Prognostic prediction of colorectal cancer using the C-reactive protein to albumin ratio: the importance of inflammatory biomarkers and their association with long-term outcomes

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Ann Coloproctol. 2023;39(4):287-288
Publication date (electronic) : 2023 August 29
doi :
Department of Surgery, Hansol Hospital, Seoul, Korea
Correspondence to: Chul Seung Lee, MD, PhD Department of Surgery, Hansol Hospital, 445 Songpa-daero, Songpa-gu, Seoul 05616, Korea Email:
Received 2023 July 25; Revised 2023 July 30; Accepted 2023 July 30.

Colorectal cancer (CRC) is a highly prevalent disease and a leading cause of death in Korea [1]. The standard therapy recommended for high-risk stage II and III patients is oxaliplatin-based adjuvant chemotherapy combined with fluoropyrimidine. This treatment regimen has significantly enhanced both overall survival and disease-free survival rates. However, outcomes can vary greatly among patients with the same disease stage [2]. Most patients who experience recurrence ultimately succumb to distant metastases [2, 3].

Therefore, considerable efforts have been made to investigate risk factors linked to distant metastasis in colorectal cancer, as well as to develop strategies for its prevention and management to improve oncological outcomes. Systemic inflammation has been identified as a key factor affecting the prognosis of colorectal cancer, prompting extensive research into various biomarkers [47]. Inflammatory indicators, such as the Glasgow Prognostic Score, neutrophil to lymphocyte ratio, and lymphocyte to monocyte ratio, have been extensively studied [6, 7]. More recently, the C-reactive protein to albumin ratio (CAR) has been reported to be a useful predictor of the prognosis of CRC.

Kataoka et al. [8] found a distinct association between CAR on postoperative day (POD) 7 and prognosis. They proposed that CAR on POD 7 plays a significant role in the metastatic process of cancer. Even when patients undergo scheduled adjuvant chemotherapy after surgery based on the TNM stage, recurrence is still a possibility. The CAR may be indicative of postoperative inflammation triggered by remaining tumor cells. These tumor cells experience the epithelial-mesenchymal transition, eventually detaching from the primary tumor and entering the circulatory system via neovascularization [9]. These circulating tumor cells are believed to be the main culprits for tumor dissemination through the bloodstream [10], and surgical stress can promote this hematogenous spread.

Postoperative complications can weaken the immune system and trigger a systemic inflammatory response, which can negatively impact the long-term oncological outcomes of various malignancies. Interestingly, in this study, CAR on POD 7 was independently associated with the prognosis, regardless of postoperative complications. It was not possible, however, to ascertain the mechanism by which CAR is associated with long-term oncologic outcomes [8]. There is compelling speculation that immunological markers, which are associated with the systemic inflammatory response, may be linked to cancer prognosis, as observed in clinical settings. The challenge we face now is to provide evidence that this association is not simply coincidental or a random observation. While the exact relationship between the CAR on POD 7 and long-term survival rates remains uncertain, future research should focus on developing more effective postoperative strategies and treatments for CRC.


Conflict of interest

No potential conflict of interest relevant to this article was reported.


This work was supported by a grant from the National Research Foundation of Korea (NRF), funded by the Korean government (No. NRF-2021M3A9I2080494).


1. Kim MH, Park S, Yi N, Kang B, Park IJ. Colorectal cancer mortality trends in the era of cancer survivorship in Korea: 2000-2020. Ann Coloproctol 2022;38:343–52.
2. Nakamura Y, Hokuto D, Koyama F, Matsuo Y, Nomi T, Yoshikawa T, et al. The prognosis and recurrence pattern of right- and left-sided colon cancer in stage II, stage III, and liver metastasis after curative resection. Ann Coloproctol 2021;37:326–36.
3. Hari DM, Leung AM, Lee JH, Sim MS, Vuong B, Chiu CG, et al. AJCC Cancer Staging Manual 7th edition criteria for colon cancer: do the complex modifications improve prognostic assessment? J Am Coll Surg 2013;217:181–90.
4. Haram A, Boland MR, Kelly ME, Bolger JC, Waldron RM, Kerin MJ. The prognostic value of neutrophil-to-lymphocyte ratio in colorectal cancer: a systematic review. J Surg Oncol 2017;115:470–9.
5. An S, Shim H, Kim K, Kim B, Bang HJ, Do H, et al. Pretreatment inflammatory markers predicting treatment outcomes in colorectal cancer. Ann Coloproctol 2022;38:97–108.
6. Neofytou K, Smyth EC, Giakoustidis A, Khan AZ, Williams R, Cunningham D, et al. The preoperative lymphocyte-to-monocyte ratio is prognostic of clinical outcomes for patients with liver-only colorectal metastases in the neoadjuvant setting. Ann Surg Oncol 2015;22:4353–62.
7. An SH, Kim IY. Can pretreatment platelet-to-lymphocyte and neutrophil-to-lymphocyte ratios predict long-term oncologic outcomes after preoperative chemoradiation followed by surgery for locally advanced rectal cancer? Ann Coloproctol 2022;38:253–61.
8. Kataoka M, Gomi K, Ichioka K, Iguchi T, Shirota T, Makino A, et al. Clinical impact of C-reactive protein to albumin ratio of the 7th postoperative day on prognosis after laparoscopic colorectal cancer surgery. Ann Coloproctol 2023;39:315–25.
9. Chaffer CL, Weinberg RA. A perspective on cancer cell metastasis. Science 2011;331:1559–64.
10. Cao H, Xu E, Liu H, Wan L, Lai M. Epithelial-mesenchymal transition in colorectal cancer metastasis: a system review. Pathol Res Pract 2015;211:557–69.

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