Prognostic influence of metformin in strong most cancers sufferers receiving immune checkpoint inhibitors: novel evidences from a multicenter retrospective research

Most cancers is one in every of main public well being burdens worldwide, with roughly 20 million new instances and 9.7 million related deaths estimated in 2022 (Bray et al., 2024). Regardless of improved precancerous screening and diagnostic strategies, a substantial proportion of most cancers sufferers are initially identified at superior stage and beneficial to obtain complete therapies together with surgical procedure, chemoradiotherapy, focused remedy and immunotherapy. The previous decade has witnessed the nice success of immunotherapy in superior tumors and its consultant medication are generally known as immune checkpoint inhibitors (ICIs) together with anti-programmed cell death-1 (PD-1), programmed cell demise ligand-1 (PD-L1) and Cytotoxic T lymphocyte-associated antigen-4 (CTLA-4) antibodies (Capella et al., 2024; Jama et al., 2024). Though mounting medical trials have proved their sturdy anti-cancer efficacy and acceptable toxicity, restricted sufferers are literally discovered to learn from ICI therapies. Quite a few inherent elements have been intently linked to the efficacy of ICI medication equivalent to PD-L1 expression, microsatellite standing, tumor mutation burden (TMB) and microbiome (Emens et al., 2024; Holder et al., 2024). Beforehand, our group has recognized particular person dietary and efficiency standing as important elements affecting ICI efficacy (Yan et al., 2023; Wang et al., 2024). As well as, our group have discovered the precise efficacy of ICI medication could also be additionally affected by some concomitant drugs together with antibiotics, proton pump inhibitors, corticosteroids, β-blockers and opioids (Yang et al., 2020; Wang et al., 2021; Liu et al., 2022; Yan et al., 2022; Guo et al., 2024). A latest evaluation has summarized the conflicting outcomes in regards to the influence of concomitant drugs on ICI medication in non-small cell lung most cancers (NSCLC), emphasizing the need of extra investigations on this facet (Chen et al., 2023). An extra understanding in regards to the position of concomitant drugs in most cancers immunotherapy will undoubtedly contribute to extra exact affected person administration, and eventually result in general survival profit.

Metformin, as a first-line treatment for sort 2 diabetes mellitus (T2DM), has not too long ago exhibited its anti-cancer potential in quite a few organic and medical research. A nationwide cohort research has discovered melanoma sufferers with T2DM who acquired metformin had decreased threat of cancer-specific mortality (Urbonas et al., 2020). A complete meta-analysis together with 166 research has proved metformin use is considerably correlated with a decreased threat for gastrointestinal, urologic and hematologic cancers (O’connor et al., 2024). Metformin use can be correlated with higher medical consequence in most cancers sufferers and may act as an efficient adjuvant remedy mixed with conventional chemoradiotherapy (Júnior et al., 2021; Bahardoust et al., 2024). When it comes to anti-cancer mechanisms, metformin can immediately inhibit the malignant traits of most cancers cells via activating AMPK signaling, or not directly forestall tumorigenesis via controlling circulating glucose and insulin ranges (Linkeviciute-Ulinskiene et al., 2020). A latest evaluation has intently linked metformin use with elevated CD8⁺ T cells and pure killer (NK) cells, suggesting its potential boosting impact on most cancers immunotherapy (Panaampon et al., 2023). Nonetheless, the precise influence of metformin use on ICI efficacy stays controversial in medical research. For example, Afzal et al. have discovered ICIs mixed with metformin might successfully enhance the tumor response, general survival (OS) and progression-free survival (PFS) of NSCLC sufferers (Afzal et al., 2019). In distinction, one other retrospective research has demonstrated no important correlation between metformin use and medical consequence in NSCLC sufferers receiving nivolumab (Svaton et al., 2020). Furthermore, a multicenter retrospective research even has discovered metformin use was correlated with elevated threat of illness development and demise in ICI-treated strong most cancers sufferers (Cortellini et al., 2023). Due to this fact, extra investigations are urgently wanted to make clear the precise position of metformin in most cancers immunotherapy.

On this research, a multicenter cohort of 516 strong most cancers sufferers receiving ICI-based therapies was used to judge the influence of metformin use on affected person prognosis. As well as, a complete bioinformatic evaluation was carried out to analyze the potential correlation between the metformin goal genes (MTGs) and immune cells. The research will present novel insights into the anti-cancer position of metformin, contributing to express administration of concomitant drugs throughout ICI remedy.

Between January 2018 and December 2023, a complete of 680 sufferers have been initially chosen from three medical facilities: The Affiliated Hospital of Yangzhou College (n = 492), Northern Jiangsu Folks’s Hospital Affiliated to Yangzhou College (n = 120) and Baoying Conventional Chinese language Drugs Hospital (n = 68). The inclusion standards have been as follows: 1) age over 18 years outdated; 2) sufferers have been pathologically identified as strong cancers together with lung and digestive cancers; 3) sufferers acquired ICI remedy with or with out different anti-cancer therapies together with chemotherapy, radiotherapy and focused remedy. The exclusion standards have been as follows: 1) a number of main tumors; 2) incomplete medical and/or follow-up data; 3) inadequate ICI remedy (lower than two cycles); 4) unavailable knowledgeable consents for utilizing affected person info. In consequence, a complete of 516 sufferers have been included within the research, amongst which 76 sufferers acquired metformin remedy earlier than and/or throughout ICI remedy. The flowchart of affected person recruitment was proven in Determine 1A. This research was accepted by the native ethics committee (No. 2022-YKL11-class 05) and knowledgeable consents have been acquired from sufferers or their authorized guardians for utilizing their medical and follow-up data in scientific researches.

The metformin goal genes (MTGs) have been obtained from the DrugBank (Knox et al., 2024) (https://go.drugbank.com), Comparative Toxicogenomics Database (Davis et al., 2023) (https://ctdbase.org/), Swiss Goal Prediction (Daina et al., 2019) (http://www.swisstargetprediction.ch/) and TargetNet (Yao et al., 2016) (http://targetnet.scbdd.com/calcnet/index/). As well as, the transcriptomic knowledge of Lung Adenocarcinoma (LUAD) and Lung Squamous Cell Carcinoma (LUSC) from The Most cancers Genome Atlas (TCGA, https://portal.gdc.most cancers.gov/v1/) have been downloaded because the NSCLC dataset. Firstly, favorable prognostic genes have been recognized from the NSCLC dataset utilizing the univariate Cox regression technique. The eligibility standards have been used as follows: 1) p-value lower than 0.05; 2) hazard ratio (HR) worth lower than 1. Secondly, the shared genes of each the favorable NSCLC prognostic genes and MTGs have been chosen. Lastly, the Kaplan-Meier mannequin was utilized to validate the prognostic worth of the prognostic MTGs within the NSCLC dataset. The flowchart of figuring out prognostic MTGs was proven in Determine 1B.

The correlation between MTGs and proportions of immune cells was analyzed utilizing single pattern gene set enrichment evaluation (ssGSEA) in “GSVA” and “GSEABase” packages. As well as, the expressions of MTGs in immune cells of NSCLC sufferers have been analyzed utilizing single-cell sequencing knowledge that have been out there in TISCH database (http://tisch.comp-genomics.org/house/).

Based mostly on the inclusion and exclusion standards, a complete of 516 sufferers have been lastly chosen for our retrospective evaluation and their medical options have been proven in Desk 1. In short, 123 (23.8%) and 393 (76.2%) sufferers have been feminine and male respectively, with the general median age of 68 years outdated. The commonest most cancers sort was lung most cancers (n = 199), adopted by esophageal most cancers (n = 164), gastrointestinal most cancers (n = 85), hepatobiliary and pancreatic most cancers (n = 68). 125 (24.2%) sufferers had beforehand acquired tumor resection and 209 (40.5%) sufferers had smoking historical past. Solely 36 (7.0%) sufferers acquired ICI monotherapy, whereas the others acquired mixed therapies. Earlier than the final follow-up, 294 sufferers have been useless from tumor development whereas 55 sufferers have been useless from different causes equivalent to an infection, cerebrovascular ailments and therapy-related hostile occasions. 76 sufferers acquired metformin remedy with drug dose starting from 500 mg to 2000 mg per day. The correlation evaluation demonstrated metformin use have been considerably correlated with physique mass index (BMI) (p = 0.028) and therapy technique (p = 0.005). No important correlation was noticed between metformin use and different medical options together with gender (p = 0.973), age (p = 0.955), most cancers sort (p = 0.231), surgical procedure historical past (p = 0.453), tumor staging (p = 0.333), ECOG rating (p = 0.568) and smoking historical past (p = 0.286).

Desk 1. Baseline traits of the complete cohort.

As proven in Supplemenary Determine S1A, no statistically important distinction was noticed within the OS between the metformin group and non-metformin group (p = 0.064). Equally, the PFS of the metformin group was discovered to be no higher than that of non-metformin group (p = 0.059, Supplemenary Determine S1B). As well as, the univariate evaluation didn’t establish metformin use as a major prognostic issue affecting the OS or PFS of the sufferers (OS: p = 0.073; PFS: p = 0.072; Desk 2).

Desk 2. Univariate evaluation for general survival and progression-free survival of the complete cohort.

For additional clarifying the prognostic significance of metformin use in ICI-treated sufferers, the subgroup evaluation was carried out primarily based on most cancers varieties. In sufferers with lung most cancers (n = 199), 34 sufferers acquired metformin remedy. As proven in Figures 2A,B, metformin use was discovered to be considerably correlated with higher OS and PFS in ICI-treated lung most cancers sufferers (OS: p = 0.012; PFS: p = 0.005). This correlation was additionally statistically important within the subgroup evaluation primarily based on small cell lung most cancers (SCLC, OS: p = 0.010, Supplementary Determine S2A; PFS: p = 0.017; Supplementary Determine S2B) and NSCLC (OS: p = 0.033, Supplementary Determine S2C; PFS: p = 0.009; Supplementary Determine S2D). Within the univariate evaluation, metformin use (p = 0.008), along with tumor staging (p = 0.005), ECOG (p = 0.001) and smoking historical past (p = 0.005) have been important elements affecting the PFS of lung most cancers sufferers (Desk 3). Within the multivariate evaluation, metformin use (p = 0.013), along with tumor staging (p = 0.017) and smoking historical past (p = 0.028) have been additional recognized as unbiased predictive elements for the PFS of lung most cancers sufferers. When it comes to OS, metformin use (p = 0.016), ECOG (p = 0.016) and smoking historical past (p = 0.023) have been important prognostic elements within the univariate evaluation (Desk 4). Nonetheless, solely metformin use was discovered to be an unbiased predictive issue for OS (p = 0.026).

Determine 2. Kaplan-Meier curves for the affiliation of metformin use with general survival (OS) (A) and progression-free survival (PFS) (B) in lung most cancers sufferers receiving immune checkpoint inhibitors.

Desk 3. Univariate and multivariate evaluation for the progression-free survival of the lung most cancers cohort.

Desk 4. Univariate and multivariate evaluation for the general survival of the lung most cancers cohort.

In sufferers with esophagus most cancers (n = 164), 22 sufferers acquired metformin remedy. As proven in Supplementary Determine S3A and B, no important correlation was noticed between metformin use and OS (p = 0.672) or PFS (p = 0.898). In sufferers with hepatobiliary or pancreatic most cancers (n = 68), 11 sufferers acquired metformin remedy. The correlation between metformin use and medical consequence nonetheless didn’t be statistically important (OS: p = 0.439, Supplementary Determine S3C; PFS: p = 0.754; Supplementary Determine S3D). We didn’t carry out the evaluation within the gastrointestinal subgroup as a result of restricted pattern dimension of the metformin group (n = 9).

Since our subgroup evaluation revealed metformin use was related to higher medical consequence in ICI-treated lung most cancers sufferers, we subsequent aimed to analyze the underlying molecular mechanisms primarily based on community pharmacology. As proven in Determine 3A, a complete of 1,026 MTGs have been initially recognized from 4 on-line databases and the main points have been offered in Supplementary Desk S1. In the meantime, utilizing a univariate Cox regression mannequin, 457 favorable prognostic genes associated with NSCLC have been recognized from the TCGA cohort and the main points have been offered in Supplementary Desk S2. Then, the next 23 shared genes between MTGs and favorable prognostic genes have been chosen: SLC47A1, CYP17A1, RPS6KA5, TP53INP1, ABCC4, BCL6, CCR2, CD40LG, CD74, CISH, GDF15, GMPR, IL33, MCTP2, NUPR1, PLEKHB1, PLPPR1, PXMP4, SH3BP5, TLR2, TLR5, CA5B, and RORA. The Kaplan-Meier mannequin was used to validate the prognostic significance of those genes within the NSCLC cohort. In consequence, 5 MTGs (RPS6KA5, RORA, SH3BP5, NUPR1 and CD40LG) have been discovered to be considerably correlated with a greater OS of NSCLC sufferers (Determine 3B). The additional evaluation demonstrated the expressions of those 5 MTGs have been all considerably downregulated in tumor tissues as in contrast with these in regular tissues in NSCLC sufferers (Determine 3C). Lastly, the ROC evaluation was used to judge their efficiency in predicting the OS of NSCLC sufferers (Determine 3D). The outcome demonstrated SH3BP5 had the most effective predictive efficiency with AUC of 0.935, adopted by NUPR1 (AUC = 0.890), RORA (AUC = 0.809), CD40LG (AUC = 0.793) and RPS6KA5 (AUC = 0.656).

Determine 3. Identification of prognostic metformin goal genes (MTGs) in NSCLC sufferers. (A) Veen plot for the MTGs within the on-line databases. (B) The survival curves stratified by expressions of 5 MTGs in NSCLC sufferers from TCGA cohort. (C) Expressions of 5 MTGs within the tumor and regular tissues of NSCLC sufferers from TCGA cohort. (D) Receiver working attribute curves for figuring out the predictive efficiency of 5 MTGs in predicting the OS of NSCLC sufferers from TCGA cohort.

As proven in Determine 4A, the ssGSEA evaluation indicated the expressions of 4 favorable prognostic MTGs (RORA, SH3BP5, NUPR1 and CD40LG) have been positively correlated with proportion of most infiltrated immune cells. For instance, CD40LG expression was positively correlated with the proportion of activated dendritic cells, B cells, CD8⁺ T cells, check-point, macrophage, and so on. For additional investigating the mobile distribution of those MTGs, a NSCLC single-cell dataset was utilized (GSE146100). The distributions of cell varieties and matched annotations have been demonstrated in Figures 4B,C respectively. The relative quantitative evaluation for detecting gene expressions in immune cells was then carried out and the outcome was proven in Determine 4D. For instance, the expression of RORA was considerably elevated in CD4⁺ T cells, CD8⁺ T cells and pure killer cells. The expression of NUPR1 was considerably elevated in monocytes or macrophages, whereas that of SH3BP5 was considerable in B cells, pure killer cells and Treg cells. Lastly, the mobile localization evaluation confirmed the correlation between MTGs expression and immune cells (Determine 4E).

Determine 4. Correlations of prognostic metformin goal genes (MTGs) with immune infiltration in NSCLC sufferers. (A) Correlations of 5 prognostic MTGs with immune infiltration in NSCLC sufferers from TCGA cohort. (B and C) Cell distribution (B) and matched annotation (C) of NSCLC sufferers from GSE146100 cohort. (D) Expression profiles of 5 prognostic MTGs in varied immune cells. (E) Localization of 5 prognostic MTGs in immune cells.

Regardless of encouraging outcomes from organic experiments, the precise efficacy of metformin together with anti-cancer therapies remains to be controversial. In regionally superior NSCLC sufferers, further use of metformin resulted in worse medical consequence and elevated poisonous occasions (Tsakiridis et al., 2021). A retrospective evaluation discovered metformin use failed to supply long-term survival profit in colorectal most cancers sufferers receiving neoadjuvant remedy adopted by surgical resection (Sonal et al., 2024). A Part I/II trial (NCT02949700) is ongoing to establish metformin as a chemo-radiosensitizer for head and neck most cancers sufferers (Kemnade et al., 2023). The preliminary outcome has demonstrated an bettering development of affected person survival within the metformin group, though it failed to succeed in statistical significance. To our data, a latest meta-analysis together with 22 research has summarized the retrospective research concerning the position of metformin use together with ICI remedy (Shen et al., 2024). The outcome suggests metformin use is considerably correlated with worse OS (p = 0.004) as a substitute of PFS (p = 0.345) in ICI-treated most cancers sufferers. Nonetheless, varied inherent elements equivalent to affected person choice and remedy methods could outcome within the heterogeneous outcomes of the meta-analysis. Due to this fact, extra medical investigations with adequate pattern sizes are urgently wanted. On this research, utilizing a multicenter cohort, we discovered metformin use was considerably correlated with higher consequence in ICI-treated lung most cancers sufferers as a substitute of different most cancers sufferers, which can be partly attributed to the position of its goal genes in activating immune cells. This discovering gives novel evidences for the utilization of metformin as a promising adjuvant drug in most cancers immunotherapy.

For the complete cohort, no important correlation was noticed between metformin use and medical consequence. This discovering is according to a number of printed retrospective research (Buti et al., 2021; Gaucher et al., 2021). A latest large-scale multicenter research (n = 1,395) has even discovered metformin use was related to elevated threat of illness development and demise in ICI-treated sufferers with superior strong cancers (Cortellini et al., 2023). The researchers speculated that metformin use could impair the anti-cancer immune system via affecting intestine microbiome or immune associated cytokines. Alternatively, one other multicenter research (n = 878) has demonstrated that concomitant use of metformin was related to higher medical consequence in ICI-treated most cancers sufferers, whereas this useful impact was not noticed in sufferers who solely acquired metformin earlier than ICI remedy (Chiang et al., 2023). In medical follow, quantity prognostic elements range vastly amongst completely different cancers, equivalent to pathological varieties, therapeutic methods and immune microenvironment. Due to this fact, our world evaluation could also be inadequate to precisely consider the correlation between metformin use and ICI efficacy, suggesting the need of subgroup evaluation.

In our subgroup of lung most cancers, the survival evaluation demonstrated that metformin use was considerably correlated with higher OS and PFS in ICI handled sufferers. The univariate and multivariate evaluation recognized metformin use was an unbiased favorable prognostic issue. These findings collectively supported the useful position of metformin together with ICI medication, which was according to a number of printed research. For example, Afzal et al. discovered metformin use was correlated with higher illness management and response price in NSCLC sufferers receiving ICIs as second or third-line remedy (Afzal et al., 2019). Equally, Yang et al. discovered using metformin with or with out dipeptidyl peptidase 4 inhibitors was correlated with larger goal response price and longer PFS in metastatic NSCLC sufferers who acquired ICI monotherapy (Yang et al., 2023). A broadcast case report demonstrated metformin has the potential to beat acquired resistance to nivolumab in small cell lung most cancers sufferers (Kim et al., 2021). Some latest mechanism investigations can be utilized for explaining the useful position of metformin use in ICI-treated sufferers with lung most cancers. In lung most cancers bearing mice, metformin elevated CD8⁺ T cell infiltration and IFN-γ expression via modulating intestine microbiota, contributing to enhanced anti-cancer immunity (Zhao et al., 2024). Metformin was discovered to advertise the formation of reminiscence CD8⁺ T cells and inhibit their apoptosis, enabling elevated tumor-infiltrating CD8⁺ T cells in lung most cancers sufferers (Zhang et al., 2020). Metformin might even immediately decreased the expressions of each PD-1 and PD-L1, creating a positive microenvironment to stop tumor immune evasion (Park et al., 2024). It ought to be famous that two research didn’t show its useful position in ICI-treated lung most cancers sufferers, which can be partly attributed to the potential influence of confounding elements (equivalent to corticosteroids, antibiotics, proton pump inhibitors, and so on.) within the multivariate evaluation (Svaton et al., 2020; Cortellini et al., 2021).

Within the subgroup evaluation for esophagus most cancers sufferers, no important correlation was noticed between metformin use and medical consequence. This outcome was inconsistent with a mechanism investigation that discovered metformin improved the immunosuppressive tumor microenvironment in an esophageal spontaneous carcinogenesis rat mannequin (Takei et al., 2022). Though earlier research have confirmed the preventive position of metformin use in esophageal carcinogenesis, related medical evidences for its correlation with ICI medication are missing and additional efforts are wanted (Najafi et al., 2023). With regard to sufferers with hepatobiliary or pancreatic most cancers, the same outcome was noticed. A latest retrospective research has even discovered metformin use was related to worse goal response, median OS and PFS in ICI-treated sufferers with superior hepatocellular carcinoma (Kang et al., 2023). This discovering was contradictory with a latest complete evaluation that highlighted its position in bettering immune microenvironment and regulating expressions of immune genes in hepatocellular carcinoma (Abd El-Fattah and Zakaria, 2022). In pancreatic most cancers sufferers who acquired gemcitabine-based neoadjuvant chemoradiotherapy, metformin use might cut back pro-tumoral M2 macrophages and improve immune-activating dendritic cells, additional supporting its useful position in immunotherapy (van Eijck et al., 2024). Contemplating the nice variations between preclinical experiments and medical research, extra well-designed medical trials are urgently wanted for additional validation.

Since we discovered metformin use was correlated with higher medical consequence in ICI-treated lung most cancers sufferers, we subsequent made efforts to analyze the underlying mechanisms primarily based on the bioinformatics technique. As outcome, we recognized 5 goal genes of metformin (RPS6KA5, RORA, SH3BP5, NUPR1, and CD40LG), which have been considerably correlated with favorable prognosis and immune infiltration in lung most cancers sufferers. To our data, some not too long ago printed research have correlated these genes with lung most cancers. RPS6KA5, as a substrate of MAPK activated protein kinase household, was discovered to induce humoral immune response and its autoantibody could possibly be used to analysis lung most cancers (Pei et al., 2020). Excessive RORA expression was proved as an unbiased favorable issue for OS and correlated with quite a few immune checkpoint-related genes equivalent to CD274 and PDCD1LG2 in NSCLC sufferers (Xian et al., 2022). SH3BP5 was recognized as a downstream goal of METTL3 that inhibited lung most cancers invasion via regulating SH3BP5 mRNA stability in a YTHDF1-dependent method (Zhang et al., 2024). Metformin upregulated NUPR1 expression in NSCLC cells, whereas knockdown of NUPR1 induced cell sensitivity to metformin or ionizing radiation (Kim et al., 2022). CD40LG not solely might promote the apoptosis of lung most cancers cells, but additionally could also be concerned in regulating T cell perform (Xu et al., 2010; Guo et al., 2023). Though direct medical evidences are missing, these MTGs have the potential to be developed as novel medical biomarkers for ICI-treated lung most cancers sufferers.

Our retrospective research has some inherent limitations. Firstly, the proportion of sufferers who acquired metformin was comparatively small (76/516, 14.7%), which hampers additional subgroup evaluation. Due to this fact, multicenter validations primarily based on bigger pattern dimension are important. Secondly, as a result of retrospective nature, quite a few heterogeneous elements equivalent to affected person choice, most cancers sort, ICI drug and metformin doses considerably have an effect on the outcomes. For overcoming this limitation, extra randomized managed trials with rigorous design are extremely inspired. Thirdly, we didn’t assess the influence of the cumulative impact of metformin doses, period of DM and different antidiabetic medication, all of which ought to be emphasised in our following work. Lastly, the bioinformatics technique was used to establish prognostic MTGs and make clear their correlations with immune cells, which wants additional verification primarily based on medical samples and organic experiments.

In conclusion, metformin use was considerably correlated with higher OS and PFS in ICI-treated lung most cancers sufferers. As well as, 5 MTGs have been recognized as prognostic biomarkers for lung most cancers sufferers, which was correlated with infiltration of immune cells. The precise position of metformin and its goal genes in most cancers immunotherapy nonetheless have to be clarified by extra work in future.

The unique contributions offered within the research are included within the article/Supplementary Materials, additional inquiries may be directed to the corresponding authors.

The Supplementary Materials for this text may be discovered on-line at: https://www.frontiersin.org/articles/10.3389/fphar.2024.1419498/full#supplementary-material

SUPPLEMENTARY FIGURE S1 | Kaplan-Meier curves for the affiliation of metformin use with OS (A) and PFS (B) in strong most cancers sufferers receiving immune checkpoint inhibitors.

SUPPLEMENTARY FIGURE S2 | Prognostic significance of metformin use within the subgroup evaluation primarily based on small and non-small cell lung most cancers. (A, B) Kaplan-Meier curves for the affiliation of metformin use with OS (A) and PFS (B) in small cell lung most cancers sufferers receiving immune checkpoint inhibitors (ICIs). (C, D) Kaplan-Meier curves for the affiliation of metformin use with OS (C) and PFS (D) in non-small cell lung most cancers sufferers receiving ICIs.

SUPPLEMENTARY FIGURE S3 | Prognostic significance of metformin use within the subgroup evaluation primarily based on most cancers varieties. (A, B) Kaplan-Meier curves for the affiliation of metformin use with OS (A) and PFS (B) in esophagus most cancers sufferers receiving ICIs. (C, D) Kaplan-Meier curves for the affiliation of metformin use with OS (C) and PFS (D) in hepatobiliary and pancreatic most cancers sufferers receiving ICIs.