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Life sciences · Journal article
Frontiers in Oncology · September 17, 2026
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Background The neutrophil-to-lymphocyte ratio (NLR) is an inexpensive, routinely available marker of systemic inflammation that has been proposed as a prognostic biomarker in cancer immunotherapy. However, most evidence derives from single baseline measurements in selected populations, and the prognostic value of serial, on-treatment NLR dynamics, particularly in real-world Latin American cohorts, remains poorly defined. We evaluated whether baseline and time-varying NLR predict overall survival (OS) in patients treated with immune checkpoint inhibitors (ICI), and whether any association is independent of performance status. Methods We retrospectively analyzed 68 patients with advanced solid tumors (lung, urological, melanoma, and others) treated with ICI at two Uruguayan institutions: Hospital de Clínicas, Universidad de la República, and Instituto Nacional del Cáncer (INCA), both in Montevideo, Uruguay. NLR and platelet-to-lymphocyte ratio (PLR) were measured at baseline and at each treatment cycle (up to 12 cycles). OS and progression-free survival were analyzed using Kaplan–Meier estimates and Cox proportional-hazards models, including a time-varying covariate model using serial NLR. Six-month RECIST response and immune-related adverse events were assessed as secondary outcomes. Robustness was evaluated with bootstrap confidence intervals, permutation testing, and correction for multiple comparisons. Results Over a median follow-up of 16.8 months, 39 deaths occurred (survival population n=66). Elevated baseline NLR was associated with shorter OS (HR 1.18 per unit, 95% CI 1.04–1.34, p=0.011). In a time-varying analysis using serial measurements, higher on-treatment NLR remained independently associated with OS after adjustment for ECOG performance status (HR 1.09, 95% CI 1.00–1.19, p=0.040; ECOG p=0.021). Patients in the highest NLR quartile (>4.9) had markedly shorter median OS than the remainder of the cohort (7.3 vs ~25 months). Neither baseline nor dynamic NLR/PLR predicted six-month RECIST response. Combination anti-PD-1/anti-CTLA-4 therapy was associated with higher odds of immune-related toxicity (OR 5.03, p=0.023). Conclusions In this real-world Latin American ICI cohort, dynamic on-treatment NLR was independently associated with overall survival, supporting serial monitoring of this inexpensive marker over single baseline assessment. NLR did not predict tumor response, underscoring that its prognostic value reflects systemic host condition rather than direct antitumor activity. These findings, though exploratory, support NLR trajectory as a low-cost prognostic adjunct warranting prospective validation. Since complete blood counts are already obtained at every treatment cycle for routine hematologic surveillance, this information could be captured at no additional cost to clinical practice.