Prognostic value of the HALP score in esophageal cancer: a meta-analysis of 1785 patients – Correspondence

Dear Editor, Esophageal cancer (EC) remains one of the most aggressive and challenging malignancies to treat, with poor survival rates despite advancements in multimodal therapy. This highlights the importance of identifying novel, cost-effective, and clinically accessible biomarkers that can improve risk stratification, guide therapy, and enhance postoperative surveillance. Among the various emerging prognostic markers, the hemoglobin–albumin–lymphocyte–platelet (HALP) score stands out as a promising indicator, integrating the patient’s nutritional and inflammatory status. Although the HALP score has been evaluated across various cancers[1], its prognostic value in EC has yet to be systematically examined in the literature. Furthermore, our analyses were carried out in accordance with the TITAN 2025 guideline[2], thereby enhancing the robustness, reproducibility, and transparency of our work in identifying emerging priorities within this research field. To fill this gap, we conducted a meta-analysis to assess the association between the HALP score and key oncological outcomes in EC. We adhered to the PRISMA guidelines to ensure the rigor and transparency of our study. Our analysis included six retrospective cohort studies[1,3–7], published between 2021 and 2025, encompassing a total of 1785 patients with EC from China and Japan (Supplemental Digital Content Table S1, available at: https://links.lww.com/JS9/G578). The outcomes of interest in our analysis included overall survival (OS), cancer-specific survival (CSS), progression-free survival (PFS), disease-free survival (DFS), and recurrence-free survival (RFS). Hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated using a fixed-effects model to synthesize the data. Our pooled analysis revealed that a low HALP score is significantly associated with poorer survival outcomes across multiple endpoints. Specifically, four studies provided data on OS, showing that a low HALP score was strongly correlated with worse OS (HR = 1.62, 95% CI: 1.39–1.89; P < 0.001), with no observed heterogeneity (I2 = 0%). In addition, when analyzing dichotomous outcomes, low HALP consistently predicted adverse prognosis across all endpoints (overall HR = 1.87, 95% CI: 1.53–2.27; P < 0.00001; I2 = 0%). Subgroup analyses indicated significant associations for CSS (HR = 2.01, 95% CI: 1.53–2.65), PFS (HR = 1.40, 95% CI: 0.91–2.16), DFS (HR = 2.64, 95% CI: 1.18–5.89), and RFS (HR = 1.86, 95% CI: 1.21–2.86) (Fig. 1). Figure 1.: A. The association between HALP score and OS in esophageal cancer patients. B. The association between HALP score, CSS, PFS, DFS, and RFS in esophageal cancer patients. CSS, cancer-specific survival; DFS, disease-free survival; HALP score, hemoglobin–albumin–lymphocyte–platelet score; OS, overall survival; PFS, progression-free survival; RFS, recurrence-free survival. Importantly, the lack of heterogeneity across all subgroups underscores the robustness and reliability of HALP as a prognostic biomarker in EC. These findings are consistent with the known biological roles of the components of the HALP score. The score reflects tumor-induced malnutrition, systemic inflammation, immune suppression, and hematologic depletion – all of which are factors that can drive cancer progression and contribute to treatment resistance. By integrating these factors, the HALP score provides a holistic view of the patient’s condition, making it a valuable tool for predicting prognosis in EC. This meta-analysis represents the first comprehensive evaluation of HALP as a prognostic tool in EC. It demonstrates that the HALP score is an inexpensive, widely accessible biomarker with robust prognostic value. Given that HALP is derived from routine laboratory tests, it can be easily implemented in clinical practice for preoperative risk stratification, guiding perioperative management, and tailoring postoperative surveillance strategies. However, there are limitations to our study. The retrospective nature of the included studies introduces potential biases, including variations in the cutoff values used for the HALP score and differences in treatment protocols. These factors may affect the generalizability of our findings. Nonetheless, the consistent directionality and magnitude of the associations across all subgroups strongly support the clinical utility of the HALP score in EC prognosis. In conclusion, our meta-analysis confirms that low HALP is significantly associated with poorer OS, CSS, DFS, and RFS in EC patients. HALP can be incorporated into clinical practice as an easy-to-use, low-cost prognostic tool, improving patient management and decision-making in surgical oncology. Future prospective multicenter studies are needed to determine the optimal HALP cutoff and to explore its integration with existing staging systems for even greater precision in prognostication.