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

Study Overview
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Brief Summary
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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
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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.

Official Title
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Atezolizumab/Carboplatin/Nab-Paclitaxel vs. Pembrolizumab/Platinum/Pemetrexed in Metastatic TTF-1 Negative Lung Adenocarcinoma

Conditions
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Non-Small Cell Lung Cancer Metastatic

Intervention / Treatment
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* Drug: Atezolizumab
* Drug: Nab paclitaxel
* Drug: Carboplatin
* Drug: Pembrolizumab
* Drug: Cisplatin
* Drug: Carboplatin
* Drug: Pemetrexed


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Patient has provided written informed consent Patient* 18 years or older at time of signing the informed consent form Histologically or cytologically confirmed metastatic stage IV non-squamous NSCLC Negative local testing for TTF-1 Negative molecular testing for EGFR mutations and ALK rearrangements (tested locally) PD-L1 tumor proportion score (TPS) < 50%, tested locally by QUiP®-certified immunohistochemistry ECOG performance status ≤ 1 Measurable lesions according to RECIST v1.1 Life expectancy ≥ 12 weeks Adequate hepatic, renal and bone marrow function Hemoglobin ≥ 8.0 g/dL Absolute neutrophil count ≥ 1.5 x 109/L Platelets ≥ 100 x 109/L Calculated creatine clearance ≥ 50 mL/min as determined by the Cockcroft-Gault equation and/or creatinin ≤ 1,5x upper limit of normal (ULN) Serum bilirubin ≤ 1.5 x institutional ULN AST/ ALT and alkaline phosphatase ≤ 2.5 x ULN 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 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. 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 Exclusion Criteria: 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) Patients having received: Systemic treatment for metastatic or locally advanced disease 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) Symptomatic, neurologically unstable central nervous system (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) Leptomeningeal disease History of interstitial lung disease Severe infection within 2 weeks prior to study entry. Clinical signs must have been resolved to CTCAE grade ≤ 1 Active infection with hepatitis B or C virus (HBV, HCV), human immunodeficiency virus (HIV) or Mycobacterium tuberculosis Known additional malignancies other than NSCLC, either untreated or having required active treatment within the past 3 years Significant cardiovascular disease (≥ NYHA 3) 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: Patients with vitiligo or alopecia Patients with hypothyroidism (e.g., following Hashimoto's disease) stable on hormone replacement Patients with controlled Type I diabetes mellitus on an insulin regimen Any chronic skin condition that does not require systemic therapy Patients without active disease in the last 5 years may be included but only after consultation with the study physician Current or prior use of immunosuppressive medication within 14 days before the first dose of atezolizumab/pembrolizumab. The following are exceptions to this criterion: Intranasal, inhaled, topical steroids, or local steroid injections (e.g. intra articular injection) Systemic corticosteroids at physiologic doses not to exceed 10 mg/day of prednisone or its equivalent Steroids as premedication for hypersensitivity reactions (e.g. CT scan premedication) 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 Live vaccine within 30 days prior to first dose of trial treatment Known allergy or hypersensitivity to any component of the chemotherapy regimen or to atezolizumab or pembrolizumab or any constituents of the products 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. Patient who has been incarcerated or involuntarily institutionalized by court order or by the authorities.

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Pemetrexed-free Immunochemotherapy (Arm A)<br>Atezolizumab 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) | Drug: Atezolizumab<br>* 1200 mg i.v. q3w<br>* Other names: Tecentriq;Drug: Nab paclitaxel<br>* 100 mg/m² i.v. qw<br>* Other names: Abraxane;Drug: Carboplatin<br>* AUC 5-6 i.v. q3w<br>|
| Active Comparator: Pemetrexed-based Immunochemotherapy (Arm B)<br>Pembrolizumab 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) | Drug: Pembrolizumab<br>* 200 mg i.v. q3w<br>* Other names: Keytruda;Drug: Cisplatin<br>* 75 mg/m² i.v. q3w<br>Drug: Carboplatin<br>* AUC 5-6 i.v. q3w<br>Drug: Pemetrexed<br>* 500 mg/m² i.v. q3w<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Overall Survival (OS) | time from randomization to the date of death due to any case | 30 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Objectice Response Rate (ORR) | proportion of subjects with best response of complete or partial response (CR & PR) according to RECIST v1.1 | 30 months | 
| Progression-Free Survival (PFS) | time from randomization until progression defined by RECIST v1.1 or death due to any cause | 30 months | 
| One-Year Overall Survival Rate | percentage of patients alive at 12 months after randomization | 30 months | 
| Time to Next Treatment or Death (TNTD) | time from initial study randomization to the start of next subsequent treatment or death, whichever occurs first | 30 months | 
| Progression-Free Survival 2 (PFS2) | time from initial study randomization to second disease progression or death from any cause to assess efficacy post-trial-treatment anti-cancer therapy | 30 months | 
| Health-related quality of life 1 (HRQoL) | 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. | 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) | 
| Health-related quality of life 2 (HRQoL) | 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. | 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) | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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NSCLC, checkpoint inhibitors, immunochemotherapy