Usefulness of the Neutrophil-to-Lymphocyte Ratio in Predicting Short- and Long-Term Mortality in Breast Cancer Patients

Department of Internal Medicine, Staten Island University Hospital, Staten Island, NY, USA.
Annals of Surgical Oncology (Impact Factor: 3.93). 06/2011; 19(1):217-24. DOI: 10.1245/s10434-011-1814-0
Source: PubMed


The neutrophil-to-lymphocyte ratio (NLR) is a strong predictor of mortality in patients with colorectal, gastric, hepatocellular, pancreatic, and lung cancer. To date, the utility of NLR to predict mortality in breast cancer patients has not been studied. Therefore, the aim of our study was to determine whether the NLR is predictive of short- and long-term mortality in breast cancer patients.
Our observational study used an unselected cohort of breast cancer patients treated at the Staten Island University Hospital between January 2004 and December 2006. A total of 316 patients had a differential leukocyte count recorded prior to chemotherapy. Survival status was retrieved from our cancer registry and Social Security death index. Survival analysis, stratified by NLR quartiles, was used to evaluate the predictive value of NLR.
Patients in the highest NLR quartile (NLR > 3.3) had higher 1-year (16% vs 0%) and 5-year (44% vs 13%) mortality rates compared with those in the lowest quartile (NLR < 1.8) (P < .0001). Those in the highest NLR quartile were statistically significantly older and had more advanced stages of cancer. After adjusting for the factors affecting the mortality and/or NLR (using two multivariate models), NLR level > 3.3 remained an independent significant predictor of mortality in both models (hazard ratio 3.13, P = .01) (hazard ratio 4.09, P = .002).
NLR is an independent predictor of short- and long-term mortality in breast cancer patients with NLR > 3.3. We suggest prospective studies to evaluate the NLR as a simple prognostic test for breast cancer.

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Available from: Vijaya Raj Bhatt,
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    • "Although evidence on the prognostic role of the NLR in breast cancer has been relatively scarce (Azab et al, 2012, 2013; Noh et al, 2013; Dirican et al, 2014; Nakano et al, 2014; Yao et al, 2014), our robust results add valuable evidence that the NLR is also an adverse prognostic indicator in breast cancer. An earlier study in breast cancer patients, which stratified the NLR according to quartiles, reported that mortality was higher in the highest NLR quartile but closely similar among the lower three quartiles, suggesting a threshold effect (Azab et al, 2012). In our study, although the risk of mortality increased substantially with each NLR quintile in univariable analysis, the observation that this trend was attenuated after multivariable adjustment seems to suggest that the association between the NLR and mortality in breast cancer may not be entirely linear. "
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    ABSTRACT: Peripheral blood-derived inflammation-based scores such as the neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) have recently been proposed as prognostic markers in solid tumours. Although evidence to support these markers as unfavourable prognostic factors is more compelling in gastrointestinal cancers, very little is known of their impact on breast cancer. We investigated the association between the NLR and PLR, and overall survival after breast cancer. Data from the University of Malaya Medical Centre Breast Cancer Registry was used. Of 2059 consecutive patients diagnosed from 2000 to 2008, we included 1435 patients with an available pre-treatment differential blood count (∼70%). Patients were stratified into quintiles of the NLR/PLR. Multivariable Cox regression was used to determine the independent prognostic significances of the NLR/PLR. Compared with the first quintile of the NLR, women in quintile 5 were younger, had bigger tumours, nodal involvement, distant metastases and higher tumour grades. Higher NLR quintiles were significantly associated with poorer survival with a 5-year relative survival ratio (RSR) of 76.4% (95% CI: 69.6-82.1%) in quintile 1, 79.4% (95% CI: 74.4-83.7%) in quintile 2, 72.1% (95% CI: 66.3-77.3%) in quintile 3, 65.6% (95% CI: 59.8-70.8%) in quintile 4 and 51.1% (95% CI: 43.3-58.5%) in quintile 5. Following adjustment for demography, tumour characteristics, treatment and the PLR, the adjusted hazard ratio (HR) for quintile 5 vs quintile 1 was 1.50 (95% CI: 1.08-1.63); Ptrend=0.004. Results were unchanged when the NLR was analysed as a dichotomous variable using different cutoff points. Although patients in PLR quintile 5 had lower survival than in quintile 1 (5-year RSR: 53.2% (95% CI: 46.9-59.2%) vs 77.0% (95% CI: 70.9-82.2%)), this association was not significant after multivariable adjustment. However, a PLR >185 was significantly associated with poorer survival; adjusted HR: 1.25 (95% CI: 1.04-1.52). Both the NLR and PLR are independently associated with an increased risk of mortality in breast cancer. Their added value in the prognostication of breast cancer in clinical practice warrants investigation.British Journal of Cancer advance online publication, 28 May 2015; doi:10.1038/bjc.2015.183
    British Journal of Cancer 05/2015; 113(1). DOI:10.1038/bjc.2015.183 · 4.84 Impact Factor
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    • "Accumulated evidence has demonstrated that an elevated NLR represents a significant prognostic factor of poor clinical outcome in different types of cancer (Azab et al. 2012; Chua et al. 2011; Kao et al. 2010; Keizman et al. 2012). In addition to being measured easily, NLR is more valuable due to its special property as a combined factor of inflammation and host immune reaction. "
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    ABSTRACT: Purpose Neutrophil-to-lymphocyte ratio (NLR) was evaluated as a prognostic factor in patients with metastatic clear cell renal cell carcinoma (RCC) receiving sunitinib as first line therapy. Methods Between December 2005 and December 2011, 109 patients with metastatic clear cell RCC were treated with sunitinib. The values of NLR were assessed at two time points: at baseline (pre-treatment) and on day 1 of the second cycle (post-treatment). The prognostic significance of NLR on treatment outcome was evaluated with adjustment for known confounding risk factors. Results The median follow-up duration after sunitinib treatment was 24 months. There was no association between the pre-treatment NLR and tumor response (median pre-treatment NLRs: 2.2 for partial response [PR], 2.3 for stable disease [SD], and 1.9 for progressive disease [PD]; p = 0.531). However, lower post-treatment NLR (1.1 for PR, 1.2 for SD, 2.3 for PD; p = 0.021) and larger reduction in NLR after treatment (-45.8% for PR, -45.6% for SD, 14.8% for PD; p = 0.009) was significantly associated with a better tumor response. When the patients were divided into two subgroups according to the cutoff value of the post-treatment NLR 1.1, the differences in median cancer-specific survival were observed between subgroups (not reached vs. 19.0 months, p = 0.012). In multivariate analysis, body mass index, MSKCC risk group, serum hemoglobin, and post-treatment NLR were significantly associated with cancer-specific mortality. Conclusions Higher post-treatment NLR was associated with poor prognosis. An early reduction in the NLR after sunitinib treatment may indicate survival benefit in patients with metastatic clear cell RCC.
    SpringerPlus 05/2014; 3(1):243. DOI:10.1186/2193-1801-3-243
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    • "Recently, there is increasing evidence that the presence of systemic inflammation correlates with poor cancer-specific survival. The prognostic value of various markers of systemic inflammatory, including cytokines such as intercellular adhesion molecule 1 and neutrophil-to-lymphocyte ratio (NLR) has been investigated in certain cancer populations [6] [7] [8] [9] [10] [11] [12] [13] [14]. Previous studies have demonstrated that an elevated NLR may correlate with a poor prognosis in patients who underwent curative resection of HCC. "
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    ABSTRACT: Preoperative peripheral blood neutrophil-to-lymphocyte ratio (NLR) has been proposed to predict prognosis of hepatocellular carcinoma (HCC). However, the cutoff value of NLR in several studies is not consistent. This study aims to investigate the correlation of preoperative NLR with clinicopathologic features and the prognosis in patients who have undergone resection for HCC. Clinical data of 256 patients with HCC who underwent radical hepatectomy were retrospectively analyzed. The patients were divided into the low-NLR group (NLR ≤ 2.31) and the high-NLR group (NLR > 2.31). A univariate analysis was performed to assess clinicopathologic characteristics that influenced disease-free survival (DFS) and overall survival (OS) in patients. The significant variables were further analyzed by a multivariate analysis using Cox regression. The Kaplan-Meier method was used to assess the DFS and OS rate. The value of NLR was associated with tumor size, clinical tumor-node-metastasis (TNM) stage, portal vein tumor thrombus (PVTT), distant metastasis, and aspartate aminotransferase (AST) in HCC. NLR > 2.31, size of tumor > 5 cm, number of multiple tumors, III-IV of TNM stage, PVTT, distant metastasis, and AST > 40 U/l were predictors of poorer DFS and OS. NLR > 2.31, size of tumor >5 cm, III-IV of TNM stage, and AST > 40 U/l were independent predictors of DFS and OS. Preoperative NLR > 2.31 was an adverse predictor of DFS and OS in HCC after hepatectomy. This study suggested that NLR might be a novel prognostic biomarker in HCC after curative resection.
    Translational oncology 03/2014; 7(2). DOI:10.1016/j.tranon.2014.02.011 · 2.88 Impact Factor
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