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Case history

image A woman with poorly controlled type 2 diabetes presented with pulmonary metastases from a colon cancer, 3 years after right hemicolectomy and adjuvant chemotherapy. Initial management was expectant. On progression she remained fit, performance status 0, isotope glomerular filtration rate (GFR) 72 ml/min per 1.73 m2; treatment with irinotecan, fluorouracil and bevacizumab was started within a first-line clinical trial.

During the first two cycles of treatment the patient was admitted twice: first, with a line infection treated with intravenous antibiotics, and then for a line replacement and further antibiotics when the infection failed to settle; second, with an acute kidney injury attributed to NSAIDs. During these admissions it was noted that her diabetes control was poor; therefore, insulin was commenced and chemotherapy was paused. One month later the patient was admitted with sepsis due to a retroperitoneal abscess which required drainage and protracted antibiotic treatment. Her recovery from this third infective episode was complicated by Clostridium difficile-related diarrhoea.

Five months after the two cycles of chemotherapy, the patient was reviewed in clinic, having chosen to revert to oral glucose-lowering agents. A CT scan showed disease control. Two months later, however, her disease progressed and she was re-challenged with reduced-dose fortnightly irinotecan and capecitabine (to avoid an indwelling line). After the second cycle she was admitted with necrotizing fasciitis of the scalp, requiring surgical debridement and protracted antibiotic treatment. Chemotherapy was stopped. She died 4 months later from acute bowel ischaemia.

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

Can cancer patients with diabetes be risk-stratified?

Should patients with diabetes be managed differently?

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

An estimated 3.8 million people in the UK have diabetes, 960,000 of whom are undiagnosed. The prevalence increases with age from 9.0% of people aged 45–54 to 24% of those aged ≥75 years.1 People with diabetes have a higher risk of hospital admission, have a 10% longer stay, and after adjusting for confounding factors have a 1.6-fold higher in-hospital mortality.2 They have an increased risk of infection and there is a subsequent doubling of infection-related mortality.3,4 They are also at higher risk of multiple solid organ cancers.5,6 Emerging evidence suggests that metformin may have cancer-protective properties.7,8

During the management of potentially curative cancer treatment, diabetes has been found to be associated with:

  • an increased postoperative mortality in patients with colorectal cancer (CRC);8,9

  • a lower likelihood of being offered adjuvant chemotherapy, and when offered receiving a simpler regimen;10,11

  • an increased risk of diarrhoea with adjuvant fluoropyrimidine chemotherapy (found in some studies) and a consistent, increased rate of severe toxicity;11,12

  • an increased risk of oxaliplatin-related neuropathy (found in some studies; one study reported an earlier occurrence with ...

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