Drug-induced interstitial lung disease in the era following the introduction of novel anticancer agents: a narrative review

Purpose: Drug-induced interstitial lung disease (DILD), or drug-induced pneumonitis, is an uncommon but potentially fatal adverse drug reaction. This review summarizes recent changes in the epidemiology, classification, diagnosis, and treatment of DILD with introduction of novel anticancer agents.Current concepts: Although diagnosis still relies on the temporal relationship between drug exposure and new pulmonary abnormalities, alongside exclusion of alternative causes, the clinical landscape of DILD has changed substantially in recent years. Novel anticancer agents, including antibody-drug conjugates such as trastuzumab deruxtecan and datopotamab deruxtecan, third-generation epidermal growth factor receptor tyrosine kinase inhibitors, bispecific antibodies, immune checkpoint inhibitors, cyclin-dependent kinase 4/6 inhibitors, rearranged during transfection inhibitors, and KRAS G12C inhibitors, are important causes of DILD. The 2025 European Respiratory Society/American Thoracic Society classification update incorporates secondary interstitial pneumonia (IP), including drug-induced disease, and emphasizes diagnostic confidence and multidisciplinary discussion. High-resolution computed tomography patterns, including organizing pneumonia, nonspecific IP, hypersensitivity pneumonitis-like pattern, diffuse alveolar damage, and bronchiolocentric IP, may support differential diagnosis and severity assessment. Bronchoalveolar lavage, serum biomarkers, and emerging radiomics-based tools further aid diagnosis. Management remains centered on prompt discontinuation of the suspected drug, severity-based corticosteroid therapy, respiratory support, and individualized rechallenge decisions. In patients with progressive fibrosis despite withdrawal of the offending agent and anti-inflammatory treatment, antifibrotic therapy with nintedanib may be considered.Discussion and conclusion: Clinicians should maintain a high index of suspicion for DILD in patients receiving newly developed oncological and immunomodulatory therapies and should apply a multidisciplinary, pattern-based, and severity-adapted approach to diagnosis and treatment.