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BackgroundThe neutrophil-to-lymphocyte ratio (NLR) is an inflammatory index calculated by the absolute neutrophil count dividing the absolute lymphocyte count, and its prognostic role in esophageal cancer (EC) patients with anti-PD-1 therapy remains unclear.MethodsA total of 140 unresectable or metastatic EC patients receiving PD-1 inhibitor treatment were included from Jan 2016 to Mar 2020. Kaplan–Meier method and log-rank test were used for comparing overall survival (OS) and progression-free survival (PFS) between groups. Multivariate Cox analysis was performed to assess the prognostic value of NLR.ResultsThe cutoff value of NLR was set at 5, and the median follow-up time was 20.0 months. Patients with pretreatment NLR <5 had higher ORR (46.7% vs. 12.1%; p < 0.001) and DCR (85.0% vs. 69.7%; p = 0.047) than those with NLR ≥5. Kaplan–Meier curves showed that pretreatment NLR <5 was associated with longer PFS (median: 10.0 vs. 3.5 months, p < 0.0001) and OS (median: 22.3 vs. 4.9 months, p < 0.0001). Multivariate analysis demonstrated that pretreatment NLR ≥5 independently and significantly increased the risk of disease progression (hazard ratio (HR), 1.77 (95% confidence interval (CI), 1.12–2.82); p = 0.015) and death (HR, 4.01 (95% CI, 2.28–7.06); p < 0.001). Subgroup analysis showed that pretreatment NLR ≥5 was associated with poor efficacy and survival in most subsets.ConclusionsOur findings showed that pretreatment NLR was independently and significantly associated with the efficacy and prognosis of EC patients treated with PD-1 inhibitors. NLR could serve as a convenient and useful prognostic biomarker for EC patients with anti-PD-1 therapy.