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Background  We determined the clinical characteristics and predictive factors of long‐term response to pemetrexed maintenance therapy as first‐line treatment for non‐small cell lung cancer (NSCLC).    Methods  A total of 950 advanced NSCLC patients received pemetrexed (500 mg/m 2 ) plus cisplatin (60 mg/m 2 ) (Pem‐Cis) induction chemotherapy every three weeks as first‐line treatment between January 2010 and August 2018. Patients who did not show progression after four cycles of Pem‐Cis and received at least one cycle of pemetrexed maintenance were recruited ( n  = 199).    Results  Patients were divided into subgroups according to total cycles of pemetrexed: ≤ 10 (F10,  n  = 134) and > 10 (M10,  n  = 65). The M10 group had a higher proportion of patients with stage M1a (intrathoracic metastasis alone) and exhibited lower levels of thymidylate synthase (TS) than the F10 group (median H‐score 10.0% vs. 60.0%;  P  = 0.031). Further subgrouping identified extreme responders: ≤ 7 (F7,  n  = 101) and ≥ 20 (M20,  n  = 26) cycles. The M20 group showed lower mean serum CEA levels before (17.5 vs. 147.0;  P  = 0.099) and after (6.9 vs. 53.2;  P  = 0.001) Pem‐Cis treatment, and a higher incidence of normalization after Pem‐Cis (abnormal 41.7% vs. 68.5%;  P  = 0.015). M1a stage, normalization of CEA levels after Pem‐Cis, and lower TS H‐score were predictors of progression‐free survival in patients administered pemetrexed maintenance.    Conclusion  M1a stage and lower TS expression were predictors of long‐term response to pemetrexed maintenance. CEA normalization after Pem‐Cis could be an additional surrogate marker of positive response to long‐term treatment.

Predictive factors for long‐term responders of pemetrexed maintenance treatment in non‐small cell lung cancer