CMV serostatus is associated with improved survival and delayed toxicity onset following anti-PD-1 checkpoint blockade

Cytomegalovirus (CMV) is a globally endemic latent herpes virus that profoundly impacts T cell immunity. We investigated the oncological consequences of CMV infection across 341 prospectively recruited patients receiving immune checkpoint blockade (ICB) for melanoma. CMV⁺ patients with metastatic melanoma (MM) have higher lymphocyte counts, reduced neutrophil to lymphocyte ratio and divergent CD8⁺ T cell gene expression. Combination anti-CTLA-4/anti-PD-1 ICB, but not single-agent anti-PD-1 ICB, induces cytotoxicity and CMV-associated gene expression in CD8⁺ T cells from CMV⁻ patients. Correspondingly, overall survival was independent of CMV serostatus in combination anti-CTLA-4/anti-PD-1 ICB recipients (CMV⁺ hazard ratio for death: 1.02, P = 0.92), whereas CMV⁺ single-agent anti-PD-1 ICB recipients had improved overall survival (CMV⁺ hazard ratio for death: 0.37, P < 0.01), a finding also seen in CMV⁺ adjuvant single-agent anti-PD-1 ICB recipients (CMV⁺ hazard ratio for recurrence: 0.19, P = 0.03). We identify TBX21, encoding T-bet, as a transcriptional driver of CMV-associated CD8⁺ T cell gene expression, finding that TBX21 expression is predictive of overall survival (hazard ratio: 0.62, P = 0.026). CMV⁺ patients unexpectedly show reduced cumulative incidence of grade 3+ immune-related adverse events at 6 months (0.30 versus 0.52, P = 2.2 × 10⁻⁵), with lower incidence of colitis (P = 7.8 × 10⁻⁴) and pneumonitis (P = 0.028), an effect replicated in non-melanoma ICB recipients (n = 58, P = 0.044). Finally, we find reduced CMV seropositivity rates in patients with MM compared with UK Biobank controls (odds ratio: 0.52, P = 1.8 × 10⁻⁴), indicating CMV seropositivity may protect against MM. Specifically, patients with BRAF-mutated MM are less likely to be CMV⁺ (odds ratio = 2.2, P = 0.0054), while CMV⁻ patients present 9 yr earlier with BRAF wild-type MM (P = 1.3 × 10⁻⁴). This work reveals an interaction between CMV infection, MM development according to BRAF status and response to ICB, while demonstrating CMV infection is protective against severe ICB immune-related adverse events, highlighting the potential importance of previous infection history and chronic immune activation in MM development and immunotherapy outcomes.