Maintenance therapy in advanced non-small cell lung cancer. Egbert F. Smit MD PhD Dept Thoracic Oncology Netherlands Cancer Institute

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1 Maintenance therapy in advanced non-small cell lung cancer. Egbert F. Smit MD PhD Dept Thoracic Oncology Netherlands Cancer Institute

2 Evolution of front line therapy in NSCLC unselected pts 1970 s 1980 s: Treatment until progression 1990 s: Treatment limited to 6 8 courses 2000 s: 3 4 courses of platinum-based therapy. Provided 2nd-line therapy is considered 2010: 4 6 courses of platinum-based therapy + maintenance

3 Strategies for post Platinum therapy

4 Switch Maintenance Concepts of Maintenance 1st-line: Platin-based Combination CR, PR, SD Maintenance Monotherapy with new compound Progression Second Line Treatment JMEN (Pemetrexed) 1 SATURN (Erlotinib) 2 4 cycles until Progression Continuation bis Maintenance Progress 1st-line: Pemetrexed/Cisplatin Pemetrexed/Cisplatin/Bev CR, PR, SD Maintenance Pemetrexed or Pemetrexed/Bev 4 cycles until Progression Progression Second Line Treatment PARAMOUNT 3 AVAPERL 4 Selection of patients with good prognosis Endpoints: Quality of Life Symptom Control Tolerability

5 Gemcitabine vs placebo in NSCLC Primary endpoint: 1. Time to progression Secondary endpoints: 1. ORR 2. Response duration 3. Overall survival 4. Toxicity 5. Symptom control Brodowicz et al. Lung Cancer 52,155,2006

6 Gemcitabine vs Placebo in NSCLC Progression free survival through study period (left) and maintenance phase (right) Brodowicz et al. Lung Cancer 52,155,2006

7 Gemcitabine vs placebo in NSCLC BSC Gem-BSC P-value TTP, overall 5.0 ( ) 6.6 ( ) <0.001 TTP, maintenance 2.0 ( ) 3.6 ( ) <0.001 OS 11 ( ) 13 ( ) Brodowicz et al. Lung Cancer 52,155,2006.

8 Immediate vs delayed docetaxel (Phase III) Fidias, et al. ASCO 2007; Abstract No. LBA7516

9 Probability of PFS Docetaxel Switch Maintenance: PFS HR=0.71 (95% CI: ) p< Delayed Immediate Mos Patients at Risk, n Delayed Immediate Median PFS delayed vs immediate: 2.7 vs 5.7 mos (P =.0001) 48 Fidias PM, et al. J Clin Oncol. 2009;27:

10 Probability of OS Docetaxel Switch Maintenance: OS Delayed Immediate HR=0.84 (95% CI: ) p< Mos Patients at Risk, n Delayed Immediate Median OS delayed vs immediate: 9.7 vs 12.3 mos (P =.0853) 1-yr survival delayed vs immediate: 43.5% vs 51.1% 60 Fidias PM, et al. J Clin Oncol. 2009;27:

11 Pem/BSC vs placebo/bsc in NSCLC: Study design Stage IIIB/IV NSCLC PS 0/1 4 prior cycles of gem, doc, or tax + cis or carb, with CR, PR, or SD (NO PEMETREXED) Randomization factors: gender PS stage best tumor response to induction non-platinum induction drug brain mets 2:1 Randomization Pemetrexed 500 mg/m 2 (d1,q21d) + BSC (N=441)* Primary Endpoint = PFS Placebo (d1, q21d) + BSC (N=222)* *B 12, folate, and dexamethasone given in both arms Ciuleanu, et al. Presented at: Annual Meeting of the American Society of Clinical Oncology, June 2, 2008; Chicago, IL.

12 Progression-free Probability Pem/BSC vs placebo/bsc in NSCLC: Progression-free survival 1.0 N=581 HR=0.599 (95% CI: ) p < Pemetrexed: 4.04 mos (95% CI: ) Placebo: 1.97 mos (95% CI: ) Time (months) 24% censored Ciuleanu, et al. Presented at: Annual Meeting of the American Society of Clinical Oncology, June 2, 2008; Chicago, IL.

13 Maintenance pemetrexed (JMEN): PFS (n=581) OS (n=663) Cielanu et al., Lancet 2010

14 Switch Maintenance: Pemetrexed Response after induction therapy Non squamous NSCLC Induction response CR/PR 0,81 HR Induction response SD 0,61 0,4 0,6 0,8 1,0 HR 1,2 Favours pemetrexed Favours Placebo Belani CP, et al. ASCO 2009 (Abs. CRA8000).

15 Second Line Pemetrexed after Maintenance Gemcitabine or Erlotinib. IFCT-GFPC 0502 Perol et al. Proc ESMO 2010

16 IFCT-GFPC 0502: Treatment Outcomes Outcome Gemcitabine (n = 149) Erlotinib (n = 153) Observation (n = 152) Median PFS, mos HR vs observation (95% CI) 0.55 ( ) 0.82 ( ) P value < Median OS*, mos HR vs observation (95% CI) 0.86 ( ) 0.91 ( ) P value NS NS Perol M, et al. ASCO Abstract 7507.

17 IFCT-GFPC 0502: Treatment Outcomes Perol M. Poster presented at ESMO 2010: PD370

18 IFCT-GFPC 0502: OS Pérol M et al. JCO 2012;30:

19 Switch Maintenance Concepts of Maintenance 1st-line: Platin-based Combination CR, PR, SD Maintenance Monotherapy with new compound Progression Second Line Treatment JMEN (Pemetrexed) 1 SATURN (Erlotinib) 2 4 cykles until Progression Continuation bis Maintenance Progress 1st-line: Pemetrexed/Cisplatin Pemetrexed/Cisplatin/Bev CR, PR, SD Maintenance Pemetrexed or Pemetrexed/Bev 4 cykles until Progression Progression Second Line Treatment PARAMOUNT 3 AVAPERL 4 Selection of patients with good prognosis Endpoints: Quality of Life Symptom Control Tolerability

20 Pemetrexed Continuation-Maintenance (PARAMOUNT) Start of trial medication Induction treatment (4 cycles) days Maintenance treatment (until PD) Progression Inclusion criteria Non-squamous NSCLC Stage IIIB/IV Chemonaïve ECOG PS 0-1 (n=939) Stratification: PS (0 vs. 1) Stage (IIIB vs. IV) before induction Response after induction (CR/PR vs. SD) Pemetrexed 500 mg/m 2 iv q21d Cisplatin 75 mg/m 2 iv q21d CR, PR, SD n=539 PD R 2:1 Pemetrexed 500 mg/m 2 iv q21d n=359 Supplementation with Folic acid and Vitamin B12 in both arms Placebo n=180 Primary endpoint: Progression free survival PS, propensity score; CR, complete response: vollständiges Ansprechen; PR, partial response: teilweises Paz-Ares L, et al. Lancet Oncol 2012; 13:247-55; Ansprechen; SD, stable disease: Krankheitsstabilisierung; Paz-Ares L, et al. J Clin Oncol 2013; 31: ; ClinicalTrials.gov Identifier NCT PD, progressive disease: progressiver Krankheitsverlauf

21 Survival Probability PARAMOUNT: Progression free survival PFS: Primary Efficacy Endpoint PFS: Reassessed at Time of Final OS Survival Probability Pemetrexed Placebo Unadjusted HR: 0.62 ( ) Time (Months) Patients at Risk Pem + BSC Plac+ BSC Patients at Risk Pemetrexed Placebo Unadjusted HR: 0.60 ( ) Time (Months) Pem +BSC Plac + BSC Paz-Ares LG, et al. Lancet Oncology 2012; 13: Paz-Ares LG, et al. J Clin Oncol 2013: 31:

22 Paramount: Overall survival Paz Ares, L. et al J Clin Oncol 2013; 31:

23 Probability of survival Probability of survival All randomized patients (n=539) Stage IV (n=490) Stage IIIB (n=49) Response after induction CR/PR (n=234) Response after Induction SD (n=285) PS 1 before randomisation (n=363) PS 0 before randomisation (n=173) Neversmoker (n=117) smoker (n=418) male (n=313) female (n=226) age <70 (n=447) ager 70 (n=92) age <65 (n=350) age 65 (n=189) Other histology (n=32) Large cell histology (n=36) adenocarcinoma (n=471) PARAMOUNT: OS; Subgroup analysis 0,0 0,5 1,0 1,5 2,0 2,5 Hazard Ratio (95% KI) Favours Pemetrexed Favours Placebo Hazard Ratio 0,78 0,79 0,82 0,81 0,76 0,82 0,70 0,75 0,83 0,82 0,73 0,75 0,89 0,82 0,71 0,81 0,44 0,80 Pemetrexed Placebo CR/PR HR = 0, SD HR = 0, Time since start of maintenance (monthers) CR, complete response: vollständiges Ansprechen; PR, partial response: teilweises Ansprechen; SD, stable disease: Krankheitsstabilisierung; PS, propensity score Paz-Ares L, et al. J Clin Oncol 2012; 30(Suppl):LBA7507

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25 Efficacy: PFS & OS Trial N Maintenance drug Switch Maintenance PFS HR (95% CI) OS HR (95% CI) Westeel et al. 181 Vinorelbine 0.77 ( ) 1.08 ( ) Fidias et al. 309 Docetaxel 0.71 ( ) 0.84 ( ) Capuzzo 889 Erlotinib 0.71 ( ) 0.81 ( ) Ciuleanu et al. 663 Pemetrexed 0.60 ( ) 0.79 ( ) Continuation Maintenance Paz-Ares et al 539 Pemetrexed 0.62 ( ) NA Brodowicz et al. 206 Gemcitabine 0.69 ( ) 0.84 ( ) Belani et al. 255 Gemcitabine 1.09 ( ) 0.97 ( ) Perol et al. 309 Gemcitabine 0.56 ( ) 0.89 ( )

26 Efficacy: QOL Trial N Maintenance drug Switch Chemotherapy Maintenance Westeel et al. 181 Vinorelbine NR Fidias et al. 309 Docetaxel No differences QoL & Symptom Control Capuzzo 889 Erlotinib Better pain control Cielanu et al. 663 Pemetrexed Better pain and hemoptisis control Continuation Chemotherapy Maintenance Paz-Ares et al 539 Pemetrexed No detrimental effect Brodowicz et al. 206 Gemcitabine NR Belani et al. 255 Gemcitabine NR Perol et al. 309 Gemcitabine NR

27 Antibody maintenance E4599: study design Previously untreated stage IIIB, IV or recurrent predominantly nonsquamous NSCLC (n=878) CP q3w x6 (n=444) Bevacizumab (15mg/kg) + CP q3w x6 (n=434) Bevacizumab PD* PD Primary endpoint overall survival (OS) Secondary endpoints objective response rate progression-free survival (PFS) duration of response safety *No crossover permitted Sandler, et al. N Engl J Med 2006

28 OS estimate E Bev + CP CP CP (n=444) Bevacizumab 15mg/kg + CP (n=434) 0.6 HR (95% CI) 0.79 ( ) p value Median OS (months) Time (months) CP=carboplatin/paclitaxel Sandler, et al. N Engl J Med 2006

29 Pemetrexed or Bevacizumab maintenance? Key patient inclusion criteria No prior systemic treatment ECOG PS 0-1 Stable IIIB-IV nonsquamous NSCLC Stable treated brain mets (n=361) R Induction phase 4 cycles, q3w Pem 500 mg/m 2 + Cb AUC6 (n=182) Stratification PS (0 vs. 1); sex (M vs. F); disease stage (M1a vs. M1b) Pac 200 mg/m 2 + Cb AUC6 + Bev 15 mg/kg (n=179*) Maintenance treatment q3w Pem 500 mg/m 2 (n=98) Bev 15 mg/kg (n=95) PD PD Primary endpoint PFS without Grade 4 AE (G4PFS) Secondary endpoints PFS, OS, RR, DCR Safety and tolerability Zinner et al. J Clin Oncol 31, 2013 (suppl; abstr LBA8003)

30 Proportion Primary Endpoint: G4PFS (ITT) Pem+Cb: Pac+Cb+Bev: median G4PFS = 3.9 mo median G4PFS = 2.9 mo Log-rank p value = HR (90% CI) = 0.85 ( ) Number of G4PFS events Pem+Cb (n=152) % Pac+Cb+Bev (n=144) % G4 AE PD Death Patients at Risk Pem+Cb Pac+Cb+Bev Zinner et al. J Clin Oncol 31, 2013 (suppl; abstr LBA8003)

31 Maintenance with Bevacizumab ± Start of induction treatment Pemetrexed (AVAPERL): Randomised, open phase III trial Progression Induction therapy (4 cycles) Maintenance therapy until PD) Inclusion criteria: Non-squamous NSCLC Stage IIIb/IV No prior treatment n=414 Stratification: gender smoker vs never smoker CR/PR vs. SD Pemetrexed 500 mg/m 2 iv q21d Cisplatin 75 mg/m 2 iv q21d Bevacizumab 7,5 mg/kg iv q21d n=376 CR, PR, SD n=253 PD R Bevacizumab 7,5 mg/kg iv q21d n=125 Pemetrexed 500 mg/m 2 iv q21d Bevacizumab 7,5 mg/kg iv q21d n=128 Primary Endpoint: Progression free survival Barlesi F, et al. J Clin Oncol 2013, e-published ClinicalTrials.gov Identifier NCT

32 Progressionsfreies Überleben ab dem Tag der Randomisierung (%) AVAPERL: PFS from randomisation Therapx PFS (Months) Bev + Pem 7,4 (81 Events) Bev 3,7 (104 Events) HR 0,48 (0,35 0,66); p<0,001 Maintenance Bev+Pem (n=128) Maintenance Bev (n=125) 25 0 Patients at risk Time (months) Bev + Pem Bev Barlesi F, et al. J Clin Oncol 2013, e-published

33 AVAPERL: Overall survival Barlesi et al. Ann. Oncol. 2014

34 POINTBREAK phase III trial 4 cycles Previously untreated, stage IIIB or IV, non-squamous NSCLC, treated CNS mets, PS 0 1 n=939 R 1:1 n=442* Bevacizumab 15 mg/kg q3w n=292 + carboplatin + pemetrexed (66%) n=443* Bevacizumab 15 mg/kg q3w + carboplatin + paclitaxel n=298 (67%) Bevacizumab 15 mg/kg q3w + pemetrexed Bevacizumab 15 mg/kg q3w Treat to PD Treat to PD Primary endpoint OS PI: J Patel *Patient numbers excluding those not treated Secondary endpoints ORR and DCR PFS and TTP safety and QoL Patel, et al. IASLC 2012 (Chicago)

35 OS estimate POINTBREAK: OS (primary endpoint) ITT population Pem + Carbo + Bev Pac + Carbo + Bev HR=1.00 ( ) p= Time (months) Patel, et al. IASLC 2012 (Chicago)

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38 SQUIRE: Study Design Population NECI + Gem-Cis q3w (N=545) CR PR SD NECI q3w PD First-Line Stage IV squamous NSCLC ECOG PS 0-2 R Maximum of 6 cycles Gem-Cis q3w (N=548) PD PD Primary Objective: Overall survival Secondary Objectives: PFS, ORR, safety, QoL Exploratory Objective: EGFR protein expression (IHC, DAKO PharmDx)

39 OS (%) SQUIRE: G/C + Neci vs G/C in Stage IV 1093 pts First-line stage IV SqCLC ECOG PS R SqCLC G/C (1250 mg/m 2 ;75 mg/m 2 ) + Neci 800 mg d 1,8 (n = 545) Maximum of 6 cycles G/C (n = 548) CR PR SD PD Neci PD PD G/C + Neci G/C Stratified HR (95% CI) 0.84 ( ) Stratified P value (log-rank).01 Median OS, mos (95% CI) 11.5 ( ) 9.9 ( ) Mos Thatcher N, et al. Lancet Oncol. 2015;16:

40 Evolution of front line therapy in NSCLC selected pts : molecular selected patients continue treatment until progression: EGFR Alk ROS1 B-RAF

41 Maintenance in Lung Cancer Oncogene Addicted Erlotinib in EGFR m+ NSCLC EURTAC Trial Simulation- EURTAC Trial 4 months treatment X Rosell R et al., Lancet Oncol 2012

42 Evolution of front line therapy in NSCLC selected pts : molecular selected patients continue treatment until progression 2016: PD-L1 positive (>50%) continue pembrolizumab

43 KEYNOTE-024 Study Design (NCT ) Key Eligibility Criteria Untreated stage IV NSCLC PD-L1 TPS 50% ECOG PS 0-1 No activating EGFR mutation or ALK translocation No untreated brain metastases No active autoimmune disease requiring systemic therapy R (1:1) N = 305 Pembrolizumab 200 mg IV Q3W (2 years) Platinum-Doublet Chemotherapy (4-6 cycles) Key End Points Primary: PFS (RECIST v1.1 per blinded, independent central review) Secondary: OS, ORR, safety Exploratory: DOR

44 Progression-Free Survival Events, n Median, mo HR (95% CI) P PFS, % No. at risk Minority received pemetrexed maintenance Assessed per RECIST v1.1 by blinded, independent central review. Data cut-off: May 9, % 50% Pembro Chemo ( ) Time, months 48% 15% <0.001

45 Overall Survival Events, n Median, mo HR (95% CI) P OS, % % 72% No. at risk Pembro 44 NR 0.60 Chemo 64 NR ( ) Time, months 70% 54% Data cut-off: May 9, 2016.

46 Evolution of front line therapy in NSCLC mutation status unknown Platin based chemotherapy Maintenance?

47 Continuation Gefitinib when EGFR mut status is unknown Yang et al. J.Thor. Oncol. 2015

48 Continuation Gefitinib when EGFR mut status is unknown Yang et al. J.Thor. Oncol. 2015

49 Guidelines Maintenance therapy recommended by ESMO ASCO

50 Conclusions Both switch and continuation maintenance chemotherapy prolong PFS and OS Antibody maintenance prolong PFS and OS (?) Small molecule offered untill PD.