Relationship of driver oncogenes to long term pemetrexed response in non-small cell lung cancer

BACKGROUND: Pemetrexed is approved in the treatment of advanced stage non-squamous non-small-cell lung cancer (NSCLC). The length of response is variable, and we thus sought to identify which clinicopathologic characteristics are associated with long term disease control with pemetrexed. METHODS: Patients with metastatic NSCLC were identified who received pemetrexed (with or without bevacizumab) for 12 months or longer, either as maintenance treatment after first-line platinum-based chemotherapy or as subsequent treatment. Clinical and pathological characteristics were collected. RESULTS: Of a total of 196 patients who received pemetrexed starting in 2007, 25 patients were identified who received pemetrexed for over one year. Of these, 15 patients received pemetrexed with or without bevacizumab as maintenance treatment and 10 patients received pemetrexed as subsequent treatment. Fifteen of the 25 patients (60%) had an oncogenic driver mutation as follows: five (20%) had ROS1 gene rearrangements, four (16%) had ALK gene rearrangements, three (12%) had KRAS mutations, two (8%) had epidermal growth factor receptor (EGFR) mutations, and one (4%) had an NRAS mutation. The median overall survival (OS) was 42.2 months (95% confidence interval [CI]: 37.4–61.3) and median progression free survival (PFS) was 22.1 months (95% CI: 15.1–29.1). Patients with an oncogenic driver mutation had significantly better PFS (p=0.006) and OS (p=0.001). CONCLUSIONS: Among patients with NSCLC who received pemetrexed for an extended time, those with ALK and ROS1 gene rearrangements are proportionally overrepresented compared with that anticipated in a general non-squamous NSCLC population, and patients with oncogenic driver mutations had improved outcomes.