Pemetrexed Disodium, Gemcitabine, and Bevacizumab in Treating Patients With Stage IIIB or Stage IV Non-Small Cell Lung Cancer

• Histologic or cytologic proof of non-squamous non-small cell lung cancer (NSCLC) (adenocarcinoma, bronchioloalveolar, large cell carcinoma).
• Must have Stage IV or IIIB NSCLC. Patients with Stage IIIB must have a pleural effusion or not be candidates for treatment for locally advanced disease with chemoradiotherapy.
• Cannot have a tumor with cavitation..
• Have uni-dimensional measurable or evaluable disease. If disease is within a previous radiation port there must be documented progression.
• 18 years of age and have a life expectancy of greater than 12 weeks.
• Must not have had prior chemotherapy for advanced disease.
• Must have an ECOG performance status of 0-1.
• With treated brain metastases are eligble. for details.
• Adequate organ function:

Absolute neutrophil count of > 1.5 x 109/L Platelet count > 100,000/109/L Hemoglobin > 8g/dl Calculated creatinine clearance > 45mL/min using the standard Cockroft and Gault formula Hepatic: bilirubin \< 1.5 times the upper limit of normal,alkaline phosphatase, aspartate transaminase (AST) and alanine transaminase (ALT) \< 3 times upper limit of normal. Alkaline phosphatase, AST, ALT \< 5 times upper limit of normal is acceptable if liver has tumor involvement. Urine protein:creatinine ratio ≤1.0 at screening

• Patients of reproductive potential must use an approved contraceptive method during and for 3 months after study.
• Must sign an informed consent that details the investigational nature of the study according to the institutional and federal guidelines.
• Registered with the clinical trials office of the institution.

Exclusion Criteria

• Current, recent (within 4 weeks of the first infusion of this study), or planned participation in an experimental drug study other than a Genentech-sponsored bevacizumab cancer study
• Prior chemotherapy except for erlotinib for advanced disease.
• Uncontrolled hypertension (Blood pressure of >150/100 mmHg )
• Unstable angina
• New York Heart Association (NYHA) Grade II or greater congestive heart failure (see Appendix E)
• History of myocardial infarction within 6 months prior to day 1
• History of hemorrhagic or thrombotic stroke or other CNS bleed within 6 months prior to day 1
• Clinically significant peripheral vascular disease of 61
• Evidence of bleeding diathesis or coagulopathy. Patients must not require full dose anticoagulants for any reason.
• Known CNS disease, except for treated brain metastasis Treated brain metastases are defined as having no evidence of progression or hemorrhage after treatment and no ongoing requirement for dexamethasone, as ascertained by clinical examination and brain imaging (MRI or CT) during the screening period.
• Major surgical procedure, open biopsy, or significant traumatic injury within 28 days prior to Day 0, anticipation of need for major surgical procedure during the course of the study
• Minor surgical procedures such as fine needle aspirations or core biopsies within 7 days prior to Day 0
• Urine protein:creatinine ratio > or = 1.0 at screening
• History of abdominal fistula, gastrointestinal perforation, or intraabdominal abscess within 6 months prior to Day 0
• Serious, non-healing wound, ulcer, or bone fracture
• Evidence of cavitation in the tumor.
• Intrathoracic lung carcinoma of squamous cell histology Mixed tumors will be categorized by the predominant cell type unless small cell elements are present, in which case the patient is ineligible; sputum cytology alone is unacceptable.
• Extrathoracic-only squamous cell NSCLC are eligible. Patients with only peripheral lung lesions (of any NSCLC histology) will also be eligible.
• History of hemoptysis (bright red blood of 1/2 teaspoon or more within 28 days of registration or clinical history of > Grade 2
• Clinically significant effusions that cannot be drained
• Inability to comply with study and/or follow-up procedures
• Previous or concurrent malignancies with the exception of adequately treated squamous cell or basal cell carcinoma of the skin, in situ carcinoma of the cervix, or any other malignancy treated and in clinical remission for more than 3 years.
• Prior radiation therapy to the target lesion, unless the lesion is clearly progressing and the interval between the most recent radiation therapy and enrollment is at least 4 weeks.
• Pregnancy or lactating females. All pre-menopausal women should have a negative urine pregnancy test prior to enrollment. All patients of reproductive potential should agree to use an effective contraceptive method.
• Serious concomitant systemic disorders (including oncologic emergencies) incompatible with the study (at the discretion of the investigator).
• Inability to interrupt non-steroidal anti-inflammatory agents 2 days before, the day of, and 2 days after the dose of pemetrexed.
• Disease which cannot be radiologically imaged.
• Inability to take dexamethasone, folic acid or vitamin B12 administration.