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Case History

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Image not available. A female patient with poorly controlled type 2 (non-insulin dependent) diabetes mellitus (DM) presented with pulmonary metastases from a colon cancer, three years after right hemicolectomy and adjuvant chemotherapy.

The patient was initially managed expectantly; on progression she remained fit, performance status 0, isotope GFR 72 ml/min, and was treated with irinotecan/5-fluorouracil/bevacizumab within a clinical trial for first line treatment.

Immediate complications occurred, with two Hickman line infections requiring intravenous antibiotics and line replacement, and a further admission with acute kidney injury (AKI) attributed to NSAIDs, all prior to cycle 3. Control insulin was initiated and chemotherapy paused to try and improve DM control. One month later the patient was admitted from clinic with septis due to a retroperitoneal abscess. After drainage and protracted antibiotics, her recovery was complicated by Clostridium difficile diarrhoea.

Five months after the two cycles of chemotherapy, the patient was reviewed in clinic: she had chosen to revert to oral hypoglycaemic drugs, and a CT scan showed disease control of the colon cancer.

The patient's disease progressed two months later and she was re-challenged with reduced dose irinotecan and capecitabine every two weeks (to avoid an indwelling line). Following the second cycle she was admitted with necrotising fasciitis of the scalp, which required surgical debridement and protracted antibiotics. Chemotherapy was stopped. The patient died four months later from acute bowel ischaemia.

What risks does a diagnosis of diabetes mellitus pose to a cancer patient?

Can cancer patients with diabetes mellitus be risk stratified?

Should patients with diabetes mellitus be managed differently?

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Background

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Image not available. The prevalence of DM (366 million worldwide in 2011) increases with age and reaches 15% in the 60-79-year-old age bracket. A significant proportion of patients remain undiagnosed.1 In general, these diabetic patients have a 20% higher risk of hospital admission and 10% higher in-hospital mortality, after adjusting for confounding factors.1 Patients with diabetes are at increased risk of infection and there is a doubling of infection-related mortality.2,3 Diabetic patients are also at higher risk of some types of solid organ cancers.4

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What risks does a diagnosis of diabetes mellitus pose to a cancer patient?

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During the management of potentially curative treatment DM has been found to be associated with:

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  • increased post-operative mortality in colorectal cancer patients

  • lower likelihood of being offered adjuvant chemotherapy

  • increased risk of diarrhoea following adjuvant fluoropyrimidine chemotherapy

  • increased risk of hospital admission following adjuvant chemotherapy for breast cancer due to toxicity and infection.

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Less information is available on the impact of DM on the management of advanced cancers. At the St James's Institute of Oncology (SJIO), a retrospective cohort study was conducted comparing diabetic patients treated for advanced colorectal cancer and gynaecological cancers from 2001 to 11 during their first 18 weeks of chemotherapy.5 Diabetes was associated with:

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  • A three fold ...

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