Immunodynamics-Guided Optimization of Individualized Immunochemotherapy in Advanced Driver-Negative NSCLC: A Randomized Trial

The goal of this clinical trial is to evaluate whether individualized sequencing of immunotherapy and chemotherapy based on immune dynamics can improve treatment outcomes in adults with advanced non-small cell lung cancer (NSCLC) without driver gene mutations. This study will also assess the safety and feasibility of different infusion strategies. The main questions it aims to answer are: Does optimizing the timing of PD-1 inhibitor infusion relative to chemotherapy improve the objective response rate (ORR)? Does individualized infusion sequencing enhance progression-free survival (PFS) compared to standard or fixed-delay administration? What safety concerns or immune-related adverse events occur with different infusion timing strategies? Researchers will compare three treatment strategies: Group A (Standard Concurrent Group): Immunotherapy and chemotherapy administered on the same day (D1). Group B (Fixed Delay Group): Chemotherapy on D1, followed by PD-1 inhibitor infusion on Day 3. Group C (Individualized Delay Group): Chemotherapy on D1, and PD-1 inhibitor infusion scheduled on D2-D6 based on daily immune monitoring. Participants will: Receive a PD-1 inhibitor (e.g., sintilimab, pembrolizumab, camrelizumab) combined with platinum-based chemotherapy. Attend clinic visits for regular immune monitoring, imaging assessments, and safety checks during each treatment cycle. Undergo blood tests to evaluate immune biomarkers (e.g., CD8⁺PD-1⁺ T cells, MDSC, Treg、IFN-γ、NLR、ALC、CRP) to guide individualized treatment decisions.

Detailed Description This study is a prospective, randomized, open-label, multicenter exploratory clinical trial designed to evaluate the efficacy and safety of immunodynamics-guided optimization of chemoimmunotherapy scheduling in patients with advanced non-small cell lung cancer (NSCLC) without targetable driver mutations. The trial specifically investigates whether individualized scheduling of PD-1 inhibitor infusion, guided by dynamic immune monitoring, can improve antitumor activity compared with standard synchronous or fixed-delay administration. Rationale and Background For patients with metastatic NSCLC lacking EGFR, ALK, or other approved targetable alterations, chemoimmunotherapy has become the standard first-line treatment. However, clinical outcomes remain heterogeneous, and not all patients benefit equally. Preclinical and translational evidence suggests that the timing of immune checkpoint blockade relative to chemotherapy exposure may significantly influence immune response, tumor microenvironment remodeling, and overall treatment efficacy. Immunodynamics-the dynamic assessment of immune status during therapy-offers a novel approach to guide individualized administration of immunotherapy, potentially enhancing efficacy while maintaining safety. Study Objectives Primary Objective: To compare the objective response rate (ORR) among three treatment arms: Arm A: Standard synchronous administration of chemotherapy and PD-1 inhibitor. Arm B: Fixed-delay administration, with PD-1 inhibitor given three days after chemotherapy. Arm C: Individualized-delay administration, where PD-1 inhibitor infusion timing (Day 2-6) is determined by peripheral blood immunodynamic markers. Secondary Objectives: To evaluate progression-free survival (PFS), overall survival (OS), disease control rate (DCR), duration of response (DOR), safety, and incidence of immune-related adverse events (irAEs). Exploratory Objectives: To explore the relationship between immune scheduling and peripheral immune dynamics (CD8⁺PD-1⁺ T cells, myeloid-derived suppressor cells \[MDSCs\], Tregs, cytokines, etc.), as well as the predictive value of these markers for therapeutic outcomes. Study Design A total of 246 eligible patients with untreated metastatic, driver gene-negative NSCLC will be randomized in a 1:1:1 ratio into Arms A, B, and C (82 patients per arm). Treatment will consist of four cycles of chemoimmunotherapy followed by PD-1 inhibitor maintenance until disease progression, unacceptable toxicity, or a maximum of 2 years. Arm A (Standard Synchronous): Chemotherapy and PD-1 inhibitor administered on Day 1 of each cycle. Arm B (Fixed-Delay): Chemotherapy on Day 1; PD-1 inhibitor on Day 4. Arm C (Individualized-Delay): Chemotherapy on Day 1; immune markers (CD8⁺PD-1⁺ T cells, MDSCs, Tregs, ± cytokines) measured on Days 2-5; PD-1 inhibitor administered when immunodynamic criteria are met, or on Day 6 as default. Treatment cycles will repeat every 3 weeks. Imaging will be performed every 6 weeks during the first 48 weeks, then every 9 weeks, using RECIST v1.1 criteria. Patients will be followed for safety and survival after treatment discontinuation. Endpoints Primary Endpoint: Objective response rate (ORR) assessed by independent radiologic review committee (IRC). Secondary Endpoints: PFS, OS, DCR, DOR, safety, incidence and severity of irAEs and treatment-related adverse events. Exploratory Endpoints: Dynamic immune monitoring parameters, association between immune recovery patterns and clinical outcomes, correlation of PD-L1 expression and immune biomarkers, and exploratory ctDNA analyses if feasible. Statistical Considerations The study is powered to detect clinically meaningful improvements in ORR. Stratified CMH tests will be used for ORR comparisons. Kaplan-Meier methods and Cox proportional hazards models will be applied for time-to-event endpoints (PFS, OS, DOR). Exploratory analyses will examine associations between immunodynamic markers and outcomes, and predictive biomarker models will be developed. Safety analyses will summarize adverse events by frequency, grade, and relatedness. Significance This trial represents the first randomized study to prospectively test immunodynamics-guided optimization of immunochemotherapy scheduling in NSCLC. By integrating real-time immune monitoring into treatment decision-making, the study aims to generate evidence for precision timing of PD-1 inhibitor administration, potentially enhancing treatment efficacy and safety. Results from this study may inform future clinical practice and contribute to individualized immunotherapy strategies in lung cancer and beyond.