Prognosis:

A Critical Appraisal
PGI Kim Adarem Joy Manimtim - Cariaga
 Clinical Scenario

Your neighbor, a 60 year old male with diabetes mellitus type II was recently
diagnosed with colorectal cancer. His maintenance medication was Metformin 500
mg/tablet, 1 tablet twice a day which he is adherent and for his cancer treatment, he
undergone endoscopic mucosal resection.
Now he asked you what will be his colorectal cancer prognosis since he is
diabetic and taking metformin as an anti diabetic medication?
As a post graduate medical intern, you searched for journals that might help
you answer his question.

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 RESEARCH QUESTION

Among adult diabetic male patients

with colorectal cancer, is good
adherence vs poor adherence to
metformin associated with the
prognosis of colorectal cancer?

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 PICO-M

P Adult diabetic patients with colorectal cancer

I Good adherence to metformin

C Poor adherence to metformin

O Risk of Death

M Retrospective Cohort study

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 SEARCH

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 JOURNAL DETAILS

▪ TITLE: Prognosis of Patients with Colorectal Cancer with Diabetes

According to Medication Adherence: A Population-Based Cohort Study
▪ AUTHOR: Choe, et al.
▪ DATE ACCEPTED: March 11, 2020
▪ DATE PUBLISHED: June 1, 2020
▪ JOURNAL REFERENCE: Choe S, Lee J, Park JW, Jeong SY, Cho YM, Park BJ, Shin A.
Prognosis of Patients with Colorectal Cancer with Diabetes According to Medication Adherence: A Population-
Based Cohort Study. Cancer Epidemiol Biomarkers Prev. 2020 Jun;29(6):1120-1127. doi: 10.1158/1055-
9965.EPI-19-1455.

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 BACKGROUND OF THE STUDY

▪ Diabetes mellitus is known to have a negative effect on colorectal

cancer survival due to hyperinsulinemia or hyperglycemia, and
medications such as metformin, which targets insulin resistance
and hyperinsulinemia, have a preventive effect on the risk of
death.

▪ The aim of this study was to compare the risk of death among
patients with colorectal cancer with diabetes with different levels
of adherence to oral antidiabetics.
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 METHODOLOGY

▪ National Health Information Database  National Health Insurance in Korea (2002 - 2016)
▪ Retrospective cohort study
▪ Newly diagnosed patients with colorectal cancer among diabetics were followed up

▫ Date of diagnosis until death or December 31, 2016

Inclusion Criteria Exclusion Criteria

▪ Newly diagnosed colorectal cancer patients ▪ Diagnosed with colorectal cancer before 2003
▪ Received any cancer treatment ▪ Patients with only one prescription record
▪ Diagnosed with Diabetes Mellitus with record
of being prescribed medication from the date
of colorectal cancer diagnosis

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 METHODOLOGY

▪ Medication adherence  Proportion of days covered (PDC)

▫ PDC = _ # of days with drug on hand _
# of days in the specified time interval
▪ Chi square test or t test  Basic characteristics
▪ Univariate regression analysis  Possibly related to risk of death of patients
with colorectal cancer
▪ Cox proportional hazard regression model  Estimate risk of death of
patients with colorectal cancer as hazard ratio and 95% CI using nonadherent
colorectal cancer as reference
▪ Kaplan-Meier method and log-rank test  Cumulative survival between
different adherence in total and stratified groups for metformin or insulin
usage.
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 Adherent Non-Adherent

RESULTS

Table 1. Characteristics of patients

with colorectal cancer with diabetes
mellitus by medication adherence

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 CRITICAL
APPRAISAL

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 1 Primary Validity

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 1. Was there a representative sample of
patients without the outcome at the
start of observation?
YES

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 2. Was follow-up sufficiently long and complete? YES

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 2 Secondary Validity

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 3. Was the criteria for determining the prognostic factor and
outcome explicit and credible?
YES

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 4. Was there adjustments for other prognostic factors? YES

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 OVERALL , IS THE
STUDY VALID? YES!

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 1. How large is the chance of the
outcome to occur in a specified
period of time?

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 RISK IN TREATMENT
RT = total number of outcome in treatment
total number of test patients RELATIVE RISK
RT = _ 1,747 _
RR = RT/RC
7,153
RR = 0.24/ 0.30
= 0.24 or 24%
 
= 0.8
RISK IN CONTROL Good Prognosis
RC = total number of outcome in control
total number of test patients
RC = _7,348_
24,867
=0.30 or 30%
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 How precise were they?

Adherent to Anti-diabetic
medication
95% Confidence Interval
0.77-0.86 (narrow)

P Value: <0.0001 (extremely

significant)

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 Can the results help me in
caring for my patients?

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 1. Are the study patients similar to my own? YES

• 60 year old
• Male
• Diabetic
• Newly diagnosed with colorectal
cancer
• Adherent to anti-diabetic medication

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 2. Can I use the results to decide on the intervention or reassure my
patient?
YES
• Adherence to Metformin  Lower risk of death from colorectal
cancer
- Improves hyperglycemia or hyperinsulinemia
• Better the adherence the stronger the effect of improving the
survival of cancer patients
• Anti-cancer effect of Metformin (Abundance of Akkermansia
muciniphilia)  Enhances metabolism and improves insulin
resistance

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 RESOLUTION OF THE PROBLEM

▪ Colorectal cancer is one of the major cancers globally.

▪ Maintaining good medication adherence was related to favorable
prognosis of patients with colorectal cancer.

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 THANK YOU FOR LISTENING!

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