Prognostic value of C-reactive protein to albumin ratio in patients with pancreatic cancer：a meta-analysis_CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Authors：

ZHANG Bolin ,  XU Xinjian

Department of Hepatobiliary and Pancreatic Surgery, The Fifth Affiliated Hospital of Xinjiang Medical University (The Fifth Clinical Medical College of Xinjiang Medical University), Urumqi 830011, P. R. China;

Corresponding author：

XU Xinjian, Email: xxj0991@163.com

Keywords：

Pancreatic cancer; C-reactive protein to albumin ratio; prognosis; overall survival; meta-analysis

DOI：

10.7507/1007-9424.202108023

Video：

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Abstract Full text Figures/Tables Video References Cited by

Objective To systematically evaluate the potential value of C-reactive protein to albumin ratio (CAR) as an indicator of prognosis and survival in patients with pancreatic cancer. Methods The literatures were searched comprehensively in the PubMed, Embase, Web of Science, Cochrane Library, CBM, Wanfang, CNKI, and CQVIP databases from the establishment of the databases to May 20, 2021. The combined hazard ratio (HR) and 95% confidence interval (95%CI) were used to evaluate the correlation between the CAR and the overall survival (OS), progression-free survival (PFS), or disease-free survival (DFS) in the patients with pancreatic cancer. The Newcastle-Ottawa scale (NOS) was used to evaluate the quality of the non-randomized controlled studies, and the Stata SE 15.0 software was used for meta-analysis. Results A total of 2 985 patients with pancreatic cancer were included in this meta-analysis of 15 studies. The results of meta-analysis showed that the higher CAR value, the shorter OS [effect size (ES)=0.60, 95%CI (0.50, 0.69), Z=12.04, P<0.001], DFS [ES=0.63, 95%CI (0.47, 0.78), Z=3.61, P<0.001], and PFS [ES=0.41, 95%CI (0.19, 0.63), Z=7.91, P<0.001] in the patients with pancreatic cancer. The results of subgroup analysis of OS according to different countries, sample size, mean age, follow-up time, CAR cut-off value, and NOS score showed that the higher CAR value was related to the shorter OS (P<0.05). The result of linear regression analysis showed that there was no correlation between the CAR cut-off value and lnHR of OS (r²=0.947, P=0.455). Conclusion From results of this study, CAR is closely related to OS of patients, and it is expected to be used as a new reference index for monitoring and judging prognosis of patients with pancreatic cancer.

Citation： ZHANG Bolin, XU Xinjian. Prognostic value of C-reactive protein to albumin ratio in patients with pancreatic cancer：a meta-analysis. CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY, 2022, 29(3): 345-352. doi: 10.7507/1007-9424.202108023 Copy

1.	赵玉沛. 胰腺癌诊断与治疗的现状与未来. 中华肝胆外科杂志, 2009, 15(5): 321-323.
2.	中国临床肿瘤学会胰腺癌专家委员会. 胰腺癌综合诊治中国专家共识(2014年版). 临床肿瘤学杂志, 2014, 19(4): 358-370.
3.	Okabayashi T, Shima Y, Iwata J, et al. S-1 vs. gemcitabine as an adjuvant therapy after surgical resection for ductal adenocarcinoma of the pancreas. World J Surg, 2014, 38(11): 2986-2993.
4.	Bilimoria KY, Bentrem DJ, Ko CY, et al. National failure to operate on early stage pancreatic cancer. Ann Surg, 2007, 246(2): 173-180.
5.	Kamisawa T, Wood LD, Itoi T, et al. Pancreatic cancer. Lancet, 2016, 388(10039): 73-85.
6.	Jamieson NB, Denley SM, Logue J, et al. A prospective comparison of the prognostic value of tumor- and patient-related factors in patients undergoing potentially curative surgery for pancreatic ductal adenocarcinoma. Ann Surg Oncol, 2011, 18(8): 2318-2328.
7.	Antonioli L, Blandizzi C, Pacher P, et al. Immunity, inflammation and cancer: a leading role for adenosine. Nat Rev Cancer, 2013, 13(12): 842-857.
8.	Li N, Tian GW, Wang Y, et al. Prognostic role of the pretreatment C-reactive protein/albumin ratio in solid cancers: a meta-analysis. Sci Rep, 2017, 7: 41298. doi: 10.1038/srep41298.
9.	Ventriglia J, Petrillo A, Huerta Alváro M, et al. Neutrophil to lymphocyte ratio as a predictor of poor prognosis in metastatic pancreatic cancer patients treated with nab-paclitaxel plus gemcitabine: a propensity score analysis. Gastroenterol Res Pract, 2018, 2018: 2373868. doi: 10.1155/2018/2373868.
10.	Maruyama H, Hirano S, Kakiya Y, et al. Tu1440 – Preoperative C-reactive protein/albumin ratio predicts cancerization and recurrence in patients with resectable intraductal papillary mucinous neoplasms. Gastroenterology, 2019, 156(6): S-1040. doi: 10.1016/S0016-5085(19)39553-8.
11.	Yılmaz EM, Kandemir A. Significance of red blood cell distribution width and C-reactive protein/albumin levels in predicting prognosis of acute pancreatitis. Ulus Travma Acil Cerrahi Derg, 2018, 24(6): 528-531.
12.	Fan Y, Xiang S, Dai Z, et al. Prognostic significance of C-reactive protein to albumin ratio in colorectal cancer patients: a meta-analysis. Int J Colorectal Dis, 2019, 34(6): 1105-1111.
13.	Wei XL, Wang FH, Zhang DS, et al. A novel inflammation-based prognostic score in esophageal squamous cell carcinoma: the C-reactive protein/albumin ratio. BMC Cancer, 2015, 15: 350. doi: 10.1186/s12885-015-1379-6.
14.	Deng TB, Zhang J, Zhou YZ, et al. The prognostic value of C-reactive protein to albumin ratio in patients with lung cancer. Medicine (Baltimore), 2018, 97(50): e13505. doi: 10.1097/MD.0000000000013505.
15.	Zhou W, Zhang GL. C-reactive protein to albumin ratio predicts the outcome in renal cell carcinoma: a meta-analysis. PLoS One, 2019, 14(10): e0224266. doi: 10.1371/journal.pone.0224266.
16.	Cui X, Jia Z, Chen D, et al. The prognostic value of the C-reactive protein to albumin ratio in cancer: an updated meta-analysis. Medicine (Baltimore), 2020, 99(14): e19165. doi: 10.1097/MD.0000000000019165.
17.	Park HC, Kim MY, Kim CH. C-reactive protein/albumin ratio as prognostic score in oral squamous cell carcinoma. J Korean Assoc Oral Maxillofac Surg, 2016, 42(5): 243-250.
18.	Piciucchi M, Stigliano S, Archibugi L, et al. The neutrophil/lymphocyte ratio at diagnosis is significantly associated with survival in metastatic pancreatic cancer patients. Int J Mol Sci, 2017, 18(4): 730. doi: 10.3390/ijms18040730.
19.	Lee JM, Lee HS, Hyun JJ, et al. Prognostic value of inflammation-based markers in patients with pancreatic cancer administered gemcitabine and erlotinib. World J Gastrointest Oncol, 2016, 8(7): 555-562.
20.	Wu M, Guo J, Guo L, et al. The C-reactive protein/albumin ratio predicts overall survival of patients with advanced pancreatic cancer. Tumour Biol, 2016, 37(9): 12525-12533.
21.	Haruki K, Shiba H, Shirai Y, et al. The C-reactive protein to albumin ratio predicts long-term outcomes in patients with pancreatic cancer after pancreatic resection. World J Surg, 2016, 40(9): 2254-2260.
22.	Hang J, Xue P, Yang H, et al. Pretreatment C-reactive protein to albumin ratio for predicting overall survival in advanced pancreatic cancer patients. Sci Rep, 2017, 7(1): 2993. doi: 10.1038/s41598-017-03153-6.
23.	Liu Z, Jin K, Guo M, et al. Prognostic value of the CRP/Alb ratio, a novel inflammation-based score in pancreatic cancer. Ann Surg Oncol, 2017, 24(2): 561-568.
24.	Ikeguchi M, Hanaki T, Endo K, et al. C-reactive protein/albumin ratio and prognostic nutritional index are strong prognostic indicators of survival in resected pancreatic ductal adenocarcinoma. J Pancreat Cancer, 2017, 3(1): 31-36.
25.	Fujiwara Y, Haruki K, Shiba H, et al. C-reactive protein-based prognostic measures are superior at predicting survival compared with peripheral blood cell count-based ones in patients after curative resection for pancreatic cancer. Anticancer Res, 2018, 38(11): 6491-6499.
26.	Arima K, Yamashita YI, Hashimoto D, et al. Clinical usefulness of postoperative C-reactive protein/albumin ratio in pancreatic ductal adenocarcinoma. Am J Surg, 2018, 216(1): 111-115.
27.	罗宝洋, 杨勇, 段云飞, 等. 术前C反应蛋白和清蛋白比值对可切除胰腺癌患者预后的影响. 中华外科杂志, 2018, 56(9): 712-717.
28.	Kim HJ, Lee SY, Kim DS, et al. Inflammatory markers as prognostic indicators in pancreatic cancer patients who underwent gemcitabine-based palliative chemotherapy. Korean J Intern Med, 2020, 35(1): 171-184.
29.	Ikuta S, Aihara T, Yamanaka N. Preoperative C-reactive protein to albumin ratio is a predictor of survival after pancreatic resection for pancreatic ductal adenocarcinoma. Asia Pac J Clin Oncol, 2019, 15(5): e109-e114. doi: 10.1111/ajco.13123.
30.	Vujic J, Marsoner K, Wienerroither V, et al. The predictive value of the CRP-to-albumin ratio for patients with pancreatic cancer after curative resection: a retrospective single center study. In Vivo, 2019, 33(6): 2071-2078.
31.	Fan Z, Fan K, Gong Y, et al. The CRP/albumin ratio predicts survival and monitors chemotherapeutic effectiveness in patients with advanced pancreatic cancer. Cancer Manag Res, 2019, 11: 8781-8788.
32.	Murakawa M, Yamamoto N, Kamioka Y, et al. Clinical implication of pre-operative C-reactive protein-albumin ratio as a prognostic factor of patients with pancreatic ductal adenocarcinoma: a single-institutional retrospective study. In Vivo, 2020, 34(1): 347-353.
33.	Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ, 2009, 339: b2535. doi: 10.1136/bmj.b2535.
34.	Stang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol, 2010, 25(9): 603-605.
35.	Alifano M, Mansuet-Lupo A, Lococo F, et al. Systemic inflammation, nutritional status and tumor immune microenvironment determine outcome of resected non-small cell lung cancer. PLoS One, 2014, 9(9): e106914. doi:10.1371/journal.pone.0106914.
36.	Zhang J, Zhang HY, Li J, et al. The elevated NLR, PLR and PLT may predict the prognosis of patients with colorectal cancer: a systematic review and meta-analysis. Oncotarget, 2017, 8(40): 68837-68846.
37.	Zhou Y, Wei Q, Fan J, et al. Prognostic role of the neutrophil-to-lymphocyte ratio in pancreatic cancer: a meta-analysis containing8 252 patients. Clin Chim Acta, 2018, 479: 181-189.
38.	Chen H, Hu N, Chang P, et al. Modified Glasgow prognostic score might be a prognostic factor for hepatocellular carcinoma: a meta-analysis. Panminerva Med, 2017, 59(4): 302-307.
39.	Zhou Y, Cheng S, Fathy AH, et al. Prognostic value of platelet-to-lymphocyte ratio in pancreatic cancer: a comprehensive meta-analysis of 17 cohort studies. Onco Targets Ther, 2018, 11: 1899-1908.
40.	Dequanter D, Lothaire P. Serum albumin concentration and surgical site identify surgical risk for major post-operative complications in advanced head and neck patients. B-ENT, 2011, 7(3): 181-183.
41.	Gupta D, Lis CG. Pretreatment serum albumin as a predictor of cancer survival: a systematic review of the epidemiological literature. Nutr J, 2010, 9: 69. doi: 10.1186/1475-2891-9-69.
42.	Stevens L, Pathak S, Nunes QM, et al. Prognostic significance of pre-operative C-reactive protein and the neutrophil-lymphocyte ratio in resectable pancreatic cancer: a systematic review. HPB (Oxford), 2015, 17(4): 285-291.
43.	Qu G, Wang D, Xu W, et al. The systemic inflammation-based prognostic score predicts postoperative complications in patients undergoing pancreaticoduodenectomy. Int J Gen Med, 2021, 14: 787-795.
44.	Serafini S, Friziero A, Sperti C, et al. The ratio of C-reactive protein to albumin is an independent predictor of malignant intraductal papillary mucinous neoplasms of the pancreas. J Clin Med, 2021, 10(10): 2058. doi: 10.3390/jcm10102058.
45.	Makiyama A, Nakazawa J, Otsuka T, et al. Prognostic impact of the C-reactive protein/albumin ratio in advanced pancreatic cancer treated with GEM plus nab-PTX or FOLFIRINOX: based on the results of a multicenter retrospective study (the NAPOLEON study). Ann Oncol, 2019, 30: ix58. doi: org/10.1093/annonc/mdz422.044.
46.	van Wijk L, de Klein GW, Kanters MA, et al. The ultimate preoperative C-reactive protein-to-albumin ratio is a prognostic factor for survival after pancreatic cancer resection. Eur J Med Res, 2020, 25(1): 46. doi: 10.1186/s40001-020-00444-z.
47.	Zang Y, Fan Y, Gao Z. Pretreatment C-reactive protein/albumin ratio for predicting overall survival in pancreatic cancer: a meta-analysis. Medicine (Baltimore), 2020, 99(23): e20595. doi: 10.1097/MD.0000000000020595.
48.	Wu J, Tan W, Chen L, et al. Clinicopathologic and prognostic significance of C-reactive protein/albumin ratio in patients with solidtumors: an updated systemic review and meta-analysis. Oncotarget, 2018, 9: 13934-13947.

1. 赵玉沛. 胰腺癌诊断与治疗的现状与未来. 中华肝胆外科杂志, 2009, 15(5): 321-323.
2. 中国临床肿瘤学会胰腺癌专家委员会. 胰腺癌综合诊治中国专家共识(2014年版). 临床肿瘤学杂志, 2014, 19(4): 358-370.
3. Okabayashi T, Shima Y, Iwata J, et al. S-1 vs. gemcitabine as an adjuvant therapy after surgical resection for ductal adenocarcinoma of the pancreas. World J Surg, 2014, 38(11): 2986-2993.
4. Bilimoria KY, Bentrem DJ, Ko CY, et al. National failure to operate on early stage pancreatic cancer. Ann Surg, 2007, 246(2): 173-180.
5. Kamisawa T, Wood LD, Itoi T, et al. Pancreatic cancer. Lancet, 2016, 388(10039): 73-85.
6. Jamieson NB, Denley SM, Logue J, et al. A prospective comparison of the prognostic value of tumor- and patient-related factors in patients undergoing potentially curative surgery for pancreatic ductal adenocarcinoma. Ann Surg Oncol, 2011, 18(8): 2318-2328.
7. Antonioli L, Blandizzi C, Pacher P, et al. Immunity, inflammation and cancer: a leading role for adenosine. Nat Rev Cancer, 2013, 13(12): 842-857.
8. Li N, Tian GW, Wang Y, et al. Prognostic role of the pretreatment C-reactive protein/albumin ratio in solid cancers: a meta-analysis. Sci Rep, 2017, 7: 41298. doi: 10.1038/srep41298.
9. Ventriglia J, Petrillo A, Huerta Alváro M, et al. Neutrophil to lymphocyte ratio as a predictor of poor prognosis in metastatic pancreatic cancer patients treated with nab-paclitaxel plus gemcitabine: a propensity score analysis. Gastroenterol Res Pract, 2018, 2018: 2373868. doi: 10.1155/2018/2373868.
10. Maruyama H, Hirano S, Kakiya Y, et al. Tu1440 – Preoperative C-reactive protein/albumin ratio predicts cancerization and recurrence in patients with resectable intraductal papillary mucinous neoplasms. Gastroenterology, 2019, 156(6): S-1040. doi: 10.1016/S0016-5085(19)39553-8.
11. Yılmaz EM, Kandemir A. Significance of red blood cell distribution width and C-reactive protein/albumin levels in predicting prognosis of acute pancreatitis. Ulus Travma Acil Cerrahi Derg, 2018, 24(6): 528-531.
12. Fan Y, Xiang S, Dai Z, et al. Prognostic significance of C-reactive protein to albumin ratio in colorectal cancer patients: a meta-analysis. Int J Colorectal Dis, 2019, 34(6): 1105-1111.
13. Wei XL, Wang FH, Zhang DS, et al. A novel inflammation-based prognostic score in esophageal squamous cell carcinoma: the C-reactive protein/albumin ratio. BMC Cancer, 2015, 15: 350. doi: 10.1186/s12885-015-1379-6.
14. Deng TB, Zhang J, Zhou YZ, et al. The prognostic value of C-reactive protein to albumin ratio in patients with lung cancer. Medicine (Baltimore), 2018, 97(50): e13505. doi: 10.1097/MD.0000000000013505.
15. Zhou W, Zhang GL. C-reactive protein to albumin ratio predicts the outcome in renal cell carcinoma: a meta-analysis. PLoS One, 2019, 14(10): e0224266. doi: 10.1371/journal.pone.0224266.
16. Cui X, Jia Z, Chen D, et al. The prognostic value of the C-reactive protein to albumin ratio in cancer: an updated meta-analysis. Medicine (Baltimore), 2020, 99(14): e19165. doi: 10.1097/MD.0000000000019165.
17. Park HC, Kim MY, Kim CH. C-reactive protein/albumin ratio as prognostic score in oral squamous cell carcinoma. J Korean Assoc Oral Maxillofac Surg, 2016, 42(5): 243-250.
18. Piciucchi M, Stigliano S, Archibugi L, et al. The neutrophil/lymphocyte ratio at diagnosis is significantly associated with survival in metastatic pancreatic cancer patients. Int J Mol Sci, 2017, 18(4): 730. doi: 10.3390/ijms18040730.
19. Lee JM, Lee HS, Hyun JJ, et al. Prognostic value of inflammation-based markers in patients with pancreatic cancer administered gemcitabine and erlotinib. World J Gastrointest Oncol, 2016, 8(7): 555-562.
20. Wu M, Guo J, Guo L, et al. The C-reactive protein/albumin ratio predicts overall survival of patients with advanced pancreatic cancer. Tumour Biol, 2016, 37(9): 12525-12533.
21. Haruki K, Shiba H, Shirai Y, et al. The C-reactive protein to albumin ratio predicts long-term outcomes in patients with pancreatic cancer after pancreatic resection. World J Surg, 2016, 40(9): 2254-2260.
22. Hang J, Xue P, Yang H, et al. Pretreatment C-reactive protein to albumin ratio for predicting overall survival in advanced pancreatic cancer patients. Sci Rep, 2017, 7(1): 2993. doi: 10.1038/s41598-017-03153-6.
23. Liu Z, Jin K, Guo M, et al. Prognostic value of the CRP/Alb ratio, a novel inflammation-based score in pancreatic cancer. Ann Surg Oncol, 2017, 24(2): 561-568.
24. Ikeguchi M, Hanaki T, Endo K, et al. C-reactive protein/albumin ratio and prognostic nutritional index are strong prognostic indicators of survival in resected pancreatic ductal adenocarcinoma. J Pancreat Cancer, 2017, 3(1): 31-36.
25. Fujiwara Y, Haruki K, Shiba H, et al. C-reactive protein-based prognostic measures are superior at predicting survival compared with peripheral blood cell count-based ones in patients after curative resection for pancreatic cancer. Anticancer Res, 2018, 38(11): 6491-6499.
26. Arima K, Yamashita YI, Hashimoto D, et al. Clinical usefulness of postoperative C-reactive protein/albumin ratio in pancreatic ductal adenocarcinoma. Am J Surg, 2018, 216(1): 111-115.
27. 罗宝洋, 杨勇, 段云飞, 等. 术前C反应蛋白和清蛋白比值对可切除胰腺癌患者预后的影响. 中华外科杂志, 2018, 56(9): 712-717.
28. Kim HJ, Lee SY, Kim DS, et al. Inflammatory markers as prognostic indicators in pancreatic cancer patients who underwent gemcitabine-based palliative chemotherapy. Korean J Intern Med, 2020, 35(1): 171-184.
29. Ikuta S, Aihara T, Yamanaka N. Preoperative C-reactive protein to albumin ratio is a predictor of survival after pancreatic resection for pancreatic ductal adenocarcinoma. Asia Pac J Clin Oncol, 2019, 15(5): e109-e114. doi: 10.1111/ajco.13123.
30. Vujic J, Marsoner K, Wienerroither V, et al. The predictive value of the CRP-to-albumin ratio for patients with pancreatic cancer after curative resection: a retrospective single center study. In Vivo, 2019, 33(6): 2071-2078.
31. Fan Z, Fan K, Gong Y, et al. The CRP/albumin ratio predicts survival and monitors chemotherapeutic effectiveness in patients with advanced pancreatic cancer. Cancer Manag Res, 2019, 11: 8781-8788.
32. Murakawa M, Yamamoto N, Kamioka Y, et al. Clinical implication of pre-operative C-reactive protein-albumin ratio as a prognostic factor of patients with pancreatic ductal adenocarcinoma: a single-institutional retrospective study. In Vivo, 2020, 34(1): 347-353.
33. Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ, 2009, 339: b2535. doi: 10.1136/bmj.b2535.
34. Stang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol, 2010, 25(9): 603-605.
35. Alifano M, Mansuet-Lupo A, Lococo F, et al. Systemic inflammation, nutritional status and tumor immune microenvironment determine outcome of resected non-small cell lung cancer. PLoS One, 2014, 9(9): e106914. doi:10.1371/journal.pone.0106914.
36. Zhang J, Zhang HY, Li J, et al. The elevated NLR, PLR and PLT may predict the prognosis of patients with colorectal cancer: a systematic review and meta-analysis. Oncotarget, 2017, 8(40): 68837-68846.
37. Zhou Y, Wei Q, Fan J, et al. Prognostic role of the neutrophil-to-lymphocyte ratio in pancreatic cancer: a meta-analysis containing8 252 patients. Clin Chim Acta, 2018, 479: 181-189.
38. Chen H, Hu N, Chang P, et al. Modified Glasgow prognostic score might be a prognostic factor for hepatocellular carcinoma: a meta-analysis. Panminerva Med, 2017, 59(4): 302-307.
39. Zhou Y, Cheng S, Fathy AH, et al. Prognostic value of platelet-to-lymphocyte ratio in pancreatic cancer: a comprehensive meta-analysis of 17 cohort studies. Onco Targets Ther, 2018, 11: 1899-1908.
40. Dequanter D, Lothaire P. Serum albumin concentration and surgical site identify surgical risk for major post-operative complications in advanced head and neck patients. B-ENT, 2011, 7(3): 181-183.
41. Gupta D, Lis CG. Pretreatment serum albumin as a predictor of cancer survival: a systematic review of the epidemiological literature. Nutr J, 2010, 9: 69. doi: 10.1186/1475-2891-9-69.
42. Stevens L, Pathak S, Nunes QM, et al. Prognostic significance of pre-operative C-reactive protein and the neutrophil-lymphocyte ratio in resectable pancreatic cancer: a systematic review. HPB (Oxford), 2015, 17(4): 285-291.
43. Qu G, Wang D, Xu W, et al. The systemic inflammation-based prognostic score predicts postoperative complications in patients undergoing pancreaticoduodenectomy. Int J Gen Med, 2021, 14: 787-795.
44. Serafini S, Friziero A, Sperti C, et al. The ratio of C-reactive protein to albumin is an independent predictor of malignant intraductal papillary mucinous neoplasms of the pancreas. J Clin Med, 2021, 10(10): 2058. doi: 10.3390/jcm10102058.
45. Makiyama A, Nakazawa J, Otsuka T, et al. Prognostic impact of the C-reactive protein/albumin ratio in advanced pancreatic cancer treated with GEM plus nab-PTX or FOLFIRINOX: based on the results of a multicenter retrospective study (the NAPOLEON study). Ann Oncol, 2019, 30: ix58. doi: org/10.1093/annonc/mdz422.044.
46. van Wijk L, de Klein GW, Kanters MA, et al. The ultimate preoperative C-reactive protein-to-albumin ratio is a prognostic factor for survival after pancreatic cancer resection. Eur J Med Res, 2020, 25(1): 46. doi: 10.1186/s40001-020-00444-z.
47. Zang Y, Fan Y, Gao Z. Pretreatment C-reactive protein/albumin ratio for predicting overall survival in pancreatic cancer: a meta-analysis. Medicine (Baltimore), 2020, 99(23): e20595. doi: 10.1097/MD.0000000000020595.
48. Wu J, Tan W, Chen L, et al. Clinicopathologic and prognostic significance of C-reactive protein/albumin ratio in patients with solidtumors: an updated systemic review and meta-analysis. Oncotarget, 2018, 9: 13934-13947.

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Prognostic value of C-reactive protein to albumin ratio in patients with pancreatic cancer：a meta-analysis

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