Our study describes the incidence and risk factors for undiagnosed diabetes in elderly cancer patients. Using Surveillance, Epidemiology, and End Results-Medicare data, we followed patients with breast, colorectal, lung, or prostate cancer from 24 months before to 3 months after cancer diagnosis. Medicare claims were used to exclude patients with diabetes 24 to 4 months before cancer (look-back period), identify those with diabetes undiagnosed until cancer, and construct indicators of preventive services, physician contact, and comorbidity during the look-back period. Logistic regression analyses were performed to identify factors associated with undiagnosed diabetes. Overall, 2,678 patients had diabetes undiagnosed until cancer. Rates were the highest in patients with both advanced-stage cancer and low prior primary care/medical specialist contact (breast 8.2%, colorectal 5.9%, lung 4.4%). Nonwhite race/ethnicity, living in a census tract with a higher percent of the population in poverty and a lower percent college educated, lower prior preventive services use, and lack of primary care and/or medical specialist care prior to cancer all were associated with higher adjusted odds of undiagnosed diabetes. Undiagnosed diabetes is relatively common in selected subgroups of cancer patients, including those already at high risk of poor outcomes due to advanced cancer stage. 1. Introduction Diabetes and the metabolic derangements typical of diabetes are associated with poor prognosis in cancer [1–11]. In perhaps the most comprehensive study to date; Barone and colleagues [2] performed a systematic review and meta-analysis of the literature and found that preexisting diabetes was associated with statistically significant increases of 41% for all-cause mortality, across multiple tumor types, and 76%, 61%, and 32% in endometrial, breast, and colorectal cancer, respectively. Poor prognosis may be influenced through biological mechanisms related to hyperglycemia, hyperinsulinemia, and inflammation, which result in tumor cell proliferation and metastases [3–5, 12]. Other factors include less aggressive cancer treatment due to diabetes-related comorbidity [13], poorer response to cancer treatment [7, 11], presentation with later-stage cancer due to suboptimal cancer screening practices and other preventive health-seeking behavior [14], and that diagnosis of cancer may distract both the patient and the health care team from appropriate management of glycemia, blood pressure, and lipids [2]. Factors thought to play a role in observed associations between preexisting
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