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 bronchiolitis obliterans syndrome (BOS), according to a late-breaking poster at the American Thoracic Society (ATS) International Conference 2026 in Orlando, Florida.1

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.2 Extracorporeal photopheresis has previously been associated with stabilization of lung function in observational studies of BOS, although randomized controlled trial data remain limited.3

“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 HCPLive. “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.1

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 (FEV1) decline and evaluated survival outcomes using Cox proportional hazards regression models adjusted for demographic, operative, and clinical covariates.1

Among 191 participants assigned to ECP treatment, investigators observed an 89% reduction in FEV1 decline 12 months after ECP initiation. However, Betensley cautioned against overinterpreting physiologic improvement in the absence of matched controls.1

“In this population of patients with bronchiolitis obliterans syndrome, even without any treatment, we typically do see that the rate of reduction in FEV1 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.1

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.1

“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.1

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

References

1. Despotis G, Hachem R, Hage C, et al. (Poster Board #P1988) 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.

2. Morrell MR, Despotis GJ, Lublin DM, Patterson GA, Trulock EP, Hachem RR. The efficacy of photopheresis for bronchiolitis obliterans syndrome after lung transplantation. J Heart Lung Transplant. 2010;29(4):424-431. doi:10.1016/j.healun.2009.08.029

3. 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