Type 2 Diabetes

Type 2 Diabetes May Increase Breast Cancer Risk in African-American Women

Findings from an observational study show type 2 diabetes increased the risk for an aggressive form of breast cancer in African-American women by more than 40 percent (Cancer Res 2017;77(22):6462-6469).

African-American women are disproportionately diagnosed with ER-negative breast cancer, with double the incidence of white women, according to researchers.

“Our results showed statistically significant evidence of an increased risk of ER-negative breast cancer in black women who had type 2 diabetes before they ever had breast cancer, primarily in the women who had diabetes for at least 5 years,” said Julie R. Palmer, ScD, Associate Director of Boston University’s Slone Epidemiology Center, Professor of Epidemiology at Boston University School of Public Health, and Associate Director of Population Sciences at the BU-BMC Cancer Center.

“If these results are confirmed, type 2 diabetes would be a modifiable risk factor for ER-negative breast cancer.”

The study did not show diabetes increased incidence of estrogen receptor (ER)-positive breast cancer, which is the most common subtype (75%) and has a very high survival rate, Palmer noted.

Also garnering attention from oncologists and cancer researchers around the country is that the association Palmer and colleagues made between type 2 diabetes and ER-negative breast cancer was only observed in non-obese black women.

“This study’s findings are both surprising and compelling,” commented Dennis Holmes, MD, Breast Cancer Surgeon and Researcher, and Interim Director of the Margie Petersen Breast Center, John Wayne Cancer Institute, at Providence Saint John’s Health Center, Santa Monica, Calif.

“Obesity has long been recognized as a cause of both diabetes and breast cancer. However, this study demonstrates a convincing direct relationship between type 2 diabetes and ER-negative breast cancer, even among non-obese women. This insight is critically important, because [ER]-negative breast cancer is particularly challenging to treat,” Holmes told Oncology Times.

Troubling Epidemiology

Although black women and white women get breast cancer at about the same rate, black women have a 40 percent higher mortality rate, according to the CDC. About 20 percent of white women in the U.S. are diagnosed with the ER-positive subtype, which is typically treated very successfully with hormone therapies (MMWR 2016;65(40):1093-1098).

The far more aggressive ER-negative breast cancer subtype typically is treated with chemotherapy, radiation, or surgery. It also is prone to returning, according to the CDC (MMWR 2016;65(40):1093-1098).

“A troubling aspect of breast cancer epidemiology is the higher risk of ER-negative breast cancer in African-Americans, which accounts significantly for the higher risk of breast cancer-related deaths among African-American women,” Holmes said.

Yet, little is known about associations by breast cancer subtype in African-American women, Palmer revealed. “We are still trying to understand the basic biological processes that lead to ER-negative breast cancer. One way to do this is to study factors that are more common in an African-American population.”

For the study, Palmer and colleagues analyzed data from the Black Women’s Health Study (BWHS) to assess for an association between type 2 diabetes and breast cancer. The nationwide prospective cohort study utilizes questionnaires to collect self-reported medical histories from 59,000 enrollees on a biennial basis. Palmer was instrumental in creating the BWHS, which began in 1995.

From this massive dataset, the researchers identified 1,851 cases of invasive breast cancers, including 914 ER-positive diagnoses, and 468 women with ER-negative breast cancer. Among the latter group of women, the researchers found a 43 percent greater risk. Among non-obese black women, type 2 diabetes was associated with increased risk for ER-negative cancer 92 percent of the time.

“Our findings may account for some of the racial disparity in breast cancer, and could partly explain why mortality from breast cancer is so much higher in black women than white women,” Palmer stated.

Metabolic Derangement

African-American women also are twice as likely as white women to be diagnosed with diabetes, according to the CDC. The federal agency estimates more than 50 percent of black women will develop type 2 diabetes due to a high prevalence of obesity, high blood pressure, high cholesterol, and a lack of exercise.

“Researchers now believe triple-negative cancers have an inflammatory component, and patients with diabetes are in a perpetual inflammatory state,” noted Nisha Unni, MD, Assistant Professor and Breast Cancer Oncologist, University of Texas Southwestern Medical Center, Dallas.

About 20-25 percent of all breast cancers are the so-called “triple-negative” subtypes, which include ER-negative, progesterone-negative, and HER2-negative breast cancers; hence, the name (MMWR 2016;65(40):1093-1098).

But while the observational study led by Palmer showed incidence of ER-negative breast cancer is higher in black women with type 2 diabetes, “it does not prove a causal association, which means it does not prove that diabetes led to the development of breast cancer,” Unni pointed out. “Since the prevalence of both triple-negative breast cancer, as well as type 2 diabetes, is higher in African-American women, the association could just be a reflection of that,” she told Oncology Times.

Jack Jacoub, MD, Medical Oncologist and Medical Director, MemorialCare Cancer Institute at Orange Coast Medical Center, Fountain Valley, Calif., agreed the study by Palmer, et al. “is a hypothesis-generating dataset, as we have long known African-American women have worse prognostic breast cancer, higher mortality rates from breast cancer, and high rates of triple-negative breast cancer than their white counterparts.”

However, the study’s findings helped reinforce Jacoub’s position that women at risk “be counseled about metabolic health, diabetic control, and the possible link to increased breast cancer risk due to chronic inflammation.

“Cancer-screening should be emphasized,” Jacoub told Oncology Times. “Frankly, I also look for reasons to put female patients at risk on metformin, given the recently accumulating data on its efficacy (Curr Oncol 2017;24(2):e85-e91).”

The study by Palmer, et al. “also informs physicians that diabetic and metabolic derangement control should be emphasized, and perhaps that more metformin and other hypoglycemic agents should be used in treating this patient population,” he commented.

Targeted Clinical Strategies

Several studies have suggested diabetes is a risk factor for breast cancer. One recent study also found an association between type 2 diabetes and breast cancer in African-American women, for example; however, the researchers did not report results separately for ER-negative and ER-positive disease.

Tomi Akinyemiju, PhD, MS, Associate Professor of Epidemiology and Assistant Dean for Inclusive Excellence, College of Public Health and Markey Cancer Center, University of Kentucky, Lexington, said the findings in the Palmer-led study “are in line with recently published work by our group (Obesity 2017; doi:10.1002/oby.22067).”

The research led by Akinyemiju showed a significant association between lack of metabolic health—defined as a patient with any combination of the following three conditions: high blood pressure, dyslipidemia, high triglycerides, diabetes or high fasting blood glucose, high waist circumference and cancer mortality—but only among normal-weight individuals, she explained.

Speaking to the clinical implications of the results from the Palmer-led study, Akinyemiju told Oncology Times: “If type 2 diabetes is found to increase the risk of the more aggressive ER-negative breast cancer subtype, then targeted interventions focused on patients with diabetes may help reduce breast cancer incidence among African-American women, and reduce racial disparity in breast cancer outcomes that have remained intractable over the past few decades.”

Akinyemiju further noted the study led by Palmer also shows women with diabetes and using medication to treat it had a 30 percent increased risk of ER-negative breast cancer, compared with more than a two-fold increased risk among those not using medications.

“This suggests strongly that clinical strategies to ensure that type 2 diabetes is well-controlled using either medication, or lifestyle changes, such as weight loss and exercise, may be a promising approach to reducing the risk and mortality of breast cancer in African-American women,” she concluded.

If borne out with additional research, the findings of Palmer, et al. could lead to new treatment approaches “to reduce risk or even prevent triple-negative breast cancer in a population that is at higher risk,” said Melissa D. Fana, MD, FACS, Chief of Breast Surgery, Southside Hospital at Northwell Health System, Bay Shore, N.Y.

The results of the study “also support the recent understanding that it is the biology of breast cancer which is key in understanding how to better treat patients with individualized treatment regimens, and perhaps one day soon prevent breast cancer with targeted strategies,” she concluded.

Chuck Holt is a contributing writer.

Breast Implants

FDA Links Breast Implants with Rare Form of Cancer

A rare form of cancer tied to breast implants has been linked with nine deaths, the Food and Drug Administration announced on Tuesday.

Anaplastic large-cell lymphoma (ALCL), a rare type of non-Hodgkin’s lymphoma, was first associated with breast implants in 2011, and the FDA has been investigating the link ever since.

The FDA has received 359 reports of the cancer associated with breast implants as of Feb. 1. However, the organization says, the number of cases could be underreported. The administration also found a stronger link between textured breast implants and this particular form of cancer. Of 359 cases the FDA uncovered, 231 had information on the surface of the implant — 203 were textured and 28 were smooth.

There does not seem to be a significant link between what’s in the implants and cancer — 312 of the 359 reports included information on implant contents, with 186 filled with silicone gel and 126 filled with saline.

It’s worth noting that anaplastic large-cell lymphoma is not a form of breast cancer. Rather, it’s a cancer of the immune system. Only about 1 percent of non-Hodgkin’s lymphomas are ALCLs, according to the Lymphoma Research Foundation, and symptoms typically include fever, backache, painless swelling of lymph nodes, loss of appetite, and tiredness. ALCL can appear in the skin via raised red skin lesions that don’t go away, in the lymph nodes, or in organs throughout the body, the Lymphoma Research Foundation says.

More than 290,000 women received breast augmentation in 2016, according to the American Society of Plastic Surgeons — a 4 percent increase over 2015 — making this a concern for a lot of women.

The FDA is not the only organization to link this form of cancer with breast implants: The World Health Organization also recognized it in 2016, and the Plastic Surgery Foundation and the National Comprehensive Cancer Network published information to help doctors understand more about the disease, its diagnosis, and treatment.

Brian Czerniecki, MD, chair of the Moffitt Cancer Center department of breast oncology, tells Yahoo Beauty that breast implants may cause cancer because they can create bodily inflammation. “Your body wants to create a wall around the implants,” he explains. “You get some inflammation — your immune system is attracted to that — and you can get lymphoma from your immune system being overstimulated.”

Textured implants may be particularly suspect because more of the implant goes into bodily tissue, causing more of an inflammatory response, Jack Jacoub, MD, medical oncologist and director of thoracic oncology at MemorialCare Cancer Institute at Orange Coast Memorial Medical Center in Fountain Valley, Calif., tells Yahoo Beauty.

Why use the textured implants? Surgeons do so if they want the implant to stay in place. Smooth implants are more likely to flip or shift.

Lymphoma is typically treated with chemotherapy and radiation therapy, Jacoub says, and patients who develop ALCL would also need to have their implants removed. But, he adds, “This type of lymphoma has a good prognosis if one does develop it.”

If you have breast implants, don’t panic and remove them out of an abundance of caution. Czerniecki points out that this is a pretty rare thing that can happen and you don’t want to have unnecessary surgery.

Roberto N. Miranda, MD, a professor of hematopathology at MD Anderson Cancer Center, tells Yahoo Beauty that women who have been diagnosed with this form of cancer present with some symptoms first, including a seroma — a pocket of fluid. “It’s not like any person who has an implant and no symptoms should be concerned,” Miranda says.

However, Jacoub notes it’s a good idea to do regular breast checks — typically, ALCL manifests as a lump — and be aware of the symptoms. If you notice something off, talk to your doctor right away.

When Your Immunotherapy Stops Working

When Your Immunotherapy Stops Working

Immunotherapy is a new and different treatment option for people living with advanced lung cancer. It helps your body’s immune system better find and destroy cancer cells, even when they try to hide. The breakthrough therapy is helping some people with hard-to-treat cancer feel better and live longer.

But it doesn’t work for everyone. Currently approved drugs for lung cancer only help 1 out of 5 people. Scientists are hard at work to find new treatments to help more.

If you or a loved one is scheduled to have lung cancer immunotherapy, you need to know the key warning signs of treatment failure and what to do if they occur.

How Do You Know It Isn’t Working?

Three immunotherapy medicines, called checkpoint inhibitors, are FDA-approved for lung cancer: atezolizumab (Tecentriq), nivolumab (Opdivo), and pembrolizumab (Keytruda).

No one can tell you how well these treatments will work for you. There’s no blood test or other method to predict if the drug will shrink your tumor or make you feel better. However, there are some signs that it isn’t helping.

Tell your doctor if you have:

  • Cough
  • Pain
  • Trouble breathing
  • Any other symptoms that concern you

They may be a sign that your cancer is getting worse, or they may be side effects of treatment. Only a doctor can tell the difference. However, pain is rarely a side effect of lung cancer immunotherapy treatment.

Side effects don’t mean the medicine isn’t fighting your cancer — but a severe reaction can be life threatening and may require you to stop treatment. Serious side effects are rare, but include inflammation of the lungs (pneumonitis), liver, kidneys, intestines, and other parts of the body.

When the Cancer Looks Worse but Isn’t

Your doctor will order CT scans of your tumor to keep track of it and make sure your treatment is working.

Your cancer might look worse on the first CT scan after your start immunotherapy. But it may really be getting better. Doctors call this “pseudoprogression.“ It doesn’t mean the drug isn’t working. Immunotherapy causes your immune system to attack cancer cells. The rush of helper immune cells can cause your tumor to swell and look bigger. The report may say your cancer has progressed, when it really hasn’t.

Your doctor will review your scans and discuss your symptoms. She’ll decide if your treatment is really working and your cancer is stable.

  • If the scan shows a larger tumor but there are no new areas of cancer and you feel OK, it may be pseudoprogression. Doctors usually suggest you wait two or three more treatment cycles (about 2 months) then get another scan.
  • If you feel worse and the scan shows a larger tumor and new lesions, immunotherapy likely isn’t working. The doctor will recommend you stop it and try something else.

Other Treatment Options

If immunotherapy doesn’t work, you and your doctor will discuss other ways to treat your cancer. These include:

  • Chemotherapy
  • Targeted drug treatments

If these options also fail, your doctor may suggest you to take part in a clinical trial. They provide access to cutting-edge immunotherapy treatments that aren’t yet approved for lung cancer. These include other checkpoint inhibitors, therapeutic vaccines, and adoptive T-cell transfer.

If nothing helps at all, it may be time to ask your doctor if it’s time to stop treatment and start hospice and palliative care to ease your symptoms and make you feel better. An honest discussion will help you and your family make the most of every day.


New Cancer Drug Is So Effective Against Tumors, the FDA Approved It Immediately

A small but significant new study is blowing experts away after it found that a particular cancer drug overwhelmingly helped shrink or eradicate tumours in patients whose cancer had resisted every other form of treatment.

The study, which was published in the journal Science, followed 86 patients who had advanced cancer of the pancreas, prostate, uterus, or bone.

The patients were given pembrolizumab, which also goes by the brand name Keytruda, and the results were very promising.

Sixty-six patients had tumors that shrank significantly and stabilized, among them 18 patients whose tumours disappeared and haven’t returned.

The patients all carried genetic mutations that kept their cells from fixing damaged DNA.
Pembrolizumab is known as a PD-1 blocker, an emerging type of immunotherapy drug that helps the immune system find cancer cells and attack tumours.

The study was small, and there was no control group (i.e., a group that didn’t receive pembrolizumab that scientists could compare results against), but the results were so striking that the US Food and Drug Administration, or FDA, has already approved pembrolizumab for patients whose cancer comes from this particular genetic abnormality.

According to the New York Times, this is the first time a drug has been approved for use against tumours that share a particular genetic profile, regardless of where they appear in the body.

Dr Jack Jacoub, a medical oncologist and director of thoracic oncology at MemorialCare Cancer Institute at Orange Coast Memorial Medical Center in Fountain Valley, California, told Yahoo Beauty that the study was “interesting, welcomed, and exciting.”

There has been a general opinion that the immune system is integral in the development and spread of cancer and these new findings show that targeting the immune system to treat cancer can be effective.

“To finally see now proof that targeting the immune system improves the situation and doesn’t necessarily correlate with one specific cancer … that’s a really powerful message,” Dr Jacoub said.
Dr Jacoub also points out that the FDA’s move to approve pembrolizumab quickly was a big step.
“The FDA doesn’t take these kinds of things lightly,” he said. “The data was so good, they had to approve it.”

Dr Jacoub says he suspects that drugs like this will be used in the future in connection with more established cancer treatments for specific types of the disease.

“This may improve outcomes,” he said.

“This form of therapy, plus something else, may allow us to potentially cure and eradicate cancer. These are the steps that are getting us closer to that goal.”