A Trial of Androgen Deprivation, Docetaxel, and Enzalutamide for Metastatic Prostate Cancer

This is a single center, single arm, phase II trial designed to evaluate the 12 month PSA complete response rate in patients with metastatic hormone sensitive prostate cancer treated with ADT, docetaxel and enzalutamide. The primary endpoint of this study will be 12-month PSA complete response rate, which will be assessed against a contemporary historical control rate for the combination of ADT and docetaxel alone in the metastatic hormone naive setting. The study will be conducted at all participating sites across North and South Carolina within the Levine Cancer Institute network. Enrollment is anticipated to be completed within 24 months.

• ADT+Docetaxel+Enzalutamide (Drug), also known as Taxotere, Xtandi: combination therapy as listed above

Primary outcomes

• 52-week PSA Complete Response (CR) Rate [52 weeks]: The 52-week PSA CR rate was defined as the proportion of participants achieving PSA complete response (CR) at 52-weeks (+/- 1 week) from date of enrollment (i.e., initiation of both enzalutamide and docetaxel) of all evaluable participants. PSA CR was defined as PSA level less than 0.2 ng/ml for two consecutive measurements at least three weeks apart (date of initial PSA level 0.2 ng/ml was acknowledged as date of response). In subjects with missed PSA assessments at 52 (+/- 1) weeks, (a) if a confirmed CR was achieved and at least one PSA assessment occurred beyond the 52-week window showed serologic complete response (providing the subject did not earlier experience confirmed progressive disease), the subject achieved 52-week PSA Complete Response and (b) if confirmed CR was achieved before the 52-week window and the first assessment after the 52-week window was not a CR, the subject did not achieve a 52-week PSA Complete Response.

Secondary outcomes

• Serologic Response Rate [Duration of study participation, an average of 2 years]
• Radiographic Response Rate [Duration of study participation, an average of 2-3 years]
• Time to Castrate Resistance [Duration of study participation, an average of 2 years]
• Serologic Progression Free Survival [Duration of study participation, an average of 2 years]
• Radiographic Progression Free Survival [Duration of study participation, an average of 2-3 years]
• Overall Survival [Duration of study participation, an average of 5 years]
• Time to Treatment Failure [Duration of study participation, an average of 2-3 years]
• Treatment-related Adverse Events as Assessed by CTCAE v4.0 [Duration of study participation, an average of 5 years]

Sex: Male, ages: 18 Years to any

Inclusion Criteria:

* Histologically or cytologically confirmed adenocarcinoma of the prostate without evidence of small cell carcinoma or greater than 50% neuroendocrine differentiation. Metastatic disease must be present including soft tissue, and/or bone metastases OR nonregional lymph node involvement prior to study enrollment. If the subject has regional lymph node involvement, there must be at least one additional site of disease including visceral, non-regional nodal or skeletal metastases.
* ADT with surgical castration with bilateral orchiectomy or medical castration with LHRH agonist or LHRH antagonist therapy may have been initiated no greater than 112 days (16 weeks) prior to enrollment date. Subjects who initiated ADT prior to consent, are not eligible if PSA has risen ≥ 25% and ≥ 2 ng/ml above nadir value since initiation of ADT prior to consent.
* At least one PSA level of ≥ 5 ng/ml within 90 days prior to consent.
* Prior ADT for non-metastatic disease with LHRH agonist or LHRH antagonist therapy in the neoadjuvant/adjuvant setting is permitted if:

  1. Total duration of therapy did not exceed 36 months
  2. 6 months have elapsed since completion of therapy prior to consent,
  3. Serum testosterone > 50 ng/dl within 28 days prior to reinitiation of ADT for metastatic disease
  4. Prior ADT for non-metastatic disease must have accompanied definitive local therapy for curative intent.
* Age ≥ 18 years.
* ECOG performance status 0-2.
* Adequate liver function: AST and ALT <1.5x upper limit of normal, total bilirubin < 1x upper limit of normal.
* Adequate bone marrow function: Platelets >100,000 cells/mm3, Hemoglobin > 8.0g/dL and ANC > 1,500 cells/mm3.
* Adequate renal function with a creatinine clearance (based on Cockcroft-Gault formula) ≥ 30 mL/min.
* Ability to understand and the willingness to sign a written informed consent document.
* Able to swallow and retain oral medication

Exclusion Criteria:

* Personal history of seizure.
* Personal history of conditions that may predispose to seizure activity including cortical cerebrovascular accident or brain trauma.
* Known central nervous system metastases, including involvement of brain parenchyma and leptomeninges.
* Personal history of any condition that may impair absorption of enzalutamide.
* Prior or current therapy with ketoconazole, abiraterone, enzalutamide, apalutamide (ARN-509, JNJ-56021927), darolutamide (ODM-201, BAY1841788) or cytotoxic chemotherapy such as docetaxel, cabazitaxel, cyclophosphamide.
* Prior therapy with bicalutamide, nilutamide or flutamide within 14 days of enrollment.
* Within 28 days of major surgery and/or lack of recovery from prior surgical procedure or 14 days of palliative radiation prior to enrollment.
* Prior or current therapy with an investigational agent for metastatic prostate cancer.
* Known hypersensitivity to drugs formulated with polysorbate 80.
* Personal history of posterior reversible encephalopathy syndrome.
* CTCAE version 4.0 grade 2-4 peripheral sensory neuropathy.
* Human immunodeficiency virus infection or active hepatitis B or C infection.
* Uncontrolled and current illness including, but not limited to, ongoing or active infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac arrhythmia, or psychiatric illness/social situations that would limit compliance with study requirements in the opinion of the investigator.
* Presence of any of the following within the previous 3 months prior to enrollment: myocardial infarction, severe/unstable angina, coronary/peripheral artery bypass graft, congestive heart failure, or cerebrovascular accident including transient ischemic attack.
* History of an additional active malignancy within 12 months prior to the date of consent (except non-melanoma skin cancer).
* Current use of strong CYP2C8 inhibitors, CYP3A4 inducers or CYP3A4, CYP2C9 or CYP2C19 substrates with a narrow therapeutic range as listed in Section 7.2.1.
* Any condition that requires the use of prednisone > 10mg daily, or equivalent daily glucocorticoid dose, for greater than 14 days

Participant flow

Outcome results

• 52-week PSA Complete Response (CR) Rate (Primary), Count of participants, Participants: Single Arm 22 (p <0.001)
• Serologic Response Rate (Secondary)
• Radiographic Response Rate (Secondary)
• Time to Castrate Resistance (Secondary)
• Serologic Progression Free Survival (Secondary)
• Radiographic Progression Free Survival (Secondary)
• Overall Survival (Secondary)
• Time to Treatment Failure (Secondary)
• Treatment-related Adverse Events as Assessed by CTCAE v4.0 (Secondary)

Adverse events

Time frame: Adverse events are collected from initiation of study drugs to 30 days following cessation of study drugs. The maximum adverse event collection timeframe was 5.8 years.

Serious adverse events by term

Other adverse events by term

9 more terms not shown.

• Study Protocol and Statistical Analysis Plan (PDF, 2022-03-14)
• Informed Consent Form (PDF, 2022-06-06)

• Earle Burgess, MD, Principal investigator, Wake Forest University Health Sciences