Relationship Between Prognostic Nutritional Index and Mortality in Overweight or Obese Patients with Cancer: A Multicenter Observational Study

Figures & data

Table 1 Detailed Baseline Characteristics of the Study Population

Characteristics	PNI Levels		P-value
	High PNI (n=2433)	Low PNI (n=1099)
Age, years, n (%)			<0.001
<65	1893 (77.8%)	722 (65.7%)
≥65	540 (22.2%)	377 (34.3%)
Gender, n (%)			<0.001
Male	1112 (45.7%)	579 (52.7%)
Female	1321 (54.3%)	520 (47.3%)
ECOG performance status, n (%)			<0.001
≤1	2301 (94.6%)	918 (83.5%)
>1	132 (5.4%)	181 (16.5%)
Smoking, n (%)			0.036
Absent	1585 (65.1%)	675 (61.4%)
Present	848 (34.9%)	424 (38.6%)
Drinking, n (%)			0.012
Absent	2036 (83.7%)	881 (80.2%)
Present	397 (16.3%)	218 (19.8%)
TNM stages, n (%)			<0.001
I	411 (16.9%)	117 (10.6%)
II	705 (29.0%)	271 (24.7%)
III	656 (27.0%)	290 (26.4%)
IV	661 (27.2%)	421 (38.3%)
M category, n (%)			<0.001
M0	1853 (76.2%)	707 (64.3%)
M1	580 (23.8%)	392 (35.7%)
BMI category, n (%)			0.001
Overweight	1922 (79.0%)	920 (83.7%)
Obese	511 (21.0%)	179 (16.3%)
NRS-score, n (%)			<0.001
NRS ≥3	293 (12.0%)	331 (30.1%)
NRS <3	2140 (88.0%)	768 (69.9%)
Weight-loss, n (%)			<0.001
Absent	2208 (90.8%)	882 (80.3%)
Present	225 (9.2%)	217 (19.7%)
Tumor types, n (%)			<0.001
Lung cancer	522 (21.5%)	293 (26.7%)
GC	154 (6.3%)	139 (12.6%)
Esophagus cancer	71 (2.9%)	40 (3.6%)
CRC	350 (14.4%)	218 (19.8%)
NPC	328 (13.5%)	46 (4.2%)
Breast cancer	692 (28.4%)	156 (14.2%)
HPPC	49 (2.0%)	49 (4.5%)
Cervical cancer	103 (4.2%)	66 (6.0%)
Others	164 (6.7%)	92 (8.4%)
Comorbidity
Diabetes mellitus	237 (9.7%)	124 (11.3%)	0.161
Hypertension	561 (23.1%)	287 (26.1%)	0.049
Coronary heart disease	134 (5.5%)	74 (6.7%)	0.152
Previous treatments, n (%)
Radical surgery	1021 (42.0%)	477 (43.4%)	0.423
Chemotherapy	1204 (49.4%)	545 (49.6%)	0.954
Radiotherapy	251 (10.3%)	162 (14.7%)	<0.001
Summary score of QLQ-C30, median (median [IQR])	93.59 [87.18, 97.44]	90.09 [81.99, 95.45]	<0.001
MAMC, cm, (median [IQR])	22.46 [20.59, 24.46]	22.35 [20.43, 24.37]	0.275
MAC, cm, (median [IQR])	29.00 [27.10, 30.70]	28.50 [27.00, 30.30]	0.005
TSF, mm, (median [IQR])	20.00 [15.20, 26.00]	20.00 [15.00, 25.00]	0.031
HGS, kg, (median [IQR])	25.20 [19.00, 32.90]	24.40 [17.80, 32.10]	0.002
CC, cm, (median [IQR])	36.00 [34.00, 38.00]	35.00 [33.00, 37.00]	<0.001
Hemoglobin, g/L, (median [IQR])	134.00 [124.00, 145.00]	120.00 [106.00, 131.00]	<0.001
Total protein, g/L, (median [IQR])	71.40 [67.80, 75.00]	63.80 [59.70, 68.00]	<0.001
NLR (median [IQR])	2.09 [1.55, 2.85]	3.34 [2.19, 5.16]	<0.001
PLR (median [IQR])	126.14 [97.75, 165.35]	182.12 [133.99, 257.99]	<0.001

Abbreviations: ECOG, Eastern Cooperative Oncology Group; GC, gastric cancer; CRC, colorectal cancer; HPPC, hepatobiliary and pancreatic cancer; NPC, nasopharyngeal carcinoma; M, metastasis; BMI, body mass index; NRS-2002, Nutritional Risk Screening-2002; TSF, triceps skinfold; MAC, Mid-arm circumference; MAMC, Mid-arm muscular circumference; CC, calf-circumference; HGS, hand grip strength; NLR, neutrophil-to-lymphocyte ratio; PLR, platelet-to-lymphocyte ratio; PNI, prognostic nutritional index; IQR, interquartile range.

Figure 1 Time-dependent changes in the area under the curve (AUC) for overall survival of prognostic nutritional index (PNI), neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR). (A) Temporal changes of the AUC, (B) ROC curves for 1-year mortality, (C) ROC curves for 3-year mortality.

Table 2 The Association Between PNI Level and All-Cause Mortality in Overweight or Obese Patients with Cancer

Groups	Total Patients	Crude Model		Adjusted Model*		Adjusted Model**
		HR (95% CI)	P-value	HR (95% CI)	P-value	HR (95% CI)	P-value
PNI in all patients	n=3532
By cut-off values		0.42 (0.37,0.48)	<0.001	0.46 (0.40,0.52)	<0.001	0.73 (0.63,0.84)	<0.001
By per SD		0.64 (0.60,0.68)	<0.001	0.66 (0.62,0.70)	<0.001	0.79 (0.74, 0.85)	<0.001
By quantile
Q1 (≤44.8)	886	Reference				Reference
Q2 (44.8 to 49)	883	0.69 (0.58, 0.80)	<0.001	0.73 (0.62, 0.86)	<0.001	0.86 (0.73, 1.02)	0.088
Q3 (49 to 52.7)	892	0.46 (0.38, 0.55)	<0.001	0.50 (0.42, 0.60)	<0.001	0.81 (0.67, 0.98)	0.027
Q4 (>52.7)	871	0.26 (0.21, 0.33)	<0.001	0.29 (0.23, 0.36)	<0.001	0.56 (0.44, 0.70)	<0.001
P value for trend			<0.001		<0.001		<0.001

Notes: *Adjusted for age, gender; **adjusted for age, gender, TNM stage, Eastern Cooperative Oncology Group performance status, tumor type, previous treatment, smoking and drinking status, weight loss, NRS score, hemoglobin level, hand grip strength, calf-circumference, triceps skinfold, mid-arm circumference, calf circumference, diabetes mellitus, hypertension and coronary heart disease.

Abbreviations: PNI, prognostic nutritional index; SD, standard deviation.

Figure 2 Association of PNI levels with mortality (A) and Kaplan-Meier survival analysis of OS (B) in overweight or obese patients with cancer. Hazard ratios are indicated by solid lines and 95% confidence intervals (CIs) by shaded area. Reference point was calculated cut-off value (PNI=46.05). The model was adjusted for cofounders including age, gender, TNM stage, Eastern Cooperative Oncology Group performance status, tumor type, previous treatment, smoking and drinking status, weight loss, NRS score, hemoglobin levels, hand grip strength, calf-circumference, triceps skinfold, mid-arm circumference, calf circumference, diabetes mellitus, hypertension and coronary heart disease.

Abbreviations: OS, overall survival; PNI, prognostic nutritional index.

Table 3 The Association Between PNI and All-Cause Mortality Stratified by Age and Nutrition Status

Groups	n=3532	Crude Model		Adjusted Model*		Adjusted Model**
		HR (95% CI)	P-value	HR (95% CI)	P-value	HR (95% CI)	P-value
Age
<65 years	2615
By cut-off value		0.42 (0.36, 0.50)	<0.001	0.44 (0.37, 0.51)	<0.001	0.74 (0.62, 0.89)	0.001
By per SD		0.64 (0.59, 0.69)	<0.001	0.65 (0.60, 0.70)	<0.001	0.82 (0.75, 0.89)	<0.001
≥65 years	917
By cut-off value		0.48 (0.38, 0.60)	<0.001	0.50 (0.40, 0.62)	<0.001	0.71 (0.56, 0.91)	0.007
By per SD		0.66 (0.59, 0.74)	<0.001	0.67 (0.60, 0.75)	<0.001	0.74 (0.64, 0.84)	<0.001
Nutrition status
NRS score <3	2908
By cut-off value		0.42 (0.36, 0.49)	<0.001	0.45 (0.39, 0.53)	<0.001	0.72 (0.61, 0.86)	<0.001
By per SD		0.64 (0.60, 0.69)	<0.001	0.66 (0.62, 0.71)	<0.001	0.81 (0.75, 0.88)	<0.001
NRS score ≥3	624
By cut-off value		0.53 (0.40, 0.69)	<0.001	0.55 (0.42, 0.72)	<0.001	0.67 (0.49, 0.91)	0.011
By per SD		0.66 (0.58, 0.76)	<0.001	0.67 (0.59, 0.77)	<0.001	0.67 (0.57, 0.78)	<0.001

Notes: *Adjusted for age, gender; **adjusted for age, gender, TNM stage, Eastern Cooperative Oncology Group performance status, tumor type, previous treatment, smoking and drinking status, weight loss, NRS score, hemoglobin level, hand grip strength, calf-circumference, triceps skinfold, mid-arm circumference, calf circumference, diabetes mellitus, hypertension and coronary heart disease.

Abbreviations: PNI, prognostic nutritional index; NRS, nutritional risk screening; SD, standard deviation.

Figure 3 Kaplan-Meier survival analysis for overweight or obese patients with cancer according to PNI levels stratified by tumor type. (A) OS of lung cancer; (B) OS of gastric cancer; (C) OS of esophagus cancer; (D) OS of colorectal cancer; (E) OS of nasopharyngeal carcinoma (NPC); (F) OS of breast cancer; (G) OS of hepatobiliary and pancreatic cancer (HPPC); (H) OS of cervical cancer; (I) OS of other cancer.

Abbreviation: OS, overall survival.

Figure 4 Subgroup analysis for evaluating the prognostic effect of PNI on overall survival.

Abbreviations: ECOG, Eastern Cooperative Oncology Group; CRC, colorectal cancer; HPPC, hepatobiliary and pancreatic cancer; NPC, nasopharyngeal carcinoma; M, metastasis; NRS, Nutritional Risk Screening; PNI, prognostic nutritional index.