Can a life-saving lung transplant strategy that has contained the new coronavirus save patients with advanced lung cancer that has not metastasized?
That question is what led surgeons and oncologists at Northwestern Medicine to offer double-lung transplants to patients who have exhausted treatment options but whose terminal cancer has not left their lungs. Patients with terminal lung cancer have traditionally not been candidates for transplantation for two reasons: high cancer recurrence rates and poor survival rates.
Ethical considerations also need to be considered when deciding how to allocate donated organs.
On Wednesday, the Northwestern University team reported in JAMA that 17 patients who received lung transplants after advanced but limited cancer fared better than 81 similar patients who continued with standard immunotherapy, chemotherapy, or radiation therapy. Overall, the study followed 404 patients with end-stage lung disease, including 98 patients with stage 4 lung cancer.
After one year, ending in June 2025, all lung cancer transplant patients were alive, but 88% of those who received a cancer-free transplant survived. Of these 17 patients, by January 2026, four had cancer recurrence and two had died unrelated to cancer (one from infection and one from blood clots). Of the 81 cancer patients receiving standard treatment, 74 had cancer progression.
“We thought that by combining appropriate patient selection to ensure that there is no disease outside the lungs, improved surgical techniques, and ensuring that these patients receive currently available chemotherapy and immunotherapy prior to transplantation, we could dramatically improve these outcomes,” study co-author Ankit Bharat, chief of thoracic surgery at Northwestern Medical School, told STAT.
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The protocol evolved from the team’s experience performing the first lung transplant on a coronavirus patient in 2020, and applied those lessons to removing lungs that had trapped treatment-resistant cancer and replacing them with transplanted organs.
“We thought, if we can get rid of badly damaged lungs that are full of nasty bugs and resistant bugs, maybe we can recreate that in the cancer setting, because these patients are really unhappy,” Bharat said.
There is precedent for liver transplantation in carefully selected patients with small and inoperable liver cancer. This is encouraging, Ese Kali Daylan and Ramaswamy Govindan of Washington University School of Medicine and the Siteman Cancer Center in St. Louis wrote in an editorial also published in JAMA on Wednesday, but the results of lung transplants need to be confirmed in large randomized studies before they can be more widely adopted.
“The ethical implications are difficult to ignore; lung transplants occur in a zero-sum system,” they write. “Each organ assigned to a recipient is not available to another recipient.”
In response, Bharat said he personally did not believe in denying stage 4 cancer patients organ transplants that could dramatically extend their lives. This is because people without cancer may have to wait longer. Rather, the question to ask is whether transplanting these carefully selected cancer patients meaningfully improves outcomes comparable to those of transplanted patients without cancer, he said.
“We didn’t really see a difference. In fact, there was a trend toward better early outcomes in cancer patients compared to non-cancer patients,” he said. “We’ll have to see what happens in the long term, but there’s no concern, at least in the early results, that this won’t be a good use of organs.”
The number of patients with stage 4 non-small cell lung cancer that has not spread outside the lungs is small, estimated at about 300 per year in the United States. Jody Graf, 61, a robotic software engineer at NASA, was one of those patients.
A non-smoker like more than 30% of people diagnosed with lung cancer, she has lived with the lung disease for decades, ever since she realized she could not complete a half marathon despite her experience as a long-distance runner. She was diagnosed with asthma at age 34, but was convinced it was something else.
That something wasn’t her next diagnosis, idiopathic pulmonary fibrosis. Further medical investigation into an autoimmune disease of connective tissue with progressive pulmonary fibrosis was conducted in 2008 after she survived beyond the expected five-year prognosis of death. It is so rare that it does not have a name.
It was the first time Graf had been considered for a lung transplant, but the immunosuppressants were so effective in controlling her breathing that she no longer needed the up to 12 liters of supplemental oxygen she needed to see doctors at the Jewish National Hospital in Denver. She needed extra oxygen to keep moving, which meant visiting only the lower elevations of her beloved national parks in the West with her husband and two sons.
That’s why, while walking around her Houston neighborhood with her husband in 2020, she realized something was amiss. A PET scan of her lungs showed a spot, and a biopsy confirmed it was not just a scar. It was cancer.
“I was already too ill to undergo chemotherapy and my lung capacity was definitely too low to undergo cancer surgery,” she said in an interview. “They could have done radiation, but that was it.”
She didn’t panic. Because I read somewhere that a certain center performs lung transplants for lung cancer patients. It turned out to be Northwestern University, and among various tests, she underwent a lymph node biopsy to confirm that the cancer had not spread.
Jody Graff’s new lung, left, and old lung.northwestern medicine
Twenty-four hours after her negative biopsy results put her on the transplant waiting list, she received a call about her new lungs. She was surprised at how fast it was. (Separately, Surgeon Bharat pointed out that the average waiting time at the hospital is three days. This is a result of new technologies that reduce waiting times and new donation practices that improve the quality of organs.)
Graff was hospitalized for two weeks and made a good recovery with outpatient rehabilitation and frequent follow-up visits to Chicago, where she and her husband moved for a year. Immunosuppressants to prevent graft rejection were not new to her.
“They say that when you get a lung transplant, you get a new disease in exchange for one disease, right? Because the post-transplant condition is important in and of itself,” she said. “But I traded two. I got two furs.”
Graf now plans to climb the mountain, which was previously off-limits, even on supplemental oxygen. That means Yellowstone and the Canadian Rockies.
“Life is beautiful,” she said.
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