Molecular Diagnostics

Prognostic significance of pre-treatment neutrophil-to-lymphocyte ratio (NLR) in patients with oropharyngeal cancer treated with radiotherapy



This study aimed to evaluate the prognostic value of pre-treatment NLR in patients with oropharyngeal cancer.


Patients who completed definitive radiotherapy (RT) for oropharyngeal cancer and had blood counts taken pre-RT from 2002 to 2013 were included. NLR was calculated as total neutrophil/lymphocytes. Survival rates were estimated using the Kaplan–Meier method. Univariable and multivariable analyses were conducted with linear and Cox regression methods. NLR was analysed posteriori and dichotomised on the discovered median.


Eight hundred and forty-eight patients were analysed. The median pre-RT NLR was 3. Patients with NLR of <3 had improved overall survival (OS) than those with NLR ≥ 3 (5-year OS 85 vs 74%, p < 0.0001). OS differences remained significant when stratified according to HPV status (HPV-positive p = 0.011; HPV-negative p = 0.003). Freedom from any recurrence (FFR), locoregional control (LRC) and freedom of distant recurrence (FDR) were better in those with NLR < 3. The negative impact of elevated pre-RT NLR on OS (HR = 1.64, p = 0.001), FFR (HR = 1.6, p = 0.006) and LRC (HR = 1.8, p = 0.005) remained significant on multivariable analysis.


Pre-RT NLR is an independent prognostic factor in patients with oropharyngeal cancer regardless of HPV status. Patients with lower NLR had more favourable OS and disease control.

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Author information




S.P.N.: conceptualisation, data curation, formal analysis, investigation, methodology, project administration, visualisation, writing—original draft, and writing—review and editing. H.B.: data curation, investigation, visualisation, and writing—review and editing. A.J.: data curation and writing—review and editing. E.M.S., F.M.J., G.B.G., R.F., J.P., D.I.R., S.J.F. and C.D.F.: resources, methodology, and writing—review and editing. B.E.: methodology and writing—review and editing. A.S.G.: supervision, project administration, resources, writing—original draft, and writing—review and editing.

Corresponding authors

Correspondence to Sweet Ping Ng or Adam S. Garden.

Ethics declarations

Ethics approval and consent to participate

This study was approved by the Institutional Review Board of The University of Texas MD Anderson Cancer Center. Informed consent was waived. This study was performed in accordance with the Declaration of Helsinki.

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Not applicable.

Data availability

Data will be available on request.

Competing interests

The authors declare no competing interests.

Funding information

S.P.N. is funded by the Australian Postgraduate Award, the Royal Australian and New Zealand College of Radiologists (RANZCR) Research Grant and the Radiological Society of North America (RSNA) Fellow Grant. C.D.F. was supported by Andrew Sabin Family Fellowship. C.D.F. received funding support from the National Institutes of Health (NIH)/National Institute for Dental and Craniofacial Research (NIDCR) (1R01DE025248-01/R56DE025248-01). C.D.F. was previously funded via the National Science Foundation (NSF), Division of Mathematical Sciences, Joint NIH/NSF Initiative on Quantitative Approaches to Biomedical Big Data (QuBBD) Grant (NSF DMS-1557679) and is currently supported by the NIH National Cancer Institute (NCI)/Big Data to Knowledge (BD2K) Program (1R01CA214825-01), the NIH/NCI Head and Neck Specialized Programs of Research Excellence (SPORE) Developmental Research Program Career Development Award (P50CA097007-10); the NCI Paul Calabresi Clinical Oncology Program Award (K12 CA088084-06); a General Electric Healthcare/MD Anderson Center for Advanced Biomedical Imaging In-Kind Award; an Elekta AB/MD Anderson Department of Radiation Oncology Seed Grant; the Center for Radiation Oncology Research (CROR) at MD Anderson Cancer Center Seed Grant and the MD Anderson Institutional Research Grant (IRG) Program. C.D.F. has received speaker travel funding from Elekta AB. This study was supported in part by the NIH/NCI Cancer Center Support (Core) Grant CA016672 to The University of Texas MD Anderson Cancer Center (P30 CA016672). F.M.J. has received research funding from PIQUR Therapeutics and Trovagene. E.M.S. has a research award from Roche Diagnostics supporting HPV testing of oral rinse and mucosal swab samples on the clinical trial for HPV-related cancers screening in men (HOUSTON study).

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Ng, S.P., Bahig, H., Jethanandani, A. et al. Prognostic significance of pre-treatment neutrophil-to-lymphocyte ratio (NLR) in patients with oropharyngeal cancer treated with radiotherapy. Br J Cancer (2020).

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