Cancer Catabolism reflected by Prognostic Nutritional Index (PNI) is a better predictor of prognosis in early bladder cancers than Systemic Inflammation measured by Neutrophil Lymphocyte Ratio (NLR)


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Jessica Davies, Santhanam Sundar

Abstract

Background

Both systemic inflammatory response and cancer catabolism have value in prognostication in advanced cancers. Although PNI is well established as a prognostic marker for gastrointestinal cancers, we have identified only one study assessing PNI in bladder cancer patients receiving radical radiotherapy. NLR has some value in predicting response rate in bladder cancer post radical cystectomy. 

Method

Baseline data, prior to treatment commencement, was collected from all patients (N=155) recieving radical radiotherapy between 2010 and 2015 at a single centre. 


The median PNI was 44 (calculated as 10 x serum albumin [g/dl] + 0.005 x lymphocyte count [mm3]). Survival was assessed by log rank test for PNI above and below the median. 


The median NLR was 3.53.  Again,  log rank test assessed survival above and below the median.  Age, sex, TNM stage, chemotherapy, radiation dose, baseline Hb and albumin were assessed as covariates.


Results

Demographics showed the median age to be 77yrs, 2:1 male:female ratio. The majority (84%) had stage T2 or T3 cancer. 40% received chemotherapy neoadjuvantly or concurrently. 94% completed radical radiotherapy - median 64Gy in 32#. 


70% died during the follow up period. Survival was calculated from July 2020 with a median of 24.6months. 


Low NLR (<3.5) was associated with increased overall survival - 48m vs 20m (p=0.002) on univariate analysis. However, after covariate analysis of age, sex, TNM stage, chemotherapy, radiation dose and baseline Hb and albumin it was non-significant. 


High PNI, however, was associated with increased overall survival - 51m vs 20m(p=0.011) on univariate analysis and still significant following covariate analysis (p=0.017).

Conclusion

Cancer catabolism and related nutritional status significantly impacts post-radical radiotherapy survival in early stage bladder cancer. PNI is an easily accessible proxy measure of this. 


PNI has potential to aid clinician’s treatment decision making and prognostication. It also suggests that inhibiting the chemical cascade responsible for cancer catabolism may improve survival. 

Impact statement

Showing that cancer catabolism has a significant negative impact on survival in radical bladder patients, suggests that targeting and inhibiting this pathway may have potential to improve prognosis in these patients.