Originally published as JCO Early Release 10.1200/JCO.2008.19.1650 on March 23 2009

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Randomized Phase II and Pharmacogenetic Study of Pemetrexed Compared With Pemetrexed Plus Carboplatin in Pretreated Patients With Advanced Non–Small-Cell Lung Cancer

From the Department of Pulmonary Diseases Vrije Universiteit Medical Centre; Department of Medical Oncology, Netherlands Cancer Institute; Nederlandse Vereniging Artsen voor Longziekten en Tuberculose Data Centre, Amsterdam; Jeroen Bosch Hospital, 's-Hertogenbosch; Rijnstate Hospital, Arnhem; Nij Smellinghe, Drachten; Academisch Ziekenhuis Maastricht, Maastricht; University Medical Centre Groningen, Groningen, the Netherlands; Department of Oncology and Hematology, Cantonal Hospital, St Gallen, Switzerland; and Bernie Banton Centre, University of Sydney, Sydney, Australia.

Corresponding author: Egbert F. Smit, MD, PhD, Department of Pulmonary Diseases, Vrije Universiteit Medical Centre, P.O. Box 7057, 1007 MB Amsterdam, the Netherlands; e-mail: ef.smit{at}vumc.nl.

Purpose We performed a randomized phase II trial comparing pemetrexed with pemetrexed plus carboplatin (PC) in patients experiencing relapse after platinum-based chemotherapy.

Patients and Methods Main eligibility criteria were histologic or cytologic proof of advanced non–small-cell lung cancer (NSCLC), relapse more than 3 months after platinum-based chemotherapy, normal organ function, and Eastern Cooperative Oncology Group performance status 0 to 2. Patients were randomly assigned to pemetrexed 500 mg/m² (arm A) or carboplatin area under the curve 5 and pemetrexed 500 mg/m² (arm B), both administered intravenously every 3 weeks. Response assessment was performed every 6 weeks; toxicity assessment was performed every 3 weeks. Primary end point was time to progression (TTP); secondary end points were objective response rate (ORR), overall survival (OS), and toxicity. The study was designed to detect a 33% decrease in the hazard of disease progression in the combination arm ( = 0.05, two-sided log-rank test). Polymorphisms of thymidylate synthase, the reduced folate carrier, -glutamyl hydrolase, and methylenetetrahydrofolate reductase (MTHF) were investigated in peripheral WBCs of consenting patients.

Results Two hundred forty patients were enrolled. Median TTP was 2.8 months for arm A versus 4.2 months for arm B (hazard ratio, 0.67; 95% CI, 0.51 to 0.89; P = .005). Median OS was 7.6 months and 8.0 months and ORR was 4% and 9% for arms A and B, respectively. Subgroup analyses found adenocarcinoma to be associated with favorable outcome. Toxicities in both arms was negligible, with one potential toxic death in arm A. Patients with MTHFR C677T homozygous mutation had increased progression-free survival compared with patients with wild-type or heterozygous mutations (P = .03).

Conclusion PC as second-line treatment for relapsed NSCLC resulted in a significant 33% reduction of the hazard of disease progression as compared with pemetrexed alone.

Written on behalf of the Nederlandse Vereniging Artsen voor Longziekten en Tuberculose Lung Cancer Group.

Supported by an unrestricted educational grant from Eli Lilly Co. The translational part of this study was supported by a gift from the legacy of Liesbeth van Vuuren-Martens.

Presented as a poster at the 44th Annual Meeting of the American Society of Clinical Oncology, May 30-June 3, 2008, Chicago, IL.

Authors' disclosures of potential conflicts of interest and author contributions are found at the end of this article.

Clinical Trials repository link available on JCO.org.

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