Enzalutamide/Leuprolide +/- Abiraterone/Pred in Prostate

A Phase II Randomized Study of Enzalutamide+Leuprolide Versus Enzalutamide+Leuprolide+Abiraterone Acetate+Prednisone as Neoadjuvant Therapy for HIgh-Risk Prostate Cancer Undergoing Prostatectomy

This study is comparing the effectiveness of enzalutamide with or without abiraterone acetate for men with high-risk, localized prostate cancer.

Study Overview

• Status: Completed
• Conditions: Prostate Cancer; Prostate Adenocarcinoma; High Risk Prostate Cancer
• Intervention / Treatment: Drug: Enzalutamide; Drug: Abiraterone Acetate; Drug: Prednisone; Drug: Leuprolide Acetate

Detailed Description

In this research study, the investigators are comparing the effectiveness of enzalutamide with or without abiraterone acetate for men with high-risk, localized prostate cancer.

Abiraterone acetate with prednisone and enzalutamide are currently FDA-approved for use in the treatment of patients with metastatic castration-resistant prostate cancer, however they are investigational for the treatment of localized prostate cancer. Abiraterone acetate works by decreasing the production of male sex hormones, which cause prostate cancer growth. Enzalutamide works by blocking the effects of male sex hormones, which cause prostate cancer growth.

The FDA (the U.S. Food and Drug Administration) has not approved the combination of enzalutamide and abiraterone acetate as neoadjuvant therapy for high risk prostate cancer undergoing prostatectomy but each drug has been approved for the treatment of more advanced prostate cancer.

Participants will be randomized to one of two study arms. Randomization means that the participant is put into a group by chance. It is like flipping a coin. Neither participant nor the research doctor will choose what group participants are randomized to.

The names of the study medications involved in this study are:

• Enzalutamide
• Abiraterone Acetate
• Prednisone
• Leuprolide Acetate

• Study Type: Interventional
• Enrollment (Actual): 75
• Phase: Phase 2

Contacts and Locations

Study Locations

• United States
  • Maryland
    • Baltimore, Maryland, United States, 21231
      • Johns Hopkins University
  • Massachusetts
    • Boston, Massachusetts, United States, 02115
      • Dana-Farber Cancer Institute
    • Boston, Massachusetts, United States, 02115
      • Beth Israel Deaconess Medical Center
  • Washington
    • Seattle, Washington, United States, 98109
      • University of Washington

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: Male

Description

Inclusion Criteria:

• Male greater than or equal 18 years of age.
• Histologically confirmed adenocarcinoma of the prostate without histological variants (including overt neuroendocrine differentiation, small cell neuroendocrine carcinoma features, sarcomatoid features, pure ductal adenocarcinoma, squamous or transitional cell carcinoma).
• Must have tissue available from the pre-treatment diagnostic biopsy (tissue blocks if possible; if not possible, 10 unstained slides from each positive core sample for a total of 30 slides).
• Must have three core biopsies involved with cancer (a minimum of 6 core biopsies must be obtained). Prostate biopsy must be within three months from screening.

• Participants must have the following features:

  • Intermediate-risk disease defined as Gleason 4+3=7 disease OR
  • High-risk disease defined as Gleason 8-10 OR PSA > 20 ng/dL OR T3 disease (by prostate MRI)
• No evidence of metastatic or nodal disease as determined by radionuclide bone scans CT/MRI.
• Participants must be candidates for RP and considered surgically resectable by urologic evaluation.
• ECOG performance status 0 to 1 (Appendix A).

• Participants must have normal organ and marrow function as defined below:

  • WBC ≥ 3,000/mcL
  • ANC ≥ 1,500/mcL
  • Platelets ≥ 100,000/mcL
  • Serum potassium ≥ 3.5 mmol/L
  • AST, ALT, and total bilirubin ≤ 1.5 x Institutional ULN
  • Calculated creatinine clearance ≥ 60 mL/min
  • PTT ≤ 60, INR ≤ 1.5 x Institutional ULN unless on warfarin therapy (investigator would need to determine if safe for participant to stop warfarin prior to biopsy and warfarin therapy)
  • Controlled blood pressure defined as a systolic blood pressure ≤ 140 mmHg and diastolic blood pressure ≤ 90 mmHg on no more than three anti-hypertensive agents. Drug formulations containing two or more anti-hypertensive agents will be counted based on the number of active agents in each formulation.

Exclusion Criteria:

• Prior hormone therapy for prostate cancer including orchiectomy, antiandrogens (including first-generation antiandrogens, enzalutamide, ARN-509 and others), CYP17 inhibitors (including abiraterone, TAK-700, galeterone, ketoconazole, and others), estrogens, LHRH agonist/antagonists. Prior therapy with 5α-reductace inhibitors is allowed. LHRH therapy allowed if begun within 4 weeks of day 1.
• Prior chemotherapy, radiation therapy, or immunotherapy for prostate cancer.
• Prior systemic treatment with an azole drug within four weeks of screening visit.
• Hypogonadism or severe androgen deficiency as defined by screening serum testosterone < 200 ng/dL.
• Clinically significant cardiovascular disease including:

• Acute coronary syndrome within 6 months of screening visit;

  • Hypotension defined as a systolic blood pressure < 86 mmHg;
  • Bradycardia defined as a heart rate of < 50 beats per minute, unless pharmaceutically induced and thus reversible (i.e. beta blockers);
  • Uncontrolled angina (requiring escalating doses of nitrates) within 3 months of screening visit;
  • Congestive heart failure NYHA Class III or IV or subjects with a history of congestive heart failure NYHA Class III or IV, unless screening ECHO results in left ventricular ejection fraction that ≥ 45%;
  • History of clinically significant ventricular arrhythmias (e.g. ventricular tachycardia, ventricular fibrillation, torsades de pointes);
  • Prolonged corrected QT interval by the Fridericia correction formula (QTcF) on screening EKG > 470 msec;
  • History of Mobitz II second degree or third degree heart block without a permanent pacemaker in place;
• History of seizure or any condition or concurrent medication that may predispose to seizure.
• Thromboembolism within 6 months of screening visit.
• Severe hepatic impairment (Child-Pugh Class C).
• Active or symptomatic viral hepatitis or chronic liver disease.
• History of pituitary or adrenal dysfunction.
• GI disorders which may interfere with the absorption of the study drug.
• Pre-existing condition that warrants long-term corticosteroid use.
• Concomitant use of medications that may alter pharmacokinetics of abiraterone or enzalutamide.
• Individuals with a history of a different malignancy are ineligible except for the following circumstances: 1) individuals with a history of other malignancies are eligible if they have been disease-free for at least 5 years and are deemed by the investigator to be at low risk for recurrence of that malignancy, or 2) individuals with the following cancers are eligible if diagnosed and treated within the past 5 years: non-muscle invasive bladder cancer, basal cell or squamous cell carcinoma of the skin.
• Major surgery or radiation therapy within 30 days of screening.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Single Group Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: ARM 1; Participants will be randomized in a 2:1 ratio to neoadjuvant treatment (ARM 1) or (ARM 2). Participants will receive the assigned study treatment per cycle; Enzalutamide- Once daily at prespecified dose, orally; Abiraterone Acetate- Once daily at prespecified dose, orally; Prednisone-Once daily at prespecified dose, orally; Leuprolide Acetate-Intermuscular injection at prespecified dose and duration	Drug: Enzalutamide; 160 mg (four 40 mg capsules), oral, once daily, 28 days (4 weeks) 6 cycles maximum. Can be taken with or without food.; Other Names: XTANDI; Drug: Abiraterone Acetate; 1000 mg (four 250 mg tablets), oral, once daily, 28 days (4 weeks) 6 cycles maximum. No food should be consumed for at least two hours before the dose and for at least one hour after the dose.; Other Names: Zytiga; Drug: Prednisone; 5 mg, oral, once daily, 28 days (4 weeks) 6 cycles maximum.Take with food, preferred to be taken in the morning .; Drug: Leuprolide Acetate; Either 7.5 mg monthly or 22.5 mg every three months, Intramuscular, monthly or every three months.; Other Names: - Lupron Depot-3 Month; - Lupron Depot-4 Month; - Lupron Depot; - Lupron; - Viadur
Experimental: ARM 2; Participants will be randomized in a 2:1 ratio to neoadjuvant treatment (ARM 1) or (ARM 2). Participants will receive the assigned study treatment per cycle.; Enzalutamide- once daily at prespecified dose, orally; Leuprolide Acetate- Intermuscular injection at prespecified dose and duration	Drug: Enzalutamide; 160 mg (four 40 mg capsules), oral, once daily, 28 days (4 weeks) 6 cycles maximum. Can be taken with or without food.; Other Names: XTANDI; Drug: Leuprolide Acetate; Either 7.5 mg monthly or 22.5 mg every three months, Intramuscular, monthly or every three months.; Other Names: - Lupron Depot-3 Month; - Lupron Depot-4 Month; - Lupron Depot; - Lupron; - Viadur

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Percentage of Participants With Pathologic Complete Response (pCR) or Minimal Residual Disease (MRD)	pCR is defined as the absence of morphologically identifiable carcinoma in the radical prostatectomy (RP) specimen. MRD is defined as the largest cross-sectional dimension of residual tumor measuring </= 0.5 cm. If the tumor is multifocal, the size of the largest focus will be used to determine the size of the residual tumor.	after RP approximately 24 weeks from study entry

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Participants With Pathologic Complete Response (pCR)	pCR is defined as the absence of morphologically identifiable carcinoma in the radical prostatectomy (RP) specimen.	after RP approximately 24 weeks from study entry
Residual Cancer Burden (RCB)	RCB was analyzed using radical prostatectomy (RP) tissue. The largest area of tumor was measured by ruler and the longest tumor dimension in this area was used as the dimension for calculation.	after RP approximately 24 weeks from study entry
Positive Surgical Margin Status	Participants were classified by presence or absence of positive surgical margins defined as margins, which are the edges of the removed tumor, that show some cancer cells.	after RP approximately 24 weeks from study entry
Median Prostate Specific Antigen (PSA) Nadir	PSA nadir is the lowest PSA level recorded during neoadjuvant therapy.	PSA was assessed at baseline and every cycle during neoadjuvant therapy (up to 24 weeks).

Collaborators and Investigators

• Sponsor: Dana-Farber Cancer Institute
• Collaborators: Medivation, Inc.

Publications and helpful links

General Publications

• McKay RR, Ye H, Xie W, Lis R, Calagua C, Zhang Z, Trinh QD, Chang SL, Harshman LC, Ross AE, Pienta KJ, Lin DW, Ellis WJ, Montgomery B, Chang P, Wagner AA, Bubley GJ, Kibel AS, Taplin ME. Evaluation of Intense Androgen Deprivation Before Prostatectomy: A Randomized Phase II Trial of Enzalutamide and Leuprolide With or Without Abiraterone. J Clin Oncol. 2019 Apr 10;37(11):923-931. doi: 10.1200/JCO.18.01777. Epub 2019 Feb 27.

Helpful Links

• 2019 ASCO Publication: Evaluation of Intense Androgen Deprivation Before Prostatectomy: A Randomized Phase II Trial of Enzalutamide and Leuprolide With or Without Abiraterone

Study record dates

Study Major Dates

• Study Start: October 1, 2014
• Primary Completion (Actual): January 1, 2018
• Study Completion (Actual): December 1, 2021

Study Registration Dates

• First Submitted: October 14, 2014
• First Submitted That Met QC Criteria: October 14, 2014
• First Posted (Estimate): October 20, 2014

Study Record Updates

• Last Update Posted (Actual): April 19, 2022
• Last Update Submitted That Met QC Criteria: March 30, 2022
• Last Verified: March 1, 2022

More Information

Terms related to this study

• Keywords: advanced prostate cancer; prostate adenocarcinoma; high risk prostate cancer
• Additional Relevant MeSH Terms: Neoplasms by Histologic Type; Neoplasms; Urogenital Neoplasms; Neoplasms by Site; Carcinoma; Neoplasms, Glandular and Epithelial; Genital Neoplasms, Male; Prostatic Diseases; Prostatic Neoplasms; Adenocarcinoma; Physiological Effects of Drugs; Molecular Mechanisms of Pharmacological Action; Enzyme Inhibitors; Anti-Inflammatory Agents; Antineoplastic Agents; Glucocorticoids; Hormones; Hormones, Hormone Substitutes, and Hormone Antagonists; Antineoplastic Agents, Hormonal; Cytochrome P-450 Enzyme Inhibitors; Hormone Antagonists; Steroid Synthesis Inhibitors; Reproductive Control Agents; Fertility Agents, Female; Fertility Agents; Leuprolide; Prednisone; Abiraterone Acetate
• Other Study ID Numbers: 14-283