Evaluation of Optimal Threshold of Neutrophil-Lymphocyte Ratio and Its Association with Survival Outcomes among Patients with Head and Neck Cancer

Sung Jun Ma, Han Yu, Michael Khan, Jasmin Gill, Sharon Santhosh, Udit Chatterjee, Austin Iovoli, Mark Farrugia, Hemn Mohammadpour, Kimberly Wooten, Vishal Gupta, Ryan McSpadden, Moni A. Kuriakose, Michael R. Markiewicz, Wesley L. Hicks, Mary E. Platek, Mukund Seshadri, Andrew D. Ray, Elizabeth Repasky, Anurag K. Singh

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5 Scopus citations


Importance: Given the role of inflammation in cancer progression, neutrophil-lymphocyte ratio (NLR) from peripheral blood has been suggested as a readout of systemic inflammation and a prognostic marker in several solid malignant neoplasms. However, optimal threshold for NLR in US patients with head and neck cancer remains unclear. Objective: To evaluate the optimal NLR threshold as a potential prognostic biomarker for survival outcomes. Design, Setting, and Participants: This retrospective cohort study was conducted at a single institution. Participants included 496 patients with nonmetastatic head and neck cancer who underwent chemoradiation from April 2007 to March 2021. Statistical analysis was performed from September to December 2021. Exposures: High vs low NLR. Main Outcomes and Measures: Overall survival (OS) and cancer-specific survival (CSS). Results: A total of 496 patients (411 male patients [82.9%]; 432 White patients [87.1%]; 64 patients with other race or ethnicity [12.9%]; median [IQR] age, 61 [55-67] years) were identified. Median (IQR) follow-up was 44.4 (22.8-74.0) months. Thresholds of NLR for both OS and CSS were 5.71. High NLR above 5.71 was associated with worse OS (adjusted hazard ratio [aHR], 1.97; 95% CI, 1.26-3.09; P =.003) and CSS (aHR, 2.33; 95% CI, 1.38-3.95; P =.002). On logistic multivariable analysis, patients were more likely to have high NLR if they had higher T and N staging (T3-4: aOR, 4.07; 95% CI, 1.92-9.16; P <.001; N2: aOR, 2.97; 95% CI, 1.04-9.17; P =.049; N3: aOR, 11.21; 95% CI, 2.84-46.97; P <.001), but less likely if they had a good performance status (Karnofsky Performance Status 90-100: aOR, 0.29; 95% CI, 0.14-0.59; P <.001). Among 331 patients (66.7%) with available human papillomavirus (HPV) data, high NLR was not associated with OS (HPV-negative: aHR, 2.46; 95% CI, 0.96-6.31; P =.06; HPV-positive: aHR, 1.17; 95% CI, 0.38-3.56; P =.78) and CSS (HPV-negative: aHR, 2.55; 95% CI, 0.81-7.99; P =.11; HPV-positive: aHR, 1.45; 95% CI, 0.44-4.76; P =.54). Conclusions and Relevance: High NLR was associated with worse survival. Patients with substantial disease burden and poor performance status were more likely to have high NLR. These findings suggest that further studies would be warranted to investigate the role of such prognostic marker to identify patients at risk to tailor interventions.

Original languageEnglish
Pages (from-to)E227567
JournalJAMA network open
Issue number4
StatePublished - 15 Apr 2022
Externally publishedYes


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