BACKGROUND: 25% to 30% of primary stage IV pulmonary adenocarcinomas (PUAD-IV) die within 3 months. Many ≥3 months survivors at long follow-up are alive with disease (AWD). Platinum-based chemotherapy (PBC), tyrosine kinase inhibitors- targeted therapy (TKI-TT), and Chinese herbal medicines (oral CHM) improve prognosis. In China, moxibustion treatment (Moxa) is also used, without prognostic proof. METHODS: Prospective observational Moxa evaluation in 412 first-onset consecutive PUAD-IV performance score 0 to 1 patients with 3 to 120 months follow-up. All received oral CHM with PBC, TKI-TT, or PBC + TKI-TT. Moxa was given as indicated at the start of the treatment (and eventually adapted in the follow-up period by de novo development) of well-established TCM syndromes and symptoms. Survival was analyzed using Kaplan-Meier and Cox regression. Propensity score analysis (PSA) with matching and inverse probability of treatment weighting (IPTW) were used to adjust for baseline covariate imbalances. RESULTS: Of 412 patients, 117 received no Moxa, 239 had 1 to 4 treatments, and 56 received >4 treatments alongside conventional treatments. Tumor-Node-Metastasis (TNM) stage IVB and male sex increased dead of disease (DOD)-risk, while TKI-TT, ≥4 Chemotherapy cycles, and Moxa improved survival ( < .05). Median survival (MST): Reference group (PBC + CHM) 20.0 months; Moxa 32.0; TKI-TT 33.0; TKI-TT+1-4 Moxa 33.0; TKI-TT+>4 Moxa 40.0 months (all  < .05). Cox regression indicated a dosage-dependent Moxa effect ( = .0004). Restricted Mean Survival Time (RMST) at 36 months favored >4 Moxa+TKI-TT over TKI-TT (+6.2 months,  = .01). PSA confirmed results were not due to baseline covariate imbalance. CONCLUSIONS: Moxibustion may dosage-dependently improve survival in PUAD-IV, both in TKI- and non-TKI-treated patients. Randomized clinical trials (RCT) are needed to confirm this.