Risk stratification for gastric cancer can be enhanced with an albumin-prealbumin-globulin ratio (APGR) to mid-arm circumference (MAC), according to an article published in Scientific Reports in August. By incorporating serological and anthropometric parameters, the composite index outperformed either measure alone in predicting outcomes, with consistent prognostic value across (Tumor, Nodes, Metastasis) TNM stages, sexes and sensitivity analyses excluding early mortality.
Gastric cancer remains a significant global health challenge, ranking fifth in incidence and fourth in cancer-related mortality worldwide. The prognosis is particularly poor in East Asia, where late-stage diagnosis is common and malnutrition is highly prevalent. In China, the five-year survival rate is just 35%, compared with over 90% when the disease is detected early.
Malnutrition in gastric cancer is a byproduct of disease progression, and it actively worsens outcomes by impairing treatment tolerance, accelerating tumor growth, and increasing mortality risk. Yet, widely used prognostic tools such as TNM staging and histopathology fail to capture the complex interplay between nutritional status, inflammation, and tumor biology.
Shulin Xian, from the department of Gastrointestinal and Gland Surgery, the First Affiliated Hospital, Guangxi Medical University in China, and others developed a multidimensional prognostic index that integrates two complementary measures: the APGR, a composite serum biomarker reflecting hepatic synthetic function, recent nutritional intake, and immune/inflammatory status and MAC, a simple anthropometric measure of muscle and fat reserves that is independent of height or weight.
By combining these parameters into a single APGR-MAC grade, the study aimed to create a clinically feasible tool that could better predict survival and malnutrition risk in gastric cancer patients.
The multicenter cohort study drew on data from the Investigation on Nutrition Status and Clinical Outcome of Common Cancers project, which included 1803 patients with pathologically confirmed gastric cancer. Eligible participants were between 18 and 80 years old, with complete clinical and laboratory records.
APGR was calculated as albumin (g/L) × prealbumin (mg/L) / globulin (g/L), and MAC was measured at the midpoint of the non-dominant upper arm. Patients were classified into three grades: normal (both measures above cutoff), medium risk (one below cutoff), and high-risk (both below cutoff). The primary endpoint was overall survival, with malnutrition and metastasis as secondary outcomes.
Results showed that 33.5% of patients were classified as normal grade, 44.5% as medium-risk, and 22.0% as high-risk. Overall survival was 68.6% in the normal group, 53.9% in medium-risk, and 39.9% in high-risk (P<0.001). Compared with high-risk patients, those in the normal group had a 50% lower mortality risk.
It’s important to note, the APGR–MAC grade outperformed either measure alone in predicting outcomes, with consistent prognostic value across TNM stages, sexes, and sensitivity analyses excluding early mortality.
Beyond survival, the APGR-MAC grade was strongly associated with malnutrition and metastasis. Normal-grade patients had 75% lower odds of malnutrition (odds ratio [OR], 0.249) and 52% lower odds of metastasis (OR, 0.477) compared to their high-risk counterparts. These prognostic trends remained consistent across all TNM stages and sex subgroups
The authors believe the APGR–MAC grade offers a low-cost, scalable, and actionable tool to improve gastric cancer care pathways. It enables early risk stratification at diagnosis, even before advanced imaging or molecular testing, allowing clinicians to prioritize high-risk patients for intensive nutritional support, closer monitoring, and tailored treatment plans.
Because malnutrition is a modifiable risk factor, incorporating APGR–MAC into routine assessments can trigger early dietitian referral, targeted supplementation, and prehabilitation strategies. Identifying patients with poor nutritional and inflammatory profiles also supports more vigilant surveillance and consideration of aggressive systemic therapy or clinical trial enrollment. Prospective validation in diverse populations will be essential to confirm its utility and pave the way for widespread clinical integration.