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Study protocol: Insulin and its role in cancer
BMC Endocrine Disorders 2007,
7:10 doi:10.1186/1472-6823-7-10
K Harish (
[email protected])
M Dharmalingam (
[email protected])
M Himanshu (
[email protected])
ISSN 1472-6823
Article type Study protocol
Submission date 16 July 2007
Acceptance date 22 October 2007
Publication date 22 October 2007
Article URL
http://www.biomedcentral.com/1472-
Abstract
Background: Studies have shown that metabolic syndrome and its consequent
biochemical derangements in the various phases of diabetes may contribute to
carcinogenesis. A part of this carcinogenic effect could be attributed to
hyperinsulinism. High levels of insulin decrease the production of IGF-1 binding
proteins and hence increase levels of free IGF-1.
It is well established that bioactivity of free insulin growth factor 1 (IGF-1) increases tumor turnover rate.
The objective is to investigate the role of insulin resistance/sensitivity in carcinogenesis by studying the relation between insulin resistance/sensitivity and IGF-1 levels in cancer patients. We postulate that hyperinsulinaemia which prevails during initial phases of insulin resistance (condition prior to overt diabetes) increases bioactivity of free IGF-1, which may contribute to process of carcinogenesis.
Methods / Design: Based on our pilot study results and power analysis of the same, we have designed a two group case-control study. 800 proven untreated cancer patients (solid epithelial cell tumors) under age of 50 shall be recruited with 200 healthy subjects serving as controls. Insulin resistance/sensitivity and free IGF-1 levels shall be determined in all subjects. Association between the two parameters shall be tested using suitable statistical methods.
Discussion: Well controlled studies in humans are essential to study the link
between insulin resistance, hyperinsulinaemia, IGF-1 and carcinogenesis. This study could provide insights to the role of insulin, insulin resistance, IGF-1 in
carcinogenesis although a precise role and the extent of influence cannot be determined. In future, cancer prevention and treatment strategies could revolve around insulin and insulin resistance.
Background
The association of diabetes mellitus and cancer has been reported more than 100 years ago [1]. Population studies have shown increased evidence of this
association.
Diabetes has been recognized as a risk factor for development of
breast, endometrial, colorectal and pancreatic carcinomas [2]. Breast, endometrial, colorectal and pancreatic carcinomas are best studied with regard to their association with diabetes/insulin resistance. Population studies have shown that the effects of diabetes mellitus on colorectal cancer may be mediated through mechanisms ranging from increased colonic transit time to hyperinsulinaemia.
In relation to the latter, at least in the early phase of development, type 2 diabetes mellitus is associated with increased circulating insulin concentrations [3, 4]. A large cohort study concluded that diabetes is associated with a modestly increased risk for endometrial cancer among women [5]. Future research, particularly prospective studies with biological samples, could be very helpful in answering questions aimed at clarifying these mechanisms [5]. Data suggest that type 2 diabetes might be associated with up to 10–20% excess risk for breast cancer and that it could also have detrimental effects on the natural history, diagnosis, and treatment of breast cancer [1, 6].
In the past few years both laboratory investigations and population studies have provided some circumstantial evidence that insulin growth factor biochemical derangements may contribute to carcinogenesis.
Several studies implicate hyperinsulinism, a condition that prevails prior to the onset of diabetes (part of metabolic syndrome) as candidate mediator in carcinogenesis [10].
Studies have revealed that high levels of circulating insulin decreases levels of insulin like growth factor binding protein 1 and 3 (IGFBP 1,3). Thus free IGF-1 levels increase in circulation [11, 12].
Another aspect of IGF physiology is the IGF signaling. In this signaling process, IGF-1 receptor is a predominant factor and is crucial for tumor
transformation and survival of malignant cell. It has comparatively less role in normal cell growth [13].
Thus role of IGF-1 in promoting carcinogenesis and its prognosis is
well established. Over the recent years, IGF-1 physiology has been widely studied.
The IGF system, comprises of insulin-like IGF-I, IGF-II, and IGFBPs. IGF-1 as a
growth factor plays a dominant role over IGF-2 and hence is widely studied.
Until recently, growth hormone was the only known stimulant of IGF-1 production.
Different lines of evidence suggest that the IGF/IGFBP system may be regulated by factors other than growth hormones. States of nutritional deprivation, such as starvation and protein caloric under-nutrition and type 1 diabetes mellitus, in animal models have long been known to influence the production of IGFs [14-16].
Various studies have shown that resistance to insulin action, as found in diabetic patients, has been associated with an increase IGFBP-3 protease activity, there by reducing IGFBP-3 levels [17]. Also, Insulin increases IGF-I bioavailability through IGFBP-1 suppression [14, 18, 19]. Thus there is ample evidence to suggest that insulin resistant states increase free IGF-1 levels.
Medical literature suggests that well controlled biochemical and genetic studies are required to establish the link between insulin, IGF-1, diabetes and cancer. We propose to investigate the role of hyperinsulinemia in carcinogenesis.
The primary objective of the study is to investigate the role of insulin resistance or sensitivity in carcinogenesis.
This is done by studying the relation between insulin resistance/sensitivity and IGF-1 levels in cancer patients. The secondary objective is to study the above mentioned association with organ specific cancers if possible.
Carcinogenesis is multi-factorial.
The metabolic and genetic derangements that take place during carcinogenesis may be induced by carcinogens and inherited genetic
factors. The role of either could be variable in a given case. We hypothesize that people with insulin resistance are at risk of developing cancer due to high levels of circulating IGF-1.
Such a risk would increase if other such factors are prevalent / acquired. A person with high levels of IGF-1 may be predisposed to cancer and his/her risk of developing cancer would increase with the presence of other such factors. Cancer being a non-communicable disease, with multiple risk factors,
modifiable risk factors are very few.
Controlling hyperinsulinaemia would modify one major risk factor. IGF-1 levels in body change with age. In addition, risk IGF-1 has high bioactivity on epithelial cells. Thus their role in carcinomas is of significance rather than other types of malignancies. Hence we limit our study to carcinomas of breast, GIT, liver, prostate, uterus, cervix and ovaries.