Could a lifesaving lung transplant strategy that contained the Covid-19 virus also save patients whose advanced lung cancer hasn’t spread?
That’s the question that inspired surgeons and oncologists at Northwestern Medicine to offer double lung transplants to patients who had run out of treatment options but whose late-stage cancer hadn’t left their lungs. People with late-stage lung cancer have not been transplant candidates before for two reasons: rates were high for cancer recurrence and low for survival.
There are ethical considerations to weigh, too, when deciding how to allot donated organs.
On Wednesday, the Northwestern team reported in JAMA that the 17 patients who received lung transplants after advanced but limited cancer fared better than 81 similar patients who continued standard immunotherapy, chemotherapy, or radiation treatments. Overall, the study followed 404 patients with end-stage pulmonary disease, including 98 with stage 4 lung cancer.
After one year, through June 2025, all the lung cancer transplant patients had survived compared to 88% of patients transplanted without cancer. Among those 17 patients, by January 2026, there were four recurrences of cancer and two deaths unrelated to cancer — one from an infection and one from a blood clot. Among the 81 cancer patients getting standard care, 74 saw their cancers progress.
“We thought by combining a good patient selection to make sure there’s no disease outside the lung, improving on the surgical technique, and making sure these patients prior to getting to transplant go through the chemo and immunotherapy that is available now, we can improve those outcomes dramatically,” study co-author Ankit Bharat, chief of thoracic surgery at Northwestern Medicine, told STAT.
That protocol grew from the team’s experience performing the first lung transplant in a Covid patient in 2020, applying the lessons to removing lungs where treatment-resistant cancer was confined and replacing them with transplanted organs.
“We felt like if we can take out these heavily damaged lungs full of nasty bugs and resistant bugs,” Bharat said, “maybe we can replicate that in cancer settings, because these patients are just so unfortunate.”
There is a precedent with liver transplantation for carefully selected patients with small, inoperable liver cancer. That offers some hope, Ece Cali Daylan and Ramaswamy Govindan of Washington University School of Medicine and Siteman Cancer Center in St. Louis, wrote in an editorial also published Wednesday in JAMA, but before the results in lung transplantation can be adopted more widely, they must be confirmed in larger, randomized studies.
“The ethical implications are hard to ignore. Lung transplant operates within a zero-sum system,” they wrote. “Each organ allocated to a recipient is unavailable to another recipient.”
In response, Bharat said he personally doesn’t believe in denying an organ transplant that could dramatically extend life for a stage 4 cancer patient, because someone who doesn’t have cancer might have a longer wait time. Instead, he said, the question to ask is whether transplants in these carefully selected cancer patients meaningfully improve outcomes comparable to transplant patients without cancer.
“We actually saw no difference. In fact, there was a trend towards improved earlier outcomes in cancer patients compared to the noncancer patients,” he said. “Now we’ll have to see what the long term plays out, but at least the early results have no concerns that this would be not a good use of organs.”
The number of patients who have stage 4 non-small cell lung cancer that has not spread beyond the lungs is small, estimated to be about 300 cases per year in the United States. Jodi Graf, a 61-year-old robotic software engineer for NASA, was one of those patients.
A nonsmoker, like more than 30% of people diagnosed with lung cancer, she had lived with lung disease for decades, ever since noticing she couldn’t complete a half-marathon despite her experience as a long-distance runner. She was diagnosed with asthma at age 34, but she was certain it was something more.
That something wasn’t idiopathic pulmonary fibrosis, her next diagnosis. After she outlived its predicted five-year prognosis of death, further medical investigation landed in 2008 on an autoimmune disease of connective tissue with progressive pulmonary fibrosis. It’s so rare it doesn’t have a single name.
That was the first time Graf was considered for a lung transplant, but her immunosuppressant drugs worked so well to control her breathing, she no longer needed the up to 12 liters of supplemental oxygen she’d required when visiting her doctors at National Jewish Hospital in Denver. She did rely on extra oxygen to keep up her exercise, which meant visiting only the lower elevations of her beloved national parks in the West with her husband and two sons.
That’s why in 2020 on a walk in her Houston neighborhood with her husband, she knew something more was wrong. There was a spot on a PET scan of her lung that a biopsy confirmed wasn’t just scarring. It was cancer.
“I was already too sick for chemo, and I definitely had too little lung capacity to have surgery on the cancer,” she said in an interview. “They could do radiation, but that was it.”
She didn’t panic, because she had read somewhere that a center was doing lung transplants for people with lung cancer. That turned out to be Northwestern, where among other evaluations, she underwent lymph node biopsies to make sure her cancer hadn’t spread.
Twenty-four hours after being added to the transplant waitlist based on the negative biopsies, she got the call about her new lungs. The speed surprised her. (Separately, surgeon Bharat pointed out that the average wait at the hospital is three days, a product of newer technologies that shorten wait times and new donation practices that improve organ quality.)
In the hospital for two weeks, Graf recovered well with outpatient rehab and frequent follow-up visits in Chicago, where she and her husband have moved for a year. For her, the immunosuppressant drugs to prevent graft rejection were nothing new.
“They say when you get a lung transplant, you trade one disease for a new one, right? Because being post-transplant is a thing in and of itself,” she said. “But I traded two. I got a twofer.”
Now, Graf plans to climb mountains that were off-limits before, even with supplemental oxygen. That means Yellowstone and the Canadian Rockies.
“Life is awesome,” she said.
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