• Quincy Chu, Francesco Perrone, Laurent Greillier, Wei Tu, Maria Carmela Piccirillo, Federica Grosso, Giuseppe Lo Russo, Marie Florescu, Manlio Mencoboni, Alessandro Morabito, Fabiana Letizia Cecere, Giovanni Luca Ceresoli, David E Dawe, Paolo Andrea Zucali, Maria Pagano, John R Goffin, Myriam Locatelli Sanchez, Cesare Gridelli, Gerard Zalcman, Xavier Quantin, Virginie Westeel, Piera Gargiulo, Sara Delfanti, Dongsheng Tu, Christopher W Lee, Natasha Leighl, Joana Sederias, Pamela Brown-Walker, Yiwen Luo, Sylvie Lantuejoul, Ming-Sound Tsao, Arnaud Scherpereel, Penelope Bradbury, Scott A Laurie, and Lesley Seymour.
• Cross Cancer Institute, Edmonton, AB, Canada.
• Lancet. 2023 Dec 16; 402 (10419): 229523062295-2306.

BackgroundPleural mesothelioma usually presents at an advanced, incurable stage. Chemotherapy with platinum-pemetrexed is a standard treatment. We hypothesised that the addition of pembrolizumab to platinum-pemetrexed would improve overall survival in patients with pleural mesothelioma.MethodsWe did this open-label, international, randomised phase 3 trial at 51 hospitals in Canada, Italy, and France. Eligible participants were aged 18 years or older, with previously untreated advanced pleural mesothelioma, with an Eastern Cooperative Oncology Group performance status score of 0 or 1. Patients were randomly assigned (1:1) to intravenous chemotherapy (cisplatin [75 mg/m2] or carboplatin [area under the concentration-time curve 5-6 mg/mL per min] with pemetrexed 500 mg/m2, every 3 weeks for up to 6 cycles), with or without intravenous pembrolizumab 200 mg every 3 weeks (up to 2 years). The primary endpoint was overall survival in all randomly assigned patients; safety was assessed in all randomly assigned patients who received at least one dose of study therapy. This trial is registered with ClinicalTrials.gov, NCT02784171, and is closed to accrual.FindingsBetween Jan 31, 2017, and Sept 4, 2020, 440 patients were enrolled and randomly assigned to chemotherapy alone (n=218) or chemotherapy with pembrolizumab (n=222). 333 (76 %) of patients were male, 347 (79%) were White, and median age was 71 years (IQR 66-75). At final analysis (database lock Dec 15, 2022), with a median follow-up of 16·2 months (IQR 8·3-27·8), overall survival was significantly longer with pembrolizumab (median overall survival 17·3 months [95% CI 14·4-21·3] with pembrolizumab vs 16·1 months [13·1-18·2] with chemotherapy alone, hazard ratio for death 0·79; 95% CI 0·64-0·98, two-sided p=0·0324). 3-year overall survival rate was 25% (95% CI 20-33%) with pembrolizumab and 17% (13-24%) with chemotherapy alone. Adverse events related to study treatment of grade 3 or 4 occurred in 60 (27%) of 222 patients in the pembrolizumab group and 32 (15%) of 211 patients in the chemotherapy alone group. Hospital admissions for serious adverse events related to one or more study drugs were reported in 40 (18%) of 222 patients in the pembrolizumab group and 12 (6%) of 211 patients in the chemotherapy alone group. Grade 5 adverse events related to one or more drugs occurred in two patients on the pembrolizumab group and one patient in the chemotherapy alone group.InterpretationIn patients with advanced pleural mesothelioma, the addition of pembrolizumab to standard platinum-pemetrexed chemotherapy was tolerable and resulted in a significant improvement in overall survival. This regimen is a new treatment option for previously untreated advanced pleural mesothelioma.FundingThe Canadian Cancer Society and Merck & Co.Copyright © 2023 Elsevier Ltd. All rights reserved.

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