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IntroductionImmune checkpoint inhibitors (ICIs) are standard therapy for metastatic non-small cell lung cancer (NSCLC). Blood transfusions, particularly erythrocyte suspension (ES) transfusions, may induce immunomodulatory effects and potentially influence cancer outcomes. This study investigated the association between transfusions and survival in NSCLC patients treated with nivolumab.MethodsWe retrospectively reviewed 88 patients with metastatic NSCLC who received nivolumab between January 2018 and December 2023. Transfusion status, baseline inflammatory markers, progression-free survival (PFS), and overall survival (OS) were evaluated. Survival outcomes were assessed using Kaplan-Meier analysis and univariable statistical methods.ResultsThe median patient age was 64 years (range, 41-76). Median PFS was 5.93 months (95% Confidence Interval [CI], 3.72-8.14), and median OS was 8.23 months (95% CI, 6.19-10.27). Patients who received ES transfusions during nivolumab therapy experienced shorter PFS (p=0.033) and OS (p=0.039), predominantly driven by the non-squamous subgroup (PFS: p=0.002; OS: p=0.008). In univariable analyses, nivolumab cycle count, pre-treatment hemoglobin, neutrophil-to-lymphocyte ratio (NLR), C-reactive protein-to-albumin ratio (CAR), and systemic immune-inflammation index were associated with PFS, while programmed cell death ligand-1 (PD-L1) status, treatment line, number of cycles, pre-treatment hemoglobin, NLR, CAR, and prognostic nutritional index were associated with OS (all p< 0.05).ConclusionES transfusions administered during nivolumab therapy were associated with poorer PFS and OS in patients with metastatic NSCLC, particularly in those with non-squamous histology. Given the retrospective design and limited number of transfused patients, these findings should be interpreted with caution and considered hypothesis-generating. Larger, prospective multicenter studies are warranted to further clarify the relationship between transfusion exposure and ICI outcomes.