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V. Hirsh



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    Best of Posters - IASLC Selection - Part 2 (ID 263)

    • Event: WCLC 2013
    • Type: Exhibit Showcase Session
    • Track:
    • Presentations: 1
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      P2.11-024 - Efficacy Analysis for Molecular Subgroups in MARQUEE: a Randomized, Double-blind, Placebo-controlled, Phase 3 Trial of Tivantinib (ARQ 197) Plus Erlotinib versus Placebo plus Erlotinib in Previously Treated Patients with Locally Advanced or Metastatic, Non-squamous, Non- small Cell Lung Cancer (NSCLC) (ID 2909)

      10:00 - 10:05  |  Author(s): V. Hirsh

      • Abstract
      • Slides

      Background
      MARQUEE, a Phase 3 study which investigated the role of tivantinib, a c-MET inhibitor, in previously treated non-squamous NSCLC, collected EGFR and KRAS genotype on >90% of randomized patients, and MET expression was determined for 42%. In the ITT population, addition of tivantinib to erlotinib significantly improved PFS and ORR but did not show benefit in OS. Additional efficacy analyses in the pre-defined molecular subgroups are presented.

      Methods
      Patients with locally advanced or metastatic non-squamous, EGFR inhibitor naive NSCLC previously treated with 1 or 2 lines of systemic therapy, including a platinum-doublet, were stratified by number of prior therapies, sex, smoking history, and EGFR and KRAS mutation status, then randomized to oral tivantinib (360 mg twice daily) + erlotinib (150 mg once daily) or placebo + erlotinib until disease progression. Primary endpoint was OS with one interim analysis for futility/superiority. MET was assessed centrally by IHC using CONFIRM (SP44) antibody. Based upon a stability study, tumor tissue must have been sectioned within 90 days prior to MET immunostaining to be considered reliable. MET High was pre-specified as ≥50% of tumor cells staining with 2+ or 3+ intensity.

      Results
      From 1/2011 to 7/2012, 1048 patients were randomized to tivantinib + erlotinib (TE, n=526) or placebo + erlotinib (PE, n=522). Baseline characteristics were median age = 62 years (range, 24-89), prior therapies = 1 (66%) or 2 (34%), ECOG performance status = 0 (32%) or 1 (68%), EGFR mutant (10.4%), and KRAS mutant (27.1%). In 9/2012, the data monitoring committee recommended trial discontinuation because the pre-planned interim analysis of OS crossed the futility boundary. At the 12/2012 data cutoff, median OS was 8.5 months and 7.8 months for TE and PE, respectively (hazard ratio [HR] = 0.98; 95% CI, 0.84-1.15; p = 0.81). Median PFS was 3.6 months and 1.9 months, respectively (HR = 0.74; 95% CI, 0.62-0.89; p < 0.0001). Overall response rate (ORR) improved to 10.3% for TE compared with 6.5% for PE (p < 0.05). MET expression was obtained for 445 patients. In the pre-specified, MET High subgroup (n = 211), median OS improved to 9.3 months for TE vs 5.9 months for PE (HR = 0.70; 95% CI, 0.49-1.01; p = 0.03). In the MET Low subgroup (n = 234), median OS was 8.5 months for TE and 7.7 months for PE (HR=.90, 95% CI, 0.64-1.26, p=.53). OS did not differ between treatments in KRAS wildtype (n=702), KRAS mutant (n=284), and EGFR wildtype (n=937) subgroups; OS was immature for the EGFR mutant (n=109) subgroup at the cut-off time. Consistent with ITT, PFS was increased with TE vs PE across all molecular subgroups. Common adverse events (TE vs PE, respectively) included rash (33.1% vs 37.3%), diarrhea (34.6% vs 41.0%), and asthenia/fatigue (43.5% vs 38.1%), which occurred at similar rates between treatments; neutropenia (Grade 3/4: 10.0% vs 1.0%) was more common with TE.

      Conclusion
      Tivantinib significantly improved PFS and OS in the prospectively defined MET High subgroup. Further investigation of tivantinib in MET High selected, non-squamous NSCLC is warranted.

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    MO07 - NSCLC - Targeted Therapies II (ID 114)

    • Event: WCLC 2013
    • Type: Mini Oral Abstract Session
    • Track: Medical Oncology
    • Presentations: 1
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      MO07.13 - Efficacy of afatinib vs. chemotherapy in treatment-naïve patients with non-small cell lung cancer (NSCLC) harbouring activating EGFR mutations with or without metastatic brain disease (ID 1923)

      17:25 - 17:30  |  Author(s): V. Hirsh

      • Abstract
      • Presentation
      • Slides

      Background
      Afatinib, an irreversible ErbB Family Blocker, was superior to pemetrexed/cisplatin in previously untreated patients with epidermal growth factor receptor (EGFR) mutation-positive non-small cell lung cancer (NSCLC) in a global Phase III trial, LUX-Lung 3. In patients with the two most common EGFR mutations (Del19, L858R) median progression-free survival (PFS) was 13.6 vs. 6.9 months (HR=0.47, 95% CI: 0.34–0.65; p<0.0001). Here we present the results for subgroups of patients with or without brain metastases (BM) with NSCLC harbouring common EGFR mutations.

      Methods
      In LUX-Lung 3 EGFR mutation-positive patients were randomized 2:1 to afatinib 40 mg daily or up to 6 cycles of pemetrexed/cisplatin at standard doses. Patients with stable BM (asymptomatic, stable >4 weeks with no treatment required) were allowed. Presence of BM was documented by the investigator during screening. Tumour assessments were performed every 6 weeks until 48 weeks and every 12 weeks thereafter until progression, and reviewed independently and by the investigator.

      Results
      308 patients with common EGFR mutations were randomized (afatinib: 204, pemetrexed/cisplatin: 104), including 35 with baseline BM (afatinib: 20, pemetrexed/cisplatin: 15). Of these, Del19 mutation was detected in 11 (afatinib) and 8 (pemetrexed/cisplatin) patients and L858R in 9 (afatinib) and 7 (pemetrexed/cisplatin) patients. The baseline characteristics of patients with or without BM were comparable (females: 74% vs. 66%, median age: 61 vs. 62 years, ECOG 0: 31% vs. 41%, median time since diagnosis: 1.2 vs. 1.1 months, respectively). Within the BM group, baseline characteristics were balanced between treatment arms with the exception of ECOG 1; 80% of afatinib-treated patients had ECOG 1 compared with 53% of those treated with pemetrexed/cisplatin. Median PFS by independent review was 13.7 (afatinib) vs. 8.1 (pemetrexed/cisplatin) months in patients without BM (HR=0.47, 95% CI: 0.33–0.68; p<0.0001), and 11.1 (afatinib) vs. 5.4 (pemetrexed/cisplatin) months in patients with BM (HR=0.52, 95% CI: 0.22–1.23; p=0.13). Objective response in patients without BM was 59% (afatinib) vs. 23% (pemetrexed/cisplatin), odds ratio=4.8, p<0.0001, and 70% (afatinib) vs. 20% (pemetrexed/cisplatin), odds ratio=11.0, p=0.007, in patients with BM. Investigator review showed a median PFS of 13.6 (afatinib) vs. 6.9 (pemetrexed/cisplatin) months in patients without BM (HR=0.38, 95% CI: 0.27–0.53; p<0.0001), and 6.7 (afatinib) vs. 5.4 (pemetrexed/cisplatin) months in those with BM (HR=0.67, 95% CI: 0.29–1.57; p=0.36). By investigator review, progressive disease in the brain was observed for 4.2% (7/167) and 3.7% (3/82) of patients without BM at baseline for afatinib and pemetrexed/cisplatin, respectively. All but one of these patients (on afatinib) had intracranial progression only. The median (range) time to progression in the brain in this small group was 11.6 (1.3, 20.2) months (afatinib) and 5.5 (2.6, 8.2) months (pemetrexed/cisplatin).

      Conclusion
      In patients with previously untreated NSCLC harbouring common EGFR mutations afatinib remains efficacious regardless of the presence or absence of BM. Control of synchronous asymptomatic BM with afatinib compares favourably with existing data for cranial radiation therapy.

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    O03 - NSCLC - Targeted Therapies I (ID 113)

    • Event: WCLC 2013
    • Type: Oral Abstract Session
    • Track: Medical Oncology
    • Presentations: 1
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      O03.01 - GALAXY-1: Randomized phase II study of docetaxel with or without ganetespib in advanced lung adenocarcinoma: Results in biomarker sub-groups and all adenocarcinoma patients. (ID 1715)

      10:30 - 10:40  |  Author(s): V. Hirsh

      • Abstract
      • Presentation
      • Slides

      Background
      Ganetespib (G) is a highly potent 2[nd]-generation Hsp90 inhibitor showing synergistic activity with docetaxel (D) in NSCLC xenografts. G has a favorable clinical safety profile and has shown single-agent clinical activity in NSCLC patients with tumors harboring EML4-ALK translocations and KRAS mutations (mKRAS).

      Methods
      We conducted a randomized, international open-label Phase 2 study of D with or without G in patients with advanced lung adenocarcinoma, one prior systemic therapy, and ECOG PS 0/1. D was given at 75 mg/m[2] on Day 1 of a three-week cycle in both arms. In the combination arm, G was given at 150 mg/m[2] on Days 1 and 15. The co-primary endpoints were PFS in patients with elevated LDH (eLDH) levels, or tumors harboring KRAS mutation. Key secondary endpoints were OS and PFS in all adenocarcinoma patients. Target enrollment was 240 adenocarcinoma patients, including 120 eLDH and 80 mKRAS patients. The study was initiated in all NSCLC patients and amended to include only those with adenocarcinoma histology.

      Results
      Enrollment of 252 adenocarcinoma patients completed in November 2012; enrollment of eLDH (total N=112) and mKRAS (total N= 86) patients completed in May 2013. In all adenocarcinoma patients (N=252), baseline characteristics were balanced between the two arms (median age 60 years, males 56%, PS 0 41% and never-smokers 25%). Median numbers of cycles delivered were 6 and 4 for D+G and D, respectively. Grade 3/4 adverse events for the D+G and D alone arms were: neutropenia 37% vs. 38%; fatigue 6% vs. 3%; anemia 8% vs. 2%; diarrhea 3% vs. 0; fever with neutropenia 11% vs. 2%. A pre-specified analysis was conducted in May 2013. PFS HR for eLDH population (N=76) was 0.88 (90% CI: 0.57, 1.36, p=0.310); OS HR was 0.63 (90% CI: 0.40, 0.99, p=0.046). PFS HR for mKRAS population (N=63) was 0.83 (90% CI: 0.51, 1.37, p=0.271); and OS HR was 0.85 (90% CI: 0.48, 1.50, p=0.313). OS HR in the all adenocarcinoma population was 0.82 (90% CI: 0.62, 1.09, p=0.082), and the PFS HR was 0.84 (90% CI: 0.65, 1.07, p=0.038). For patients that were enrolled >6 months after diagnosis of advanced NSCLC (N=176), a pre-specified stratification factor, the OS HR was 0.61 (90% CI: 0.43, 0.87, p=0.0093), and the PFS HR was 0.61 (90% CI: 0.45, 0.83, p=0.0041). Final data analysis is expected by end of September 2013. Updated PFS and OS results for all populations will be presented at the meeting.

      Conclusion
      Survival improvement was noted in all adenocarcinoma patients with the addition of ganetespib to docetaxel. The maximal benefit was achieved in patients with eLDH and those diagnosed with advanced NSCLC >6 months prior to study entry.

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    O16 - NSCLC - Targeted Therapies III (ID 115)

    • Event: WCLC 2013
    • Type: Oral Abstract Session
    • Track: Medical Oncology
    • Presentations: 1
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      O16.05 - Efficacy, safety, and patient-reported outcomes (PROs) with crizotinib versus chemotherapy in Asian patients in a phase III study of previously treated advanced <em>ALK</em>-positive non-small cell lung cancer (NSCLC) (ID 2818)

      11:15 - 11:25  |  Author(s): V. Hirsh

      • Abstract
      • Presentation
      • Slides

      Background
      Crizotinib is a potent selective ATP-competitive ALK inhibitor demonstrating a high ORR in patients with advanced ALK-positive NSCLC. The main objective of the present post hoc analyses was to compare the impact of crizotinib on efficacy, safety, and PROs with that of standard second-line chemotherapy in a subgroup of patients of Asian ethnicity from the ongoing phase III study PROFILE 1007.

      Methods
      Patients with stage IIIB/IV ALK-positive NSCLC who had received one prior platinum-based regimen were randomized to open-label crizotinib (250 mg PO BID) or chemotherapy (pemetrexed 500 mg/m[2] or docetaxel 75 mg/m[2], IV q3w). In these subgroup analyses, PFS and ORR based on independent radiologic review, OS, safety, and PROs were evaluated. PROs were assessed at baseline, on day 1 of each cycle, and at end of treatment using the validated cancer-specific questionnaire EORTC QLQ-C30 and its LC module QLQ-LC13. Time to deterioration (TTD) was defined as the time from randomization to the earliest time with a ≥10-point increase from baseline (worsening) in pain in chest, dyspnea, or cough. Repeated measures mixed-effects analyses were performed to compare change from baseline scores between the treatment arms.

      Results
      Of 347 patients randomized, 45% were of Asian ethnicity (crizotinib, n=79; chemotherapy, n=78 [pemetrexed, 50; docetaxel, 27; no treatment, 1]). At data cutoff (March 2012), 52 Asian patients (crizotinib, 41; chemotherapy, 11) were continuing on treatment. PFS was significantly longer with crizotinib than with chemotherapy (median 8.1 vs. 2.8 months; HR, 0.53; P=0003). The ORR on crizotinib (75%) was significantly higher than on chemotherapy (22%; P<0.0001). In an interim analysis, median OS had not yet been reached in the crizotinib arm and was 22.8 months in the chemotherapy arm (HR, 0.89; P=0.347, noting that in the overall study population, only 40% of planned events had occurred and 64% of patients in the chemotherapy arm subsequently received crizotinib in another study). The most common all-causality AEs with crizotinib were diarrhea (70%), vision disorder (68%), and nausea (66%) and with chemotherapy were decreased appetite (40%), nausea (39%), and fatigue (35%). Crizotinib treatment was associated with a significantly longer TTD in LC symptoms compared with chemotherapy (median 4.2 vs. 1.6 months; HR, 0.66; 95% CI, 0.44−0.98; P=0.037). A significantly greater improvement from baseline was observed with crizotinib for global QOL (P<0.05), cough (P<0.001), dyspnea (P<0.001), pain in arm or shoulder (P<0.001), pain in chest (P<0.001), pain in other parts (P<0.05), fatigue (P<0.05), insomnia (P<0.05), and pain (P<0.001). A significantly greater improvement was observed with crizotinib compared with chemotherapy for emotional functioning (P<0.05), physical functioning (P<0.05), hair loss (P<0.001), and sore mouth (P<0.05). A significantly greater deterioration was observed in the crizotinib arm for constipation (P<0.05) and diarrhea (P<0.001) compared with chemotherapy.

      Conclusion
      Consistent with previously reported results in the overall study population, crizotinib treatment showed significantly greater improvement in PFS, ORR, patient-reported LC symptoms, and global QOL compared with chemotherapy in a subgroup of patients of Asian ethnicity with previously treated advanced ALK-positive NSCLC, confirming the utility of crizotinib in this patient population.

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    P1.10 - Poster Session 1 - Chemotherapy (ID 204)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Medical Oncology
    • Presentations: 1
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      P1.10-044 - nab-Paclitaxel in combination with carboplatin as first-line therapy in diabetic patients with advanced non-small cell lung cancer (NSCLC) (ID 2446)

      09:30 - 09:30  |  Author(s): V. Hirsh

      • Abstract

      Background
      Diabetes and other age-related comorbidities frequently occur together in patients with NSCLC and may affect treatment efficacy and tolerability. Several studies demonstrated that diabetic patients have worse outcomes than those without diabetes. Additionally, studies have suggested that metformin may enhance the effects of chemotherapy, leading to improved outcomes. In a phase III trial, nab-paclitaxel (nab-P, 130 nm albumin-bound paclitaxel particles) + carboplatin (C) significantly improved the primary endpoint of overall response rate (ORR) from 25% to 33% (P = 0.005), with a trend toward improved overall survival (OS) and progression-free survival (PFS) vs solvent-based paclitaxel (sb-P) + C in patients with advanced NSCLC. This exploratory analysis examined efficacy and safety outcomes in diabetic patients with advanced NSCLC.

      Methods
      Patients with untreated stage IIIB/IV NSCLC were randomized 1:1 to nab-P 100 mg/m[2] on d 1, 8, 15 or sb-P 200 mg/m[2] d 1 q21d; both arms received C AUC 6 d 1 q21d. ORR and PFS were determined by blinded, centralized review. P values for ORR were based on chi-square test, and those for OS and PFS were based on log-rank test. Multiple sensitivity analyses were performed to confirm treatment differences and to rule out confounding effects from other baseline covariates.

      Results
      31 patients in the nab-P/C and 30 patients in the sb-P/C arms were included in this analysis. Similar to the intent-to-treat (ITT) population, most diabetic patients were male (75%), white (62%), with ECOG PS 1 (79%), and stage IV disease (85%). In these patients, ORR for nab-P/C vs sb-P/C was 52% vs 27% (response rate ratio 1.935; P = 0.046), median PFS was 10.9 vs 4.9 months (HR 0.416; P = 0.016), and median OS was 17.5 vs 11.1 months (HR 0.553; P = 0.057). Treatment difference in PFS remained significant (P ≤ 0.026) after adjusting for baseline characteristics (including histology, region, stage, and age). For OS, region, stage, race, and age were not observed to be confounding factors on treatment effect. Metformin was concomitantly used in 29% and 37% of diabetic patients in the nab-P/C vs sb-P/C arms, respectively. The percentage of patients experiencing ≥ 1 adverse event (AE) was similar between the diabetic and ITT populations. Among diabetic patients, the most common grade 3/4 AEs in the nab-P/C vs sb-P/C arms were neutropenia (53% vs 55%), anemia (23% vs 10%), peripheral neuropathy (PN, 7% vs 23%), thrombocytopenia (20% vs 7%), and fatigue (7% vs 10%); differences were not statistically significant. Safety findings were similar to those observed in the ITT population; however, the incidence of grade 3/4 PN was slightly higher for both arms in the diabetic population compared with the ITT population (for nab-P/C vs sb-P/C, 3% vs 12%; P < 0.001).

      Conclusion
      In this analysis, nab-P/C demonstrated improved efficacy and was well tolerated in diabetic patients with advanced NSCLC. These findings warrant further study in a larger diabetic patient population. The relationship between the efficacy of nab-P and glucose level/metformin use also merits additional study.

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    P2.10 - Poster Session 2 - Chemotherapy (ID 207)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Medical Oncology
    • Presentations: 1
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      P2.10-038 - nab-Paclitaxel in combination with carboplatin as first-line therapy in patients with advanced non-small cell lung cancer (NSCLC): analysis of predictive factors (ID 2462)

      09:30 - 09:30  |  Author(s): V. Hirsh

      • Abstract

      Background
      Identification of predictive factors is critical for appropriate selection of patients and chemotherapy regimen. In a phase III trial, nab-paclitaxel (nab-P, 130 nm albumin-bound paclitaxel particles) + carboplatin (C) vs solvent-based paclitaxel (sb-P) + C significantly improved ORR (primary endpoint; 33% vs 25%, P = 0.005), with a trend toward improved OS and PFS in patients with advanced NSCLC. nab-P/C vs sb-P/C was associated with less severe peripheral neuropathy, arthralgia, and myalgia, but more anemia and thrombocytopenia. This exploratory analysis examined the correlation between several key patient and clinical factors and clinical outcomes with nab-P/C vs sb-P/C.

      Methods
      Patients with untreated stage IIIB/IV NSCLC were randomized 1:1 to nab-P 100 mg/m[2] on d 1, 8, 15 or sb-P 200 mg/m[2] d 1 q21d; both arms received C AUC 6 d 1 q21d. ORR and PFS were assessed by blinded, centralized review. P values for ORR were based on chi-square test, and those for OS and PFS were based on log-rank test. Factors, including sex, age (< 70 and ≥ 70 y), histology (squamous and nonsquamous), stage (IIIB/IV), and geographic region (North America, Eastern Europe, and Asia/Pacific), baseline ECOG score, smoking status, diabetes, body mass index, number and location of metastatic sites, were analyzed for association with outcomes; of these, the first 5 were prespecified stratification factors for the trial.

      Results
      The hazard ratio (HR)/risk ratio favored nab-P/C for ORR, PFS, and OS for most factors analyzed. Significant quantitative treatment-by-predictive factor interactions were noted for several key factors, including number of metastatic sites, diabetes, histology, and age, with respect to outcomes, and the comparative treatment effect was maintained in all other subgroups. In patients with ≥ 4 metastatic sites, significant treatment differences favoring nab-P/C were noted for ORR (response rate ratio [RRR] 3.40; P = 0.003) and OS (HR 0.562; P = 0.009) and trended in favor of nab-P/C for PFS (HR 0.735; P = NS). In patients with diabetes, significant treatment differences favoring nab-P/C were noted for ORR (RRR 1.935; P = 0.046) and PFS (HR 0.416; P = 0.016) and trended in favor of nab-P/C for OS (HR 0.553; P = NS). In patients with squamous NSCLC, significant treatment differences favoring nab-P/C were noted for ORR (RRR 1.68; P < 0.001) and trended in favor of nab-P/C for OS (HR 0.890; P = NS). In patients ≥ 70 y, significant treatment differences favoring nab-P/C were noted for OS (HR 0.583; P = 0.009) and trended in favor of nab-P/C for ORR (RRR 1.385; P = 0.196) and PFS (HR 0.687; P = NS). No treatment differences significantly favoring sb-P/C were observed.

      Conclusion
      A trend toward improved outcomes was noted with nab-P/C vs sb-P/C in most factors analyzed. Squamous NSCLC, diabetes, age ≥ 70 y, and ≥ 4 metastatic sites were predictive of improved outcomes with nab-P/C vs sb-P/C. These predictive factors should be taken into consideration when selecting the appropriate treatment for patients with advanced NSCLC.

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    P3.11 - Poster Session 3 - NSCLC Novel Therapies (ID 211)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Medical Oncology
    • Presentations: 1
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      P3.11-027 - A randomised, open-label phase II trial of volasertib as monotherapy and in combination with standard dose pemetrexed compared with pemetrexed monotherapy in second-line non-small cell lung cancer (NSCLC) (ID 2307)

      09:30 - 09:30  |  Author(s): V. Hirsh

      • Abstract

      Background
      Polo-like kinases (Plks) are overexpressed in many cancers including NSCLC. Volasertib (BI 6727; an investigational drug) is a selective and potent Plk inhibitor, which induces mitotic arrest and apoptosis. This 3-arm trial compared the efficacy, safety and pharmacokinetics of volasertib monotherapy, volasertib combined with pemetrexed and single-agent pemetrexed as second-line therapy in patients with advanced/metastatic NSCLC (NCT00824408).

      Methods
      An initial run-in phase was conducted to determine the tolerability and dose of volasertib combined with pemetrexed 500mg/m[2]. Subsequent patients were randomised to one of three arms: (A) volasertib 300mg, (B) volasertib 300mg plus pemetrexed 500mg/m[2], or (C) pemetrexed 500mg/m[2]. Both drugs were administered on Day 1 every 21 days. Eligible patients had advanced/metastatic NSCLC, ECOG PS 0–2, adequate organ function and prior platinum-based chemotherapy. The primary endpoint was progression-free survival (PFS) evaluated using a stratified one-sided log-rank test (Arms B versus C); an exploratory analysis was performed for Arms A versus C. Secondary endpoints included objective response rate (ORR), overall survival (OS), safety and pharmacokinetics.

      Results
      Twelve patients were included in the run-in phase; the volasertib dose selected for the randomised phase was 300mg. 131 patients were then randomised to the three arms (A: n=37, B: n=47, C: n=47). Arm A recruitment was stopped early due to an increased rate of early progression. Demographic data were balanced between the arms. One patient per arm did not receive treatment. The median number (range) of treatment cycles in Arms A, B and C was 2 (1–49), 4 (1–36) and 5.5 (1–38), respectively. Median PFS (Arms A/B/C) was 1.4/3.3/5.3 months (HR B versus C =1.141 [95% CI: 0.735–1.771; p=0.2804]; HR A versus C =2.045 [95% CI: 1.271–3.292; two-sided p=0.0030]). ORR (Arms A/B/C) was 8%/21%/9%; no complete responses were observed. Disease control rates (Arms A/B/C) were 27%/66%/68%. Median OS (Arms A/B/C) was 22.9/17.1/17.4 months. Median relative dose intensity was 100% for both volasertib and pemetrexed in all arms with a range of 80.6–111.1% in Arm A and 83.3–100.0% in Arm B for volasertib, and 87.5–100% in Arm B and 81.3–100% in Arm C for pemetrexed. The most common all-grade adverse events (AEs) were (Arms A/B/C): fatigue (56%/74%/70%), nausea (14%/48%/54%), decreased appetite (8%/44%/41%), constipation (17%/37%/22%), dyspnoea (17%/28%/30%) and vomiting (19%/33%/24%). Most common grade 3/4 AEs (>5%) were (Arms A/B/C): fatigue (8%/13%/17%), neutropenia (14%/11%/4%) and dyspnoea (3%/9% /13%). Grade 3/4 febrile neutropenia was seen in 2 (4%) patients in Arm B and 1 (2%) patient in Arm C. One fatal AE of septic shock (Arm B) was considered drug-related; 22%/22%/26% of patients experienced a serious AE. Pharmacokinetic analysis of volasertib in Arms A and B, together with historical pharmacokinetic data for pemetrexed, did not reveal any evidence of pharmacokinetic interactions between volasertib and pemetrexed.

      Conclusion
      Volasertib and pemetrexed could be combined at full single-agent doses, with generally acceptable toxicities, and demonstrated modest antitumour activity. However, the addition of volasertib did not improve PFS compared to single-agent pemetrexed in patients with relapsed or refractory NSCLC after platinum-based first-line therapy.