Association Between Metformin Therapy and Mortality After Breast Cancer: A population-based study

OBJECTIVE

Metformin has been associated with a reduction in breast cancer risk and may improve survival after cancer through direct and indirect tumor-suppressing mechanisms. The purpose of this study was to evaluate the effect of metformin therapy on survival in women with breast cancer using methods that accounted for the duration of treatment with glucose-lowering therapies.

RESEARCH DESIGN AND METHODS

This population-based study, using Ontario health care databases, recruited women aged 66 years or older diagnosed with diabetes and breast cancer between 1 April 1997 and 31 March 2008. Using Cox regression analyses, we explored the association between cumulative duration of past metformin use and all-cause and breast cancer–specific mortality. We modeled cumulative duration of past metformin use as a time-varying exposure.

RESULTS

Of 2,361 breast cancer patients identified, mean (± SD) age at cancer diagnosis was 77.4 ± 6.3 years, and mean follow-up was 4.5 ± 3.0 years. There were 1,101 deaths(46.6%), among which 386 (16.3%) were breast cancer–specific deaths. No significant association was found between cumulative duration of past metformin use and all-cause mortality (adjusted hazard ratio 0.97 95% CI 0.92–1.02]) or breast cancer–specific mortality (0.91 0.81–1.03]) per additional year of cumulative use.

CONCLUSIONS

Our findings failed to show an association between improved survival and increased cumulative metformin duration in older breast cancer patients who had recent-onset diabetes. Further research is needed to clarify this association, accounting for effects of cancer stage and BMI in younger populations or those with differing stages of diabetes as well as in nondiabetic populations.Pre-existing diabetes may increase the risk of death by as much as 40% in cancer patients (1). Up to 16% of patients with breast cancer have pre-existing diabetes and are thus at risk for worse outcomes (2,3). Metformin, an insulin sensitizer, is the most commonly prescribed diabetes treatment and is currently recommended as first-line therapy for patients with type 2 diabetes (4,5). If glycemic targets are not met with metformin alone, other glucose-lowering medications are added to or substituted for metformin. Recent evidence suggests that metformin may have antitumor effects (6). Several studies have evaluated the effect of metformin on cancer incidence, and meta-analyses suggest that metformin is associated with a 20–30% reduction in new cancers (6–8). However, of greater interest is the potential therapeutic role of metformin in patients with pre-existing cancer.There is mounting evidence that metformin may affect the prognosis of breast cancer. Metformin use has been associated with higher rates of pathologic complete response after chemotherapy in breast cancer patients with diabetes (9), and clinical trials have shown a reduction in tumor proliferation markers in nondiabetic breast cancer patients treated with metformin (10–12). However, observational studies evaluating the effect of metformin on survival after breast cancer have been inconsistent. One study of women with HER2+ breast cancer found metformin exposure was associated with a 48% reduction in overall mortality compared with other glucose-lowering medications (13). However, another study of women with triple-negative receptor breast cancer did not show a significant association between metformin and cancer mortality (hazard ratio HR] 1.63 95% CI 0.87–3.06]) (13,14). Interpretation of these previous studies is hampered by small sample sizes, heterogeneity of disease subtypes, inclusion of diabetic populations with varying disease severity and duration, and inconsistent definitions of metformin exposure. The objective of this study was to evaluate the relationship between cumulative metformin use and mortality in patients with breast cancer and recently diagnosed diabetes.