Delaying immunotherapy does not worsen survival in extensive-stage small cell lung cancer

For patients hospitalized with aggressive lung cancer, treatment decisions often need to be made quickly. New research suggests that starting immunotherapy later rather than immediately may not compromise outcomes for those with extensive-stage small cell lung cancer (ES-SCLC), offering reassurance for clinicians managing acutely ill patients.

Small cell lung cancer is a fast-growing malignancy characterized by early spread and poor prognosis, with a 5-year survival rate of about 7%. It is less common than non-small cell lung cancer, accounting for approximately 15% of cases. Most patients are diagnosed with extensive-stage disease, where treatment focuses on prolonging survival and relieving symptoms rather than cure. In recent years, adding immunotherapy such as Tecentriq (atezolizumab) or Imfinzi (durvalumab) to platinum-based chemotherapy has become standard first-line care based on improved survival in phase 3 trials.

In a study published online ahead of the August 2026 issue of the Journal of Hematology Oncology Pharmacy, Matthew Warrick, Pharm.D., and colleagues at Novant Health Presbyterian Medical Center in Charlotte, North Carolina, evaluated whether delaying immunotherapy affects outcomes in real-world practice. Warrick is currently an oncology clinical pharmacy specialist at the Medical University of South Carolina in Charleston, South Carolina. Th retrospective analysis included 171 adults with ES-SCLC treated between January 2020 and July 2022 with platinum chemotherapy and etoposide plus either Tecentriq or Imfinzi.

Patients were grouped based on when immunotherapy was started: 120 patients (70.2%) received it during the first cycle, while 51 patients (29.8%) began immunotherapy in the second or later cycles, often after hospitalization. Delays were most commonly due to inpatient treatment needs, but also included factors such as radiation therapy, insurance authorization issues and liver function abnormalities.

The data suggest that starting immunotherapy later did not negatively affect outcomes. Patients in both groups went a median of 5.83 months before their disease progressed and overall survival was nearly identical at 9.83 months for early treatment and 10.03 months for delayed treatment. One-year survival rates were also similar between the groups.

Safety findings were largely consistent between groups. Grade 3 or higher adverse events occurred in approximately three-quarters of patients in both cohorts, and immune-related adverse events were similar overall. Thyroid dysfunction was more common in the early immunotherapy group, though the difference may have been influenced by baseline characteristics.

The findings are particularly relevant for patients who present with oncologic emergencies requiring immediate chemotherapy. In these situations, logistical and financial barriers often limit the use of immunotherapy in the inpatient setting. The study suggests that initiating immunotherapy after discharge, once patients are stabilized, may be a reasonable approach without compromising efficacy.

“The financial toxicity associated with immune checkpoint inhibitors is a significant barrier to administering such agents during admission. Unlike in the clinic setting, health systems are unable to mitigate large acquisition costs using 340B pricing and direct drug reimbursement from payers to justify their inpatient use,” noted Warrick and his co-authors. The 340B Drug Pricing Program allows many health systems to purchase drugs at a discounted rate Admitted patients also require urgent tumor debulking to stabilize their clinical status and preserve organ function because of the rapid doubling time that characterizes SCLC.⁹ The delayed onset of action for immunotherapy and the high sensitivity of the malignancy to cytotoxic chemotherapy emphasizes the utility of the latter in the initial treatment of hospitalized patients.^8,10 Furthermore, the use of inpatient immunotherapy in medically frail patients can worsen performance status and lead to an increased risk of immune-related adverse events (irAEs) or death.¹¹

The authors note several limitations, including the study’s retrospective design, single-center setting and reliance on electronic health record data, which may introduce bias or incomplete reporting. In addition, the sample size was relatively small and not powered to detect small differences in survival, meaning the results should be considered hypothesis-generating rather than definitive.

Still, the study provides practical insight into real-world care. The findings support flexibility in treatment sequencing and suggest that delaying immunotherapy until after initial chemotherapy and hospital discharge may be a viable option for patients with ES-SCLC, particularly when immediate clinical stabilization is the priority.

“Delaying the initiation of immunotherapy to subsequent cycles in patients with ES-SCLC did not result in a numerically shorter PFS [progression-free survival] or OS [overall survival]; however, future prospective studies that assess the timing of immunotherapy initiation could provide more definitive evidence to this claim,” concluded Warrick and his colleagues.