High NLR associated with treatment failure in melanoma when treated with PD-1 as a single agent

We have known that an elevated neutrophil-to-lymphocyte ratio (NLR) is associated with decreased response to immunotherapy and shortened overall survival in melanoma patients for some time.  I first reported on it in this post from 2015 which also includes some basic information on neutrophils and lymphocytes generally:  Lab values that may predict response to Ipi/Yervoy????  Unfortunately, we have also learned that high baseline NLR has an adverse impact on melanoma peeps being treated with targeted therapy as well:  Neutrophil-to-lymphocyte ratio and outcomes in melanoma. Yep, AGAIN!!!!! (High baseline neutrophil-to-lymphocyte ratio predicts worse outcome in patients with metastatic BRAF-positive melanoma treated with BRAF and MEK inhibitors)

Since then, many posts have followed, including those out of ASCO 2019:   Posts addressing NLR and response in melanoma

Now, there's this:

High neutrophil-to-lymphocyte ratio (NLR) is associated with treatment failure and death in patients who have melanoma treated with PD-1 inhibitor monotherapy.  Bartlett, Flynn, Panageas, et al.  Cancer.  2019 Oct 4.  An elevated neutrophil-to-lymphocyte ratio (NLR) is associated with poor survival in patients with cancer, including those who receive immunotherapies. The authors sought to investigate NLR as a biomarker of treatment outcomes in patients with melanoma who were treated with PD-1 inhibition. Patients undergoing initial treatment with PD-1 inhibitor monotherapy for stage IV melanoma at a single center from 2012 to 2015 were included. Clinical characteristics and the NLR at baseline and before subsequent treatment cycles were collected. The time to treatment failure (TTF) and overall survival (OS) were evaluated using Kaplan-Meier and landmark analyses. Among 224 study patients, 63 (28%) had a baseline NLR greater than/= to 5. The baseline NLR was significantly associated with Eastern Cooperative Oncology Group performance status and the number of involved metastatic sites. With a median follow-up of 39 months in survivors, a baseline NLR greater than/= to 5 was independently associated with shorter OS and TTF. An NLR increase greater than/= to 30% during the first 2 cycles of treatment was associated with worse OS (median, 47 vs 13.5 months) and a trend toward shorter TTF (12.8 vs 5.9 months). A combined baseline NLR greater than/= to 5 and an NLR increase greater than/= to 30% identified a small cohort with markedly shortened OS (median, 5.8 months) and TTF (median, 1.8 months). Elevated baseline NLR and an increased NLR early during treatment are prognostic for TTF and OS in patients who have melanoma treated with PD-1 inhibitor monotherapy. Combined, these biomarkers can widely risk-stratify patients for treatment failure and survival.

What is lacking in all this research is any precise answer as to what to do with this information.  If it were me, I would have docs follow my ratios, scary though that may be.  I don't think oncologists follow these labs consistently with an eye toward this result and I am certain that patients are not routinely made aware of such laboratory findings (much less their implications) when they are.  However, these lab values could be an important factor in decision making about whether or not to switch the type of therapy the patient in pursuing, look at clinical trial options, etc.  

Ain't nothing in melanoma easy.  For what it's worth ~ c