A Randomized Prospective Trial of Adjuvant Chemotherapy in Patients with Completely Resected Stage I or IIA Non-Squamous Non-Small Cell Lung Cancer Identified as High or Intermediate Risk by a 14-Gene Prognostic Assay

Prior treatment

• Evidence of incomplete resection, including positive resection margins, additional suspect nodules.
• Any pre-operative systemic chemotherapy or treatment with an anti-cancer agent within 5 years prior to study enrollment.
• Radiotherapy to the chest in the immediate pre- or post-operative period.
• Malignancies other than the current NSCLC within 5 years prior to randomization, except for adequately treated carcinoma in situ of the cervix, non-melanoma cell skin cancer, localized prostate cancer treated locally with curative intent, ductal carcinoma in situ treated surgically with curative intent.
• Treatment with any investigational drug or participation in another clinical trial within 28 days prior to enrollment.

Other illness

• Known hypersensitivity to any of the study treatment agents.
• Evidence of any other disease including infection (see above) such as neurologic or metabolic dysfunction or physical examination finding giving reasonable suspicion of a disease or condition that contraindicates the use of systemic cytotoxic chemotherapy or puts the patient at high risk for treatment related complications.
• Wound dehiscence or infection.
• Evidence of greater than stage I or IIA pathologic staging per the 8th edition of the TNM staging system, including loco-regional regional (hilar) or mediastinal lymph node involvement or nodal enlargement that has not been biopsied, or of distant metastatic disease (lesions that have been biopsy-proven or that are suspicious on brain MRI and/or PET scan).
• Active infection, either systemic or at site of primary resection

Other

• Final pathologic diagnosis on resected specimen is pure squamous cell, pure small cell or pure neuroendocrine histology, or any combination of only these three histologies.
• Patient who is subject to legal protection or who is unable to express his will (only for patient enrolled in France).
• Pregnant or lactating women

• Subjects must have signed and dated an IRB/IEC approved written informed consent form in accordance with regulatory and institutional guidelines. This must be obtained before the performance of any protocol related procedures that are not part of normal subject care.
• Men who agree to meet one of the following criteria from the first administration of chemotherapy, during the treatment and for a period of 6 months following the last administration of study chemotherapy: - Correct use of two reliable contraception methods with female partners. This include every combination of a hormonal implant, transdermal hormonal patch, hormonal vaginal device, hormonal injection or of an intrauterine device or system (IUD/IUS) with a barrier method (condom or occlusive cap), - True abstinence (periodic abstinence and withdrawal are not acceptable methods of contraception), - Sexual relationship only with male partners and/or sterile female partners.
• Patient should be covered by a national health insurance (only for patient enrolled in France).
• Age ≥ 18 years
• Able to comply with the protocol, including acceptable candidacy for adjuvant chemotherapy according to local institutional standards and likely compliance with follow-up for anticipated length of study (i.e. 5 years from the initiation of enrollment).
• Willing to be randomized to chemotherapy.
• Histologically documented completely resected (R0) Stage I or IIA non-squamous NSCLC per 8th edition, TNM staging system (See Appendix A). Mixed histologies that include a squamous cell or small cell or neuroendocrine component are eligible for the study, as long as they contain at least some component that is neither squamous cell, nor small cell nor neuroendocrine. Eligible resections include segmentectomy, lobectomy, bi-lobectomy, sleeve lobectomy, and pneumonectomy. Resections via wedge resection will not be eligible. Complete resection must also be accompanied by mediastinal lymph node sampling via mediastinoscopy, bronchoscopic sampling (e.g., endobronchial ultrasound guided biopsy) or surgical sampling. Nodes must be sampled from at least one of the following nodal stations: levels 2, 4, 7, 8, 9 for a right-sided cancer and levels 2, 4, 5, 6, 7, 8, 9 for left-sided cancers.
• Adequate tissue sample available for the 14-Gene Prognostic Assay (paraffin block with tumor occupying at least 25% of the tissue surface area).
• Life expectancy excluding NSCLC diagnosis ≥ 5 years
• ECOG performance status 0-1
• Women of childbearing potential: - who are practicing true abstinence from sexual intercourse (periodic abstinence and withdrawal are not acceptable), - who have sexual relationships with female partners only and/or with sterile male partners, or women of childbearing potential and sexually active with fertile male partner must have a negative pregnancy test during screening and agree to use reliable methods of contraception from the time of screening, during the study and for a period of 6 months following the last administration of study medication. The following methods of contraception are acceptable: Correct use of two reliable contraception methods. This includes every combination of a hormonal implant, transdermal hormonal patch, hormonal vaginal device, hormonal injection or of an intrauterine device or system (IUD/IUS) with a barrier method (condom or occlusive cap), women without childbearing potential defined as follows: at least 6 weeks after surgical sterilization by bilateral tubal ligation or bilateral oophorectomy, hysterectomy or uterine agenesis, ≥ 50 years and in postmenopausal state > 1 year, or < 50 years and in postmenopausal state > 1 year with serum FSH > 40 IU/l and serum estrogen < 30 ng/l or a negative estrogen test, both at screening.