This study is being carried out to see if a new drug called Apatorsen in combination with standard gemcitabine/carboplatin chemotherapy is effective in treating squamous cell lung cancer.

This study is part of a research project for collecting information about the effectiveness and safety of Apatorsen when used with gemcitabine/carboplatin chemotherapy. The main purpose of this study is to see if Apatorsen, when combined with gemcitabine/carboplatin, is an effective treatment for squamous cell lung cancer.

Recent research has found that a protein called Hsp27 can help cancer cells protect themselves against the effects of cancer treatments. Hsp27 is only found in some lung cancers but when it is present, cancer drugs might not work as well as they would without Hsp27 being present. Blocking the action of Hsp27 or removing Hsp27 from cancer cells with Apatorsen may slow down or stop the cancer growing. This study will therefore look at the relationship between the Hsp27 levels in tumour and blood and the effect of the treatment.

The development of Apatorsen is intended to provide a new treatment option for patients with cancer. Apatorsen may also make the cancer more sensitive to gemcitabine and carboplatin and so make this chemotherapy treatment more effective.

This is an open-label, multicentre, 2-arm randomised phase II trial of gemcitabine/carboplatin + Apatorsen (OGX-427) versus gemcitabine/carboplatin alone in patients with previously untreated advanced squamous cell lung cancers. Patients will be randomised (1:1) to one of the two treatment arms:

• Gemcitabine/carboplatin
• Gemcitabine/carboplatin + Apatorsen (OGX-427)

Randomisation will be stratified by the following criteria:

• Stage (IIIB versus IV versus recurrent disease)
• Performance status (0 or 1 versus 2)

Gemcitabine/carboplatin chemotherapy will be continued for 4-6 cycles unless there is evidence of unacceptable toxicity, disease progression, or if the patient requests that study treatment be discontinued or to be withdrawn from the study. If chemotherapy is discontinued prior to disease progression, patients in the combination arm should be continued on Apatorsen (OGX-427) single agent therapy until disease progression unless there is evidence of unacceptable toxicity, patient withdrawal of consent or termination of the study, whichever occurs first. All patients will be followed for disease progression. Tumour evaluations will be performed before the initiation of treatment and every 6 weeks during and after completion of chemotherapy. Once disease progression is documented, patients will enter a Survival Follow-up Period during which data will be collected every two months regarding further cancer therapy, secondary malignancy and survival status. The study will also assess the relationship between the anticipated anti-tumour activity of the treatment regimen and biological characteristics of patients' tumours at baseline.

Inclusion Criteria:

1. Written informed consent prior to admission to this study

2. Histological or cytological diagnosis of squamous non-small cell lung cancer. Patients with adenosquamous or mixed histology are not eligible for this study.

3. Stage IIIB disease that is unsuitable to radio-chemotherapy or Stage IV disease or recurrent NSCLC; recurrent disease must not be amenable to resection or radical radiotherapy with curative intent.

4. Patients must have:

   • at least one lesion, not previously irradiated, that can be measured accurately at baseline as ≥10 mm in the longest diameter (except lymph nodes which must have short axis ≥15 mm) OR
   • lytic or mixed (lytic + sclerotic) bone lesions in the absence of measurable disease as defined above

5. Willing to donate archival diagnostic tissue for translational research, if available.

6. Haematologic and biochemical indices within the ranges shown below. These measurements must be performed within one week prior to randomisation

   • ANC ≥1.5 x 109/L;, platelet count ≥100 x 109/L,
   • Serum creatinine < 1.5 times the upper limit of normal (ULN)
   • Bilirubin level < 1.5 X ULN
   • AST or ALT <3.0 X ULN or <5 X ULN in the presence of liver metastases

7. ECOG performance status 0-2

8. Non-childbearing potential (i.e., physiologically incapable of becoming pregnant)

9. Male or Female aged ≥18 years

Exclusion Criteria:

1. Symptomatic CNS involvement or CNS involvement requiring steroid therapy; patients with treated brain metastases that are asymptomatic and have been clinically stable for 1 month will be eligible for protocol participation

2. Previous systemic treatment for lung cancer (exception for patients who have previously received immunotherapy without chemotherapy, and for patients with recurrent disease: adjuvant chemotherapy is allowed as long as this was finished at least 1 year prior to enrolment and did not contain gemcitabine)

3. Known tumour EGFR mutation, unless contraindication to EGFR-directed therapy

4. Known tumour ALK rearrangements, unless contraindication to Alk-directed therapy or Alk-directed therapy not available 1

5. Pre-existing sensory or motor polyneuropathy >Grade 2 according to NCI CTCAE

6. Significant cardiovascular disease, such as

   • History of myocardial infarction, acute coronary syndromes (including unstable angina), or history of coronary angioplasty/stenting/bypass grafting within past 6 months.
   • History of symptomatic congestive heart failure (CHF) New York Heart Association (NYHA) Classes III-IV.
   • Severe cardiac arrhythmia requiring medication or severe conduction abnormalities
   • Poorly controlled hypertension (resting diastolic blood pressure >115 mmHg)
   • Clinically significant valvular disease, cardiomegaly, ventricular hypertrophy, or cardiomyopathy

7. Active second malignancy (except non-melanomatous skin cancer): active secondary malignancy is defined as a current need for cancer therapy or a high possibility (>30%) of recurrence during the study.

8. Concurrent treatment with other experimental drugs or participation in another clinical trial with any investigational drug within 30 days prior to study entry.

9. Any other disease, metabolic dysfunction, physical examination finding, or clinical laboratory finding that, in the investigator's opinion, gives reasonable suspicion of a disease or condition that contraindicates the use of an investigational drug, may affect the interpretation of the results, render the patient at high risk from treatment complications or interferes with obtaining informed consent.

10. Psychological, familial, sociological or geographical conditions that do not permit compliance with the study protocol.