Alan D. Betensley, MD, is a board-certified pulmonologist and associate professor at the Feinberg School of Medicine in Northwestern Medicine.

Alan D. Betensley, MD

American Thoracic Society (ATS) 2026 Annual Meeting

 in Orlando, Florida, Alan Daniel Betensley, MD, of Northwestern University, presented late-breaking registry data suggesting that maintenance extracorporeal photopheresis (ECP) may independently improve survival in lung transplant recipients who develop 

 refractory to standard immunosuppression.

89% reduction in FEV1 decline rate observed at 12 months post-initiation

Participants without maintenance ECP had a significantly higher mortality risk (

 <.001) vs those who received maintenance ECP

The survival benefit of maintenance ECP persisted after multivariate adjustment (

The analysis drew on a prospective, Medicare-approved clinical trial registry enrolling 258 lung transplant recipients across 20 US centers. Among participants who survived ≥ 6 months after ECP initiation, those who did not receive maintenance ECP had a significantly greater mortality hazard ratio (HR) of 2.43 (95% CI, 1.75–3.4; 

 <.001) compared with those who did. That association persisted after multivariate adjustment (HR, 1.8; 95% CI, 1.8–2.7; 

 decline rate was also observed at 12 months post-initiation, though investigators noted the need for a risk-adjusted control cohort before broader clinical or coverage implications can be established.

 interview with Betensley, he discusses how clinicians should interpret the survival and FEV

 findings, what the data may mean for patients with refractory BOS, and what evidence CMS would need to expand the ECP National Coverage Decision to include BOS.

 What's the most important clinical message from this registry analysis of maintenance ECP in chronic lung allograft rejection?

 When we looked at the subjects who had received the maintenance ECP, those patients, compared with those who didn't receive maintenance, had better survival outcomes. In lung transplants, we really don't have a lot of treatments with [a] proven survival benefit for recipients who develop a chronic lung graft dysfunction. Anything that could improve long-term survival would a benefit to lung transplant patients.

 How should clinicians interpret the reported reduction in FEV

 We have to be a little bit cautious with that, because in this population of patients with bronchiolitis obliterans syndrome, we typically do see that the rate of reduction in FEV

 does decrease over time. That's because when we measure it as a milliliter decline per month, as we did in this study, patients…start with a much higher volume for their FEV

. Even if they lose a fixed percentage every month, [as] the overall volume [decreases], [the] milliliters per month [decline tends to] level off over time. We're going to know a little bit more if we have [well-matched] control patients to compare [against], and that is something we’re looking at.

 How might this data change your current approach to patients with refractory BOS?

 We don't really understand what causes bronchiolitis obliterans syndrome, especially when it seems refractory to treatments. ECP can be somewhat burdensome for the patients, but looking at this data, I think it's reasonable to initiate trial therapy. If [it is] tolerated well and the patient [shows clinical] benefit, it would make sense to continue for long-term maintenance in those patients.

 What do you see as the most important next step before these findings could change broader clinical guidelines or CMS coverage?

 Having a control group. We have some idea about the natural time course of bronchiolitis obliterans [syndrome], [but] unfortunately, we haven't discovered anything short of a retransplant that can actually recover lost lung functions. With any of these treatments, we're really just trying to prevent further loss of lung function.

Ideally, [we would have a] comparison group [of] similar patients that did not receive ECP and show that receiving ECP led to better outcomes than we saw in [those] patients. That's really what CMS is looking for [before an approval].

 Is anything else you'd like to highlight about this data for our clinician audience?

 Lung transplants are different than other solid organ transplants, primarily because of bronchiolitis obliterans syndrome, or what we now call chronic lung allograft dysfunction, and that really limits the long-term survival and good long-term outcomes. It's very important for us to be doing the research and trying to identify something that can help improve lung transplant outcomes to bring the long-term lung transfer survival up to the level that we see with other organs such as hearts, livers, and kidneys.

 discussing why maintenance ECP may improve long-term outcomes in BOS, the uncertainty surrounding its apparent survival benefit, and how ongoing therapy may help control the disease process after lung transplantation.

Editor’s note: Disclosures for Betensley include Melinta Therapeutics, Merck Sharp & Dohme, Regeneron Healthcare Solutions, and ABBVIE.

) Analysis of Data From a Prospective Medicare Approved Clinical Trial Registry Indicates That Use of Maintenance Extracorporeal Photopheresis Is Independently Associated With Enhanced Survival of Lung Allograft Recipients Who Have Developed Life-Threatening Chronic Lung Allograft Rejection (Bronchiolitis Obliterans Phenotype) Refractory to Standard of Care Immunosuppressive Therapy. Poster presented at ATS 2026 on May 17 in Orlando, Florida.

Betensley A. Maintenance ECP Linked to Survival Benefit in BOS After Lung Transplant, With Alan Betensley, MD. HCPLive. Published on May 17, 2026. Accessed June 2, 2026. https://www.hcplive.com/view/maintenance-ecp-linked-survival-bos-lung-transplant-alan-betensley-md

Articles

Data suggest long-term extracorporeal photopheresis may reduce mortality risk in patients with chronic lung allograft dysfunction unresponsive to standard immunosuppression.

ECP Linked to Improved Survival in Refractory Bronchiolitis Obliterans Syndrome

Maintenance ECP Linked to Survival Benefit in BOS After Lung Transplant, With Alan Betensley, MD

Maintenance extracorporeal photopheresis (ECP) following an initial treatment phase was independently associated with enhanced survival among lung transplant recipients with 

), according to a late-breaking poster at the 

American Thoracic Society (ATS) International Conference 2026

Bronchiolitis obliterans syndrome remains the most common phenotype of chronic lung allograft dysfunction and a leading cause of long-term morbidity and mortality after lung transplantation.

 Extracorporeal photopheresis has previously been associated with stabilization of lung function in observational studies of BOS, although randomized controlled trial data remain limited.

“We really don't have a lot of treatments with proven survival benefit for recipients who develop chronic lung allograft dysfunction and, in this case, bronchiolitis obliterans syndrome,” investigator Alan Betensley, MD, from Northwestern University, told 

. “Anything that could improve long-term survival would really be a benefit to lung transplant patients.”

The analysis, led by George Despotis, MD, from the Washington University School of Medicine, evaluated data from a prospective Medicare-approved clinical trial registry involving patients with chronic lung allograft dysfunction refractory to standard immunosuppressive therapies. Investigators observed that recipients who continued maintenance ECP after the initial 6-month treatment phase demonstrated improved long-term survival compared with those who discontinued therapy.

The registry enrolled 258 lung transplant recipients across 20 US transplant centers. Participants received 24 ECP procedures during a 6-month induction period, with continuation into maintenance therapy left to the discretion of treating clinicians. Investigators assessed changes in forced expiratory volume in 1 second (FEV

) decline and evaluated survival outcomes using Cox proportional hazards regression models adjusted for demographic, operative, and clinical covariates.

Among 191 participants assigned to ECP treatment, investigators observed an 89% reduction in FEV

decline 12 months after ECP initiation. However, Betensley cautioned against overinterpreting physiologic improvement in the absence of matched controls.

“In this population of patients with bronchiolitis obliterans syndrome, even without any treatment, we typically do see that the rate of reduction in FEV

does decrease over time,” Betensley said. “We're going to know a little bit more if we have some good, matched control patients to compare to.”

The survival analysis focused on 159 participants who survived at least 6 months after ECP initiation. Investigators found patients who did not receive maintenance ECP had significantly worse survival outcomes compared with those who continued maintenance therapy. The association persisted after multivariate adjustment, with maintenance ECP independently associated with improved survival.

Still, Betensley noted the observational nature of the analysis limits conclusions regarding causality. Because ECP is burdensome, involving repeated procedures over months, clinicians may have selectively continued maintenance therapy in patients who were less clinically fragile.

“The patients who ended up continuing with maintenance therapy may have been less sick or more robust than the patients who didn't receive maintenance treatment,” Betensley said. “Without having any type of control, we can't be certain that it's a survival benefit because it may be that the patients who were sicker were selected not to continue with the maintenance ECP.”

The findings may help inform individualized discussions regarding continuation of maintenance therapy after the induction phase, particularly among patients tolerating treatment without substantial adverse effects.

“If a patient is tolerating it without adverse side effects… it probably makes sense to continue with the maintenance ECP,” Betensley said. “Ultimately, these have to be individualized decisions on a patient-by-patient basis.”

Investigators indicated a risk-adjusted control cohort is being pursued to support a future petition to the Centers for Medicare & Medicaid Services to expand national coverage for ECP in BOS under updated CMS scientific guidelines.

Morrell MR, Despotis GJ, Lublin DM, Patterson GA, Trulock EP, Hachem RR. The efficacy of photopheresis for bronchiolitis obliterans syndrome after lung transplantation. 

Pilewski J. Chronic lung allograft dysfunction: Bronchiolitis obliterans syndrome. UpToDate. Published April 2026. Accessed May 17, 2026. 

https://www.uptodate.com/contents/chronic-lung-allograft-dysfunction-bronchiolitis-obliterans-syndrome/print

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Maintenance extracorporeal photopheresis was associated with improved survival in lung transplant recipients with bronchiolitis obliterans syndrome, according to Alan Betensley, MD.