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Pemetrexed-free vs. Pemetrexed-based Immunochemotherapy in Metastatic TTF-1 Negative Lung Adenocarcinoma

Phase 4
Recruiting
Conditions
Non-Small Cell Lung Cancer Metastatic
Interventions
Drug: Atezolizumab
Drug: Pembrolizumab
Drug: Nab paclitaxel
Drug: Cisplatin
Drug: Carboplatin
Drug: Pemetrexed
Registration Number
NCT05689671
Lead Sponsor
Nikolaj Frost MD
Brief Summary

This is an open-label randomized, controlled, multicenter, phase II trial with two arms. Patients with metastatic TTF-1 negative, treatment-naive lung adenocarcinoma without actionable genomic alterations are randomized in a 1:1 manner to investigate the efficiency of atezolizumab, carboplatin and nab-paclitaxel (Arm A) versus pembrolizumab, cis-/carboplatin and pemetrexed (Arm B) as first-line treatment.

Detailed Description

Thyroid transcription factor 1 (TTF-1) is expressed in the majority of lung adenocarcinoma and has a clear prognostic value. Pemetrexed-based immunochemotherapy is a standard of care for advanced lung adenocarcinoma. However, real-world data suggest that TTF-1 negative patients might derive superior outcome using pemetrexed-free regimens. The aim of this study is to compare a pemetrexed-free (Arm A) vs. a pemetrexed-based immunochemotherapy (Arm B) as first-line treatment for metastatic TTF-1 negative lung adenocarcinoma without actionable genomic alterations.

Recruitment & Eligibility

Status
RECRUITING
Sex
All
Target Recruitment
136
Inclusion Criteria

  1. Patient has provided written informed consent

  2. Patient* 18 years or older at time of signing the informed consent form

  3. Histologically or cytologically confirmed metastatic stage IV non-squamous NSCLC

  4. Negative local testing for TTF-1

  5. Negative molecular testing for EGFR mutations and ALK rearrangements (tested locally). Exception: In specific individual cases, treatment can be initiated prior to receiving molecular diagnostics after consulting with the sponsor, if the local principal investigator assesses the likelihood of an EGFR mutation or ALK fusion to be negligible. However, this should only be done in exceptional cases if the patient has particularly high demand for treatment. If it is subsequently found that patients are positive for EGFR mutations and/or ALK rearrangements, they must be withdrawn from the study immediately and must not receive any further study medication. Instead, patients should receive adequate SOC therapy outside the study.

    Awaiting results for molecular testing remains standard procedure for patient inclusion.

  6. PD-L1 tumor proportion score (TPS) < 50%, tested locally by QUiP®-certified immunohistochemistry

  7. ECOG performance status ≤ 1

  8. Measurable lesions according to RECIST v1.1

  9. Life expectancy ≥ 12 weeks

  10. Adequate hepatic, renal and bone marrow function

    1. Hemoglobin ≥ 8.0 g/dL
    2. Absolute neutrophil count ≥ 1.5 x 109/L
    3. Platelets ≥ 100 x 109/L
    4. Calculated creatine clearance ≥ 50 mL/min as determined by the Cockcroft-Gault equation and/or creatinin ≤ 1,5x upper limit of normal (ULN)
    5. Serum bilirubin ≤ 1.5 x institutional ULN
    6. AST/ ALT and alkaline phosphatase ≤ 2.5 x ULN
    7. International normalized ratio (INR)/ Activated partial thromboplastin time (aPTT) ≤1.5 × ULN unless participant is receiving anticoagulant therapy as long as PTT is within therapeutic range of intended use of anticoagulants

  11. The patient is willing and able to comply with the protocol for the duration of the study, including hospital visits for treatment and scheduled follow-up visits and examinations.

  12. Female patients who are considered as woman of childbearing potential (WOCBP) must use any contraceptive method with a failure rate of less than 1% per year during the treatment as well as up to 6 months after the last dose of study treatment. Male patients who are sexually active with WOCBP must use any contraceptive method with a failure rate of less than 1% per year during the treatment as well as at least 6 months after the last dose of IMP. Female patients who are not of childbearing potential (i.e., who are postmenopausal or surgically sterile) as well as azoospermic male patients do not require contraception

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Exclusion Criteria

  1. Mixed histologies (small-cell and non-small cell or non-squamous and squamous; patients exhibiting the latter expression pattern may be eligible if the non-squamous part predominates)

  2. Patients having received:

    1. Systemic treatment for metastatic or locally advanced disease
    2. prior PD-1/PD-L1 immunotherapies (prior treatment with CD137 agonists or immune checkpoint blockade therapies, including, but not limited to, anti-cytotoxic T lymphocyte associated protein 4 [anti-CTLA-4], anti T cell immunoreceptor with Ig and tyrosine-based inhibition motif domains [anti-TIGIT], anti-PD-1 and anti-PD-L1 therapeutic antibodies)

  3. Symptomatic, neurologically unstable CNS metastases or requiring increasing doses of steroids to manage CNS symptoms within 2 weeks prior to study entry (maximal acceptable dose must be ≤ 10 mg of prednisolone). Patients with asymptomatic, incidentally detected CNS metastases may be enrolled. Palliative radiotherapy for asymptomatic brain metastases (and any other, non-brain metastases, e.g. bone metastases) may be conducted after study entry.

  4. Leptomeningeal disease

  5. History of interstitial lung disease

  6. Severe infection within 2 weeks prior to study entry. Clinical signs must have been resolved to CTCAE grade ≤ 1

  7. Active infection with hepatitis B or C virus (HBV, HCV), human immunodeficiency virus (HIV) or Mycobacterium tuberculosis

  8. Known additional malignancies other than NSCLC, either untreated or having required active treatment within the past 3 years

  9. Significant cardiovascular disease (≥ NYHA 3)

  10. Active or prior documented autoimmune or inflammatory disorders (including but not limited to diverticulitis [with the exception of diverticulosis], celiac disease, systemic lupus erythematosus, Sarcoidosis, or Wegener's syndrome [granulomatosis with polyangiitis], Graves' disease, rheumatoid arthritis, hypophysitis, uveitis). The following are exceptions to this criterion:

    1. Patients with vitiligo or alopecia
    2. Patients with hypothyroidism (e.g., following Hashimoto's disease) stable on hormone replacement
    3. Patients with controlled Type I diabetes mellitus on an insulin regimen
    4. Any chronic skin condition that does not require systemic therapy
    5. Patients without active disease in the last 5 years may be included but only after consultation with the study physician

  11. Current or prior use of immunosuppressive medication within 14 days before the first dose of atezolizumab/pembrolizumab. The following are exceptions to this criterion:

    1. Intranasal, inhaled, topical steroids, or local steroid injections (e.g. intra articular injection)
    2. Systemic corticosteroids at physiologic doses not to exceed 10 mg/day of prednisone or its equivalent
    3. Steroids as premedication for hypersensitivity reactions (e.g. CT scan premedication)

  12. Treatment with systemic immunostimulatory agents (including, but not limited to, interferon and IL-2) within 4 weeks or 5 drug-elimination half-lives (whichever is longer) prior to initiation of study treatment

  13. Live vaccine within 30 days prior to first dose of trial treatment

  14. Known allergy or hypersensitivity to any component of the chemotherapy regimen or to atezolizumab or pembrolizumab or any constituents of the products

  15. Any co-existing medical condition that in the investigator's judgement will substantially increase the risk associated with the patient's participation in the study.

  16. Patient who has been incarcerated or involuntarily institutionalized by court order or by the authorities.

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Study & Design

Study Type
INTERVENTIONAL
Study Design
PARALLEL
Arm && Interventions
GroupInterventionDescription
Pemetrexed-free Immunochemotherapy (Arm A)Nab paclitaxelAtezolizumab 1200 mg q3w, carboplatin AUC 5-6 q3w, nab-paclitaxel 100 mg/m2 qw (administered for 4 cycles with subsequent maintenance with atezolizumab monotherapy 1200 mg q3w until loss of clinical benefit or occurrence of unacceptable toxicity)
Pemetrexed-free Immunochemotherapy (Arm A)AtezolizumabAtezolizumab 1200 mg q3w, carboplatin AUC 5-6 q3w, nab-paclitaxel 100 mg/m2 qw (administered for 4 cycles with subsequent maintenance with atezolizumab monotherapy 1200 mg q3w until loss of clinical benefit or occurrence of unacceptable toxicity)
Pemetrexed-based Immunochemotherapy (Arm B)PembrolizumabPembrolizumab 200 mg q3w, cisplatin 75 mg/m2 q3w OR carboplatin AUC 5-6 (each) q3w, pemetrexed 500 mg/m2 q3w (administered for 4 cycles with subsequent maintenance with pembrolizumab 200 mg AND pemetrexed 500 mg/m2 (each) q3w until loss of clinical benefit or occurrence of unacceptable toxicity)
Pemetrexed-free Immunochemotherapy (Arm A)CarboplatinAtezolizumab 1200 mg q3w, carboplatin AUC 5-6 q3w, nab-paclitaxel 100 mg/m2 qw (administered for 4 cycles with subsequent maintenance with atezolizumab monotherapy 1200 mg q3w until loss of clinical benefit or occurrence of unacceptable toxicity)
Pemetrexed-based Immunochemotherapy (Arm B)PemetrexedPembrolizumab 200 mg q3w, cisplatin 75 mg/m2 q3w OR carboplatin AUC 5-6 (each) q3w, pemetrexed 500 mg/m2 q3w (administered for 4 cycles with subsequent maintenance with pembrolizumab 200 mg AND pemetrexed 500 mg/m2 (each) q3w until loss of clinical benefit or occurrence of unacceptable toxicity)
Pemetrexed-based Immunochemotherapy (Arm B)CisplatinPembrolizumab 200 mg q3w, cisplatin 75 mg/m2 q3w OR carboplatin AUC 5-6 (each) q3w, pemetrexed 500 mg/m2 q3w (administered for 4 cycles with subsequent maintenance with pembrolizumab 200 mg AND pemetrexed 500 mg/m2 (each) q3w until loss of clinical benefit or occurrence of unacceptable toxicity)
Pemetrexed-based Immunochemotherapy (Arm B)CarboplatinPembrolizumab 200 mg q3w, cisplatin 75 mg/m2 q3w OR carboplatin AUC 5-6 (each) q3w, pemetrexed 500 mg/m2 q3w (administered for 4 cycles with subsequent maintenance with pembrolizumab 200 mg AND pemetrexed 500 mg/m2 (each) q3w until loss of clinical benefit or occurrence of unacceptable toxicity)
Primary Outcome Measures
NameTimeMethod
Overall Survival (OS)30 months

time from randomization to the date of death due to any case

Secondary Outcome Measures
NameTimeMethod
Progression-Free Survival (PFS)30 months

time from randomization until progression defined by RECIST v1.1 or death due to any cause

Progression-Free Survival 2 (PFS2)30 months

time from initial study randomization to second disease progression or death from any cause to assess efficacy post-trial-treatment anti-cancer therapy

One-Year Overall Survival Rate30 months

percentage of patients alive at 12 months after randomization

Health-related quality of life 1 (HRQoL)Assessed after randomization at cycle 1 day 1, after completion of cycle 4 (each cycle is 21 days) of the chemoimmunotherapy and at progressive disease (if occurring within the maximum time frame of 30 months)

assessed with the QoL questionnaire QLQ-C30 on general health conditions in lung cancer patients using numeric scales ranging from 1-4. Lower numbers indicate no, higher numbers high agreement.

Objectice Response Rate (ORR)30 months

proportion of subjects with best response of complete or partial response (CR \& PR) according to RECIST v1.1

Time to Next Treatment or Death (TNTD)30 months

time from initial study randomization to the start of next subsequent treatment or death, whichever occurs first

Health-related quality of life 2 (HRQoL)Assessed after randomization at cycle 1 day 1, after completion of cycle 4 (each cycle is 21 days) of the chemoimmunotherapy and at progressive disease (if occurring within the maximum time frame of 30 months)

assessed with the lung cancer symptom-specific QoL questionnaire QLQ-LC13 using numeric scales ranging from 1-4. Lower numbers indicate no, higher numbers high agreement.

Trial Locations

Locations (31)

LungenClinic Großhansdorf GmbH

🇩🇪

Großhansdorf, Germany

Universitätsmedizin Göttingen

🇩🇪

Göttingen, Germany

Asklepios Klinkum Hamburg

🇩🇪

Hamburg, Germany

Thoraxklinik Heidelberg gGmbH

🇩🇪

Heidelberg, Germany

Lungenklinik Hemer

🇩🇪

Hemer, Germany

Helios Klinikum Krefeld

🇩🇪

Krefeld, Germany

Kliniken der Stadt Köln GmbH

🇩🇪

Köln, Germany

ÜBAG- Medizinisches Versorgungszentrum Dr. Vehling-Kaiser GmbH

🇩🇪

Landshut, Germany

Klinikum Lippe GmbH

🇩🇪

Lemgo, Germany

Klinikum St. Marien

🇩🇪

Amberg, Germany

MVZ Taunus GmbH

🇩🇪

Bad Homburg, Germany

Evangelische Lungenklinik Krankenhausbetriebs gGmbH

🇩🇪

Berlin, Germany

Evangelische Lungenklinik

🇩🇪

Berlin, Germany

Charité Universitätsmedizin

🇩🇪

Berlin, Germany

Helios Klinikum Emil von Behring

🇩🇪

Berlin, Germany

Klinikum Bielefeld

🇩🇪

Bielefeld, Germany

Technische Universität Dresden Medizinische Fakultät Carl Gustav Carus

🇩🇪

Dresden, Germany

KEM Evang. Kliniken Essen-Mitte

🇩🇪

Essen, Germany

Klinikum Esslingen GmbH

🇩🇪

Esslingen, Germany

Universitätsklinikum Frankfurt am Main

🇩🇪

Frankfurt am Main, Germany

Krankenhaus Nordwest

🇩🇪

Frankfurt, Germany

Asklepios Klinik Gauting GmbH

🇩🇪

Gauting, Germany

Klinikum Ludwigsburg

🇩🇪

Ludwigsburg, Germany

UKSH, Campus Lübeck

🇩🇪

Lübeck, Germany

Medizinische Fakultät Mannheim der Universität Heidelberg

🇩🇪

Mannheim, Germany

LMU Klinikum

🇩🇪

München, Germany

Unversitätsklinikum Münster

🇩🇪

Münster, Germany

Überörtliche Gemeinschaftspraxis für Hämatologie und Onkologie

🇩🇪

Münster, Germany

Pius Hospital

🇩🇪

Oldenburg, Germany

Barmherzige Brüder Krankenhaus Regensburg

🇩🇪

Regensburg, Germany

Elblandkliniken Stiftung & Co. KG Elblandklinikum Riesa

🇩🇪

Riesa, Germany

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