Comment on: 'Triceps skinfold-albumin index significantly predicts the prognosis of cancer cachexia: A multicentre cohort study' by Yin et al. - the authors reply.

We would like to express our sincere gratitude for the valuable comments and interesting findings by Ding et al.1 regarding the triceps skinfold-albumin index (TA) proposed in our research article.2 Based on data from multiple cohorts of locally advanced gastric cancer (LAGC), the authors found that a higher TA was associated with prolonged overall survival (OS) and disease-free survival (DFS) in LAGC patients with cachexia. They further performed subgroup survival analyses based on tumour pTNM staging, which demonstrated similar results in stage II and stage III patients, respectively. Ding et al. provided new insights in addition to the original research, the leading one among them being that they extended the prognostic value of TA to the realm of DFS. This was meaningful because DFS is widely used as a primary endpoint in phase III trials of adjuvant therapies for gastric cancer.3, 4 Therefore, their findings imply the potential of TA as a decision support tool for the anti-cancer treatment of gastric cancer. Secondly, our original research found that the association of TA with OS was literally attenuated in stage I-II tumours. The authors further found that this association sustained in stage II gastric cancer, implying that this attenuation might be mostly concentrated in patients with stage I tumours, at least for gastric cancer. These findings are consistent with our understanding because depletion of adipose tissue is one of the earliest and most common manifestations of cancer cachexia,5, 6 and cancer cachexia is more prevalent in advanced lethal cancers.7 Therefore, patients with stage I tumours might be least affected by cachexia-induced fat depletion that reaches the threshold to cause a significant survival difference. The findings by Ding et al. align well with the original research, further supporting the use of TA as a practical prognostic tool for the risk stratification of cancer cachexia. The authors also raised several interesting points that might be addressed by upcoming studies. Looking ahead, we believe that future studies in this field should continue to explore the potential of TA as a clinically meaningful and promising biomarker in a wider spectrum of diseases and clinical scenarios. Further investigations could focus on validating the performance of TA across different cancer types and stages, or other subgroups with specific concerns, as well as evaluating its utility in guiding targeted interventions for the management of cachexia or malnutrition in oncology patients. Additionally, monitoring the dynamic changes of the TA index over time and investigating the impact of such changes on the treatment and prognosis in patients with cancer cachexia might be an interesting research direction. Once again, we were delighted that our research has generated peer interest, and we sincerely appreciate Ding et al. for their kind attention to our research and for highlighting the significance of TA in predicting the survival of LAGC patients with cancer cachexia. The authors' insights contribute to the advancement of this important area of study. This work was supported by the Natural Science Foundation of Chongqing, China (CSTB2022NSCQ-MSX1069) and the National Key Research and Development Program of China (2017YFC1309200). The authors would like to thank the INSCOC project members for their substantial work on data collection and patient follow-up. The authors declare that they have no conflict of interest.