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Prognostic value of albumin-bilirubin grade in lung cancer: a meta-analysis

Journal of Cardiothoracic Surgery volume 19, Article number: 685 (2024) Cite this article

Abstract

Purpose

To clarify the prognostic role of pretreatment albumin-bilirubin (ALBI) grade in lung cancer patients.

Methods

The PubMed, EMBASE, Web of Science and CNKI databases were searched up to April 20, 2024. Primary outcomes included the overall survival (OS), progression-free survival (PFS) and cancer-specific survival (CSS). Hazard ratios (HRs) with 95% confidence intervals (CIs) were combined and subgroup analysis based on the type of lung cancer [non-small cell lung cancer (NSCLC) vs. small cell lung cancer (SCLC)] and treatment [surgery vs. immune checkpoint inhibitors (ICIs) vs. chemotherapy] was conducted.

Results

Eight studies with 2,057 patients were included. Pooled results indicated that elevated pretreatment ALBI grade was significantly related to poor OS (HR = 2.50, 95% CI: 2.03–3.09, P<0.001), PFS (HR = 1.91, 95% CI: 1.56–2.33, P<0.001) and CSS (HR = 1.90, 95% CI: 1.11–3.11, P = 0.018). Subgroup analysis for OS based on the pathological type and primary treatment manifested similar results.

Conclusion

Pretreatment ALBI grade is associated with prognosis in lung cancer and patients with elevated ALBI grade are more likely to experience worse survival.

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Introduction

Lung cancer remains the leading cause of tumor-related death over the word and consists of non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC) [1]. In the past decades, great progress has been made in the diagnosis and treatment of lung cancer, the overall prognosis of lung cancer patients remains unsatisfied with the five-year survival of less than 30% [1]. One of the important causes for poor prognosis in lung cancer patients is the inability to accurately assess prognosis and formulate corresponding treatment strategies. As of today, we still need to identify more prognostic indicators beyond TNM staging to assist us in evaluating the prognosis of lung cancer patients.

Numerous indicators have been reported to show prognostic value in lung cancer in the past years such as the modified Glasgow prognostic score (mGPS), C-reactive protein to albumin ratio (CAR), neutrophil to lymphocyte ratio (NLR) and albumin to globulin ratio (AGR) [2,3,4,5]. In 2015, a novel index named as albumin-bilirubin (ALBI) grade was described by Johnson et al. [6]. It was calculated according to the following formula: ALBI = 0.66 × log10(bilirubin) − 0.085 × albumin. ALBI grade 1, 2 and 3 were separately defined as ALBI ≤ -2.60, -2.60 < ALBI ≤ -1.39, and ALBI > -1.39 [6]. A considerable amount of research has demonstrated the clinical value of this indicator in predicting the prognosis of hepatocellular carcinoma. Xu et al. included eight studies and indicated that elevated ALBI grade was significantly associated with poor survival in hepatocellular carcinoma [7]. Other similar meta-analyses have also clarified the clinical role of ALBI grade in hepatocellular carcinoma [8,9,10], which is easily understood, as the metabolism and production of albumin and bilirubin are closely related to liver function. However, increasing evidence suggests that cancers are actually systemic diseases, and blood indicators such as albumin could also reflect the malignancy and prognosis of tumors in other sites [11, 12].

Some studies explored the prognostic value of ALBI grade in lung cancer, but their results were inconsistent [13,14,15,16,17,18,19,20]. Therefore, this study aimed to further identify the predictive role of pretreatment ALBI grade for survival among lung cancer patients.

Materials and methods

This study was conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analyses 2020 [21].

Literature search

The PubMed, EMBASE, Web of Science and Chinese National Knowledge Infrastructure (CNKI) databases were searched up to April 20, 2024. We used the following key words during the search: albumin-bilirubin, lung, pulmonary, tumor, cancer, carcinoma and neoplasm. Specific searching strategy was as follows: (albumin-bilirubin) AND (lung OR pulmonary) AND (tumor OR cancer OR carcinoma OR neoplasm). Besides, references of included studies were also reviewed and MeSH terms were applied.

Inclusion and exclusion criteria

Studies which met following criteria were considered for inclusion: (1) lung cancer patients who were diagnosed pathologically; (2) the ALBI score was calculated before anti-tumor treatment as follows: ALBI= (log10 bilirubin [µmol/L] × 0.66) + (albumin[g/L] × − 0.085) [8]; (3) patients were divided into different groups according to the ALBI score or grade; (4) the overall survival (OS), progression-free survival (PFS) and (or) cancer-specific survival (CSS) were compared between groups with reported hazard ratios (HRs) and 95% confidence intervals (CIs); (5) full texts were available.

Studies which met following criteria were further excluded: (1) insufficient, overlapped or duplicated data; (2) non-cohort studies such as the letters, animal trials, reviews, case reports and meeting abstracts.

Data collection

We extracted following information from included studies: the publication year, country, first author, number of cases, type of lung cancer (NSCLC or SCLC), primary treatment strategy (surgery, ICIs, chemotherapy or others), tumor stage, definition of ALBI grade, endpoint, HRs and 95% CIs.

Quality evaluation

The methodological quality was according to the Newcastle-Ottawa Scale (NOS) score and studies with NOS score >5 were defined as high-quality studies [22].

The literature searching, selection, data collection and quality evaluation were conducted by two authors.

Statistical analysis

The analysis was conducted by STATA version 15.0 software. The heterogeneity between studies was assessed by I2 statistics and Q test. If significant heterogeneity was observed representing as I2 > 50% and/or P < 0.1, the random effects model was used; or the fixed effects model was applied [23]. HR with 95% CI were combined to evaluate the association between ALBI grade and survival. Subgroup analysis based on the type of lung cancer and treatment was performed. Sensitivity analysis was conducted to assess the stability of pooled results. Begg’s funnel plot and Egger’s test were performed to identify publication bias, and obvious publication bias was defined as P < 0.05 [24, 25].

Results

Literature search and selection

The detailed process was presented in Fig. 1. One hundred and fifty-two publications were searched from databases and 29 duplicated publications were removed. After screening the titles and abstracts, 110 publications were excluded. Then eight retrospective studies were eventually included after reviewing the full texts [13,14,15,16,17,18,19,20].

Fig. 1
figure 1

Flow diagram of this meta-analysis

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Basic characteristics of included trials

Detailed information of included studies was showed in Table 1. A total of 2,057 cases were enrolled with the sample size ranged from 58 to 947. Most studies were from China or Japan and focused on NSCLC patients. Besides, most included studies applied the criteria for ALBI grade: Grade 1 with the score ≤ − 2.60, grade 2 with the score > − 2.60 and ≤ − 1.39 and grade 3 with the score > − 1.39. Three studies divided patients into two groups with the cutoff values of -2.52, -2.18 and − 2.55, respectively. All studies were high-quality studies with the NOS score > 5 (Table 1).

Table 1 Basic characteristics of included studies
Full size table

Association of pretreatment ALBI grade with OS in lung cancer patients

All eight studies identified the prognostic role of pretreatment ALBI grade for OS. Pooled results demonstrated that higher ALBI grade predicted poorer OS (HR = 2.50, 95% CI: 2.03–3.09, P<0.001; I2 = 37.1%, P = 0.133) (Fig. 2).

Fig. 2
figure 2

The association between albumin–bilirubin grade and overall survival in lung cancer

Full size image

Subgroup analysis based on the type of lung cancer and primary treatment manifested similar results (NSCLC: HR = 2.68, 95% CI: 2.11–3.41, P<0.001; SCLC: HR = 2.02, 95% CI: 1.32–3.10, P = 0.001; surgery: HR = 2.01, 95% CI: 1.36–2.96, P<0.001; ICIs: HR = 3.20, 95% CI: 2.36–4.35, P<0.001; chemotherapy: HR = 2.04, 95% CI: 1.03–4.02, P = 0.041). (Table 2)

Table 2 Results of meta-analysis
Full size table

Association of pretreatment ALBI grade with PFS in lung cancer patients

Five studies identified the prognostic role of pretreatment ALBI grade for PFS. Pooled results demonstrated that pretreatment ALBI grade was related to PFS (HR = 1.91, 95% CI: 1.56–2.33, P<0.001; I2 = 4.2%, P = 0.383) (Fig. 3).

Fig. 3
figure 3

The association between albumin–bilirubin grade and progression-free survival in lung cancer

Full size image

Association of pretreatment ALBI grade with CSS in lung cancer patients

Only one study explored the prognostic role of pretreatment ALBI grade for CSS. According to their results, higher pretreatment ALBI grade was associated with worse CSS (HR = 1.90, 95% CI: 1.11–3.11, P = 0.018) (Table 2).

Sensitivity analysis

According to the Fig. 4, our pooled results for OS were stable and reliable and none of included studies influenced the overall conclusion obviously.

Fig. 4
figure 4

Sensitivity analysis for the association between albumin–bilirubin grade and overall survival in lung cancer

Full size image

Publication bias

Besides, according to the Begg’s funnel plot (Fig. 5) and Egger’s test (P = 0.767), no significant publication bias was detected.

Fig. 5
figure 5

Begg’s funnel plot for the association between albumin–bilirubin grade and overall survival in lung cancer

Full size image

Discussion

Our study demonstrated the prognostic value of ALBI grade in lung cancer patients for the first time. Patients with a higher ALBI grade or score were exposed to significantly increased risk for poor survival. Therefore, pretreatment ALBI grade could serve as a novel and reliable prognostic indicator for lung cancer patients and contribute to the formulation of therapy strategy. However, due to the limitations of included studies and our meta-analysis, more prospective studies are needed to verify above results.

The reasons for the correlation between serum albumin levels and prognosis of lung cancer patients may include several factors. Firstly, albumin is a primary nutritional protein in the body, and its levels can reflect the nutritional status of patients. Lung cancer patients often experience reduced intake due to loss of appetite, nausea, vomiting, etc., which can affect albumin synthesis and consequently overall nutritional status [26]. Secondly, albumin is primarily synthesized by the liver, so its levels can also reflect liver function. Lung cancer may affect liver function through metastasis or other mechanisms, leading to decreased albumin levels [27]. Thirdly, albumin levels may be influenced by systemic inflammation and immune responses [11]. Lung cancer patients often exhibit inflammatory responses, which can affect albumin synthesis and breakdown, thereby influencing albumin levels [11]. Fourthly, factors such as lung cancer type, stage, size, and metastasis can also affect patients’ albumin levels [28]. For instance, advanced-stage lung cancer patients typically have lower albumin levels because rapid tumor growth and metastasis may deplete a significant amount of nutrients and energy [28].

On the other hand, the level of bilirubin is associated with the prognosis of lung cancer for several reasons. Firstly, bilirubin is a byproduct of liver metabolism and excretion, thus its levels can reflect liver function. Lung cancer may directly infiltrate or metastasize to the liver, leading to impaired liver function and affecting bilirubin metabolism and excretion, consequently increasing bilirubin levels [16]. Secondly, lung cancer, particularly when malignant, may compress or infiltrate the surrounding bile ducts or gallbladder, causing biliary obstruction. This prevents bilirubin from being excreted normally into the intestines, resulting in its accumulation in the bloodstream and elevated bilirubin levels. Additionally, lung cancer often metastasizes to the liver, forming hepatic metastases. This metastatic liver damage can lead to impaired liver function and bilirubin metabolism, further raising bilirubin levels. Moreover, lung cancer patients may experience systemic inflammatory responses, which can affect liver function and bilirubin metabolism, contributing to elevated bilirubin levels [29]. In summary, the association between bilirubin levels and the prognosis of lung cancer may be attributed to the impact of lung cancer on liver function and the biliary system, as well as its interaction with systemic inflammatory responses.

Furthermore, we deem that there are still some fields about the clinical role of ALBI grade in lung cancer needing further exploration. First, some anti-tumor treatment such as the chemotherapy and immunotherapy might affect the liver function. Thus, it is necessary to clarify the prognostic role of pretreatment ALBI and change of ALBI during grade after anti-tumor treatment for short-term outcomes among unresectable lung cancer patients. Secondly, a combination of ALBI grade and other parameters may show higher prognostic value, which should be further investigated.

There are some limitations which should be noted. First, all included studies are retrospective and with small sample sizes. Secondly, some confounding parameters such as the tumor stage, age, pathological subtype and definition of ALBI grade might have an impact on the universality of our conclusion. Thus, more detailed analysis in future research is still needed. Thirdly, we only identified the prognostic value of pretreatment ALBI grade. It is still necessary to further clarify the prognostic role of dynamic change of ALBI grade during the anti-tumor treatment. Fourthly, the heterogeneity of the meta-analysis for association between ALBI grade and OS in ICIs treated patients was relatively high (I2 = 51.5%, P = 0.103), more studies are needed to verify this finding.

Conclusion

Pretreatment ALBI grade is related to long-term prognosis in lung cancer and patients with elevated ALBI grade are more likely to experience worse survival.

Data availability

No datasets were generated or analysed during the current study.

References

  1. Kratzer TB, Bandi P, Freedman ND, Smith RA, Travis WD, Jemal A, Siegel RL. Lung cancer statistics, 2023. Cancer. 2024;130(8):1330–48.

    Article  PubMed  Google Scholar 

  2. Min Y, Li X, Chen H, Xu Y, Lan G. Predicting outcomes of Lung Cancer using the modified glasgow prognostic score: a systematic review and meta-analysis. Pak J Med Sci. 2024;40(3Part–II):534–43.

    PubMed  PubMed Central  Google Scholar 

  3. Deng TB, Zhang J, Zhou YZ, Li WM. The prognostic value of C-reactive protein to albumin ratio in patients with lung cancer. Med (Baltim). 2018;97(50):e13505.

    Article  CAS  Google Scholar 

  4. Wang Y, Hu X, Xu W, Wang H, Huang Y, Che G. Prognostic value of a novel scoring system using inflammatory response biomarkers in non-small cell lung cancer: a retrospective study. Thorac Cancer. 2019;10(6):1402–11.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  5. Zhang H, Zhang B, Zhu K, Wu C, Gao L, Sun X, Liu C, Wang C. Preoperative albumin-to-globulin ratio predicts survival in patients with non-small-cell lung cancer after surgery. J Cell Physiol. 2019;234(3):2471–9.

    Article  CAS  PubMed  Google Scholar 

  6. Johnson PJ, Berhane S, Kagebayashi C, Satomura S, Teng M, Reeves HL, O’Beirne J, Fox R, Skowronska A, Palmer D, et al. Assessment of liver function in patients with hepatocellular carcinoma: a new evidence-based approach-the ALBI grade. J Clin Oncol. 2015;33(6):550–8.

    Article  PubMed  Google Scholar 

  7. Xu L, Wu J, Lu W, Yang C, Liu H. Application of the albumin-bilirubin Grade in Predicting the prognosis of patients with Hepatocellular Carcinoma: a systematic review and Meta-analysis. Transpl Proc. 2019;51(10):3338–46.

    Article  CAS  Google Scholar 

  8. Xu H, Cao D, Zhou D, Zhao N, Tang X, Shelat VG, Samant H, Satapathy SK, Tustumi F, Aprile G, et al. Baseline albumin-bilirubin grade as a predictor of response and outcome of regorafenib therapy in patients with hepatocellular carcinoma: a systematic review and meta-analysis. BMC Cancer. 2023;23(1):1006.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  9. Mishra G, Majeed A, Dev A, Eslick GD, Pinato DJ, Izumoto H, Hiraoka A, Huo TI, Liu PH, Johnson PJ, Roberts SK. Clinical utility of Albumin Bilirubin Grade as a prognostic marker in patients with Hepatocellular Carcinoma undergoing Transarterial Chemoembolization: a systematic review and Meta-analysis. J Gastrointest Cancer. 2023;54(2):420–32.

    Article  CAS  PubMed  Google Scholar 

  10. Marasco G, Alemanni LV, Colecchia A, Festi D, Bazzoli F, Mazzella G, Montagnani M, Azzaroli F. Prognostic value of the albumin-bilirubin Grade for the prediction of Post-hepatectomy Liver failure: a systematic review and Meta-analysis. J Clin Med 2021, 10(9).

  11. Zhang CL, Gao MQ, Jiang XC, Pan X, Zhang XY, Li Y, Shen Q, Chen Y, Pang B. Research progress and value of albumin-related inflammatory markers in the prognosis of non-small cell lung cancer: a review of clinical evidence. Ann Med. 2023;55(1):1294–307.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Farag CM, Antar R, Akosman S, Ng M, Whalen MJ. What is hemoglobin, albumin, lymphocyte, platelet (HALP) score? A comprehensive literature review of HALP’s prognostic ability in different cancer types. Oncotarget. 2023;14:153–72.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Kinoshita F, Yamashita T, Oku Y, Kosai K, Ono Y, Wakasu S, Haratake N, Toyokawa G, Takenaka T, Tagawa T, et al. Prognostic impact of albumin-bilirubin (ALBI) grade on non-small lung cell carcinoma: a propensity-score matched analysis. Anticancer Res. 2021;41(3):1621–8.

    Article  CAS  PubMed  Google Scholar 

  14. Matsukane R, Watanabe H, Hata K, Suetsugu K, Tsuji T, Egashira N, Nakanishi Y, Okamoto I, Ieiri I. Prognostic significance of pre-treatment ALBI grade in advanced non-small cell lung cancer receiving immune checkpoint therapy. Sci Rep. 2021;11(1):15057.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  15. Shi XR, Xu XY, Zhang GL, Jiang JY, Cao DD. The prognostic role of albumin-bilirubin grade in patients with advanced non-small cell lung cancer treated with immune checkpoint inhibitors. Eur Rev Med Pharmacol Sci. 2022;26(20):7687–94.

    PubMed  Google Scholar 

  16. Takada K, Takamori S, Shimokawa M, Toyokawa G, Shimamatsu S, Hirai F, Tagawa T, Okamoto T, Hamatake M, Tsuchiya-Kawano Y et al. Assessment of the albumin-bilirubin grade as a prognostic factor in patients with non-small-cell lung cancer receiving anti-PD-1-based therapy. ESMO Open 2022, 7(1) (no pagination).

  17. Qi Y, Lin L. Correlations of serum albumin-bilirubin index and systemic immune inflammatory index with pathological features and prognosis of lung cancer. Chin J Clin Lab Sci. 2023;41(09):667–73.

    CAS  Google Scholar 

  18. Kut E, Menekse S. Prognostic significance of pretreatment albumin-bilirubin (ALBI) grade and platelet-albumin-bilirubin (PALBI) grade in patients with small cell lung cancer. Sci Rep 2024, 14(1).

  19. Liu S, Zhao Q, Wang Z, Zhao B, Zhang X. Albumin-bilirubin grade is an independent prognostic factor for small lung cell cancer. Mol Clin Oncol 2024, 20(2) (no pagination).

  20. Xu X, Shi X, Zhou D, Cao D. The Association between modified albumin-bilirubin (mALBI) and survival in Advanced Non-small Cell Lung Cancer patients treated with Immunotherapy. Cureus 2024, 16(3).

  21. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, Shamseer L, Tetzlaff JM, Akl EA, Brennan SE, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ (Clinical Res ed). 2021;372:n71.

    Google Scholar 

  22. Wang Y, Li J, Chang S, Dong Y, Che G. Risk and influencing factors for subsequent primary Lung Cancer after treatment of breast Cancer: a systematic review and two Meta-analyses based on four million cases. J Thorac Oncology: Official Publication Int Association Study Lung Cancer. 2021;16(11):1893–908.

    Article  CAS  Google Scholar 

  23. Wang Y, Hu Y, Wang T, Che G, Li L. Addition of metformin for non-small cell lung cancer patients receiving antineoplastic agents. Front Pharmacol. 2023;14:1123834.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  24. Begg CB, Mazumdar M. Operating characteristics of a rank correlation test for publication bias. Biometrics. 1994;50(4):1088–101.

    Article  CAS  PubMed  Google Scholar 

  25. Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ (Clinical Res ed). 1997;315(7109):629–34.

    Article  CAS  Google Scholar 

  26. Kayauchi N, Nakagawa Y, Oteki T, Kagohashi K, Satoh H. Change in Body Weight and serum albumin levels in Febrile Neutropenic Lung Cancer patients. Asian Pac Isl Nurs J. 2020;5(3):120–7.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Zhou S, Jiang W, Wang H, Wei N, Yu Q. Predictive value of pretreatment albumin-to-alkaline phosphatase ratio for overall survival for patients with advanced non-small cell lung cancer. Cancer Med. 2020;9(17):6268–80.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  28. Yang Y, Wang Y, Li X, Xie X. Clinical role of pretreatment albumin-to-alkaline phosphatase ratio in lung cancer: a meta-analysis. Sci Rep. 2024;14(1):1166.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  29. Lee Y, Lee S, Lee DY, Yu B, Miao W, Jon S. Multistimuli-Responsive Bilirubin nanoparticles for Anticancer Therapy. Angew Chem Int Ed Engl. 2016;55(36):10676–80.

    Article  CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Lung Cancer Center, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, 610061, P.R. China

    Jiao Jiang, Hongjuan Li & Lin Chen

  2. Department of Thoracic Surgery/Lung Cancer Center, China Hospital, Sichuan University, Chengdu, 610061, P.R. China

    Xiaoming Qiu

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Contributions

Xiaoming Qiu designed this meta-analysis. Jiao Jiang and Hongjuan Li performed the literature search and selection, collected information and wrote the paper. Lin Chen performed the statistical analysis and revised the manuscript. Each author contributed substantially to its revision.

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Correspondence to Xiaoming Qiu.

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Jiang, J., Li, H., Chen, L. et al. Prognostic value of albumin-bilirubin grade in lung cancer: a meta-analysis. J Cardiothorac Surg 19, 685 (2024). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s13019-024-03311-8

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Journal of Cardiothoracic Surgery

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