Reply to “Pretreatment Neutrophil to Lymphocyte Ratio Independently Predicts Disease-specific Survival in Patients With Resectable Gastroesophageal Junction and Gastric Cancer”

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Authors’ Reply:
We appreciate the comment from Urabe et al regarding our manuscript.1 The authors raised 3 points that we would like to address.
First, they suggested analyzing the role of neoadjuvant therapy in the multivariate analysis. We chose not to incorporate neoadjuvant therapy into our model since likely only patients with locally advanced disease received therapy. Thus, neoadjuvant therapy would be a surrogate for T and N stages, which were already included in our analysis. Future analyses ideally should take place in the context of prospective trials studying the utility of neoadjuvant therapy to remove any selection bias.
Second, the authors noted that NLR obtained 3 months before treatment initiation may not be representative of the patient's status, with which we agree. As noted in the manuscript, the median time from laboratory draw to treatment initiation was 7 days, the interquartile range was 4 to 13 days, and the earliest lab value used was at 67 days. We reanalyzed our data and found that 99% of the patients had laboratories drawn within 34 days of treatment initiation. We believe that the gap between laboratory draw and treatment initiation in the great majority of our patient cohort is short enough to be representative of the disease status.
Finally, the authors note that “NLR may well not be a simple secondary event triggered by the tumor burden” and “should be combined with other diagnostic criteria to identify appropriate candidates for neoadjuvant therapy.” We agree that NLR is likely a reflection of complex tumor–host interactions and that it should be used in conjunction with other diagnostic modalities to risk stratify patients, as no test is ever perfect.

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