Inequalities in cancer mortality trends in people with type 2 diabetes: 20 year population-based study in England

Abstract

Aims/hypothesis The aim of this study was to describe the long-term trends in cancer mortality rates in people with type 2 diabetes based on subgroups defined by sociodemographic characteristics and risk factors. Methods We defined a cohort of individuals aged ≥35 years who had newly diagnosed type 2 diabetes in the Clinical Practice Research Datalink between 1 January 1998 and 30 November 2018. We assessed trends in all-cause, all-cancer and cancer-specific mortality rates by age, gender, ethnicity, socioeconomic status, obesity and smoking status. We used Poisson regression to calculate age- and calendar year-specific mortality rates and Joinpoint regression to assess trends for each outcome. We estimated standardised mortality ratios comparing mortality rates in people with type 2 diabetes with those in the general population. Results Among 137,804 individuals, during a median follow-up of 8.4 years, all-cause mortality rates decreased at all ages between 1998 and 2018; cancer mortality rates also decreased for 55- and 65-year-olds but increased for 75- and 85-year-olds, with average annual percentage changes (AAPCs) of –1.4% (95% CI –1.5, –1.3), –0.2% (–0.3, –0.1), 1.2% (0.8, 1.6) and 1.6% (1.5, 1.7), respectively. Higher AAPCs were observed in women than men (1.5% vs 0.5%), in the least deprived than the most deprived (1.5% vs 1.0%) and in people with morbid obesity than those with normal body weight (5.8% vs 0.7%), although all these stratified subgroups showed upward trends in cancer mortality rates. Increasing cancer mortality rates were also observed in people of White ethnicity and former/current smokers, but downward trends were observed in other ethnic groups and non-smokers. These results have led to persistent inequalities by gender and deprivation but widening disparities by smoking status. Constant upward trends in mortality rates were also observed for pancreatic, liver and lung cancer at all ages, colorectal cancer at most ages, breast cancer at younger ages, and prostate and endometrial cancer at older ages. Compared with the general population, people with type 2 diabetes had a more than 1.5-fold increased risk of colorectal, pancreatic, liver and endometrial cancer mortality during the whole study period. Conclusions/interpretation In contrast to the declines in all-cause mortality rates at all ages, the cancer burden has increased in older people with type 2 diabetes, especially for colorectal, pancreatic, liver and endometrial cancer. Tailored cancer prevention and early detection strategies are needed to address persistent inequalities in the older population, the most deprived and smokers. Graphical abstract

Severe hypoglycaemia in adults presenting to a hospital emergency department: Clinical characteristics, comorbidities, and mortality outcomes

“…The importance of comorbidities enhancing risk of death is supported by the finding that Charlson index was an important predictor of mortality and survival. The observation that cancer was one of the major causes of death associated with SH in T2D is consistent with the increasing incidence of malignancy observed in older people (above age 65 years) with T2D in England 35 . The present study was too small to identify every disease state associated with SH, other than cancer and cardiorenal disease, although several relevant medical conditions have been identified 3,36,37 .…”

“…The observation that cancer was one of the major causes of death associated with SH in T2D is consistent with the increasing incidence of malignancy observed in older people (above age 65 years) with T2D in England. 35 The present study was too small to identify every disease state associated with SH, other than cancer and cardiorenal disease, although several relevant medical conditions have been identified. 3,36,37 The non-DM individuals represent a group with serious ill health associated with life-threatening medical conditions.…”

Socio‐economic disparities in hospital care among Dutch patients with diabetes mellitus

“…6 During their disease, patients with lower SES also more often face complications and a reduced life expectancy compared with their counterparts with a higher SES. 7,8 Focusing on type 1 diabetes, SES influences glycaemic control in both children and adults. 9,10 Use of diabetes technology, such as continuous subcutaneous insulin infusion (CSII) and continuous glucose monitoring (CGM), is, apart from reimbursement policies, also influenced by SES-related factors at all ages.…”

“…In this patient group, SES inequity commences before the first stages of the disease, as SES is known to influence the prevalence of diabetes 6 . During their disease, patients with lower SES also more often face complications and a reduced life expectancy compared with their counterparts with a higher SES 7,8 . Focusing on type 1 diabetes, SES influences glycaemic control in both children and adults 9,10 .…”

The “sweet” path to cancer: focus on cellular glucose metabolism

“…Recent epidemiological studies have reported a transition from cardiovascular diseases to cancer as the leading cause of excess death associated with diabetes mellitus (DM) ( 1 , 2 ). Cancer mortality among people with DM, especially type 2 (T2) DM, is approximately 30%-50% higher than in the general population, particularly for pancreatic, liver, colorectal, and endometrial cancers ( 3 , 4 ). Clinical and preventive efforts must be directed at fighting DM-related risk factors for cancer to reduce the excess mortality risk in individuals with DM.…”