Lung Cancer
Conditions
Keywords
recurrent non-small cell lung cancer, stage IIIB non-small cell lung cancer, stage IV non-small cell lung cancer, adenocarcinoma of the lung, bronchoalveolar cell lung cancer, large cell lung cancer
Brief summary
RATIONALE: Drugs used in chemotherapy, such as paclitaxel and carboplatin, work in different ways to stop the growth of tumor cells, either by killing the cells or by stopping them from dividing. Monoclonal antibodies, such as bevacizumab, can block tumor growth in different ways. Some block the ability of tumor cells to grow and spread. Others find tumor cells and help kill them or carry tumor-killing substances to them. Bevacizumab may also stop the growth of non-small cell lung cancer by blocking blood flow to the tumor. Pemetrexed disodium may stop the growth of tumor cells by blocking some enzymes needed for cell growth. It is not yet known whether giving bevacizumab or pemetrexed disodium alone or in combination is more effective in treating non-squamous non-small cell lung cancer. PURPOSE: This randomized phase III trial is studying bevacizumab and pemetrexed disodium alone or in combination after induction therapy to see how well they work in treating patients with advanced non-squamous non-small cell lung cancer.
Detailed description
OBJECTIVES: Primary * To compare the overall survival (OS) of patients with advanced non-squamous non-small cell lung cancer (NSCLC) treated with maintenance therapy with bevacizumab vs pemetrexed disodium vs bevacizumab and pemetrexed disodium following induction therapy. Secondary * To determine the response rate in patients treated with these regimens. * To evaluate the progression-free survival (PFS) of patients treated with these regimens. * To define the toxicity of these regimens in these patients. * To determine the frequency of polymorphisms in VEGF 3578 AA, 1154 AA, ABCB1 G2677TT/AA, and ERCC-118 TT in patients treated with induction therapy comprising paclitaxel, carboplatin and bevacizumab and determine the association between genotypes and response rate. * To determine the association between bevacizumab and pemetrexed disodium population pharmacokinetics and patient-specific covariate with bevacizumab or pemetrexed disodium toxicity. * To determine the frequency of TSER\*3 polymorphisms in NSCLC and the association between TSER polymorphisms and benefit from pemetrexed disodium. * To evaluate TS and ERCC1 expression by RT-PCR and MTAP mutations in existing tumor specimens as a predictor of pemetrexed disodium response. * To evaluate polymorphisms within CYPs 2C8, 3A4, 3A5 and/or the UGT1A1 collectively or monogenically as markers for variation in efficacious and/or toxic response of individuals to treatment with taxanes. OUTLINE: This is a randomized, multicenter study. Patients are stratified according to gender (male vs female), stage of disease (IIIB-T4Nx \[with nodule in ipsilateral lung lobe and not candidate for combined chemotherapy and radiation\] and IV M1a vs IV M1b vs recurrent), best response to first-time therapy (complete response/partial response vs stable disease), and smoking status (never vs smoker). * Induction therapy (Arm I): Patients receive paclitaxel IV over 3 hours, carboplatin IV over 15-30 minutes, and bevacizumab IV over 30-90 minutes on day 1. Courses repeat every 21 days for 4 courses in the absence of disease progression or unacceptable toxicity. * Maintenance Therapy: Patients achieving complete response, partial response or stable disease following induction therapy are randomized to 1 of 3 treatment arms. Treatment begins within 6 weeks of the last day of induction chemotherapy administration. * Arm A: Patients receive bevacizumab IV over 30-90 minutes on day 1. * Arm B: Patients receive pemetrexed disodium IV over 10 minutes on day 1. * Arm C: Patients receive bevacizumab as in arm A and pemetrexed as in arm B. In all arms, courses repeat every 21 days in the absence of disease progression or unacceptable toxicity. Some patients undergo blood sample collection at baseline and periodically during study for correlative studies. After completion of study therapy, patients are followed up every 3 months for 2 years and then every 6 months for 2-5 years.
Interventions
DRUGPaclitaxel
Given IV
DRUGCarboplatin
Given IV
BIOLOGICALBevacizumab
Given IV
DRUGPemetrexed Disodium Heptahydrate
Given IV
Sponsors
National Cancer Institute (NCI)
ECOG-ACRIN Cancer Research Group
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
(Step 1 Induction Therapy): * Cytologically or histologically confirmed non-small cell lung cancer (NSCLC) * Predominant non-squamous histology (NSCLC not otherwise specified allowed). Mixed tumors are categorized by the predominant cell type. * Stage IV disease including M1a or M1b stages or recurrent disease * Stage IIIB (T4NX) disease with ipsilateral lung lobe allowed provided patients are not candidates for combined chemotherapy or radiotherapy * At least 12 months since prior adjuvant chemotherapy * At least 2 weeks since prior radiotherapy * Prior carboplatin allowed provided it was given as part of adjuvant chemotherapy * Patients with brain metastasis must have received local therapy to the brain and have no evidence of progression in the brain for at least 2 weeks from the time of completion of local therapy, prior to registration * ECOG (Eastern Cooperative Oncology Group) performance status 0-1 * Leukocytes ≥ 3,000/mm\^3 * Absolute neutrophil count ≥ 1,500/mm\^3 * Platelet count ≥ 100,000/mm\^3 * Total bilirubin ≤ institutional upper limit of normal (ULN) * AST and ALT ≤ 3 times ULN * Creatinine ≤ institutional ULN OR creatinine clearance ≥ 60 mL/min * Urine protein:urine dipstick ≤ 0-1+ (if \> 1+, urine protein creatinine ratio must be \< 1) * Measurable or non-measurable disease as defined by RECIST (Response Evaluation Criteria in Solid Tumours) criteria * Patients with hypertension must be adequately controlled (BP \< 150/100 mm Hg) with appropriate anti-hypertensive therapy or diet * Concurrent therapeutic anti-coagulation allowed * Fertile patients must agree to abstain from sexual intercourse or to use adequate contraceptive methods during and for at least 6 months after completion of study therapy
Exclusion criteria
(Step 1 Induction Therapy): * Prior malignancy within the past 3 years except superficial melanoma, basal cell carcinoma, or carcinoma in situ * Prior systemic chemotherapy for advanced stage lung cancer * Prior use of paclitaxel, pemetrexed disodium, or bevacizumab * Major hemoptysis within the past 4 weeks * Uncontrolled intercurrent illness including, but not limited to, active infection, symptomatic congestive heart failure, unstable angina pectoris, serious cardiac arrhythmia, psychiatric illness/social situations that would limit compliance with study requirements * History of arterial thrombotic events or major bleeding within the past 12 months * Major surgery such as thoracotomy, laparotomy, craniotomy, or significant traumatic injury within 6 weeks prior to registration. Biopsy procedures and chest tube insertion are not considered major surgery for the purpose of this protocol. * Core biopsy within 7 days of registration * Significant vascular disease (e.g., aortic aneurysm requiring surgical repair or recent peripheral arterial thrombosis) within the past 6 months * Clinically significant cardiovascular disease * Abdominal fistula, gastrointestinal perforation, or intra-abdominal abscess within the past 6 months * History of serious non-healing wounds, ulcers, or bone fractures * Cavitary lesions in the lungs * Pregnant or nursing * Concurrent anti-retroviral therapy in patients with HIV infection Inclusion Criteria (Step 2 Maintenance Therapy): * Patient must have an overall stable or better response after 4 courses of induction therapy * ECOG (Eastern Cooperative Oncology Group) performance status 0-1 * Patients must be registered to Step 2 within 6 weeks of the last day of chemotherapy administration on Step 1 * Acceptable bone marrow, renal and hepatic function within 2 weeks of registration
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Overall Survival | Assessed every 6 weeks during induction therapy and every 3 cycles during maintenance therapy; after discontinuation of study therapy, assessed every 3 months for 2 years and every 6 months for years 3-5 | Overall survival is defined as the time from randomization to death or date last known alive. The primary analysis is among patients who were randomized to the maintenance therapy. Patients who received induction therapy only and did not participate in the randomization part of the study were not included in this analysis. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Progression-free Survival | Assessed every 6 weeks during induction therapy and every 3 cycles during maintenance therapy; after discontinuation of study therapy, assessed every 3 months for 2 years and every 6 months for years 3-5 | Progression-free survival is defined as the time from randomization to progression or death, whichever occurs first. Progression is evaluated based on RECIST criteria and defined as appearance of one or more new lesions, unequivocal progression of existing non-target lesions, or at least a 20% increase in the sum of the diameters of target lesions, taking as reference the smallest sum on current step. In addition to the relative increase of 20%, the sum must also demonstrate an absolute increase of at least 5 mm. The primary analysis is among patients who were randomized to the maintenance therapy. Patients who received induction therapy only and did not participate in the randomization part of the study were not included in this analysis. |
| Response Rate | Assessed every 6 weeks during induction therapy and every 3 cycles during maintenance therapy; after discontinuation of study therapy, assessed every 3 months for 2 years and every 6 months for years 3-5 | Response is evaluated based on RECIST criteria v1.1 and defined as either complete response or partial response. Complete response is defined as disappearance of all lesions. Partial response is defined as at least a 30% decrease in the sum of the diameters of target lesions, taking as reference the current step's baseline sum diameters. The primary analysis is among patients who were randomized to the maintenance therapy. Patients who received induction therapy only and did not participate in the randomization part of the study were not included in this analysis. |
Other
| Measure | Time frame | Description |
|---|---|---|
| The Frequency of TSER*3 Polymorphisms in NSCLC and the Association Between TSER Polymorphisms and Benefit From Pemetrexed | Assessed every 3 months for 2 years and every 6 months for years 3-5 | — |
| The Associations Between Polymorphisms Within CYPs 2C8, 3A4, 3A5 and/or the UGT1A1 Collectively or Monogenically and Efficacy and/or Toxicities | Assessed every 3 months for 2 years and every 6 months for years 3-5 | — |
| The Association Between TS and ERCC1 Expression and Pemetrexed Response | Assessed every 3 months for 2 years and every 6 months for years 3-5 | — |
| The Association Between Genotypes and Response Rate | Assessed every 6 weeks during induction therapy and every 3 cycles during maintenance therapy; after discontinuation of study therapy, assessed every 3 months for 2 years and every 6 months for years 3-5 | To determine the frequency of polymorphisms in VEGF 3578 AA, 1154 AA, ABCB1 G2677TT/AA and ERCC-118 TT in patients with NSCLC receiving paclitaxel, carboplatin and bevacizumab therapy and determine the association between genotypes and response rate. |
| The Association Between Bevacizumab and Pemetrexed Population Pharmacokinetics and Patient Specific Covariates With Bevacizumab or Pemetrexed Toxicity | Assessed every 3 weeks while on treatment and for 30 days after the end of treatment | — |
Countries
United States
Participant flow
Recruitment details
A total of 1,516 patients were enrolled in the study between August 2010 and April 2015. The first patient was accrued on October 25, 2010.
Participants by arm
| Arm | Count |
|---|---|
| Induction Therapy But Not Randomized Induction Therapy:
Patients receive paclitaxel IV over 3 hours, carboplatin IV over 15-30 minutes, and bevacizumab IV over 30-90 minutes on day 1. Courses repeat every 21 days for 4 courses in the absence of disease progression or unacceptable toxicity. | 642 |
| Arm A (Induction Then Maintenance With Bevacizumab) Induction Therapy:
Patients receive paclitaxel IV over 3 hours, carboplatin IV over 15-30 minutes, and bevacizumab IV over 30-90 minutes on day 1. Courses repeat every 21 days for 4 courses in the absence of disease progression or unacceptable toxicity.
Maintenance Therapy:
Patients achieving complete response, partial response or stable disease following induction therapy are randomized to 1 of 3 treatment arms. Patients in arm A receive bevacizumab IV over 30-90 minutes on day 1 of every cycle until progression or unacceptable toxicity. | 287 |
| Arm B (Induction Then Maintenance With Pemetrexed) Induction Therapy:
Patients receive paclitaxel IV over 3 hours, carboplatin IV over 15-30 minutes, and bevacizumab IV over 30-90 minutes on day 1. Courses repeat every 21 days for 4 courses in the absence of disease progression or unacceptable toxicity.
Maintenance Therapy:
Patients achieving complete response, partial response or stable disease following induction therapy are randomized to 1 of 3 treatment arms. Patients in arm B receive pemetrexed IV over 10 minutes on day 1 of every cycle until progression or unacceptable toxicity. | 294 |
| Arm C (Inductio Then Maintenance With Bevacizumab & Pemetrexed) Induction Therapy:
Patients receive paclitaxel IV over 3 hours, carboplatin IV over 15-30 minutes, and bevacizumab IV over 30-90 minutes on day 1. Courses repeat every 21 days for 4 courses in the absence of disease progression or unacceptable toxicity.
Maintenance Therapy:
Patients achieving complete response, partial response or stable disease following induction therapy are randomized to 1 of 3 treatment arms. Patients in arm C receive bevacizumab IV over 30-90 minutes and pemetrexed IV over 10 minutes on day 1 of every cycle until progression or unacceptable toxicity. | 293 |
| Total | 1,516 |
Withdrawals & dropouts
| Period | Reason | FG000 | FG001 | FG002 | FG003 |
|---|---|---|---|---|---|
| Step 1: Induction Therapy | Adverse Event | 198 | 0 | 0 | 0 |
| Step 1: Induction Therapy | Alternative therapy | 12 | 0 | 0 | 0 |
| Step 1: Induction Therapy | Complicating disease | 13 | 0 | 0 | 0 |
| Step 1: Induction Therapy | Death | 62 | 0 | 0 | 0 |
| Step 1: Induction Therapy | Hospice care | 1 | 0 | 0 | 0 |
| Step 1: Induction Therapy | Lack of Efficacy | 167 | 0 | 0 | 0 |
| Step 1: Induction Therapy | Non-compliance | 4 | 0 | 0 | 0 |
| Step 1: Induction Therapy | Off treatment reason not reported | 50 | 0 | 0 | 0 |
| Step 1: Induction Therapy | Pain | 4 | 0 | 0 | 0 |
| Step 1: Induction Therapy | Physician Decision | 1 | 0 | 0 | 0 |
| Step 1: Induction Therapy | Protocol Violation | 1 | 0 | 0 | 0 |
| Step 1: Induction Therapy | Symptomatic deterioration | 10 | 0 | 0 | 0 |
| Step 1: Induction Therapy | Withdrawal by Subject | 54 | 0 | 0 | 0 |
| Step 2: Maintenance Therapy | Adverse Event | 0 | 32 | 29 | 46 |
| Step 2: Maintenance Therapy | Alternative therapy | 0 | 2 | 4 | 5 |
| Step 2: Maintenance Therapy | Death | 0 | 8 | 2 | 13 |
| Step 2: Maintenance Therapy | Diagnosis of progressive disease error | 0 | 1 | 1 | 0 |
| Step 2: Maintenance Therapy | Exceeded maximum delay in treatment | 0 | 2 | 2 | 3 |
| Step 2: Maintenance Therapy | Financial reason | 0 | 2 | 0 | 0 |
| Step 2: Maintenance Therapy | Hospice care | 0 | 1 | 2 | 0 |
| Step 2: Maintenance Therapy | Lack of Efficacy | 0 | 217 | 217 | 170 |
| Step 2: Maintenance Therapy | Non-compliance | 0 | 0 | 0 | 2 |
| Step 2: Maintenance Therapy | Off treatment reason not reported | 0 | 4 | 4 | 10 |
| Step 2: Maintenance Therapy | Other complicating disease | 0 | 2 | 5 | 9 |
| Step 2: Maintenance Therapy | Pain | 0 | 0 | 0 | 1 |
| Step 2: Maintenance Therapy | Physician Decision | 0 | 2 | 3 | 3 |
| Step 2: Maintenance Therapy | Symptomatic deterioration | 0 | 2 | 4 | 3 |
| Step 2: Maintenance Therapy | Withdrawal by Subject | 0 | 11 | 21 | 27 |
Baseline characteristics
| Characteristic | Induction Therapy But Not Randomized | Total | Arm C (Inductio Then Maintenance With Bevacizumab & Pemetrexed) | Arm B (Induction Then Maintenance With Pemetrexed) | Arm A (Induction Then Maintenance With Bevacizumab) |
|---|---|---|---|---|---|
| Age, Continuous | 65 years | 64 years | 64 years | 63 years | 65 years |
| Race (NIH/OMB) American Indian or Alaska Native | 6 Participants | 9 Participants | 1 Participants | 1 Participants | 1 Participants |
| Race (NIH/OMB) Asian | 8 Participants | 20 Participants | 6 Participants | 3 Participants | 3 Participants |
| Race (NIH/OMB) Black or African American | 82 Participants | 180 Participants | 22 Participants | 45 Participants | 31 Participants |
| Race (NIH/OMB) More than one race | 0 Participants | 1 Participants | 0 Participants | 0 Participants | 1 Participants |
| Race (NIH/OMB) Native Hawaiian or Other Pacific Islander | 0 Participants | 2 Participants | 0 Participants | 1 Participants | 1 Participants |
| Race (NIH/OMB) Unknown or Not Reported | 18 Participants | 31 Participants | 4 Participants | 4 Participants | 5 Participants |
| Race (NIH/OMB) White | 528 Participants | 1273 Participants | 260 Participants | 240 Participants | 245 Participants |
| Sex: Female, Male Female | 276 Participants | 724 Participants | 150 Participants | 151 Participants | 147 Participants |
| Sex: Female, Male Male | 366 Participants | 792 Participants | 143 Participants | 143 Participants | 140 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk | EG002 affected / at risk | EG003 affected / at risk |
|---|---|---|---|---|
| deaths Total, all-cause mortality | 1,290 / 1,516 | 245 / 287 | 240 / 294 | 236 / 293 |
| other Total, other adverse events | 1,178 / 1,477 | 216 / 284 | 222 / 289 | 237 / 286 |
| serious Total, serious adverse events | 825 / 1,477 | 87 / 284 | 107 / 289 | 144 / 286 |
Outcome results
Primary
Overall Survival
Overall survival is defined as the time from randomization to death or date last known alive. The primary analysis is among patients who were randomized to the maintenance therapy. Patients who received induction therapy only and did not participate in the randomization part of the study were not included in this analysis.
Time frame: Assessed every 6 weeks during induction therapy and every 3 cycles during maintenance therapy; after discontinuation of study therapy, assessed every 3 months for 2 years and every 6 months for years 3-5
Population: All randomized patients
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Arm A (Induction Then Maintenance With Bevacizumab) | Overall Survival | 14.4 months |
| Arm B (Induction Then Maintenance With Pemetrexed | Overall Survival | 15.9 months |
| Arm C (Induction Then Maintenance With Bevacizumab and Pemetrexed) | Overall Survival | 16.4 months |
p-value: 0.12Log Rank
p-value: 0.28Log Rank
Secondary
Progression-free Survival
Progression-free survival is defined as the time from randomization to progression or death, whichever occurs first. Progression is evaluated based on RECIST criteria and defined as appearance of one or more new lesions, unequivocal progression of existing non-target lesions, or at least a 20% increase in the sum of the diameters of target lesions, taking as reference the smallest sum on current step. In addition to the relative increase of 20%, the sum must also demonstrate an absolute increase of at least 5 mm. The primary analysis is among patients who were randomized to the maintenance therapy. Patients who received induction therapy only and did not participate in the randomization part of the study were not included in this analysis.
Time frame: Assessed every 6 weeks during induction therapy and every 3 cycles during maintenance therapy; after discontinuation of study therapy, assessed every 3 months for 2 years and every 6 months for years 3-5
Population: All randomized patients
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Arm A (Induction Then Maintenance With Bevacizumab) | Progression-free Survival | 4.2 months |
| Arm B (Induction Then Maintenance With Pemetrexed | Progression-free Survival | 5.1 months |
| Arm C (Induction Then Maintenance With Bevacizumab and Pemetrexed) | Progression-free Survival | 7.5 months |
Secondary
Response Rate
Response is evaluated based on RECIST criteria v1.1 and defined as either complete response or partial response. Complete response is defined as disappearance of all lesions. Partial response is defined as at least a 30% decrease in the sum of the diameters of target lesions, taking as reference the current step's baseline sum diameters. The primary analysis is among patients who were randomized to the maintenance therapy. Patients who received induction therapy only and did not participate in the randomization part of the study were not included in this analysis.
Time frame: Assessed every 6 weeks during induction therapy and every 3 cycles during maintenance therapy; after discontinuation of study therapy, assessed every 3 months for 2 years and every 6 months for years 3-5
Population: All randomized patients
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Arm A (Induction Then Maintenance With Bevacizumab) | Response Rate | 0.125 proportion of participants |
| Arm B (Induction Then Maintenance With Pemetrexed | Response Rate | 0.187 proportion of participants |
| Arm C (Induction Then Maintenance With Bevacizumab and Pemetrexed) | Response Rate | 0.212 proportion of participants |
Other Pre-specified
The Association Between Bevacizumab and Pemetrexed Population Pharmacokinetics and Patient Specific Covariates With Bevacizumab or Pemetrexed Toxicity
Time frame: Assessed every 3 weeks while on treatment and for 30 days after the end of treatment
Other Pre-specified
The Association Between Genotypes and Response Rate
To determine the frequency of polymorphisms in VEGF 3578 AA, 1154 AA, ABCB1 G2677TT/AA and ERCC-118 TT in patients with NSCLC receiving paclitaxel, carboplatin and bevacizumab therapy and determine the association between genotypes and response rate.
Time frame: Assessed every 6 weeks during induction therapy and every 3 cycles during maintenance therapy; after discontinuation of study therapy, assessed every 3 months for 2 years and every 6 months for years 3-5
Other Pre-specified
The Association Between TS and ERCC1 Expression and Pemetrexed Response
Time frame: Assessed every 3 months for 2 years and every 6 months for years 3-5
Other Pre-specified
The Associations Between Polymorphisms Within CYPs 2C8, 3A4, 3A5 and/or the UGT1A1 Collectively or Monogenically and Efficacy and/or Toxicities
Time frame: Assessed every 3 months for 2 years and every 6 months for years 3-5
Other Pre-specified
The Frequency of TSER*3 Polymorphisms in NSCLC and the Association Between TSER Polymorphisms and Benefit From Pemetrexed
Time frame: Assessed every 3 months for 2 years and every 6 months for years 3-5