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ORIGINAL ARTICLE
Year : 2017  |  Volume : 7  |  Issue : 2  |  Page : 54-60

Prognostic significance of derived neutrophil-lymphocyte ratio in Non-metastatic breast cancer


Department of Medical Oncology, All Institute of Medical Sciences, New Delhi, India

Date of Web Publication28-Apr-2017

Correspondence Address:
Chandan Krushna Das
Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2321-8568.205387

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  Abstract 

Aim: Breast cancer is the most frequent cancer among women and the prognosis depends on the tumour biology and the treatment characteristics. Derived neutrophil-lymphocyte ratio (DNLR) a surrogate marker of cancer-associated inflammatory response is a cost-effective and simple prognostic parameter for breast cancer. There is a paucity of data regarding the prognostic significance of the DNLR in breast cancer in Indian subcontinent. The aim of the study is to investigate the prognostic role of DNLR in breast cancer in the Indian population. Materials and Methods: 497 patient data were evaluated retrospectively for evaluation of DNLR as a prognostic marker in non-metastatic breast cancer. With a median time to follow-up is 33.8 months (range: 9.6-64.7). A total number of the relapse were 115 and 36 deaths occurred. Results: The predicted 5-year relapse free and overall survival were 70% and 87.5% respectively. On multivariate analyses, factors significantly associated with high DNLR were duration of presentation >6 month, pre-menopausal status, higher T stage, high leucocyte count and the presence of hypoalbuminemia. There was a significant association between DNLR with RFS and OS with P < 0.05 and 0.003 respectively. Conclusion: This is the first study to investigate the prognostic role of DNLR in breast cancer in the Indian population. With combination with other prognostic markers, DNLR, a low-cost, reliable marker of inflammation may have potential utility in breast cancer prognosis.

Keywords: Breast cancer, chemotherapy, inflammation, neutrophil-lymphocyte ratio


How to cite this article:
Das CK. Prognostic significance of derived neutrophil-lymphocyte ratio in Non-metastatic breast cancer. Adv Hum Biol 2017;7:54-60

How to cite this URL:
Das CK. Prognostic significance of derived neutrophil-lymphocyte ratio in Non-metastatic breast cancer. Adv Hum Biol [serial online] 2017 [cited 2020 Jun 2];7:54-60. Available from: http://www.aihbonline.com/text.asp?2017/7/2/54/205387


  Introduction Top


Breast cancer is the most frequent cancer among women with an age-adjusted incidence rate of 43.1/10,000 population (25% of all cancers). It is the most common cancer in women both in more and less developed regions. Overall, breast cancer ranks among the fifth most common cause of death from cancer, and the age-adjusted mortality rate is 12.9/100,000 population.[1] In India, breast cancer is the most common cancer, and cancer mortality in women with age-adjusted incidence and mortality is 25.8 and 21.5/10,000 population, respectively. In state of Delhi, breast cancer is the most common site of cancer among females with an age-adjusted incidence of 41/100,000 population.[2]

Breast cancer prognosis depends on the tumour biology and the treatment characteristics. Despite enormous progress in molecular classification of breast cancer, the usual established predictive and prognostic factors are still the age, menopausal status, pathological stage, the size of primary tumour, nodal involvement, proliferation rate and surface expression of receptors. These parameters were integrated into various predictive and prognostic models such as PREDICT score and adjuvant online. These models accurately estimate the 5- and 10-year survival in patients with breast cancer with and without adjuvant therapy.[3],[4],[5]

In the advent of rapid translational research on breast cancer biology and gene expression profiling, the incorporation of molecular predictors such as MammaPrint and Oncotype Dx may be used to gain an insight into additional prognostic and/or predictive information, but their relevance for clinical integration is still investigational.[6],[7],[8],[9] In addition, high costs, lack of standardisation and regional availability limit their application in a widescale use in routine clinical practice.

Apart from molecular characteristics of cancer, comorbidity, nutritional status, ability to mount an anti-cancer immunological response and functional status are associated with clinical outcome. Cancer-associated inflammatory response plays a unique role in the process of carcinogenesis and tumour progression associated with a poor survival, as demonstrated for several solid malignancies such as renal, prostate, bladder, gastro-oesophageal, colorectal, pancreatic or breast cancers.[10],[11]

In the calculation of derived neutrophil-lymphocyte ratio (DNLR), white blood cell (WBC) without absolute neutrophil count is used as the denominator. In the normal range, the relative ratio of monocytes to lymphocytes is approximately 1:6. In patients with malignancies, there is an absolute decreases in proportion of lymphocytes with increase in monocytes proportion. The relative changes of ratio are unlikely to fall below 1:3 even in metastatic disease.[12] Therefore, WBC sans absolute neutrophil count is a reasonable approximation to the lymphocyte fraction and the likelihood of potential error introduced by the presence of relative monocytosis, is therefore insignificant. DNLR is a cost-effective and simple prognostic parameter of systemic inflammation associated with breast cancer. There is a paucity of data regarding the prognostic significance of the DNLR in breast cancer in the Indian subcontinent.


  Materials and Methods Top


This study was a retrospective evaluation of DNLR as a prognostic marker in non-metastatic breast cancer. The objective was to assess the impact of DNLR in relapse-free survival (RFS) and overall survival (OS) of non-metastatic breast cancer. All breast cancer patients were registered and treated at Medical Oncology Department from January 01, 2011, to December 31, 2014, after fulfilling the inclusion and exclusion criteria. Data were censured in April 01, 2016. Patients with a lack of information on pathologic or laboratory results and chronic diseases such as systemic lupus erythematous, liver cirrhosis, end-stage renal disease and pregnancy-related breast cancer were excluded from the study.

Patients' files with accepted inclusion criteria and had no exclusion criteria were included in the study. A total of 767 patients who were treated at AIIMS, New Delhi, were screened. Five hundred and ninety-five patients' data were retrieved after follow-up, of them non-metastatic and metastatic patients were 497 and 98, respectively. One hundred and seventy-two patients met the exclusion criteria. Patients' details related to personal and demographic profile, underlying disease, clinical presentation, physical examination, results of blood counts and the result of imaging were recorded in a structured pro forma.

The total WBC count and the percentage of each neutrophil and lymphocyte were extracted from electronic hospital laboratory records to estimate the absolute neutrophil and the derived lymphocyte counts. The DNLR was then calculated by dividing the estimated neutrophil count by the derived lymphocyte count.

Overall survival (OS) was defined as time from initialization of treatment until death from any cause or the time upto last followup date. The relapse free survival (RFS) is the time from initialization of treatment until recurrence of tumour or death from any cause.

Statistical analysis done for distribution of data regarding total leucocyte count (TLC) and absolute neutrophil count and duration of neutropenia is described in terms of mean, median value and interquartile range and because of the non-Gaussian distribution of these values, non-parametric tests such as Mann–Whitney U-test and Kruskal–Wallis test were used for analysis between the two groups. Kaplan–Meier analysis was used for survival analysis. Univariate and multivariate Cox proportional hazards models were used for clinicopathological parameters that were significantly statistically associated with RFS and OS; the results were reported, including hazard ratios (HRs) and 95% confidence intervals (CIs). STATA Release 14. College Station, TX: StataCorp LP, USA) was used for all analyses. The accepted level of statistical significance for all the tests was P< 0.05.


  Results Top


Out of 497 analysable non-metastatic patients, the median age of our patients was 46 years (23–85 years). Young breast cancer (<35 year) constitutes 66 (13.28%) cases, while elderly (>60 year) constitutes 85 (17.1%) of the total population. According to the menopausal status, 50.9% of the patients were pre-menopausal and 49.9% of the patients were post-menopausal state.

Clinical tumour size before instituting any form of treatment was classified as cT1 in 8.25%, cT2 in 41.65%, cT3 in 35.21% and cT4 in 14.9%. Nodal involvement constitutes 62% of the patients.

Receptor status was evaluated by immunohistochemistry (IHC) and refl ex testing with fl uorescent in situ hybridisation for human epidermal growth factor receptor (HER2)/neu equivocal on IHC as per The American Society of Clinical Oncology/College of American Pathologists guideline. After immunohistochemical classification, the oestrogen receptor (ER) + progesterone receptor (PR) + HER-2−, ER + PR + HER2+++, ER − PR-HER2+++ and triple-negative breast cancer were 209 (42%), 85 (17.1%), 71 (14.3%) and 132 (26.6%), respectively.

Four hundred and eighty-one patients underwent surgery primarily or after neoadjuvant chemotherapy. Breast conservation surgery was done in 86 (17.9%) and modified radical mastectomy was done in 395 patients (82.1%). Anthracycline ± taxane-containing chemotherapy was given in 82.9% of the patients, while 18.1% of the patients received non-anthracycline-containing therapy. The median number of cycles was 8 (range: 1–8). The most common regimen used was four cycles of 5-fluorouracil (600 mg/m 2), epirubicin (75 mg/m 2), and cyclophosphamide 600 mg/m 2 for every 3 weeks followed by four cycles of docetaxel (85 mg/m 2) as infusion intravenous every 3 weeks in 267 (53.7%) in adjuvant and 33 (6%) in neoadjuvant setting.

Thirty-two (6.4%) patients were presented with anaemia (Hb <10 gm%). The median haemoglobin was 11.9 gm% (6-16). The TLC was 7200/mm 3 (2450–21,900). Leucocytosis >10000/mm 3 was seen in 49 (9.9%) patients. The median absolute neutrophil count was 4200/mm 3 (1100–19,800).

The median DNLR was 1.51. DNLR ranged from 0.34 to 9.4 (mean 1.8 ± 1.08) in the whole population [497 patients]). The significant DNLR by receiver operating characteristic curve analysis (area under the curve = 0.759), is 1.68 with the sensitivity of 77.78% and specificity 59.6%.

The significance of DNLR in subgroup analysis is summarised in [Table 1]. The high DNLR significantly associated with >6-month duration of presentation, menopausal status, tumour size, high TLC, hypoalbuminaemia and occurrence of relapse or death.
Table 1: Comparison of host and tumour characteristics between patients with high neutrophil.lymphocyte ratio (≥1.68) versus low neutrophil lymphocyte ratio (<1.68)

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Survival analysis

The median time to follow-up is 33.8 months (range: 9.6–64.7). A total number of the relapse events were 115 with 36 deaths. The median time to relapse was not reached. The estimated 5-year RFS was 70% [Figure 1]. In the further analyses of the association of neutrophil-lymphocyte ratio (NLR) with RFS, there was statistical significance between the DNLR and RFS (P < 0.05, HR: 4.03; 95% CI: 2.67–6.09) [Figure 2]. However, univariate Cox regression analyses of RFS showed a prognostic significance for the variables such as young breast cancer, menopausal status and nodal involvement. Factors such as receptor subtype, duration prior to presentation, T-size and anthracycline-based therapy were not statistically significant. There was a trend towards statistical significance in factors such as anaemia (P = 0.075), high TLC (P = 0.059) and hypoalbuminaemia (P = 0.056) for RFS. In the multivariate analyses, there was a significant association between nodal involvement and RFS. Analogous to the univariate analysis, there was a significant association between NLR and RFS in the multivariate analyses (P < 0.05, HR: 3.91, 95% CI: 2.58–5.91). These results are summarised in [Table 2].
Figure 1: Kaplan–Meier estimates for relapse-free survival.

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Figure 2: Kaplan–Meier estimates of relapse-free survival stratified on the basis of elevated derived neutrophil-lymphocyte ratio.

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Table 2: Univariate and multivariate Cox proportional analyses of clinicopathological parameters with regard to relapse-free survival

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The median time to follow-up was 33.8 months (range: 9.6–64.7). The total number of deaths was 36. The median OS was not reached [Figure 3]. The predicted 5-year OS was 87.5%. In univariate Cox regression, analyses of OS showed a prognostic significance for the variables such as young breast cancer, menopausal status, DNLR, triple-negative histology and nodal involvement. Factors such as duration prior to presentation, T-size, hypoalbuminaemia, anthracycline-based therapy, high TLC and anaemia were not statistically significant for OS. In the multivariate analyses, there was a significant association between young breast cancer, triple-negative histology, high DNLR, nodal involvement and OS. These results are summarised in [Table 3]. The 5-year estimated survival for patients with high DNLR and low DNLR was 77% and 90%, respectively [Figure 4].
Figure 3: Kaplan–Meier curves for overall survival.

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Table 3: Univariate and multivariate Cox proportional analyses of clinicopathological parameters with regard to overall survival

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Figure 4: Kaplan–Meier estimates of overall survival stratified on the basis of elevated derived neutrophil-lymphocyte ratio.

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  Discussion Top


Hallmarks of cancer classically include six biological capabilities acquired during the carcinogenesis cascade that include proliferative sustainability, evading growth suppressors, death signal resistance, replicative immortality, neo-angiogenesis and activating tumour invasion and distant metastasis. Inflammation and genomic instability constitute the major driving forces for the initiation and propagation of the hallmarks.[1] Inflammatory biomarkers such as total leucocyte count, C-reactive protein, cytokines, the platelet-lymphocyte ratio (PLR), the NLR and DNLR have shown to be associated with specific outcomes in solid tumour patients.[2],[3] DNLR is a biomarker for inflammation, it can be more easily and conveniently measured and it is economical.

Elevated pre-treatment NLR has been associated with a poor prognosis in a number of malignancies, including head and neck cancer,[4] gastric cancer,[5] renal cell carcinoma [6] and hepatocellular carcinoma.[7] The meta-analysis by Templeton et al. of 100 studies comprising 40,559 patients demonstrates that an elevated pre-treatment NLR was associated with a HR for OS of 1.81 (95% CI: 1.67–1.97; P< 0.001). The inferior outcome effect was observed across all disease subgroups, sites and stages. HRs for NLR for disease-free survival (DFS), progression-free survival (PFS) and cancer-specific survival (CSS) were 2.27, 1.63 and1.61, respectively.[2]

Previously published studies on the impact of NLR depict mostly inferior DFS and OS for the non-metastatic patients with breast cancer. A meta-analysis recently reported by Chen et al. shows a significant correlation between NLR and OS and DFS in breast cancer in overall population.[8] A study by Azab et al. showed that patients with a higher pre-treatment NLR were of higher age, more nodal involvement and advanced stage. The pre-treatment NLR was also an independent predictor of poor OS.[9] Another study from Korean cohorts show that patients with an elevated NLR showed poorer breast CSS as compared to patients with lower NLR.[10]

A retrospective analysis by Dirican et al. of 1527 Turkish patients with breast cancer has been published analysing the pre-operative NLR and derived NLR on prognostic relevance. The DFS and OS were both significantly associated with elevated NLR and DNLR.[11]

Other biomarkers such as PLR were less well studied in breast cancer. Krenn-Pilko et al. evaluated the effect of pre-operative NLR and PLR on breast CSS and OS in a total of 793 patients. This study concludes that a high PLR is a statistically significant factor for poor prognosis in patients with breast cancer.[12]

The recent retrospective cohort study of 461 breast cancer patients in the United States showed that elevated NLR of 3.7 or higher is a significant predictor of all-cause mortality in non-metastatic breast cancer patients.[13]

The present study is the first Indian study evaluating the prognostic effects of DNLR in a cohort of 497 North Indian patients with non-metastatic breast cancer. Elevated pre-treatment DNLR, defined as 1.68 or higher, was significantly associated with RFS or OS after considering patient and clinical factors.

Previously, there was one study to point to the association of pre-treatment-derived NLR with OS in breast cancer patients. However, to the best of our knowledge, there has been no research published that included Indian patients.

The DNLR, a surrogate marker of inflammation, is associated with a poor CSS and PFS and this association has been evaluated in several previous studies.[3] Absolute neutrophil and lymphocyte counts could be affected by various biological and laboratory factors while ratio is unaffected by such change. This unique characteristic indicates that the relative stability of DNLR is superior to the other parameters such as PLR or monocyte-lymphocyte ratio.[14] The relative stability of DNLR is similar to that of NLR as both of them use the same component for calculation.

The median age of our breast cancer patients was 47.5 years, which is a decade lower than the world. A significant proportion of our patients presented with locally advanced disease (42%), >6 months presentation duration (31%), anaemia (6.4%) and hypoalbuminaemia (7.8%). This is suggestive of a significant proportion of patients were at advanced disease at presentation.

The cut-off value for DNLR was determined as 1.68 in the present study, and the predicted 5-year OS rates in patients with high (≥1.68) and low (<1.68) NLR were 98.1 and 81.1, respectively [Figure 4]; log-rank; P= 0.003]. With a follow-up period of 33.8 months, the RFS between patients with high and low NLR is significant, similar to the results for OS [Table 2] and [Figure 2]; Log-rank; P< 0.05]. The present study also showed increasing NLR ratios with increasing AJCC T-stages. A higher DNLR was associated with age <35 years, pre-menopausal status, larger tumours, high total leucocyte count and the presence of hypoalbuminaemia. The present study concludes that high DNLR is an independent prognostic factor in breast cancer predicting RFS and OS as per the multivariate analysis (HR: 1.95; P= 0.001). The results of the present study are consistent with the results previously published in the study by Dirican et al. on Turkish cohorts with both metastatic and non-metastatic breast cancers.[11]

Apart from the study by Dirican et al., there are no large studies in literature demonstrating the prognostic significance of DNLR in breast cancer [Table 4].
Table 4: Comparison of the present study with previously published study on derived neutrophil-lymphocyte ratio in non-metastatic breast cancer

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Several strengths and limitations exist within the study. This is the first study to determine the significance of pre-treatment NLR to both RFS and OS in a group of North Indian patients. Limitations include even though we used retrospectively listed patients with high-quality databases, uncontrolled and unrecognised biases might exist; second, geographical differences in the frequency of breast cancer subtypes might have been contributed by the lack of uniform standardisation procedures across tumour subtype, and inviting a potential source of heterogeneity. As NLR has been previously shown to be associated with an increased incidence of coronary artery disease and cardiovascular mortality and morbidity, we lacked patient data regarding the same.[15] That could have reduced the specificity of NLR for OS. Finally, due to lack of appropriate data, the association of DNLR and other clinical parameters, such as PLR, lymphocyte-monocyte ratio, mean platelet volume, circulating tumour cells and gamma-glutamyl transferase was not explored. Thus, the prognostic implication of inflammation may not be fully captured using this single marker of inflammation. Given the heterogeneity of breast cancer and different influencing factors of NLR measurement, more studies are required to confirm the value of the DNLR test for breast cancer prognosis in the future.


  Conclusion Top


To the best of our knowledge, this is the first study to investigate the prognostic role of DNLR in breast cancer in the Indian population. In combination with other markers of local and systemic inflammation, DNLR, a low-cost, reliable marker of inflammation, may have potential utility in predicting disease prognosis and more realistic risk stratification for the management of breast cancer patients.

Acknowledgement

CK collected the data, analysed and wrote the manuscript.

Financial Support and Sponsorship

Nil.

Conflicts of Interest

There are no conflicts of interest.

 
  References Top

1.
Hanahan D, Weinberg RA. Hallmarks of cancer: The next generation. Cell 2011;144:646-74.  Back to cited text no. 1
    
2.
Templeton AJ, McNamara MG, Šeruga B, Vera-Badillo FE, Aneja P, Ocaña A, et al. Prognostic role of neutrophil-to-lymphocyte ratio in solid tumors: A systematic review and meta-analysis. J Natl Cancer Inst 2014;106:dju124.  Back to cited text no. 2
    
3.
Proctor MJ, McMillan DC, Morrison DS, Fletcher CD, Horgan PG, Clarke SJ. A derived neutrophil to lymphocyte ratio predicts survival in patients with cancer. Br J Cancer 2012;107:695-9.  Back to cited text no. 3
    
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Haddad CR, Guo L, Clarke S, Guminski A, Back M, Eade T, et al. Neutrophil-to-lymphocyte ratio in head and neck cancer. J Med Imaging Radiat Oncol 2015;59:514-9.  Back to cited text no. 4
    
5.
Hu ZD, Huang YL, Qin BD, Tang QQ, Yang M, Ma N, et al. Prognostic value of neutrophil to lymphocyte ratio for gastric cancer. Ann Transl Med 2015;3:50.  Back to cited text no. 5
    
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Hu K, Lou L, Ye J, Zhang S. Prognostic role of the neutrophil-lymphocyte ratio in renal cell carcinoma: A meta-analysis. BMJ Open 2015;5:e006404.  Back to cited text no. 6
    
7.
Xiao WK, Chen D, Li SQ, Fu SJ, Peng BG, Liang LJ. Prognostic significance of neutrophil-lymphocyte ratio in hepatocellular carcinoma: A meta-analysis. BMC Cancer 2014;14:117.  Back to cited text no. 7
    
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Chen J, Deng Q, Pan Y, He B, Ying H, Sun H, et al. Prognostic value of neutrophil-to-lymphocyte ratio in breast cancer. FEBS Open Bio 2015;5:502-7.  Back to cited text no. 8
    
9.
Azab B, Bhatt VR, Phookan J, Murukutla S, Kohn N, Terjanian T, et al. Usefulness of the neutrophil-to-lymphocyte ratio in predicting short- and long-term mortality in breast cancer patients. Ann Surg Oncol 2012;19:217-24.  Back to cited text no. 9
    
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Noh H, Eomm M, Han A. Usefulness of pretreatment neutrophil to lymphocyte ratio in predicting disease-specific survival in breast cancer patients. J Breast Cancer 2013;16:55-9.  Back to cited text no. 10
    
11.
Dirican A, Kucukzeybek BB, Alacacioglu A, Kucukzeybek Y, Erten C, Varol U, et al. Do the derived neutrophil to lymphocyte ratio and the neutrophil to lymphocyte ratio predict prognosis in breast cancer? Int J Clin Oncol 2015;20:70-81.  Back to cited text no. 11
    
12.
Krenn-Pilko S, Langsenlehner U, Thurner EM, Stojakovic T, Pichler M, Gerger A, et al. The elevated preoperative platelet-to-lymphocyte ratio predicts poor prognosis in breast cancer patients. Br J Cancer 2014;110:2524-30.  Back to cited text no. 12
    
13.
Rimando J, Campbell J, Kim JH, Tang SC, Kim S. The pretreatment neutrophil/lymphocyte ratio is associated with all-cause mortality in black and white patients with non-metastatic breast cancer. Front Oncol 2016;6:81.   Back to cited text no. 13
    
14.
Leitch EF, Chakrabarti M, Crozier JE, McKee RF, Anderson JH, Horgan PG, et al. Comparison of the prognostic value of selected markers of the systemic inflammatory response in patients with colorectal cancer. Br J Cancer 2007;97:1266-70.  Back to cited text no. 14
    
15.
Verdoia M, Barbieri L, Di Giovine G, Marino P, Suryapranata H, De Luca G, et al. Neutrophil to lymphocyte ratio and the extent of coronary artery disease: Results from a large cohort study. Angiology 2016;67:75-82.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
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