[Above and beyond BMI: Deciphering the lung cancer paradox].

Abstract

Introduction: Non-small cell lung cancer (NSCLC) remains a leading cause of cancer-related death. In addition to tumor stage, host-related factors play a critical role in determining outcomes.

State of knowledge: Data from the French Epithor database and institutional cohorts have consistently highlighted a "lung cancer paradox": while underweight is associated with increased mortality, overweight and obesity seem to confer a survival advantage. Morphometric studies have confirmed that skeletal muscle mass, which is assessed in terms of psoas or total muscle area, is an independent predictor of prognosis. On a parallel track, simple biomarkers such as preoperative C-reactive protein (CRP) and prealbumin have demonstrated strong prognostic value, as they are closely linked to systemic inflammation and intratumoral immune infiltration. More recently, patient height and height-normalized weight (sH and sHNW) have emerged as novel independent prognostic factors, once again underscoring the relevance of morphomic measures other than BMI.

Perspectives: Integration of simple and reproducible anthropometric indices (BMI, height, sHNW), body composition, and biological markers (CRP, prealbumin) provides a more comprehensive framework for risk stratification. This enriched approach may help to optimize perioperative management, identify high-risk patients, and refine indications for adjuvant or immune-based therapies in cases of resectable NSCLC.

Conclusions: Although BMI alone is only a crude measure, when interpreted within an integrative model it retains prognostic significance. The combining of nutritional, inflammatory, and morphometric parameters yields a robust overall representation of patient status, paving the way toward personalized prognostic assessment and improved therapeutic decision-making.