Diabetes and Cancer. Gentofte, Denmark ASCO, 12th Anuual Meeting Chicago, June / 16

Transcription

1 Diabetes and Cancer Bendix Carstensen Steno Diabetes Center Gentofte, Denmark ASCO, 12th Anuual Meeting Chicago, June / 16

2 Conflicts of interest Employee of Steno Diabetes Center, a research hospital owned by NovoNordisk. Stockholder of NovoNordisk. NovoNordisk is a major insulin and -analog manufacturer. 2/ 16

3 Conflicts of interest Employee of Steno Diabetes Center, a research hospital owned by NovoNordisk. Stockholder of NovoNordisk. NovoNordisk is a major insulin and -analog manufacturer. 2/ 16

4 Conflicts of interest Employee of Steno Diabetes Center, a research hospital owned by NovoNordisk. Stockholder of NovoNordisk. NovoNordisk is a major insulin and -analog manufacturer. 2/ 16

5 Diabetes and Cancer Two main questions: Do diabetes patients get cancer more often than non-diabetics? cancer incidence studies Do cancer patients with diabetes die earlier than cancer patients without diabetes? cancer survival studies Combination (ignoring the cancer diagnosis): Do diabetes patients die more frequently from cancer than non-diabetics? cancer mortality studies 3/ 16

6 Diabetes and Cancer Two main questions: Do diabetes patients get cancer more often than non-diabetics? cancer incidence studies Do cancer patients with diabetes die earlier than cancer patients without diabetes? cancer survival studies Combination (ignoring the cancer diagnosis): Do diabetes patients die more frequently from cancer than non-diabetics? cancer mortality studies 3/ 16

7 Diabetes and Cancer Two main questions: Do diabetes patients get cancer more often than non-diabetics? cancer incidence studies Do cancer patients with diabetes die earlier than cancer patients without diabetes? cancer survival studies Combination (ignoring the cancer diagnosis): Do diabetes patients die more frequently from cancer than non-diabetics? cancer mortality studies 3/ 16

8 Diabetes and Cancer Two main questions: Do diabetes patients get cancer more often than non-diabetics? cancer incidence studies Do cancer patients with diabetes die earlier than cancer patients without diabetes? cancer survival studies Combination (ignoring the cancer diagnosis): Do diabetes patients die more frequently from cancer than non-diabetics? cancer mortality studies 3/ 16

9 This discussion Broader epidemiological / demographic view of cancer incidence among diabetes patients Exemplified by two studies not included in PB s metaanalysis: Johnson et al.: Time-varying incidence of cancer after the onset of type 2 diabetes: evidence of potential detection bias Diabetologia (2011) 54: Carstensen et al.: Cancer occurrence in Danish diabetic patients: duration and insulin effects Diabetologia (2012) 55: / 16

10 This discussion Broader epidemiological / demographic view of cancer incidence among diabetes patients Exemplified by two studies not included in PB s metaanalysis: Johnson et al.: Time-varying incidence of cancer after the onset of type 2 diabetes: evidence of potential detection bias Diabetologia (2011) 54: Carstensen et al.: Cancer occurrence in Danish diabetic patients: duration and insulin effects Diabetologia (2012) 55: / 16

11 This discussion Broader epidemiological / demographic view of cancer incidence among diabetes patients Exemplified by two studies not included in PB s metaanalysis: Johnson et al.: Time-varying incidence of cancer after the onset of type 2 diabetes: evidence of potential detection bias Diabetologia (2011) 54: Carstensen et al.: Cancer occurrence in Danish diabetic patients: duration and insulin effects Diabetologia (2012) 55: / 16

12 This discussion Broader epidemiological / demographic view of cancer incidence among diabetes patients Exemplified by two studies not included in PB s metaanalysis: Johnson et al.: Time-varying incidence of cancer after the onset of type 2 diabetes: evidence of potential detection bias Diabetologia (2011) 54: Carstensen et al.: Cancer occurrence in Danish diabetic patients: duration and insulin effects Diabetologia (2012) 55: / 16

13 Diabetes and Cancer problems All studies are observational All studies are subject to confounding by indication: influenced clinically by diabetes diagnosis. influenced by decison of diabetes treatment. There is no remedy for this. Description of cancer occurrence in diabetes patients. Causal interpretations are pure speculation. 5/ 16

14 Diabetes and Cancer problems All studies are observational All studies are subject to confounding by indication: influenced clinically by diabetes diagnosis. influenced by decison of diabetes treatment. There is no remedy for this. Description of cancer occurrence in diabetes patients. Causal interpretations are pure speculation. 5/ 16

15 Diabetes and Cancer problems All studies are observational All studies are subject to confounding by indication: influenced clinically by diabetes diagnosis. influenced by decison of diabetes treatment. There is no remedy for this. Description of cancer occurrence in diabetes patients. Causal interpretations are pure speculation. 5/ 16

16 Diabetes and Cancer problems All studies are observational All studies are subject to confounding by indication: influenced clinically by diabetes diagnosis. influenced by decison of diabetes treatment. There is no remedy for this. Description of cancer occurrence in diabetes patients. Causal interpretations are pure speculation. 5/ 16

17 Diabetes and Cancer problems All studies are observational All studies are subject to confounding by indication: influenced clinically by diabetes diagnosis. influenced by decison of diabetes treatment. There is no remedy for this. Description of cancer occurrence in diabetes patients. Causal interpretations are pure speculation. 5/ 16

18 Diabetes and Cancer problems All studies are observational All studies are subject to confounding by indication: influenced clinically by diabetes diagnosis. influenced by decison of diabetes treatment. There is no remedy for this. Description of cancer occurrence in diabetes patients. Causal interpretations are pure speculation. 5/ 16

19 The Danish & British Columbia studies Carstensen et al., Diabetologia, 2012 Johnson et al., Diabetologia, 2011 Cancer incidence study in the total population. Comparing diabetes patients with non-diabetes patients. Outcome: Rate-ratio of cancer occurrence between DM-patients and non-dm persons in the entire population. Cancers in DM ptt: Denmark 22,826 B.C. 12,438 by far the largest studies to date. 6/ 16

20 The Danish & British Columbia studies Carstensen et al., Diabetologia, 2012 Johnson et al., Diabetologia, 2011 Cancer incidence study in the total population. Comparing diabetes patients with non-diabetes patients. Outcome: Rate-ratio of cancer occurrence between DM-patients and non-dm persons in the entire population. Cancers in DM ptt: Denmark 22,826 B.C. 12,438 by far the largest studies to date. 6/ 16

21 The Danish & British Columbia studies Carstensen et al., Diabetologia, 2012 Johnson et al., Diabetologia, 2011 Cancer incidence study in the total population. Comparing diabetes patients with non-diabetes patients. Outcome: Rate-ratio of cancer occurrence between DM-patients and non-dm persons in the entire population. Cancers in DM ptt: Denmark 22,826 B.C. 12,438 by far the largest studies to date. 6/ 16

22 The Danish & British Columbia studies Carstensen et al., Diabetologia, 2012 Johnson et al., Diabetologia, 2011 Cancer incidence study in the total population. Comparing diabetes patients with non-diabetes patients. Outcome: Rate-ratio of cancer occurrence between DM-patients and non-dm persons in the entire population. Cancers in DM ptt: Denmark 22,826 B.C. 12,438 by far the largest studies to date. 6/ 16

23 The Danish study main sites Rate ratios All cancers 1.2 Digestive system 1.2 Liver M: 4.0 F: 1.8 Pancreas 2.8 Lung 1.2 Breast 1.04 (1.00; 1.09) Endometrium 1.6 Kidney 1.7 Bladder M: 1.2 F: 1.0 Prostate 0.95 Brain, lymphomas 1.2 7/ 16

24 The Danish study main sites Rate ratios All cancers 1.2 Digestive system 1.2 Liver M: 4.0 F: 1.8 Pancreas 2.8 Lung 1.2 Breast 1.04 (1.00; 1.09) Endometrium 1.6 Kidney 1.7 Bladder M: 1.2 F: 1.0 Prostate 0.95 Brain, lymphomas 1.2 7/ 16

25 Danish study Well Ca (W) Dead (Ca) Dead (O) DM Ca (DM) Dead (Ca) Dead (O) DM+Ins Ca (Ins) Dead (Ca) Dead (O) 8/ 16

26 5.0 All malignant neoplasms M F Rate ratio DM, DM+Ins vs No DM Diabetes duration (years) / 16

27 5.0 All malignant neoplasms M F Rate ratio DM+Ins vs DM Insulin duration (years) / 16

28 Prostate Breast 2.0 Rate ratio DM, DM+Ins vs No DM Diabetes duration (years) / 16

29 Johnson et al, Diabetologia, 2011 Breast cancer 12/ 16

30 Johnson et al, Diabetologia, 2011 Prostate cancer 13/ 16

31 5.0 Lung, bronchus and pleura M F Rate ratio DM, DM+Ins vs No DM Diabetes duration (years) / 16

32 Cumulative risk of cancer Age at start: 60 years Age at start: 65 years Age at start: 70 years year cumulative risks of cancer and death M F M F M F No DM DM DM+Ins M F M F M F No DM DM DM+Ins M F M F M F No DM DM DM+Ins 15/ 16

33 Conclusions 1. Detection bias (shortly after diagnosis of diabetes) overall effects on incidence must evaluated in the long term 2. Short term-studies (e.g. Glargine) studies likely biased. 3. Colorectal, liver, pancreas, corpus uteri, kidney have elevated long-term rates. 4. Insulin treated generally have higher cancer rates than non-insulin treated. 5. Lung cancer elevated only for insulin treated. 6. No exess risk of breast cancer for DM patients, regardless of treatment. 7. Smaller incidence rates for prostate. 16/ 16

34 Conclusions 1. Detection bias (shortly after diagnosis of diabetes) overall effects on incidence must evaluated in the long term 2. Short term-studies (e.g. Glargine) studies likely biased. 3. Colorectal, liver, pancreas, corpus uteri, kidney have elevated long-term rates. 4. Insulin treated generally have higher cancer rates than non-insulin treated. 5. Lung cancer elevated only for insulin treated. 6. No exess risk of breast cancer for DM patients, regardless of treatment. 7. Smaller incidence rates for prostate. 16/ 16

35 Conclusions 1. Detection bias (shortly after diagnosis of diabetes) overall effects on incidence must evaluated in the long term 2. Short term-studies (e.g. Glargine) studies likely biased. 3. Colorectal, liver, pancreas, corpus uteri, kidney have elevated long-term rates. 4. Insulin treated generally have higher cancer rates than non-insulin treated. 5. Lung cancer elevated only for insulin treated. 6. No exess risk of breast cancer for DM patients, regardless of treatment. 7. Smaller incidence rates for prostate. 16/ 16

36 Conclusions 1. Detection bias (shortly after diagnosis of diabetes) overall effects on incidence must evaluated in the long term 2. Short term-studies (e.g. Glargine) studies likely biased. 3. Colorectal, liver, pancreas, corpus uteri, kidney have elevated long-term rates. 4. Insulin treated generally have higher cancer rates than non-insulin treated. 5. Lung cancer elevated only for insulin treated. 6. No exess risk of breast cancer for DM patients, regardless of treatment. 7. Smaller incidence rates for prostate. 16/ 16

37 Conclusions 1. Detection bias (shortly after diagnosis of diabetes) overall effects on incidence must evaluated in the long term 2. Short term-studies (e.g. Glargine) studies likely biased. 3. Colorectal, liver, pancreas, corpus uteri, kidney have elevated long-term rates. 4. Insulin treated generally have higher cancer rates than non-insulin treated. 5. Lung cancer elevated only for insulin treated. 6. No exess risk of breast cancer for DM patients, regardless of treatment. 7. Smaller incidence rates for prostate. 16/ 16

38 Conclusions 1. Detection bias (shortly after diagnosis of diabetes) overall effects on incidence must evaluated in the long term 2. Short term-studies (e.g. Glargine) studies likely biased. 3. Colorectal, liver, pancreas, corpus uteri, kidney have elevated long-term rates. 4. Insulin treated generally have higher cancer rates than non-insulin treated. 5. Lung cancer elevated only for insulin treated. 6. No exess risk of breast cancer for DM patients, regardless of treatment. 7. Smaller incidence rates for prostate. 16/ 16

39 Conclusions 1. Detection bias (shortly after diagnosis of diabetes) overall effects on incidence must evaluated in the long term 2. Short term-studies (e.g. Glargine) studies likely biased. 3. Colorectal, liver, pancreas, corpus uteri, kidney have elevated long-term rates. 4. Insulin treated generally have higher cancer rates than non-insulin treated. 5. Lung cancer elevated only for insulin treated. 6. No exess risk of breast cancer for DM patients, regardless of treatment. 7. Smaller incidence rates for prostate. 16/ 16

40 Conclusions 1. Detection bias (shortly after diagnosis of diabetes) overall effects on incidence must evaluated in the long term 2. Short term-studies (e.g. Glargine) studies likely biased. 3. Colorectal, liver, pancreas, corpus uteri, kidney have elevated long-term rates. 4. Insulin treated generally have higher cancer rates than non-insulin treated. 5. Lung cancer elevated only for insulin treated. 6. No exess risk of breast cancer for DM patients, regardless of treatment. 7. Smaller incidence rates for prostate. 16/ 16

41 Conclusions 1. Detection bias (shortly after diagnosis of diabetes) overall effects on incidence must evaluated in the long term 2. Short term-studies (e.g. Glargine) studies likely biased. 3. Colorectal, liver, pancreas, corpus uteri, kidney have elevated long-term rates. 4. Insulin treated generally have higher cancer rates than non-insulin treated. 5. Lung cancer elevated only for insulin treated. 6. No exess risk of breast cancer for DM patients, regardless of treatment. 7. Smaller incidence rates for prostate. 16/ 16