Prognostic significance of baseline C-reactive protein/albumin ratio for long-term outcomes in advanced gastric cancer under immunochemotherapy

doi:10.4251/wjgo.v18.i6.117582

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World Journal of Gastrointestinal Oncology

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1948-5204

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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA

Retrospective Study

Copyright: ©Author(s) 2026. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution-NonCommercial (CC BY-NC 4.0) license. No commercial re-use. See permissions. Published by Baishideng Publishing Group Inc.

World J Gastrointest Oncol. Jun 15, 2026; 18(6): 117582
Published online Jun 15, 2026. doi: 10.4251/wjgo.v18.i6.117582

Table 1 Baseline characteristics stratified by C-reactive protein to albumin ratio (< 0.21 vs ≥ 0.21), mean ± SD/n (%)

Variables	Total (n = 200)	High CAR (n = 80)	Low CAR (n = 120)	Statistic	P value
Neutrophil	3.91 ± 2.32	4.05 ± 2.44	3.81 ± 2.24	t = 0.72	0.475
Lymphocyte	1.38 ± 0.59	1.36 ± 0.67	1.39 ± 0.53	t = -0.37	0.713
Albumin	39.24 ± 5.73	36.59 ± 6.29	41.01 ± 4.55	t = -5.42	< 0.001
CRP	17.33 ± 27.09	39.74 ± 31.52	2.38 ± 2.28	t = 10.58	< 0.001
CAR	0.49 ± 0.79	1.13 ± 0.94	0.06 ± 0.06	t = 10.14	< 0.001
Sex				χ² = 1.42	0.233
Female	75 (37.50)	26 (32.50)	49 (40.83)
Male	125 (62.50)	54 (67.50)	71 (59.17)
Age				χ² = 0.42	0.515
< 60 years	78 (39.00)	29 (36.25)	49 (40.83)
≥ 60 years	122 (61.00)	51 (63.75)	71 (59.17)
BMI				χ² = 1.00	0.318
< 25	166 (83.00)	69 (86.25)	97 (80.83)
≥ 25	34 (17.00)	11 (13.75)	23 (19.17)
CEA				χ² = 2.54	0.111
< 3	79 (39.50)	37 (46.25)	42 (35.00)
≥ 3	121 (60.50)	43 (53.75)	78 (65.00)
CA199				χ² = 1.03	0.309
< 37	126 (63.00)	47 (58.75)	79 (65.83)
≥ 37	74 (37.00)	33 (41.25)	41 (34.17)
ECOG PS				χ² = 2.08	0.149
0	72 (36.00)	24 (30.00)	48 (40.00)
1	128 (64.00)	56 (70.00)	72 (60.00)
Staging				χ² = 0.48	0.487
III	91 (45.50)	34 (42.50)	57 (47.50)
IV	109 (54.50)	46 (57.50)	63 (52.50)
Differentiation				χ² = 2.08	0.149
Poorly/undifferentiated	180 (90.00)	75 (93.75)	105 (87.50)
Medium/high	20 (10.00)	5 (6.25)	15 (12.50)
Site				χ² = 0.00	0.949
Gastric and esophageal binding	58 (29.00)	23 (28.75)	35 (29.17)
Stomach	142 (71.00)	57 (71.25)	85 (70.83)
Peritoneal metastasis				χ² = 2.84	0.092
No	157 (78.50)	58 (72.50)	99 (82.50)
Yes	43 (21.50)	22 (27.50)	21 (17.50)
Liver metastasis				χ² = 3.54	0.060
No	156 (78.00)	57 (71.25)	99 (82.50)
Yes	44 (22.00)	23 (28.75)	21 (17.50)
EBV status				χ² = 1.66	0.198
No-infect	187 (93.50)	77 (96.25)	110 (91.67)
Infect	13 (6.50)	3 (3.75)	10 (8.33)
PD-L1 expression				χ² = 2.29	0.130
CPS < 5	87 (43.50)	40 (50.00)	47 (39.17)
CPS ≥ 5	113 (56.50)	40 (50.00)	73 (60.83)
MMR status				χ² = 2.24	0.135
pMMR	168 (84.00)	71 (88.75)	97 (80.83)
dMMR	32 (16.00)	9 (11.25)	23 (19.17)

CAR: C-reactive protein/albumin ratio; CRP: C-reactive protein; BMI: Body mass index; CEA: Carcinoembryonic-antigen; CA199: Carbohydrate antigen 199; ECOG PS: Eastern Cooperative Oncology Group performance status; EBV: Epstein-Barr virus; PD-L1: Programmed death-ligand 1; CPS: Combined positive score; MMR: Mismatch repair; pMMR: Proficient mismatch repair; dMMR: Deficient mismatch repair.

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Table 2 Tumor responses stratified by C-reactive protein to albumin ratio (< 0.21 vs ≥ 0.21), n (%)

Variables	Total (n = 200)	High (n = 80)	Low (n = 120)	Statistic	P value
CR
No	189 (94.50)	76 (95.00)	113 (94.17)
Yes	11 (5.50)	4 (5.00)	7 (5.83)
PR
No	104 (52.00)	48 (60.00)	56 (46.67)
Yes	96 (48.00)	32 (40.00)	64 (53.33)
SD
No	159 (79.50)	63 (78.75)	96 (80.00)
Yes	41 (20.50)	17 (21.25)	24 (20.00)
PD
No	148 (74.00)	53 (66.25)	95 (79.17)
Yes	52 (26.00)	27 (33.75)	25 (20.83)
ORR				χ² = 3.87	0.049
No	93 (46.50)	44 (55.00)	49 (40.83)
Yes	107 (53.50)	36 (45.00)	71 (59.17)
DCR				χ² = 4.16	0.041
No	52 (26.00)	27 (33.75)	25 (20.83)
Yes	148 (74.00)	53 (66.25)	95 (79.17)

CR: Complete response; PR: Partial response; SD: Stable disease; PD: Progressive disease; ORR: Objective response rate; DCR: Disease control rate.

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Table 3 Univariate and multivariate analyses of prognostic factors for progression-free survival

Variables	Univariate		Multivariate
Variables	P value	HR (95%CI)	P value	HR (95%CI)
PD-L1 expression (CPS < 5 vs CPS ≥ 5)	< 0.001	0.34 (0.24-0.50)	< 0.001	0.42 (0.28-0.62)
MMR status (pMMR vs dMMR)	< 0.001	0.25 (0.13-0.48)	0.001	0.34 (0.18-0.65)
CAR (high vs low)	0.003	0.57 (0.40-0.82)	0.034	0.67 (0.46-0.97)
Sex (male vs female)	0.908	1.02 (0.70-1.49)
Age (≥ 60 vs < 60), years	0.114	1.36 (0.93-2.00)
BMI (< 25 vs ≥ 25), kg/m²	0.813	1.06 (0.66-1.70)
CEA (< 3 vs ≥ 3), ng/mL	0.853	1.04 (0.72-1.50)
CA199 (< 37 vs ≥ 37), ng/mL	0.365	1.19 (0.82-1.73)
ECOG (0 vs 1)	0.821	1.04 (0.72-1.52)
Staging (III vs IV)	< 0.001	2.55 (1.74-3.75)	0.015	1.67 (1.10-2.52)
Differentiation (poorly/undifferentiated vs medium/high)	0.041	0.45 (0.21-0.97)	0.235	0.62 (0.29-1.36)
Site (gastric and esophageal binding vs stomach)	0.772	0.94 (0.63-1.40)
Peritoneal metastasis (no vs yes)	< 0.001	2.08 (1.44-3.00)	< 0.001	1.95 (1.31-2.88)
Liver metastasis (no vs yes)	0.072	1.47 (0.97-2.25)
EBV status (infect vs no-infect)	0.099	0.47 (0.19-1.15)
Neutrophil	0.280	1.04 (0.97-1.11)
Lymphocyte	0.971	1.01 (0.75-1.36)

HR: Hazard ratio; CI: Confidence interval; PD-L1: Programmed death-ligand 1; CPS: Combined positive score; MMR: Mismatch repair; pMMR: Proficient mismatch repair; dMMR: Deficient mismatch repair; CAR: C-reactive protein/albumin ratio; BMI: Body mass index; CEA: Carcinoembryonic-antigen; CA199: Carbohydrate antigen 199; ECOG: Eastern Cooperative Oncology Group; EBV: Epstein-Barr virus.

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Table 4 Univariate and multivariate analyses of prognostic factors for overall survival

Variables	Univariate		Multivariate
Variables	P value	HR (95%CI)	P value	HR (95%CI)
PD-L1 expression (CPS < 5 vs CPS ≥ 5)	< 0.001	0.34 (0.23-0.49)	< 0.001	0.45 (0.30-0.66)
MMR status (pMMR vs dMMR)	< 0.001	0.22 (0.12-0.42)	0.001	0.34 (0.18-0.64)
CAR (high vs low)	< 0.001	0.45 (0.31-0.64)	< 0.001	0.51 (0.35-0.73)
Sex (male vs female)	0.595	0.91 (0.63-1.31)
Age (≥ 60 vs < 60), years	0.702	1.07 (0.74-1.55)
BMI (< 25 vs ≥ 25), kg/m²	0.408	0.82 (0.51-1.31)
CEA (< 3 vs ≥ 3), ng/mL	0.644	1.09 (0.76-1.57)
CA199 (< 37 vs ≥ 37), ng/mL	0.544	1.12 (0.78-1.62)
ECOG (0 vs 1)	0.326	1.21 (0.83-1.76)
Staging (III vs IV)	< 0.001	2.69 (1.83-3.94)	0.012	1.70 (1.12-2.58)
Differentiation (poorly/undifferentiated vs medium/high)	0.131	0.59 (0.30-1.17)
Site (gastric and esophageal binding vs stomach)	0.823	1.05 (0.70-1.57)
Peritoneal metastasis (no vs yes)	< 0.001	2.02 (1.41-2.91)	0.005	1.73 (1.17-2.54)
Liver metastasis (no vs yes)	0.064	1.50 (0.98-2.29)
EBV status (infect vs no-infect)	0.196	0.60 (0.28-1.30)
Neutrophil	0.178	1.05 (0.98-1.12)
Lymphocyte	0.368	0.87 (0.65-1.17)

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Table 5 Comparison of adverse events stratified by C-reactive protein to albumin ratio (< 0.21 vs ≥ 0.21) in advanced gastric cancer, n (%)

Variables	Total (n = 200)	High (n = 80)	Low (n = 120)	χ² value	P value
Leukopenia	79 (39.50)	34 (42.50)	45 (37.50)	0.50	0.479
Anemia	83 (41.50)	32 (40.00)	51 (42.50)	0.12	0.725
Neutropenia	80 (40.00)	32 (40.00)	48 (40.00)	0.00	1.000
Thrombocytopenia	72 (36.00)	33 (41.25)	39 (32.50)	1.60	0.207
Nausea	61 (30.50)	26 (32.50)	35 (29.17)	0.25	0.616
Pyrexia	51 (25.50)	23 (28.75)	28 (23.33)	0.74	0.389
Elevated ALT	37 (18.50)	18 (22.50)	19 (15.83)	1.41	0.234
Elevated AST	41 (20.50)	17 (21.25)	24 (20.00)	0.05	0.830
Hypothyroidism	37 (18.50)	15 (18.75)	22 (18.33)	0.01	0.941
Diarrhea	39 (19.50)	19 (23.75)	20 (16.67)	1.53	0.215
Hypertension	26 (13.00)	13 (16.25)	13 (10.83)	1.25	0.264
Pneumonitis	22 (11.00)	10 (12.50)	12 (10.00)	0.31	0.580
Proteinuria	23 (11.50)	10 (12.50)	13 (10.83)	0.13	0.717
Hyperbilirubinemi	18 (9.00)	7 (8.75)	11 (9.17)	0.01	0.920
Fatigue	26 (13.00)	12 (15.00)	14 (11.67)	0.47	0.492
≥ 3 grades: Thrombocytopenia	35 (17.50)	16 (20.00)	19 (15.83)	0.58	0.447
≥ 3 grades: Neutropenia	25 (12.50)	12 (15.00)	13 (10.83)	0.76	0.383
≥ 3 grades: Leukopenia	20 (10.00)	7 (8.75)	13 (10.83)	0.23	0.630
≥ 3 grades: Anemia	15 (7.50)	5 (6.25)	10 (8.33)	0.30	0.584
≥ 3 grades: Diarrhea	6 (3.00)	3 (3.75)	3 (2.50)	0.01	0.933
≥ 3 grades: Nausea	9 (4.50)	4 (5.00)	5 (4.17)	0.00	1.000
≥ 3 grades: Elevated ALT	7 (3.50)	3 (3.75)	4 (3.33)	0.00	1.000
≥ 3 grades: Elevated AST	6 (3.00)	2 (2.50)	4 (3.33)	0.00	1.000
≥ 3 grades: Hypothyroidism	5 (2.50)	2 (2.50)	3 (2.50)	0.00	1.000
≥ 3 grades: Hypertension	4 (2.00)	2 (2.50)	2 (1.67)	0.00	1.000
≥ 3 grades: Pneumonitis	3 (1.50)	2 (2.50)	1 (0.83)	0.13	0.722
≥ 3 grades: Hyperbilirubinemia	4 (2.00)	2 (2.50)	2 (1.67)	0.00	1.000

AST: Aspartate aminotransferase; ALT: Alanine aminotransferase.

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Table 6 Comparison of features between the training and validation sets, mean ± SD/n (%)

Variables	Total (n = 200)	Test (n = 60)	Train (n = 140)	Statistic	P value
Neutrophil	3.91 ± 2.32	4.21 ± 3.06	3.78 ± 1.92	t = 1.00	0.320
Lymphocyte	1.38 ± 0.59	1.40 ± 0.69	1.37 ± 0.54	t = 0.35	0.724
PD-L1 expression				χ² = 0.12	0.732
CPS < 5	87 (43.50)	25 (41.67)	62 (44.29)
CPS ≥ 5	113 (56.50)	35 (58.33)	78 (55.71)
MMR status				χ² = 1.20	0.274
pMMR	168 (84.00)	53 (88.33)	115 (82.14)
dMMR	32 (16.00)	7 (11.67)	25 (17.86)
CAR				χ² = 0.00	1.000
High	80 (40.00)	24 (40.00)	56 (40.00)
Low	120 (60.00)	36 (60.00)	84 (60.00)
Sex				χ² = 0.63	0.426
Female	75 (37.50)	20 (33.33)	55 (39.29)
Male	125 (62.50)	40 (66.67)	85 (60.71)
Age				χ² = 0.58	0.448
< 60 years	78 (39.00)	21 (35.00)	57 (40.71)
≥ 60 years	122 (61.00)	39 (65.00)	83 (59.29)
BMI				χ² = 1.73	0.189
< 25	166 (83.00)	53 (88.33)	113 (80.71)
≥ 25	34 (17.00)	7 (11.67)	27 (19.29)
CEA				χ² = 0.01	0.925
< 3	79 (39.50)	24 (40.00)	55 (39.29)
≥ 3	121 (60.50)	36 (60.00)	85 (60.71)
CA199				χ² = 2.76	0.097
< 37	126 (63.00)	43 (71.67)	83 (59.29)
≥ 37	74 (37.00)	17 (28.33)	57 (40.71)
ECOG PS				χ² = 0.70	0.403
0	72 (36.00)	19 (31.67)	53 (37.86)
1	128 (64.00)	41 (68.33)	87 (62.14)
Staging				χ² = 0.16	0.687
III	91 (45.50)	26 (43.33)	65 (46.43)
IV	109 (54.50)	34 (56.67)	75 (53.57)
Differentiation				χ² = 0.26	0.607
Poorly/undifferentiated	180 (90.00)	55 (91.67)	125 (89.29)
Medium/high	20 (10.00)	5 (8.33)	15 (10.71)
Site				χ² = 0.04	0.838
Gastric and esophageal binding	58 (29.00)	18 (30.00)	40 (28.57)
Stomach	142 (71.00)	42 (70.00)	100 (71.43)
Peritoneal metastasis				χ² = 0.17	0.679
No	157 (78.50)	46 (76.67)	111 (79.29)
Yes	43 (21.50)	14 (23.33)	29 (20.71)
Liver metastasis				χ² = 0.20	0.655
No	156 (78.00)	48 (80.00)	108 (77.14)
Yes	44 (22.00)	12 (20.00)	32 (22.86)
EBV status				χ² = 0.06	0.802
No-infect	187 (93.50)	57 (95.00)	130 (92.86)
infect	13 (6.50)	3 (5.00)	10 (7.14)

PD-L1: Programmed death-ligand 1; CPS: Combined positive score; MMR: Mismatch repair; pMMR: Proficient mismatch repair; dMMR: Deficient mismatch repair; CAR: C-reactive protein/albumin ratio; BMI: Body mass index; CEA: Carcinoembryonic-antigen; CA199: Carbohydrate antigen 199; ECOG PS: Eastern Cooperative Oncology Group performance status; EBV: Epstein-Barr virus.

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Citation: Mei S, Ye ML, Hao QL, Li GC, Yao ZY, Wang HY. Prognostic significance of baseline C-reactive protein/albumin ratio for long-term outcomes in advanced gastric cancer under immunochemotherapy. World J Gastrointest Oncol 2026; 18(6): 117582
URL: https://www.wjgnet.com/1948-5204/full/v18/i6/117582.htm
DOI: https://dx.doi.org/10.4251/wjgo.v18.i6.117582

Mei S, Ye ML, Hao QL, Li GC, Yao ZY, Wang HY. Prognostic significance of baseline C-reactive protein/albumin ratio for long-term outcomes in advanced gastric cancer under immunochemotherapy. World J Gastrointest Oncol 2026; 18(6): 117582 [DOI: 10.4251/wjgo.v18.i6.117582]

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