Abstract Background: The folate receptor alpha (FRα) is a glycosyl-phosphatidylinositol-anchored membrane protein that binds and internalizes folate for purine and thymidine DNA biosynthesis, repair, and methylation. FRα have a role in cellular migration and invasion, and overexpression of this receptor is associated with tumor progression. FRα is known to be over-expressed in numerous epithelial malignancies and considered a potential target for anticancer treatment. However, the association between FRα expression and clinicopathologic features and prognosis in cervical cancer remains unclear. Methods: This retrospective study included patients diagnosed with cervical cancer who underwent primary surgery between 2000 and 2020. Immunohistochemical staining of FRα was performed using Anti-Folate Binding Protein/FBP antibody (abcam, ab67422). The evaluation of FRα expression was performed by an experienced pathologist. FRα-positive was defined as > 5% tumor staining. FRα-high was defined as ≥ 50% tumor staining with 2+ or 3+ intensity. A possible influence of FRα expression on survival was studied by multivariate Cox regression adjusting for established risk factors for postoperative recurrence. Results: Overall, 123 patients were enrolled, and 136 tumor samples (13 paired primary and metastatic samples) were assessed. The histopathologic classification was squamous cell carcinoma, 67; adenocarcinoma, 27; adenosquamous carcinoma, 13; other, 16. FRα-positive was found in 100% (136/136), and FRα-high was 20.8% (15/72) of squamous cell carcinoma and 33.3% (10/30) of adenocarcinoma. The FRα expression of the metastatic tumor was significantly higher than the primary tumor (H-score, 180 vs. 105, p=0.006). In 69.2% (9/13) of cases with paired samples of primary and metastatic, FRα expression was elevated in metastatic tumors than primary.In a multivariate analysis, FRα-high was associated with poor recurrence-free survival (hazard ratio [HR] 2.30, 95% confidence interval [CI] 1.17-4.52, p=0.016) and overall survival (HR 5.45, 95% CI 1.91-15.5, p=0.002). Conclusion: FRα was widely expressed regardless of histological subtypes. FRα expression was elevated in metastatic tumors, and its expression was independently associated with postoperative recurrence and decreased survival in patients with cervical cancer. FRα may be a potential target for therapy of cervical cancer. Citation Format: Shigemasa Takamizawa, Shu Yazaki, Yuki Kojima, Hiroshi Yoshida, Rui Kitadai, Tatsunori Shimoi, Tadaaki Nishikawa, Kazuki Sudo, Tomoyasu Kato, Kan Yonemori. Folate receptor alpha expression is associated with poor prognosis in patients with cervical cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 657.