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Maintenance therapy with pemetrexed plus best supportive care versus placebo plus best supportive care after induction therapy with pemetrexed plus cisplatin for advanced non-squamous non-small-cell lung cancer (PARAMOUNT): a double-blind, phase 3, randomised controlled trial

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Paz-Ares, Luis, de Marinis, Filippo, Dediu, Mircea, Thomas, Michael, Pujol, Jean-Louis, Bidoli, Paolo, Molinier, Olivier, Sahoo, Tarini Prasad +9 more·2012·The Lancet Oncology
DOI 10.1016/s1470-2045(12)70063-3
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Abstract

Background Patients with advanced non-squamous non-small-cell lung cancer (NSCLC) benefit from pemetrexed maintenance therapy after induction therapy with a platinum-containing, non-pemetrexed doublet. The PARAMOUNT trial investigated whether continuation maintenance with pemetrexed improved progression-free survival after induction therapy with pemetrexed plus cisplatin.Methods In this double-blind, multicentre, phase 3, randomised placebo-controlled trial, patients with advanced non-squamous NSCLC aged 18 years or older, with no previous systemic chemotherapy for lung cancer, with at least one measurable lesion, and an Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1 participated. Before randomisation, patients entered an induction phase which consisted of four cycles of induction pemetrexed (500 mg/m(2)) plus cisplatin (75 mg/m(2)) on day 1 of a 21-day cycle. Patients who did not progress after completion of four cycles of induction and who had an ECOG performance status of 0 or 1 were stratified according to disease stage (IIIB or IV), ECOG performance status (0 or 1), and induction response (complete or partial response, or stable disease), and randomly assigned (2:1 ratio) to receive maintenance therapy with either pemetrexed (500 mg/m(2) every 21 days) plus best supportive care or placebo plus best supportive care until disease progression. Randomisation was done with the Pocock and Simon minimisation method. Patients and investigators were masked to treatment assignment. The primary endpoint was progression-free survival in the intention-to-treat population. This study is registered with ClinicalTrials.gov, NCT00789373.Findings Of the 1022 patients enrolled, 939 participated in the induction phase. Of these, 539 patients were randomly assigned to receive continuation maintenance with pemetrexed plus best supportive care (n=359) or with placebo plus best supportive care (n=180). Among the 359 patients randomised to continuation maintenance with pemetrexed, there was a significant reduction in the risk of disease progression over the placebo group (HR 0·62, 95% CI 0·49-0·79; p<0·0001). The median progression-free survival, measured from randomisation, was 4·1 months (95% CI 3·2-4·6) for pemetrexed and 2·8 months (2·6-3·1) for placebo. Possibly treatment-related laboratory grade 3-4 adverse events were more common in the pemetrexed group (33 [9%] of 359 patients) than in the placebo group (one [<1%] of 180 patients; p<0·0001), as were non-laboratory grade 3-5 adverse events (32 [9%] of 359 patients in the pemetrexed group; eight [4%] of 180 patients in the placebo group; p=0·080); one possibly treatment-related death was reported in each group. The most common adverse events of grade 3-4 in the pemetrexed group were anaemia (16 [4%] of 359 patients), neutropenia (13 [4%]), and fatigue (15 [4%]). In the placebo group, these adverse events were less common: anaemia (one [<1%] of 180 patients), neutropenia (none), and fatigue (one <1%]). The most frequent serious adverse events were anaemia (eight [2%] of 359 patients in the pemetrexed group vs none in the placebo group) and febrile neutropenia (five [1%] vs none). Discontinuations due to drug-related adverse events occurred in 19 (5%) patients in the pemetrexed group and six (3%) patients in the placebo group.Interpretation Continuation maintenance with pemetrexed is an effective and well tolerated treatment option for patients with advanced non-squamous NSCLC with good performance status who have not progressed after induction therapy with pemetrexed plus cisplatin.Funding Eli Lilly and Company.

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  • In a prior study, maintenance pemetrexed after four cycles of cisplatin-pemetrexed improved median progression-free survival over placebo by only 1.3 months (4.1 vs 2.8 months) from the start of maintenance.

    “However, in a study of patients without disease progression after four cycles of cisplatin-pemetrexed, maintenance pemetrexed therapy improved median progression-free survival over placebo by only 1.3 months (4.1 months vs. 2.8 months) from the start of maintenance therapy.31”

    From First-Line Crizotinib versus Chemotherapy in <i>ALK</i> -Positive Lung Cancer (2014) · cites this paper as [31]

  • A large phase III randomised trial found that continuation pemetrexed after four induction cycles of cisplatin plus pemetrexed improves PFS and OS in PS 0-1 patients, confirmed at long-term follow-up.

    “A large phase III randomised trial of continuation maintenance with pemetrexed versus placebo after four induction cycles of cisplatin plus pemetrexed chemotherapy demonstrated a PFS and OS improvement in patients with a PS 0-1, confirmed at longterm follow-up [80,81].”

    From Metastatic non-small-cell lung cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up (2016) · cites this paper as [81]

  • In that trial, median OS was 13.9 months with pemetrexed versus 11.0 months with placebo; 1- and 2-year survival rates were 58% and 32% with pemetrexed versus 45% and 21% with placebo.

    “Median OS was 13.9 months (95% CI: 12.8-16.0months) pemetrexed and 11.0 months (95% CI: 10.0-12.5 months) placebo, with 1-and 2-year survival rates significantly longer for patients given pemetrexed (58% and 32%, respectively) than for those given placebo (45% and 21%).”

    From Metastatic non-small-cell lung cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up (2016) · cites this paper as [81]

  • In the PARAMOUNT trial, OS was 2.9 months longer with pemetrexed maintenance (13.9 v 11 months; unadjusted HR P = .019).

    “OS was 2.9 months longer (13.9 v 11 months; unadjusted HR P = .019).”

    From Systemic Therapy for Stage IV Non–Small-Cell Lung Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update (2015) · cites this paper as [8]

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Authors
Paz-Ares, L., de Marinis, F., Dediu, M., Thomas, M., Pujol, J.-L., Bidoli, P., Molinier, O., Sahoo, T. P., Laack, E., Reck, M., Corral, J., Melemed, S., John, W., Chouaki, N., Zimmermann, A. H., Visseren-Grul, C., & Gridelli, C.
Affiliations
  • Instituto de Biomedicina de Sevilla (ES)
  • Institutul Oncologic Bucuresti (RO)
  • Heidelberg University (DE)
  • Centre Hospitalier Universitaire de Montpellier (FR)
  • Azienda Ospedaliera San Gerardo (IT)
  • Centre Hospitalier du Mans (FR)
  • Jawaharlal Nehru Cancer Hospital and Research Centre (IN)
  • University Medical Center Hamburg-Eppendorf (DE)
  • LungenClinic Grosshansdorf (DE)
  • Eli Lilly (United States) (US)
  • Azienda Ospedaliera S.Giuseppe Moscati (IT)
Corresponding author
Paz-Ares, Luis
ORCID
Venue
The Lancet Oncology
Publisher
Elsevier BV
Published
2012-03
Volume
13
Issue
3
Pages
247-255
ISSN
1470-2045 (ISSN-L)
DOI
10.1016/s1470-2045(12)70063-3
OpenAlex
W2005244154
Cited by
610
References
33
Citations by year
2026: 9 · 2025: 9 · 2024: 18 · 2023: 15 · 2022: 23 · 2021: 37 · 2020: 38 · 2019: 40 · 2018: 47 · 2017: 63 · 2016: 44 · 2015: 72 · 2014: 67 · 2013: 80 · 2012: 46
FWCI
68.37
Type
journal article
Language
en
Open access
Licence
Locations
  • The Lancet Oncology (publishedVersion)
  • PubMed (publishedVersion)
  • BOA (University of Milano-Bicocca) (submittedVersion, cc-by-nc-nd)
Funders
Eli Lilly and Company
Topics
  • Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Lung Cancer Treatments and Mutations
  • Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Lung Cancer Diagnosis and Treatment
  • Health Sciences › Medicine › Oncology › Lung Cancer Research Studies
Keywords
maintenance therapy, non-squamous non-small cell lung cancer, cisplatin, induction chemotherapy, progression-free survival, best supportive care, disease progression, platinum-based doublets, first-line therapy, ECOG performance status, neutropenia, febrile neutropenia
MeSH terms
Pemetrexed, Adult, Aged, Aged, 80 and over, Antineoplastic Combined Chemotherapy Protocols, Carcinoma, Non-Small-Cell Lung, Cisplatin, Double-Blind Method, Drug Administration Schedule, Europe, Female, Glutamates, Guanine, Humans, Lung Neoplasms, Male, Middle Aged, Neoplasm Staging, Placebos, Time Factors, Proportional Hazards Models, Treatment Outcome, Disease-Free Survival, Kaplan-Meier Estimate

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