Long-term effects of insulin glargine on the risk of breast cancer

Suissa, Samy; Azoulay, Laurent; Dell’Aniello, Sophie; Evans, Marc; Vora, Jiten; Pollak, Michael

doi:10.1007/s00125-011-2190-9

Cited by 94 publications

(81 citation statements)

References 31 publications

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“…In our systematic review, we also identified the lack of lag periods used and the inclusion of prevalent users as additional limitations in a few studies. One of the insulin glargine and breast cancer studies only observed an association among prevalent users of insulin after 5 or more years of use (27). This study suggests that duration of insulin use could be an effect measure modifier of the insulin glargine and breast cancer relationship and that studies with shorter follow-up may not be sufficient to observe these effects.…”

Section: Implications and Solutions To The Methodological Issuesmentioning

confidence: 67%

“…Protopathic or detection bias could have resulted in 11 of the 19 studies because a lag period was not incorporated in the study design (6,7,(14)(15)(16)(18)(19)(20)(21)23,28). Furthermore, given the cancer latency and the time required to observe all the cancers that will occur in patients in these studies, short follow-up (defined here as ,5 years) was an issue in 16 studies, whose follow-up time (reported as mean, median, or maximum duration of follow-up) ranged from 0.9 to 4.5 years (5-8, [14][15][16][17]19,21,[23][24][25][26][27][28]. Only one of the studies observed an association between insulin glargine and breast cancer among prevalent users and after 5 years of use (HR 2.7 [95% CI 1.1-6.5]), which may highlight the importance of using a new user study design and having longer follow-up (27).…”

Section: Other Methodological Issuesmentioning

confidence: 99%

“…1). Following our inclusion criteria, 16 cohort and 3 case-control studies were included in this systematic review (5)(6)(7)(8)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28). All studies evaluated insulin glargine, with four studies also investigating insulin detemir (15,17,25,28).…”

Section: Study Selectionmentioning

confidence: 99%

“…The mean or median durations of follow-up and age ranged from 0.9 to 7.0 years and from 52.3 to 77.4 years, respectively. Thirteen studies examined ever use of long-acting insulin analogs, which was defined as at least one prescription, compared with nonuse, other, human, or NPH insulin (5)(6)(7)(8)14,16,18,19,21,23,(25)(26)(27). One study examined duration of time since starting long-acting insulin analogs, and one examined mean daily dose (22,28).…”

Section: Study Characteristics and Effect Estimatesmentioning

confidence: 99%

“…These studies raised important concerns but were also criticized for important methodological shortcomings (9)(10)(11)(12)(13). Since then, several observational studies assessing the association between longacting insulin analogs and cancer have been published but yielded inconsistent findings (14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28). Such discrepancies may be due to methodological limitations, including inadequate durations of followup between insulin initiation and cancer incidence, protopathic bias, detection bias, the inclusion of prevalent users, and time-related biases such as immortal time bias, time-window bias, and time-lag bias (29).…”

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confidence: 99%

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Effect of Long-Acting Insulin Analogs on the Risk of Cancer: A Systematic Review of Observational Studies

Filion

Azoulay

et al. 2016

Diabetes Care

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OBJECTIVEObservational studies examining the association between long-acting insulin analogs and cancer incidence have produced inconsistent results. We conducted a systematic review of these studies, focusing on their methodological strengths and weaknesses. RESEARCH DESIGN AND METHODSWe systematically searched MEDLINE and EMBASE from 2000 to 2014 to identify all observational studies evaluating the relationship between the long-acting insulin analogs and the risk of any and site-specific cancers (breast, colorectal, prostate). We included cohort and case-control studies published in English on insulin glargine and detemir and any cancer incidence among patients with type 1 or 2 diabetes. The methodological assessment involved the inclusion of prevalent users, inclusion of lag periods, time-related biases, and duration of follow-up between insulin initiation and cancer incidence. RESULTSA total of 16 cohort and 3 case-control studies met our inclusion criteria. All studies evaluated insulin glargine, and four studies also examined insulin detemir. Follow-up ranged from 0.9 to 7.0 years. Thirteen of 15 studies reported no association between insulin glargine and detemir and any cancer. Four of 13 studies reported an increased risk of breast cancer with insulin glargine. In the quality assessment, 7 studies included prevalent users, 11 did not consider a lag period, 6 had time-related biases, and 16 had short (<5 years) follow-up. CONCLUSIONSThe observational studies examining the risk of cancer associated with long-acting insulin analogs have important methodological shortcomings that limit the conclusions that can be drawn. Thus, uncertainty remains, particularly for breast cancer risk.NPH insulin has been the mainstay treatment for type 1 diabetes and advanced type 2 diabetes since the 1950s. However, this insulin is associated with an increased risk of nocturnal hypoglycemia, and its relatively short half-life requires frequent administration (1,2). Consequently, structurally modified insulins, known as longacting insulin analogs (glargine and detemir), were developed in the 1990s to circumvent these limitations. However, there are concerns that long-acting insulin

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Section: Implications and Solutions To The Methodological Issuesmentioning

confidence: 67%