Association of albumin to neutrophil to lymphocyte ratio with survival cachexia and severe malnutrition in patients with cancer

Abstract This study aims to develop and validate a new inflammation-related indicator - the albumin/neutrophil-to-lymphocyte ratio (ANLR) through a multicenter cohort study. The study assesses the prognostic value of this indicator for the overall survival (OS) of cancer patients, as well as its association with severe malnutrition, cachexia, and Karnofsky Performance Status (KPS). Kaplan–Meier and Cox proportional hazards regression analyses assessed the relationship between ANLR and OS. Restricted cubic spline (RCS) analysis was performed to evaluate nonlinear dose–response associations. Stratified forest plots were used to assess subgroup-specific effects and interaction terms. Logistic regression was applied to examine the associations of ANLR with cachexia and severe malnutrition. Sensitivity analyses were conducted after excluding patients who died within the early follow-up period. A total of 16,444 patients were randomly assigned to discovery cohort ( n = 11,511) and validation cohort ( n = 4,933). An ANLR cutoff of 10 was identified by ROC analysis (AUC = 0.628). High ANLR was associated with significantly better OS than low ANLR in both the discovery (60.7% vs. 38.7%) and validation cohorts (61.8% vs. 39.4%, P < 0.001). Higher ANLR independently predicted improved overall survival in the discovery (HR = 0.644, 95% CI: 0.603–0.688, P < 0.001) and validation cohorts (HR = 0.649, 95% CI: 0.588–0.717, P < 0.001). RCS analysis demonstrated a nonlinear inverse association between ANLR and mortality risk ( P < 0.001). High ANLR was associated with reduced risks of cachexia (discovery cohort: adjusted OR = 0.613, 95% CI: 0.556–0.675; validation cohort: adjusted OR = 0.646, 95% CI: 0.557–0.744), severe malnutrition (discovery cohort: adjusted OR = 0.429, 95% CI: 0.388–0.474; validation cohort: adjusted OR = 0.463, 95% CI: 0.398–0.538) and KPS score (discovery cohort: adjusted β = 0.409, 95% CI: 0.191–0.627; validation cohort: adjusted β = 0.669, 95% CI: 0.336–1.001), all P < 0.001. This overlap in indicators may have enhanced the observed correlation. ANLR is a simple composite biomarker that can independently predict the overall survival of cancer patients. It is correlated with cachexia, severe malnutrition, and a reduced risk of deteriorating physical condition, and shows stable predictive effects in different tumor types and stages.