Abstract
Retrospective studies suggest that early time-of-day (ToD) infusions of immunochemotherapy may improve efficacy. However, prospective randomized controlled trials are needed to validate it. In this randomized phase 3 LungTIME-C01 trial, 210 patients with treatment naive stage IIIC–IV non-small cell lung cancer (NSCLC) lacking driver mutations were randomly assigned in a 1:1 ratio to either an early or late ToD group, defined by the administration of the first four cycles of an anti-PD-1 agent before or after 15:00 h. The primary endpoint was progression-free survival (PFS), while secondary endpoints included overall survival (OS) and objective response rate (ORR). After a median follow-up of 28.7 months, the median PFS was 11.3 months (95% confidence interval (CI) = 9.2–13.4) in the early ToD group and 5.7 months (95% CI = 5.2–6.2) in the late ToD group, corresponding to a hazard ratio (HR) for earlier disease progression of 0.40 (95% CI = 0.29–0.55; P < 0.001). The median OS was 28.0 months (95% CI = not estimable (NE)–NE) in the early ToD group and 16.8 months (95% CI = 13.7–19.9) in the late ToD group, corresponding to an HR of an earlier death of 0.42 (95% CI = 0.29–0.60; P < 0.001). Treatment-related adverse events were consistent with the established safety profile, with no new safety signals observed. No significant differences in immune-related adverse events were observed between the two groups. Over the first four cycles, morning circulating CD8+ T cells increased in the early ToD group, whereas they declined in the late ToD group (P < 0.001). Furthermore, the ratio of activated (CD38+ HLA-DR+) versus exhausted (TIM-3+PD-1+) CD8+ T cells was higher in the early ToD group (P < 0.001) compared with the late ToD group (P < 0.001). In summary, our study indicates that early ToD immunochemotherapy substantially improves PFS and OS and is associated with enhanced antitumor CD8+ T cell characteristics compared with late ToD treatment. ClinicalTrials.gov registration: NCT05549037.
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Data availability
Due to concerns regarding patient privacy and institutional data governance, the clinical datasets generated or used in this study are not publicly accessible. To protect the confidentiality of patients, de-identified individual-level data may be made available upon reasonable request. Researchers interested in accessing the data should contact Y.Z. at Hunan Cancer Hospital. All inquiries will be addressed within approximately 10 weeks. Each request will undergo evaluation by the data oversight committee of Hunan Cancer Hospital to assess compliance with confidentiality policies and potential intellectual property constraints.
Change history
19 February 2026
Editor's Note: The editors are issuing this note to alert readers that concerns have been raised regarding inconsistencies between the registration record of this trial on clinicaltrials.gov and published version the study protocol, as well as with some of the findings in this study. Editorial action will be taken as appropriate once an investigation of the concerns is complete and all parties have been given an opportunity to respond in full.
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Acknowledgements
We are deeply grateful to all the patients and their families who participated in this study. This work received financial support from the National Natural Science Foundation of China (grants 82222048 and 82173338 to Y.Z. and 82003206 to L.Z.). The funding agencies had no role in the study design, data collection, analysis, interpretation, manuscript writing or the decision to submit the article for publication.
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Z.H., L.Z., Z.R. conceived the study, collected the data, contributed to the analysis and interpretation of the data, manuscript writing and development of figures and tables. Q.Z. conceived the study, contributed to the analysis and interpretation of the data, manuscript writing and development of figures and tables. H. Yan., W.J., Y. Xiong, C.Z., H. Yang, L.L., J. Dai, N.Z., S.X., Y.W., Z.W., J. Deng and X.C. collected the data, contributed to the analysis and interpretation of the data and to manuscript review and revision. J.W., H.X., X.L., B.D., G.C. and Y. Xia contributed to all collaborative aspects in the study and critically read and improved the manuscript. C.S. conceived the study, contributed to all study progress and development, contributed to methods, results, interpretation and manuscript writing. F.L. conceived the study, contributed to all study progress and development, contributed to methods, results, interpretation and manuscript writing. N.Y. and Y.Z. codirected this study, including conception, organization, data collection, auditing, supervision, project management, funding acquisition, writing and editing the manuscript. T.M. supervised the study and contributed to the writing, review and editing of the manuscript. Z.H., Z.R., L.Z., Q.Z., Y.Z., F.L., C.S. and T.M. verified the underlying data. All authors approved the current manuscript.
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Extended data
Extended Data Fig. 1 Distribution of immunotherapy infusion times.
(a) Distribution of first 4 infusion times among 210 patients, who were divided into early time-of-day (ToD) infusion group and late ToD group. (b) Histogram of median times of the first 4 infusions per patient (n = 210).
Extended Data Fig. 2 Univariate and multivariate Cox regression analyses of patient characteristics.
(a) Forest plots of the univariate and multivariate Cox regression results for progression-free survival (PFS) (n = 210). (b) Forest plots of the univariate and multivariate Cox regression results for overall survival (OS) (n = 210). P values (two-sided), hazard ratios (HRs), and 95% confidence intervals of HRs were estimated using univariable or multivariable Cox proportional hazards models, and P values were not adjusted for multiple comparisons. Data are presented as HR (points) with 95% CIs (horizontal lines). ICI, immune checkpoint inhibitor. LUSC, lung squamous cell carcinoma. LUAD, lung adenocarcinoma. ECOG PS, Eastern Cooperative Oncology Group Performance Status. LIPI, Lung Immune Prognostic Index.
Extended Data Fig. 3 Response rates of patients according to ToD treatment group.
The tumor response was assessed by a blinded independent review committee (BIRC) (n = 210). P values were determined using a two-sided chi-square test. ToD, time-of-day. PR, partial response. SD, stable disease. PD, progressive disease.
Extended Data Fig. 4 Dynamic alterations of lymphocyte subpopulations in peripheral blood during immunochemotherapy.
Patient values are normalized to individual baseline levels and assessed after 2 cycles (prior to cycle 3) and 4 cycles (prior to cycle 5) of treatment. Line-point graphs depict dynamic changes of CD3+ T cell proportion (a), CD8+ T cell proportion (b), CD4+ T cell proportion (f), B cell proportion (g), NK cell proportion (h) and CD8+/CD4+ T cell ratio (i) in individual patients from the early and late time-of-day (ToD) groups. Colored lines link sequential measurements from individual patients. The horizontal dotted line represents the normalized baseline (ratio = 1.0). Linear regressions (solid lines) with shaded 95% confidence intervals illustrate changes in CD4+ T cell proportions (c), B cell proportions (d) and NK cell proportions (e) over time in patients from the early and late time-of-day (ToD) groups. Data are presented as mean ± s.e. of the mean (s.e.m.). Dotted horizontal lines indicate the normalized baseline (ratio = 1.0). P values were determined using a permutation test (two-sided) and two-way repeated-measures ANOVA (two-sided), without adjustment for multiple comparisons. Flow cytometric analyses of CD4+, B and NK cells were performed on paired blood samples collected at baseline, after 2 cycles and after 4 cycles from 61 patients in the early ToD group and 44 patients in the late ToD group (n = 105 total patients; n = 315 total samples).
Extended Data Fig. 5 Shifts in peripheral lymphocyte subset composition throughout immunochemotherapy administration.
Representative flow cytometry gating strategy used to identify CD38+HLA-DR+CD8+ T cells and TIM-3+PD-1+CD8+ T cells from peripheral blood mononuclear cells (PBMCs) (a). Linear regressions (solid lines) with shaded 95% confidence intervals illustrate changes in CD38+ HLA-DR+ CD8+ T cell proportions (b). Data are presented as mean ± s.e.m. Dotted horizontal lines indicate the normalized baseline (ratio = 1.0). P values were determined using a permutation test (two-sided) and two-way repeated-measures ANOVA (two-sided), without adjustment for multiple comparisons. Line-point graphs depict dynamic changes of CD38+ HLA-DR+ CD8+ T cell (c), TIM-3+ PD-1+ CD8+ T cell proportion (d) and CD38+ HLA-DR+/ TIM-3+ PD-1+ CD8+ T cell ratio (e) in individual patients from the early and late time-of-day (ToD) groups. Colored lines connect serial measurements from the same patient. Dotted horizontal lines indicate the normalized baseline (ratio = 1.0). PBMCs, peripheral blood mononuclear cells. Flow cytometric analyses of CD3+, CD4+, CD8+ T, B and NK cells were performed on paired blood samples collected at baseline, after 2 cycles and after 4 cycles from 61 patients in the early ToD group and 44 patients in the late ToD group (n = 105 total patients; n = 315 total samples). CD38+ HLA-DR+ CD8+ T cells and TIM-3+ PD-1+ CD8+ T cells were assessed in paired cryopreserved PBMCs collected at baseline, after 2 cycles and after 4 cycles from 14 patients in the early ToD group and 25 patients in the late ToD group (n = 39 total patients; n = 117 total samples).
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Huang, Z., Zeng, L., Ruan, Z. et al. Time-of-day immunochemotherapy in non-small cell lung cancer: a randomized phase 3 trial. Nat Med 32, 1233–1240 (2026). https://doi.org/10.1038/s41591-025-04181-w
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DOI: https://doi.org/10.1038/s41591-025-04181-w
