Neutrophil-to-lymphocyte ratio as prognostic indicator in gastrointestinal cancers: a systematic review and meta-analysis

Randy C. Bowen, Nancy Ann B. Little, Joshua R. Harmer, Junjie Ma, Luke G. Mirabelli, Kyle D. Roller, Andrew Mackay Breivik, Emily Signor, Alec B. Miller and Hung T. Khong _

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Oncotarget. 2017; 8:32171-32189. https://doi.org/10.18632/oncotarget.16291

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Randy C. Bowen1, Nancy Ann B. Little1, Joshua R. Harmer1, Junjie Ma2, Luke G. Mirabelli1, Kyle D. Roller1, Andrew Mackay Breivik1, Emily Signor1, Alec B. Miller1 and Hung T. Khong1

1 Department of Oncology, University of Utah, Salt Lake City, Utah, USA

2 Department of Pharmacotherapy, University of Utah, Salt Lake City, Utah, USA

Correspondence to:

Hung T. Khong, email:

Keywords: neutrophil-to-lymphocyte ratio, gastrointestinal cancers, prognostic indicator, overall survival, biomarkers

Received: August 19, 2016 Accepted: February 20, 2017 Published: March 16, 2017


An accurate, time efficient, and inexpensive prognostic indicator is needed to reduce cost and assist with clinical decision making for cancer management. The neutrophil-to-lymphocyte ratio (NLR), which is derived from common serum testing, has been explored in a variety of cancers. We sought to determine its prognostic value in gastrointestinal cancers and performed a meta-analysis of published studies using the Meta-analysis Of Observational Studies in Epidemiology guidelines. Included were randomized control trials and observational studies that analyzed humans with gastrointestinal cancers that included NLR and hazard ratios (HR) with overall survival (OS), disease-free survival (DFS), progression-free survival (PFS), and/or cancer-specific survival (CSS).

We analyzed 144 studies comprising 45,905 patients, two-thirds of which were published after 2014. The mean, median, and mode cutoffs for NLR reporting OS from multivariate models were 3.4, 3.0, 5.0 (±IQR 2.5-5.0), respectively. Overall, NLR greater than the cutoff was associated with a HR for OS of 1.63 (95% CI, 1.53-1.73; P < 0.001). This association was observed in all subgroups based on tumor site, stage, and geographic region. HR for elevated NLR for DFS, PFS, and CSS were 1.70 (95% CI, 1.52-1.91, P < 0.001), 1.64 (95% CI, 1.36-1.97, P < 0.001), and 1.83 (95% CI, 1.50-2.23, P < 0.001), respectively.

Available evidence suggests that NLR greater than the cutoff reduces OS, independent of geographic location, gastrointestinal cancer type, or stage of cancer. Furthermore, DFS, PFS, and CSS also have worse outcomes with elevated NLR.

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