Low maintenance.

Top Line: Prior to the era of immune checkpoint inhibitors (ICI), maintenance pemetrexed was the mainstay for advanced non-squamous non-small cell lung cancer (NS-NSCLC) receiving upfront platinum-based chemo.
The Study: The ECOG-ACRIN 5508 was dreamt up in the days of yore (aka the days before ICI was mainstream) so it was interested in teasing out the best maintenance regimen among the tools of 2010. It enrolled over 1500 patients with NS-NSCLC receiving a planned 4 cycles of carbo/Taxol + bevacizumab and randomized them to one of three sequential maintenance therapy arms: [1] pemetrexed, [2] bev, or [3] pemetrexed + bev. The control group among these arms was bevacizumab maintenance, and neither pemetrexed monotherapy or combination bev+pem were able to best it in terms of overall survival. Combination therapy did improve a secondary endpoint of median progression free survival from 4.2 to 7.5 months, however that came at the cost of increased grade 3+ toxicity from 29-37% with monotherapy to 51% with combination therapy. The authors' interpretation is that combo pemetrexed + bev doesn't result in a significant enough improvement to merit a recommendation as a standard maintenance regimen. 
TBL: Combination bevacizumab and pemetrexed maintenance therapy for advanced non-squamous, non-small cell lung cancer does not improve survival over bev monotherapy. | Ramalingam, J Clin Oncol 2019


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