treatment Patients in the intensive treatment group received a continuous intravenous insulin infusion , 250 units of NovoLin R ( Novo Nordisk , Princeton , New Jersey ) in 250 mL of 0.45 % sodium chloride , when their blood glucose levels exceeded 5.6 mmol/L ( > 100 mg/dL ) . We adjusted the infusions to maintain blood glucose levels between 4.4 ( 80 mg/dL ) and 5.6 mmol/L ( 100 mg/dL ) . We adjusted the dose according to a st and ardized algorithm used by anesthesiologists ( Appendix Table 1 ) . Appendix Table 1 . Insulin Infusion Protocol * Conventional Treatment Patients in the conventional treatment group did not receive insulin during surgery unless their glucose levels exceeded 11.1 mmol/L ( 200 mg/dL ) . If glucose concentration was between 11.1 ( 200 mg/dL ) and 13.9 mmol/L ( 250 mg/dL ) , patients received an intravenous bolus of 4 units insulin every hour until the glucose concentration was less than 11.1 mmol/L ( < 200 mg/dL ) . If the intraoperative glucose concentration was greater than 13.9 mmol/L ( > 250 mg/dL ) , patients received an intravenous infusion of insulin that was continued until the glucose level was less than 8.3 mmol/L ( < 150 mg/dL ) . In both study groups , we measured arterial plasma glucose concentration every 30 minutes , starting just before anesthetic induction by using hexokinase method on a Double P Modular System ( Roche Diagnostics , Indianapolis , Indiana ) . Intraoperative procedures , including cardiopulmonary bypass , monitoring , laboratory testing , and treatment , were left to the discretion of anesthesiologists and cardiac surgeons . There was no st and ard protocol for monitoring and managing intraoperative potassium levels . Postoperative Period Intravenous insulin infusion was started in patients in the conventional treatment group on their arrival in the ICU . Thereafter , both study groups were treated identically , with the intravenous insulin infusion rates adjusted by a nursing staff that was not involved with the study according to a st and ard protocol . The target blood glucose range was 4.4 ( 80 mg/dL ) to 5.6 mmol/L ( 100 mg/dL ) ( Appendix Table 1 ) . Arterial blood glucose levels were measured every 1 to 2 hours by using the Accu-Check Inform blood glucose monitoring system ( glucometer ) ( Roche Diagnostics ) . During the first 24 hours after surgery , patients were given only clear liquids by mouth ; we did not administer subcutaneous insulin or oral diabetic medications during this time . Thereafter , the hospital diabetes consulting service saw all patients and provided individualized recommendations for ongoing care . Outcomes and Measurements The primary outcome variable was a composite of death , sternal wound infections , prolonged pulmonary ventilation , cardiac arrhythmias ( new-onset atrial fibrillation , heart block requiring permanent pacemaker , or cardiac arrest ) , stroke , and acute renal failure within 30 days after surgery . Secondary outcome measures were length of stay in the ICU and hospital . Trained study personnel identified the occurrence of a complication through chart abstract ion by using confirmable , objective criteria in accordance with st and ardized definitions from the Society of Thoracic Surgeons ( STS ) data base committee ( 17 ) . Personnel who assessed outcomes were not aware of patient treatment assignment or of the study hypothesis . Follow-up Procedures We contacted patients by telephone and used a st and ardized telephone survey at 30 days after surgery to assess outcomes that occurred after discharge . We considered Several studies have suggested that diabetes mellitus may alter the risk of developing a variety of cancers , and the associations are biologically plausible . To learn more about the relation between diabetes and cancer mortality , the authors examined associations with selected cancers in a large , prospect i ve US cohort of 467,922 men and 588,321 women who had no reported history of cancer at enrollment in 1982 . After 16 years of mortality follow-up , diabetes was significantly associated with fatal colon cancer in men ( multivariate relative risk ( RR ) = 1.20 , 95 % confidence interval ( CI ) : 1.06 , 1.37 ) and women ( RR = 1.24 , 95 % CI : 1.07 , 1.43 ) and with pancreatic cancer in men ( RR = 1.48 , 95 % CI : 1.27 , 1.73 ) and women ( RR = 1.44 , 95 % CI : 1.21 , 1.72 ) . For men , diabetes was significantly associated with liver cancer ( RR = 2.19 , 95 % CI : 1.76 , 2.72 ) and bladder cancer ( RR = 1.43 , 95 % CI : 1.14 , 1.80 ) . In addition , diabetes was significantly associated with breast cancer in women ( RR = 1.27 , 95 % CI : 1.11 , 1.45 ) . These associations were not explained by high body mass . Our findings suggest that diabetes is an independent predictor of mortality from cancer of the colon , pancreas , female breast , and , in men , of the liver and bladder There is growing evidence that patients with type 2 diabetes mellitus have increased  cancer risk . We examined the association between diabetes , cancer , and cancer-related mortality  and hypothesized that insulin sensitizers lower cancer-related mortality . Participants in the Diabetes Cardiovascular Risk and Evaluation : Targets and Essential Data for Commitment of Treatment study , a nationwide cross-sectional and prospect i ve epidemiological study , were recruited from German primary care practice s. In the cross-sectional study , subjects with type 2 diabetes mellitus had a higher prevalence of malignancies ( 66/1308 , 5.1 % ) compared to nondiabetic subjects ( 185/6211 , 3.0 % ) ( odds ratio , 1.64 ; 95 % confidence interval , 1.12 - 2.41 ) before and after adjustment for age , sex , hemoglobin A(1c ) , smoking status , and body mass index . Patients on  metformin had a lower prevalence of malignancies , comparable with that among nondiabetic patients , whereas those on any other oral combination treatment had a 2-fold higher risk for malignancies even after adjusting for possible confounders ; inclusion of metformin in these regimens decreased the prevalence of malignancies . In the prospect i ve analyses , diabetic patients in general and diabetic patients treated with insulin ( either as monotherapy or in combination with other treatments ) had a 2- and 4-fold , respectively , higher mortality rate than nondiabetic patients , even after adjustment for potential confounders ( incidence of cancer deaths in patients with type 2 diabetes mellitus [ 2.6 % ] vs the incidence of cancer deaths in patients without type 2 diabetes mellitus [ 1.2 % ] ) . Our results suggest that diabetes and medications for diabetes , with the exception of the insulin sensitizer metformin , increase cancer risk and mortality OBJECTIVE Diabetes is a leading cause of morbidity and mortality . The purpose of this study is to assess the associations between diabetes complications and mortality in the Early Treatment Diabetic Retinopathy Study ( ETDRS ) . RESEARCH DESIGN AND METHODS We examined demographic , clinical , and laboratory characteristics of the 3,711 subjects enrolled in the ETDRS , a r and omized controlled clinical trial design ed to evaluate the role of laser photocoagulation and aspirin therapy for diabetic retinopathy . The outcome assessed was all-cause mortality . Multivariable Cox proportional hazards regression was used to assess associations between diabetes complications and mortality for type 1 and type 2 diabetes separately . RESULTS The 5-year estimates of all-cause mortality were 5.5 and 18.9 % for patients with type 1 and type 2 diabetes , respectively . In patients with type 1 diabetes , amputation ( hazard ratio [ HR ] 5.08 [ 95 % CI 2.06 - 12.54 ] ) and poor visual acuity ( 1.74 [ 1.10 - 2.75 ] ) remained significantly associated with mortality , after adjusting for other diabetes complications and baseline characteristics . In patients with type 2 diabetes , macrovascular disease  and worsening levels of nephropathy , neuropathy , retinopathy , and visual acuity are associated with progressively increasing risks of mortality , after controlling for other baseline risk factors . CONCLUSIONS Amputation is the strongest predictor for mortality in patients with type 1 diabetes . All complications independently predict mortality in patients with type 2 diabetes . There is an increased risk for mortality as the degree of each complication worsens . Additional studies are needed to investigate the effectiveness of tertiary prevention to decrease mortality in these patients
Compared with their nondiabetic counterparts , cancer patients with preexisting diabetes are ∼50 % more likely to die after surgery .
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 systematic ally review postoperative mortality in cancer patients with and without preexisting diabetes and summarize results using meta- analysis .