Ovarian Cancer Outcomes Linked to Preoperative Immunonutritional Status

Poor preoperative immunonutritional status is linked to a poor prognosis in patients with ovarian cancer, according to a study published in BMC Public Health.¹

In addition to therapeutic and clinicopathologic factors, immunonutritional status is increasingly recognized as a key factor influencing ovarian cancer prognosis.² Up to 70% of patients experience malnutrition, which ultimately worsens survival outcomes by weakening the immune response, reducing chemotherapy tolerance, and increasing postoperative infection risk.¹ Meanwhile, systemic inflammation drives tumor survival, proliferation, invasion, metastasis, and angiogenesis while promoting chemotherapy resistance.

The prognostic nutritional index (PNI) and systemic immune-inflammation index (SII) are commonly used to assess immunonutritional status as they provide insight into a patient's nutritional status and inflammatory immune response, respectively. PNI, which is based on peripheral blood lymphocyte count and serum albumin concentration, is significantly associated with ovarian cancer prognosis. Additionally, high neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and SII indicate immunosuppression, correlating with higher tumor aggressiveness and poorer overall outcomes among patients with ovarian cancer.

Previous studies have explored the association between these indicators and ovarian cancer prognosis, but small sample sizes and single-center designs often limited them. To overcome these limitations, the researchers further investigated the effect of preoperative immunonutritional status on ovarian cancer prognosis.

Poor preoperative immunonutritional status as determined by prognostic nutritional index (PNI) and systemic immune-inflammation index (SII) harms the prognosis of patients with ovarian cancer | Image Credit: Viacheslav Yakobchuk - stock.adobe.com

They analyzed eligible patients with histologically confirmed epithelial ovarian cancer who received comprehensive staged surgery or debulking surgery at 7 tertiary hospitals in China between January 2012 and February 2023. The study population consisted of 922 patients, with a median age at diagnosis of 52 years (IQR, 47-59 years). Of this population, 224 patients had early-stage ovarian cancer, defined as International Federation of Gynecology and Obstetrics (FIGO) stage I to IIA disease, and 698 patients had advanced-stage ovarian cancer, defined as FIGO stage IIB to IV disease.

Among the early-stage cohort, the optimal cut-off values of PNI relative to overall survival (OS) and progression-free survival (PFS) were both 47.47. Also, the optimal cut-off values of SII relative to PFS and OS were 551.37 and 771.78, respectively. In the advanced-stage cohort, the optimal cutoff values of PNI relative to PFS and OS were 47.76 and 46.00, respectively. For SII, the optimal cut-off values relative to PFS and OS were 720.96 and 1686.11, respectively.

Patients were categorized into high- and low-index groups during follow-up according to the PNI and SII cut-off values; the median follow-up time was 55.1 months. The researchers determined through Kaplan-Meier survival curves that the median PFS and OS were significantly longer in the high PNI and low SII groups (P < .01 for both), regardless of disease stage.

Cox regression analyses were then performed to identify the factors influencing PFS and OS in both cohorts. In the multivariate analysis of patients with early-stage ovarian cancer, high PNI was an independent protective factor for both PFS (HR, 0.39; 95% CI, 0.20-0.76; P = .006) and OS (HR, 0.44; 95% CI, 0.20-0.97; P = .042). Also, high SII was an independent risk factor for PFS (HR, 2.43; 95% CI, 1.23-4.81; P = .011) and was a marginally unfavorable prognostic factor for OS (HR, 2.05; 95% CI, 0.96-4.39).

In the advanced-stage cohort, the multivariate analysis found PNI (HR, 0.77; 95% CI, 0.60-0.99; P = .043) and SII (HR, 1.34; 95% CI, 1.01-1.78; P = .064) to be independent prognostic factors for OS. However, PNI (P = .185) and SII (P = .188) had no impact on PFS within this population.

The researchers acknowledged their limitations, including the limited study population. It consisted only of patients within China, which may limit their study's broader generalizability. Despite their limitations, they expressed confidence in their findings.

“The combination of PNI and SII can be used as simple and useful markers for predicting short-term and long-term survival of ovarian cancer patients,” the authors concluded. “When patients show a poor preoperative immunonutritional status, timely intervention should be implemented to enhance their immunonutritional condition, thereby mitigating adverse prognostic outcomes.”

References

1. Yang C, Zou J, Luo X, et al. Health inequality and improvement gap in the prevalence of gynecological cancers among perimenopausal women globally, 1990-2019. BMC Public Health. 2025;25(1):590. doi:10.1186/s12889-025-21807-3
2. Chien J, Poole EM. Ovarian cancer prevention, screening, and early detection: report from the 11th Biennial Ovarian Cancer Research Symposium. Int J Gynecol Cancer. 2017;27(9S Suppl 5):S20-S22. doi:10.1097/IGC.0000000000001118