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Guo-Tian Ruan,1– 3,&ast; Ming Yang,1– 3,&ast; Xiao-Wei Zhang,1– 3,&ast; Meng-Meng Song,1– 3 Chun-Lei Hu,1– 3 Yi-Zhong Ge,1– 3 Hai-Lun Xie,1– 3 Tong Liu,1– 3 Meng Tang,1– 3 Qi Zhang,1– 3 Xi Zhang,1– 3 Kang-Ping Zhang,1– 3 Xiang-Rui Li,1– 3 Qin-Qin Li,1– 3 Yong-Bing Chen,1– 3 Kai-Ying Yu,1– 3 Ming-Hua Cong,4 Kun-Hua Wang,5 Han-Ping Shi1– 3 1Department of Gastrointestinal Surgery, Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, People’s Republic of China; 2Department of Clinical Nutrition, Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, People’s Republic of China; 3Beijing International Science and Technology Cooperation Base for Cancer Metabolism and Nutrition, Beijing, 100038, People’s Republic of China; 4Comprehensive Oncology Department, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100038, People’s Republic of China; 5Department of Surgery, The First Affiliated Hospital of Kunming Medical University, Kunming, 650000, People’s Republic of China&ast;These authors contributed equally to this workCorrespondence: Han-Ping ShiDepartment of Gastrointestinal Surgery and Beijing Shijitan Hospital, Capital Medical University, 10 Tie Yi Road, Beijing, 100038, People’s Republic of ChinaTel +86-10- 6392 6985Fax +86-10 -6392 6325Email shihp@ccmu.edu.cnBackground: Systemic inflammation and cachexia are associated with adverse clinical outcomes in elderly patients with cancer. The survival outcomes of elderly patients with cancer cachexia (EPCC) with high inflammation and a high risk of mortality are unknown. This study aimed to investigate the impact of high inflammation on the prognosis of EPCC patients with high mortality.Patients and Methods: This multicenter cohort study included 746 EPCC (age > 65 years) with a mean age of 72.00 ± 5.24 years, of whom 489 (65.5%) were male. The cut-off value for the inflammation index was obtained using the optimal survival curve. The different inflammatory indicators were assessed using the concordance index (C-index), decision curve analysis (DCA), and prognostic receiver operating characteristic (ROC). The high mortality risk group of EPCC was defined by the 2011 Fearon Cancer Diagnostic Consensus. EPCC were divided into the high-risk group, which satisfies three diagnostic criteria, and a low-risk group, which satisfies only one or two diagnostic criteria.Results: The C-index, DCA, and prognostic ROC indicated the superiority of advanced lung cancer inflammation index (ALI) compared with other indicators, including neutrophil–lymphocyte ratio (NLR), prognostic nutritional index (PNI), systemic immune-inflammation index (SII), and platelet–lymphocyte ratio (PLR). Whether ALI was used as a continuous or a categorical variable, ALI had a better prognostic value in EPCC compared with other inflammatory indicators. In particular, patients with low ALI (< 25.03) had a worse overall survival (OS) than patients with high ALI (≥ 25.03) (P < 0.001, HR [95% CI] = 2.092 [1.590– 2.751]). The combination effect analysis showed that the risk of mortality of the patients in the low-ALI and high-risk groups was 3.095-fold higher than that of patients in the high-ALI and low-risk groups.Conclusion: The prognostic and discriminative value of the inflammatory indicator ALI was better than that of NLR, PNI, SII, and PLR in EPCC. The high-risk group of EPCC with a low ALI would increase the death risk of OS.Keywords: ALI, systemic inflammation, cancer cachexia, elderly, overall survival