Nonlinear association between baseline albumin-to-alkaline phosphatase ratio and overall survival in advanced NSCLC treated with anlotinib: a two-center retrospective cohort study
- 1Department of Pulmonary Medicine, Zhongshan Hospital (Xiamen), Fudan University
- 2Department of Thoracic Surgery, Zhongshan Hospital (Xiamen), Fudan University
- 3Department of Critical Care Medicine, Zhongshan Hospital (Xiamen), Fudan University
Abstract
Background The albumin-to-alkaline phosphatase ratio (AAPR) has been reported as a prognostic biomarker in several malignancies, but its clinical relevance in advanced non-small cell lung cancer (NSCLC) patients treated with anlotinib remains unclear. This study aimed to examine the association between baseline AAPR and overall survival (OS). Methods We retrospectively and consecutively enrolled patients with advanced NSCLC who received anlotinib at Zhongshan Hospital, Fudan University (from June 2018 to September 2023) and Zhongshan Hospital (Xiamen), Fudan University (from April 2019 to February 2025). Baseline AAPR was calculated as serum albumin divided by alkaline phosphatase. The primary endpoint was OS. Cox proportional hazards models, smooth curve fitting, and two-piecewise Cox regression were used to evaluate the association between AAPR and OS. Sensitivity analyses, including prespecified subgroup analyses and distribution checks, were performed to evaluate robustness. Results During follow-up, 52.5% of patients died. Higher AAPR was independently associated with longer OS in multivariable Cox regression (HR = 0.22, 95% CI 0.09–0.56, p = 0.0014). Median OS increased progressively across AAPR tertiles (10.18, 13.93, and 20.43 months; log-rank p = 0.0010). Smooth curve fitting revealed a significant non-linear relationship (p = 0.008), with an inflection point at 0.2036: below this threshold, mortality risk decreased steeply, while above it the association remained protective but attenuated. Subgroup analyses confirmed consistency across demographic, clinical, and treatment categories. Distribution checks verified adequate data density below the threshold. Conclusion Baseline AAPR was independently and non-linearly associated with OS in advanced NSCLC patients treated with anlotinib. Patients with AAPR < 0.2036 represent a subgroup with particularly poor prognosis, while increases above the threshold remained protective but conferred diminishing benefit.
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BibTeX
@article{zhang2026nonlinear,
title = {{Nonlinear association between baseline albumin-to-alkaline phosphatase ratio and overall survival in advanced NSCLC treated with anlotinib: a two-center retrospective cohort study}},
author = {Ning Zhang and Zhenyang Lin and Jinzhan Chen and Xiong Xiao and Jiaxin Liu and Qingwei Zhang and Jinxian Huang and Hongni Jiang and Jiefei Ma and Congyi Xie},
journal = {BMC Cancer},
year = {2026},
month = jul,
doi = {10.1186/s12885-026-16482-5},
url = {https://doi.org/10.1186/s12885-026-16482-5},
note = {CC BY},
}
RIS
TY - JOUR
TI - Nonlinear association between baseline albumin-to-alkaline phosphatase ratio and overall survival in advanced NSCLC treated with anlotinib: a two-center retrospective cohort study
AU - Ning Zhang
AU - Zhenyang Lin
AU - Jinzhan Chen
AU - Xiong Xiao
AU - Jiaxin Liu
AU - Qingwei Zhang
AU - Jinxian Huang
AU - Hongni Jiang
AU - Jiefei Ma
AU - Congyi Xie
PY - 2026
DA - 2026/07/01
JO - BMC Cancer
DO - 10.1186/s12885-026-16482-5
UR - https://doi.org/10.1186/s12885-026-16482-5
AB - Background The albumin-to-alkaline phosphatase ratio (AAPR) has been reported as a prognostic biomarker in several malignancies, but its clinical relevance in advanced non-small cell lung cancer (NSCLC) patients treated with anlotinib remains unclear. This study aimed to examine the association between baseline AAPR and overall survival (OS). Methods We retrospectively and consecutively enrolled patients with advanced NSCLC who received anlotinib at Zhongshan Hospital, Fudan University (from June 2018 to September 2023) and Zhongshan Hospital (Xiamen), Fudan University (from April 2019 to February 2025). Baseline AAPR was calculated as serum albumin divided by alkaline phosphatase. The primary endpoint was OS. Cox proportional hazards models, smooth curve fitting, and two-piecewise Cox regression were used to evaluate the association between AAPR and OS. Sensitivity analyses, including prespecified subgroup analyses and distribution checks, were performed to evaluate robustness. Results During follow-up, 52.5% of patients died. Higher AAPR was independently associated with longer OS in multivariable Cox regression (HR = 0.22, 95% CI 0.09–0.56, p = 0.0014). Median OS increased progressively across AAPR tertiles (10.18, 13.93, and 20.43 months; log-rank p = 0.0010). Smooth curve fitting revealed a significant non-linear relationship (p = 0.008), with an inflection point at 0.2036: below this threshold, mortality risk decreased steeply, while above it the association remained protective but attenuated. Subgroup analyses confirmed consistency across demographic, clinical, and treatment categories. Distribution checks verified adequate data density below the threshold. Conclusion Baseline AAPR was independently and non-linearly associated with OS in advanced NSCLC patients treated with anlotinib. Patients with AAPR < 0.2036 represent a subgroup with particularly poor prognosis, while increases above the threshold remained protective but conferred diminishing benefit.
SN - 1471-2407
ER -