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

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.

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.

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.

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.