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The Evolution of Diabetes Management

Victor Lavis, MD
Professor, Department of Endocrine Neoplasia and Hormonal Disorders
Division of Internal Medicine
MD Anderson Cancer Center
Houston, TX

Diabetes management has progressed a lot over the last 13 years since I came to MD Anderson to head the diabetes program. There’s been a lot of advances. There have been multiple new medicines for Type II diabetes, many of which are useful for people with cancer at various stages of their treatment. There have also been, just in terms of the old standard insulin, which, of course, goes back to 1921. In the next couple years, we’ll be coming up to the centennial of insulin. But insulin treatment is far more sophisticated than it was even 13 years ago. There’s now new varieties of insulin that are engineered to provide either smoother or faster uptake of insulin into the circulation, and there’s been huge advances in insulin pumps, in so-called closed loop, which permits the insulin pump to listen directly to the continuous glucose monitor, so that the ability to manage patients with rapid changes of blood sugar is much greater than it was even a few years ago.

People with diabetes and cancer can take advantage of those advances but should be aware of a few things. They should be aware that their cancer treatment may well change their diabetes treatment, either qualitatively or quantitatively. That is, they should be aware, for instance, that if they get radiation to the head or neck that they may need to adjust their medicines. A classic example is that people who get radiation can’t swallow those big metformin pills for a period of time. That’s the number one medicine for the treatment of Type II diabetes, so they may need to change to another medicine for a period.

They certainly should be aware that their insulin requirements are going to fluctuate if they get treatments with steroids for lymphoma, myeloma, or leukemia. They should be prepared to ask their oncologist, if they’re not being managed by a diabetes specialist, for a referral to a diabetes specialist if they’re not coming to a big institution like MD Anderson where there are diabetes specialists on staff. There are many institutions, that do not have a diabetes physician on staff. You should ask to see the diabetes specialist or ask for a referral if you’re having problems with diabetes management.

Coordination of Care

At MD Anderson, we have a busy diabetes management service within the endocrinology department. We have three physicians who concentrate on diabetes. I concentrate largely on diabetes, as well as about five to seven advanced practice providers, physician’s assistants, and nurse practitioners. We have a big number of personnel devoted to diabetes. Importantly, we’re immediately available to the oncologists, both medical and surgical, to help them manage people with diabetes.

If our pancreatic surgeon determines that a pancreatectomy is the proper treatment for a patient’s cancer, for instance, and as we know, a total pancreatectomy renders the patient immediately fully dependent on multiple injections of insulin or an insulin pump to manage their diabetes. We coordinate care with the surgeon, see the patient, and review the treatment strategy and approach to manage their diabetes. When the patient leaves the hospital, they know how to inject themselves with insulin. They know how to check their blood sugar. They know what the proper parameters for blood sugar management are.

We also have a full-time diabetes educator who also participates in these important discussions. If the patient is going to have treatment with high dose steroids for myeloma or lymphoma, that often causes severe hyperglycemia. We’re there. We can see the patient the day that’s discovered. Some of our myeloma, lymphoma doctors send the patient to us before they start the steroids, and tell us, “Look, we’re going to put the patient on steroids. Work with the patient to anticipate the rise in blood sugar and tell them what they need to do.” We can do that.

We help the oncologists treat cancer by taking diabetes management off their hands, and by making them confident that they can do things that might disrupt diabetes care without worrying that the patient is going to have a problem with their diabetes management. We’re there to serve as their associates. It’s been a productive collaboration and leads to better patient care and management.

On the Horizon in Diabetes Management

My hope is that we will learn more, particularly about steroid effects on diabetes, which are still problematic and still very difficult to deal with. My hope is that we’ll learn more about what is the right combination of treatments to manage that effectively.

I continue to look at the burgeon in growth in diabetes technology as an area that can be immensely helpful to people with cancer. There’s a new continuous glucose monitoring technology out, practically every six months now. Each one is more sophisticated than the next. My hope is that they will provide us tools we need to develop new treatments.

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