Neoplasms

Urinary Tract, Sexual Organs, and Pregnancy Conditions

All Conditions

Symptoms and General Pathology

Prostatic Neoplasms

Carcinoma

Adenocarcinoma

Recurrence

Disease Progression

Neoplasms, Second Primary

Neoplasms, Glandular and Epithelial

Neoplasms by Histologic Type

Genital Neoplasms, Male

Urogenital Neoplasms

Genital Diseases

Genital Diseases, Male

Urogenital Diseases

Prostatic Diseases

Male Urogenital Diseases

Patients receive enzalutamide PO QD in the absence of disease progression or unacceptable toxicity. Patients undergo a tumor biopsy of a metastatic site at study entry (prior to initiation of enzalutamide) and after the time of progression. Per the investigator, patients may continue treatment beyond progression.

Enzalutamide

Alexandra Sokolova, M.D.

This phase II trial studies genetic and molecular mechanisms in assessing response in patients with prostate cancer receiving enzalutamide therapy. Androgens can cause the growth of prostate cancer cells. Antihormone therapy, such as enzalutamide, may lessen the amount of androgens made by the body. Studying samples of tissue and blood in the laboratory from patients with prostate cancer may help doctors better understand castration-resistant prostate cancer. It may also help doctors make improvements in prostate cancer treatment.

PRIMARY OBJECTIVE:

I. To assess the correlations between baseline molecular features and pathways and prostate-specific antigen (PSA) change (\</\>= 50% decline) at 12 weeks versus (vs.) baseline.

SECONDARY OBJECTIVES:

I. To measure PSA change at 12 weeks and at each study visit vs. baseline after enzalutamide treatment.

II. To measure objective response after enzalutamide treatment. III. To assess the correlations between the baseline molecular features and pathways and progression-free survival, disease-specific survival, and overall survival.

IV. To assess the correlations between the baseline molecular features and pathways and time to PSA progression.

V. To identify molecular features and cellular pathways present in tumors from men with metastatic castrate-resistant prostate cancer (CRPC) that are progressing despite enzalutamide treatment.

VI. To explore correlation between baseline molecular features and pathways and changes in circulating tumor cells (CTCs) counts.

VII. To explore correlation between baseline molecular features and pathways and objective response.

VIII. To assess the correlations between the baseline molecular features and pathways and degree of PSA decline at 12 weeks and maximal PSA decline observed while on study.

IX. To assess the correlations between the baseline molecular features and time on treatment.

EXPLORATORY OBJECTIVES:

I. To assess correlations between cell-free deoxyribonucleic acid (DNA) (cfDNA) molecular features from blood and molecular features and pathways from the biopsy samples.

II. To assess correlations between cfDNA molecular features and endpoints in the primary and secondary objectives listed above.

III. To assess correlations between cell-free DNA and tumor molecular features and changes in PSA after discontinuing enzalutamide.

IV. To explore correlations with baseline molecular features and tissue histology.

V. To explore correlations with baseline tissue histology and PSA change, time to PSA progression, time on treatment, progression-free survival, and overall survival.

OUTLINE:

Patients receive enzalutamide orally (PO) once daily (QD) in the absence of disease progression or unacceptable toxicity. Patients undergo a tumor biopsy of a metastatic site at study entry (prior to initiation of enzalutamide) and after the time of progression. Patients may continue treatment beyond progression at the investigator's discretion.

After completion of study treatment, patients are followed up at 2-3 or 6 weeks and then every 12 weeks thereafter.

Genetic and Molecular Mechanisms in Assessing Response in Patients With Prostate Cancer Receiving Enzalutamide Therapy

Molecular Mechanisms Underlying Tumor Progression Despite Enzalutamide Treatment

The percentage of participants with a \>= 50% decline in PSA values will be reported with 95% exact confidence interval. For each participant, percentage decline in PSA values are calculated as 100% times the difference between PSA values taken at baseline and 12 weeks divided by PSA values at baseline. Percentage of participants determined as 100% times the number of participants with \>= 50% decline divided by overall number of participants.

Evaluate the association between PSA response at 12 weeks after initiating therapy, and TP53 copy number alterations and mutations at baseline. Simple Logistic regression was planned but due to sample size we used Fisher's Exact test. Percentage of patients in each arm with TP53 copy number alterations and mutations will be reported and odds ratio with two-sided 95% confidence interval will be calculated.

Evaluate the association between PSA response at 12 weeks after initiating therapy, and PTEN copy number alterations and mutations at baseline. Simple Logistic regression was planned but due to sample size we used Fisher's Exact test. Percentage of patients in each arm with PTEN copy number alterations and mutations will be reported and odds ratio with two-sided 95% confidence interval will be calculated.

Evaluate the association between PSA response at 12 weeks after initiating therapy, and RB1 copy number alterations and mutations at baseline. Simple Logistic regression was planned but due to sample size we used Fisher's Exact test. Percentage of patients in each arm with RB1 copy number alterations and mutations will be reported and odds ratio with two-sided 95% confidence interval will be calculated.

Median AR mRNA expression between responders and non-responders.

Median AR-V7 expression between responders and non-responders.

Evaluate the association between PSA response at 12 weeks after initiating therapy, and AR copy number alterations and mutations at baseline. Simple Logistic regression was planned but due to sample size we used Fisher's Exact test. Percentage of patients in each arm with AR copy number alterations and mutations will be reported and odds ratio with two-sided 95% confidence interval will be calculated.

The number of participants, responders and non-responders, that were found to have protein expression of AR.

Median Normalized Enrichment Score (NES) AR activity levels of responders and non-responders. Gene Set Enrichment Analysis (GSEA) is used to interpret gene expression data. GSEA enrichment score (ES) reflects the degree to which a gene set (GS) is overrepresented at the top or bottom of a ranked list of genes. ES is calculated by walking down the list, increasing a running-sum statistic when a gene is in the GS and decreasing when it's not. Magnitude of increment depends on correlation of the gene with the phenotype. ES is the max deviation from zero encountered in walking the list. Positive ES indicates GS enrichment at the top of the list; negative indicates GS enrichment at the bottom. GSEA calculates NES as actual ES divided by mean (ESs against all permutations of the dataset). Low AR activity has been linked to stemness and lineage plasticity that are recognized as a cause of acquired resistance to AR-targeting therapies.

The percentage of participants with an objective response will be reported with 95% exact confidence interval. Objective radiographic response is evaluated using the new international criteria proposed by the revised Response Evaluation Criteria in Solid Tumors (RECIST) guideline (version 1.1). Changes in the largest diameter (unidimensional measurement) of the tumor lesions and the shortest diameter in the case of malignant lymph nodes are used in the RECIST criteria. For each participant, objective response is calculated as 100% times the difference between the sum of measurable target lesions at baseline and the smallest sum of measurable target lesions achieved after the initiation of therapy, divided by the sum of target lesions at baseline.

Correlations between baseline molecular features and pathways and PFS will be assessed using cox regression model. In addition, Kaplan-Meier plots will be used to graphically illustrate the survival distributions across the strata of categorical molecular predictors.

Correlations between baseline molecular features and pathways and DSS will be assessed using cox regression model. In addition, Kaplan-Meier plots will be used to graphically illustrate the survival distributions across the strata of categorical molecular predictors.

Correlations between baseline molecular features and pathways and OS will be assessed using cox regression model. In addition, Kaplan-Meier plots will be used to graphically illustrate the survival distributions across the strata of categorical molecular predictors.

Correlations between baseline molecular features and pathways and time to PSA progression will be assessed.

Random Forests classification will be used to identify molecular features and pathways present in patients with disease progression or who discontinue Enzalutamide treatment.

Linear regression model will be used to assess the association for changes in CTC counts from baseline and maximal prostate-specific antigen (PSA) observed while on study.

Degree of prostate-specific antigen (PSA) change from baseline to 12 weeks. PSA at week 12 minus PSA at baseline divided by PSA at baseline and multiplied by 100%. Decline shown as negative percent and incline shown as positive percent.

Correlations between baseline molecular features and pathways and maximal PSA decline observed will be assessed. Linear regression model will be used to assess the association for changes in circulating tumor cells (CTC) counts from baseline and maximal PSA observed while on study.

The association between molecular predictors and survival outcomes (e.g., progression-free survival \[PFS\], disease-free survival \[DSS\] and overall survival \[OS\]) and time on treatment will be assessed using cox regression model.

Astellas Pharma US, Inc.

Oregon Health and Science University

OHSU Knight Cancer Institute

Principal Investigator

Adverse events are collected from the start date of treatment with enzalutamide to the last date of treatment with enzalutamide. Adverse events are collected for any untoward clinical experience with the exception of lab abnormalities which are only reported if the test result is deemed Clinically Significant by the responsible or treating physician. Clinical significance is based on clinical judgement and individual patient situation, at the discretion of the physician.

Patients receive enzalutamide PO QD in the absence of disease progression or unacceptable toxicity. Patients undergo a tumor biopsy of a metastatic site at study entry (prior to initiation of enzalutamide) and after the time of progression. Per the investigator, patients may continue treatment beyond progression.

Enzalutamide: Given PO

Treatment (Enzalutamide)

Age, Categorical

Age, Continuous

Sex: Female, Male

Ethnicity (NIH/OMB)

Race (NIH/OMB)

United States

Region of Enrollment

Shawna Bailey, Data Manager

Evaluable patients will include those patients for whom data from genomic studies and IHC tests are available from the pre-treatment biopsy samples and who have completed at least 12 weeks of therapy or who have confirmed disease progression prior to 12 weeks of therapy, and for whom baseline and 12 week PSA data were available. 36 subjects shown in participant flow. 2 subjects were excluded from this PSA analysis: 1 had missing PSA data, 1 had falling PSA in setting of rapid disease progression

Percentage of Participants With a >= 50% Decline in Prostate-specific Antigen (PSA) Value

PSA Responder: A ≥ 50% reduction at 12 weeks after the initiation of therapy vs. baseline. Baseline PSA will be defined as the measurement obtained immediately prior to initiation of Enzalutamide on Day 1 of study.

Responders

PSA Non-Responder: A less than 50% reduction at 12 weeks after the initiation of therapy vs. baseline. Baseline PSA will be defined as the measurement obtained immediately prior to initiation of Enzalutamide on Day 1 of study.

PSA Non-responders

For the primary endpoint, evaluable patients will include those patients for whom data from genomic studies and IHC tests are available from the pre-treatment biopsy samples and who have completed at least 12 weeks of therapy or who have confirmed disease progression prior to 12 weeks of therapy. Targeted DNA sequencing was performed on 26 of 36 biopsies that contained sufficient material.

Percentage of Participants With Tumor Protein 53 Gene (TP53) Copy Number Alterations and Mutations

Percentage of Participants With Phosphatase and Tensin Homologue Gene (PTEN) Copy Number Alterations and Mutations

Percentage of Participants With Retinoblastoma Gene (RB1) Copy Number Alterations and Mutations

Non-responders

Evaluable patients will include those patients for whom data from genomic studies and IHC tests are available from the pre-treatment biopsy samples and who have completed at least 12 weeks of therapy or who have confirmed disease progression prior to 12 weeks of therapy, and for whom baseline and 12 week PSA data were available. RNA sequencing was performed on 25 of 36 biopsies that contained sufficient material.

Androgen Receptor (AR) Messenger RNA (mRNA) Expression

Androgen Receptor Variant 7 (AR-V7) Expression

PSA non-responders: A less than 50% reduction at 12 weeks after the initiation of therapy vs. baseline. Baseline PSA will be defined as the measurement obtained immediately prior to initiation of Enzalutamide on Day 1 of study.

For the primary endpoint, evaluable patients will include those patients for whom data from genomic studies and IHC tests are available from the pre-treatment biopsy samples and who have completed at least 12 weeks of therapy or who have confirmed disease progression prior to 12 weeks of therapy. AR immunohistochemistry was available in 22 patients with sufficient samples.

Percentage of Participants With Androgen Receptor (AR) Copy Number Alterations and Mutations

For the primary endpoint, evaluable patients will include those patients for whom data from genomic studies and IHC tests are available from the pre-treatment biopsy samples and who have completed at least 12 weeks of therapy or who have confirmed disease progression prior to 12 weeks of therapy. AR protein expression was analyzed using immunohistochemical analysis from 21 patients with sufficient samples.

Number of Participants With Protein Expression of AR

Androgen Receptor (AR) Activity Level

Prostate-specific Antigen (PSA) Changes

Only those subjects who have measurable disease present at baseline, have received at least one cycle of therapy, and have had their disease re-evaluated will be considered evaluable for objective response.

Percentage of Participants With an Objective Response

Progression-free Survival (PFS)

Disease-specific Survival (DSS)

Overall Survival (OS)

Time to Prostate-specific Antigen (PSA) Progression

Molecular Features and Cellular Pathways Present in Tumors That Are Progressing Despite Treatment With Enzalutamide

Changes in Circulating Tumor Cell (CTC) Counts

Degree of Prostate-specific Antigen (PSA) Decline

Maximal Prostate-specific Antigen (PSA) Decline Observed

Time on Treatment

Overall Study

Rare Diseases

Carcinoma, Renal Cell

Kidney Neoplasms

Urologic Neoplasms

Female Urogenital Diseases

Pregnancy Complications

Female Urogenital Diseases and Pregnancy Complications

Kidney Diseases

Urologic Diseases

Renal Cell Carcinoma

Clear Cell Renal Cell Carcinoma

All Drugs and Chemicals

Antineoplastic Agents

Antibodies

Antibodies, Monoclonal

Immunomodulating Agents

Nivolumab

Ipilimumab

Immunoglobulins

Antineoplastic Agents, Immunological

Immune Checkpoint Inhibitors

INDUCTION: Patients receive nivolumab IV over 30 minutes and ipilimumab IV over 30 minutes on day 1. Treatment repeats every 21 days for up to 4 cycles in the absence of disease progression or unacceptable toxicity.

TREATMENT:

Patients with iuPD with clinical instability receive cabozantinib PO daily on days 1-28. Treatment repeats every 28 days until further disease progression or unacceptable toxicity

Patients with iCR receive nivolumab IV over 30 minutes on day 1. Treatment repeats every 28 days in the absence of disease progression or unacceptable toxicity.

Patients with non-CR/non-PD with clinical stability receive nivolumab IV over 30 minutes on day 1. Treatment repeats every 28 days in the absence of disease progression or unacceptable toxicity.

Patients undergo CT scan, MRI and blood sample collection throughout the study.

INDUCTION: Patients receive nivolumab IV over 30 minutes and ipilimumab IV over 30 minutes on day 1. Treatment repeats every 21 days for up to 4 cycles in the absence of disease progression or unacceptable toxicity.

TREATMENT:

Patients with iuPD with clinical instability receive cabozantinib PO daily on days 1-28. Treatment repeats every 28 days until further disease progression or unacceptable toxicity.

Patients with iCR receive nivolumab IV over 30 minutes on day 1. Treatment repeats every 28 days in the absence of disease progression or unacceptable toxicity.

Patients with non-CR/non-PD rwith clinical stability eceive nivolumab IV over 30 minutes on day 1 and cabozantinib PO daily on days 1-28. Treatment repeats every 28 days in the absence of disease progression or unacceptable toxicity.

Patients undergo CT scan, MRI and blood sample collection throughout the study.

Biospecimen Collection

Cabozantinib

Computed Tomography

Magnetic Resonance Imaging

Quality-of-Life Assessment

Questionnaire Administration

Tian Zhang

This phase III trial compares the usual treatment (treatment with ipilimumab and nivolumab followed by nivolumab alone) to treatment with ipilimumab and nivolumab, followed by nivolumab with cabozantinib in patients with untreated renal cell carcinoma that has spread to other parts of the body. The addition of cabozantinib to the usual treatment may make it work better. Immunotherapy with monoclonal antibodies, such as nivolumab and ipilimumab, may help the body's immune system attack the cancer, and may interfere with the ability of tumor cells to grow and spread. Cabozantinib may stop the growth of tumor cells by blocking some of the enzymes needed for cell growth. It is not yet known how well the combination of cabozantinib and nivolumab after initial treatment with ipilimumab and nivolumab works in treating patients with renal cell cancer that has spread to other parts of the body.

PRIMARY OBJECTIVE:

I. To compare the overall survival (OS) in patients with metastatic renal cell cancer (RCC) treated with ipilimumab-nivolumab followed by either nivolumab versus cabozantinib-nivolumab.

SECONDARY OBJECTIVES:

I. To determine progression free survival (PFS) of patients treated with nivolumab versus nivolumab-cabozantinib.

II. To evaluate the 12-month complete response rate in patients treated with ipilimumab-nivolumab followed by cabozantinib-nivolumab versus ipilimumab-nivolumab followed by nivolumab (patients who have complete response \[CR\] and relapse before 12 months will not be counted as a CR at 12-months).

III. To evaluate the rates of discontinuing therapy at 1 year. IV. To compare objective response rates (ORR, assessed by Response Evaluation Criteria in Solid Tumors \[RECIST\] 1.1 and Immune Response Evaluation Criteria in Solid Tumors \[iRECIST\] criteria) for patients treated with ipilimumab-nivolumab followed by cabozantinib-nivolumab versus ipilimumab-nivolumab followed by nivolumab.

V. To document the adverse event profile of ipilimumab-nivolumab followed by cabozantinib-nivolumab.

BIOMARKER OBJECTIVES:

I. To evaluate biomarkers associated with exceptional responses in both arms (exceptional responses defined as CRs with treatment discontinuation at 12 months or 24 months).

II. To evaluate whether baseline IL-6 is predictive of outcome in patients treated with cabozantinib-containing regimen.

QUALITY OF LIFE (QOL) OBJECTIVES:

I. To compare health-related quality of life at 18 months post-registration as assessed by the Functional Assessment of Cancer Therapy (FACT)-Kidney Symptom Index 19 (FKSI-19) between patients randomized to nivolumab (nivo) versus (vs) cabozantinib (cabo)/nivo.

II. To compare health-related quality of life as assessed by the FKSI-19 between patients randomized to nivo vs cabo/nivo at other time points.

III. To compare patient-reported fatigue using Patient-Reported Outcomes Measurement Information System (PROMIS)-Fatigue between patients randomized to nivo vs cabo/nivo.

IV. To compare quality-adjusted survival (overall survival x utility score assessed by EuroQol five-dimensional questionnaire \[EQ5D-5L\]) between patients randomized to nivo vs cabo/nivo.

OUTLINE:

INDUCTION: Patients receive nivolumab intravenously (IV) over 30 minutes and ipilimumab IV over 30 minutes on day 1. Treatment repeats every 21 days for up to 4 cycles in the absence of disease progression or unacceptable toxicity.

TREATMENT:

Patients with unconfirmed but clinical progression of disease (iuPD) with clinical instability receive cabozantinib orally (PO) daily on days 1-28. Treatment repeats every 28 days until further disease progression or unacceptable toxicity.

Patients with unconfirmed CR (iCR) receive nivolumab IV between 30-60 minutes on day 1. Treatment repeats every 28 days in the absence of disease progression or unacceptable toxicity.

Patients with non-CR/non-PD or iuPD with clinical stability are randomized to 1 of 2 arms.

ARM A: Patients receive nivolumab IV between 30-60 minutes on day 1. Treatment repeats every 28 days in the absence of disease progression or unacceptable toxicity.

ARM B: Patients receive nivolumab IV between 30-60 minutes on day 1 and cabozantinib PO daily on days 1-28. Treatment repeats every 28 days in the absence of disease progression or unacceptable toxicity.

Patients undergo computed tomography (CT) scan, magnetic resonance imaging (MRI) and blood sample collection throughout the study.

Immunotherapy With Nivolumab and Ipilimumab Followed by Nivolumab or Nivolumab With Cabozantinib for Patients With Advanced Kidney Cancer, The PDIGREE Study

PD-Inhibitor (Nivolumab) and Ipilimumab Followed by Nivolumab Vs. VEGF TKI Cabozantinib With Nivolumab: A Phase III Trial in Metastatic Untreated REnal Cell CancEr [PDIGREE]

NCI is committed to sharing data in accordance with NIH policy. For more details on how clinical trial data is shared, access the link to the NIH data sharing policy page

Estimates of OS and the corresponding 95% confidence intervals (CIs) by sex will be provided (with an understanding that sometimes the CI or estimate will not be computable because of scant data).

Estimates of OS and the corresponding 95% CIs by race will be provided (with an understanding that sometimes the CI or estimate will not be computable because of scant data).

Estimates of OS and the corresponding 95% CIs by ethnicity will be provided (with an understanding that sometimes the CI or estimate will not be computable because of scant data).

OS of patients who achieve complete response (CR) and progressive disease (PD) from ipilimumab-nivolumab induction phase will be summarized. The stratified log-rank statistic will be the primary analysis to compare the hypothesis on OS with the stratification factors (presence of bone metastases and IMDC risk criteria). The Kaplan-Meier product-limit estimator will be used to estimate the OS. A stratified proportional hazards model will be used to generate estimates for the OS hazard ratio. For the randomized patients, OS will be calculated and compared from the time of randomization until the time of an OS event or time of last-follow-up, whatever occurs first. For the patients who were initially CR or PD, OS will be measured from the time of study registration. A comparison of OS will be made across the patient groups (randomized patients, patients initially CR, and patients initially PD).

Progression will be defined using the Response Evaluation Criteria in Solid Tumors (RECIST) 1.1 criteria. PFS of patients who achieve CR and PD from ipilimumab-nivolumab induction phase will be summarized (secondary analysis). The Kaplan-Meier product-limit estimator will be used to estimate the PFS distribution. A stratified proportional hazards model will be used to generate estimates for the PFS hazard ratio. For the randomized patients, PFS will be calculated and compared from the time of randomization until the time of a PFS event or time of last-follow-up, whatever occurs first. For the patients who were initially CR or PD, PFS will be measured from the time of study registration. A comparison of PFS will be made across the patient groups (randomized patients, patients initially CR, and patients initially PD). For this comparison, PFS will be measured from time of study registration all the patients, regardless of whether they were randomized or not.

Patients who had a CR prior to 12 months but have experienced a disease recurrence prior to 12 months, will not be considered to be a CR at 12 months. The Cochran-Mantel-Haenszel test will be used to compare the two arms on the proportion of patients who have a 12-month CR adjusting on the stratification factors.

Defined as the best response observed that has been confirmed by a scan performed 4 or more weeks after the observation of the initial response. The objective response will be confirmed using RECIST 1.1. In addition, objective responses will also be confirmed using Immune Response Evaluation Criteria in Solid Tumors (iRECIST).

Patients who stop their protocol directed treatment for any reason prior to one year from study registration will be considered to have discontinued their treatment. The Cochran-Mantel-Haenszel test will also be used to compare the proportion of patients who discontinue their treatment prior to one-year after study registration.

Assessed with National Cancer Institute Common Terminology Criteria for Adverse Events version 5.0. A Fisher's exact test will be used to compare the two treatment arms on the proportion of patient with a grade 3 or higher adverse event.

National Cancer Institute (NCI)

Immune System Diseases

Urinary Bladder Neoplasms

Hypersensitivity

Carcinoma, Transitional Cell

Ureteral Neoplasms

Disease Attributes

Urinary Bladder Diseases

Ureteral Diseases

Transitional Cell Carcinoma

Transitional Cell Cancer of the Renal Pelvis and Ureter

Patients undergo collection of blood and tissue samples for analysis via mutation mapping, DNA sequencing, gene expression microarray, and gene profiling.

Cytology Specimen Collection Procedure

Laboratory Biomarker Analysis

Robert B. Montgomery

This study collects and studies tissue and blood samples from patients with prostate or bladder/urothelial cancer that has recurred (come back) at or near the same place as the original (primary) tumor or has spread to other parts of the body. Studying samples of blood and tissue samples from patients with prostate or bladder/urothelial cancer in the laboratory may help doctors learn more about new biomarkers, potential drug targets, and resistance developing in response to treatment. It may also help doctors find better ways to treat the cancer.

OUTLINE:

Patients undergo collection of blood and tissue samples for analysis via mutation mapping, DNA sequencing, gene expression microarray, and gene profiling.

Collecting and Studying Blood and Tissue Samples From Patients With Locally Recurrent or Metastatic Prostate or Bladder/Urothelial Cancer

Molecular Correlates of Sensitivity and Resistance to Therapy in Genitourinary Malignancy

University of Washington

Hormones

Pembrolizumab

Vaccines

Immunoglobulin G

Immunoglobulins, Intravenous

Immunologic Factors

Patients receive pTVG-HP plasmid DNA vaccine ID every other week on days 1, 15, 29, 43, 57, and 71 and pembrolizumab IV over 30 minutes every 3 weeks on days 1, 22, 43, and 64.

Patients receive pTVG-HP plasmid DNA vaccine ID as in Arm I and pembrolizumab IV over 30 minutes every 3 weeks on days 85, 106, 127, and 148.

pTVG-HP (100 μg) with rhGM-CSF (208 μg) administered intradermally (i.d.) every 3 weeks, for a maximum of 16 doses. Pembrolizumab 2 mg/kg, with a maximum dose of 200 mg, administered intravenously every 3 weeks, for a maximum of 16 doses, beginning on day 1 after the first pTVG-HP vaccination.

pTVG-HP (100 µg) with rhGM-CSF (208 µg) administered intradermally (i.d.) every 2 weeks, for a maximum of 24 doses Pembrolizumab 2 mg/kg, with a maximum dose of 200 mg, administered intravenously every 4 weeks, for a maximum of 12 doses, beginning on day 1 after the first pTVG-HP vaccination

pTVG-HP Plasmid DNA Vaccine

Douglas G McNeel, MD PhD

This randomized pilot trial studies vaccine therapy and pembrolizumab in treating patients with prostate cancer that does not respond to treatment with hormones (hormone-resistant) and has spread to other places in the body (metastatic). Vaccines made from deoxyribonucleic acid (DNA), such as pTVG-HP plasmid DNA vaccine, may help the body build an effective immune response to kill tumor cells. Monoclonal antibodies, such as pembrolizumab, may find tumor cells and help kill them. Giving pTVG-HP plasmid DNA vaccine and pembrolizumab may kill more tumor cells.

PRIMARY OBJECTIVES:

I. To evaluate the safety of pembrolizumab in combination with pTVG-HP (pTVG-HP plasmid DNA vaccine) in patients with castration-resistant, metastatic prostate cancer.

II. To determine the 6-month progression-free survival and median time to radiographic progression in patients with castration-resistant metastatic prostate cancer treated with pembrolizumab in combination with pTVG-HP.

III. To evaluate the anti-tumor response rates (objective response rate and prostate specific antigen \[PSA\] response rate, using Prostate Cancer Clinical Trials Working Group 2 \[PCWG2\] criteria) in patients with castration-resistant metastatic prostate cancer treated with pembrolizumab in combination with pTVG-HP.

SECONDARY OBJECTIVES:

I. To determine whether either treatment sequence, or prostatic acid phosphatase (PAP)-specific immune response, is associated with prolonged (6-month) radiographic progression-free survival.

II. To evaluate effects of schedule (concurrent versus delayed administration of pembrolizumab) on the magnitude of PAP-specific T-cell responses, programmed death receptor-1 (PD-1) expression on circulating T cells, and ligands for PD-1 (PD-L1) expression on circulating epithelial cells (CEC) and on tumor biopsies.

III. To determine the median time to radiographic progression using a concurrent administration schedule

TERTIARY OBJECTIVES:

I. To evaluate effects of treatment on number of circulating tumor cells. II. To evaluate PAP-specific antibody responses following treatment with pembrolizumab and pTVG-HP DNA vaccine (pTVG-HP plasmid DNA vaccine).

III. To determine whether either treatment sequence elicits immunologic antigen spread to other prostate-associated antigens.

IV. To determine whether pre-existing or vaccine-induced PD-L1 expression on CEC or tumor biopsies is predictive of objective clinical response.

V. To determine whether treatment elicits expression of other regulatory molecules on tumor-specific T cells (e.g. hepatitis A virus cellular receptor 2 \[TIM3\], B and T lymphocyte associated \[BTLA\], and lymphocyte-activation gene 3 \[LAG3\]) or tumor cells (e.g. tumor necrosis factor receptor superfamily, member 14 \[HVEM\], phosphatidyl serine, ligands for programmed death receptor-2 \[PD-2\] \[PD-L2\]).

VI. To determine whether PD-1-regulated antigen-specific T cells identified by trans vivo delayed-type hypersensitivity (DTH) testing can identify patients who develop objective clinical responses with PD-1 blockade therapy in combination with pTVG-HP.

VII. To determine whether changes in lymph nodes and soft tissue tumor lesions are observed by fluorothymidine F-18 (FLT) positron emission tomography (PET)/computed tomography (CT) after treatment with vaccine with or without pembrolizumab.

VIII. To determine if PD-1 inhibitor therapy in combination with pTVG-HP will change number and activity (SUV) in osteoblastic metastases as measured by NaF PET/CT.

OUTLINE: Patients are randomized to 1 of 2 treatment arms.

ARM I: Patients receive pTVG-HP plasmid DNA vaccine intradermally (ID) every other week on days 1, 15, 29, 43, 57, and 71 and pembrolizumab intravenously (IV) over 30 minutes every 3 weeks on days 1, 22, 43, and 64.

ARM II: Patients receive pTVG-HP plasmid DNA vaccine ID as in Arm I and pembrolizumab IV over 30 minutes every 3 weeks on days 85, 106, 127, and 148.

After completion of study treatment, patients are followed up 3, 6, 9, and 12 months and then annually for 2 years.

ARM III: Extended Treatment. Patients received pTVG-HP + Pembrolizumab Extended Treatment

ARM IV: Extended Treatment. Patients receive pTVG-HP every two weeks, and Pembrolizumab every 4 weeks

Once at least 12 subjects per arm are accrued to Arms 1 and 2, and Arm 3 is open to accrual, accrual will occur only to Arm 3 (other arms will be closed). Extended treatment Arm 4 will open only when Arm 3 has met accrual.

Vaccine Therapy and Pembrolizumab in Treating Patients With Hormone-Resistant, Metastatic Prostate Cancer

Pilot Trial of pTVG-HP DNA Vaccine and Pembrolizumab in Patients With Castration-Resistant, Metastatic Prostate Cancer

Toxicities will be summarized by type, as reported in the adverse events section, and total events calculated per arm.

6-month progression-free survival rate will be reported for each arm, and for overall combined study. Progression is at least a 20% increase in the sum of diameters of target lesions and a 0.5cm minimum increase, or the appearance of one or more new lesions. In order to evaluate the 6-month progression-free rate as a function of baseline time point (pretreatment or 3-months post treatment), analysis will be conducted using two different baseline values: date of randomization, and 3-months disease assessment. Central tendency is appropriate due to 20% increase and measurements being a mean of growth across time periods.

Median time to radiographic progression will be estimated for each, and for both study arms combined, using Kaplan-Meier method. Log-rank test will be used to perform comparison of time to radiographic progression between study arms. A one-sided 0.10 significance level will be used to conduct the comparison of the 6-month progression-free survival rate and time to radiographic progression between study arms. In order to evaluate the median time to radiographic progression as a function of baseline time point (pretreatment or 3-months post treatment), analysis will be conducted.

Will be calculated for each study arm and for all arms combined. Complete response is the disappearance of all target lesions. Partial response is at least 30% decrease in the sum of diameters of target lesions.

Will be calculated for each study arm and for all arms combined. PSA complete response is a decrease in PSA to ,0.2 ng/mL; partial response is greater than or equal to 50% reduction in baseline PSA.

Number of PAP-specific immune responses will be summarized in tabular format for each study arm and all study arms combined. A significant antigen-specific response resulting from immunization will be defined as a PAP specific response.

Number and frequencies of PAP-specific T-cell responses will be summarized in tabular format.

PD-1 and PD-L1 expression levels will be summarized in terms of means, standard deviations and ranges for each study arm separately and for both arms combined. A linear regression model or a negative binomial regression model will be utilized to evaluate effects of schedule (concurrent versus delayed administration pembrolizumab) on PD-1 expression on number of circulating T cells, and PD-L1 expression on number of circulating epithelial cells. Choice of the model will be dependent on distribution of outcome variables (number of circulating T-cells and number of circulating epithelial cells).

Prostate Cancer Foundation

Madison Vaccines, Inc

University of Wisconsin, Madison

Patients receive pTVG-HP plasmid DNA vaccine ID every other week on days 1, 15, 29, 43, 57, and 71 and pembrolizumab IV over 30 minutes every 3 weeks on days 1, 22, 43, and 64.

Pembrolizumab: Given IV

pTVG-HP Plasmid DNA Vaccine: Given ID

Arm I (pTVG-HP Plasmid DNA Vaccine, Concurrent Pembrolizumab)

Patients receive pTVG-HP plasmid DNA vaccine ID as in Arm I and pembrolizumab IV over 30 minutes every 3 weeks on days 85, 106, 127, and 148.

Pembrolizumab: Given IV

pTVG-HP Plasmid DNA Vaccine: Given ID

Arm II (pTVG-HP Plasmid DNA Vaccine, Sequential Pembrolizumab)

pTVG-HP (100 μg) with rhGM-CSF (208 μg) administered intradermally (i.d.) every 3 weeks, for a maximum of 16 doses. Pembrolizumab 2 mg/kg, with a maximum dose of 200 mg, administered intravenously every 3 weeks, for a maximum of 16 doses, beginning on day 1 after the first pTVG-HP vaccination.

Pembrolizumab: Given IV

pTVG-HP Plasmid DNA Vaccine: Given ID

Extended Treatment Arm III

pTVG-HP (100 µg) with rhGM-CSF (208 µg) administered intradermally (i.d.) every 2 weeks, for a maximum of 24 doses Pembrolizumab 2 mg/kg, with a maximum dose of 200 mg, administered intravenously every 4 weeks, for a maximum of 12 doses, beginning on day 1 after the first pTVG-HP vaccination

Pembrolizumab: Given IV

pTVG-HP Plasmid DNA Vaccine: Given ID

Extended Treatment Arm IV

Total

Age, Customized

Douglas McNeel, MD

Incidence of Adverse Events, Using the National Cancer Common Terminology Criteria, Version 4

Combination of results from all 4 arms of the study

Study title	NCT ID	Conditions	Interventions	Eligibility	Organization
Genetic and Molecular Mechanisms in Assessing Response in Patients With Prostate Cancer Receiving Enzalutamide Therapy	NCT02099864	Castration-Resi... Metastatic Mali... Metastatic Mali... Metastatic Pros... Recurrent Prost... Stage III Prost... Stage IV Prosta...	Enzalutamide	18 Years -	OHSU Knight Cancer Institute
Immunotherapy With Nivolumab and Ipilimumab Followed by Nivolumab or Nivolumab With Cabozantinib for Patients With Advanced Kidney Cancer, The PDIGREE Study	NCT03793166	Clear Cell Rena... Metastatic Mali... Metastatic Mali... Metastatic Mali... Metastatic Mali... Sarcomatoid Ren... Stage III Renal... Stage IV Renal ...	Biospecimen Col... Cabozantinib Computed Tomogr... Ipilimumab Magnetic Resona... Nivolumab Quality-of-Life... Questionnaire A...	18 Years -	National Cancer Institute (NCI)
Collecting and Studying Blood and Tissue Samples From Patients With Locally Recurrent or Metastatic Prostate or Bladder/Urothelial Cancer	NCT01050504	Localized Renal... Malignant Solid... Metastatic Mali... Metastatic Mali... Metastatic Rena... Recurrent Bladd... Recurrent Prost... Recurrent Renal... Stage IV Bladde... Stage IV Bladde... Stage IV Prosta...	Cytology Specim... Laboratory Biom...	18 Years -	University of Washington
Collecting and Studying Blood and Tissue Samples From Patients With Locally Recurrent or Metastatic Prostate or Bladder/Urothelial Cancer	NCT01050504	Localized Renal... Malignant Solid... Metastatic Mali... Metastatic Mali... Metastatic Rena... Recurrent Bladd... Recurrent Prost... Recurrent Renal... Stage IV Bladde... Stage IV Bladde... Stage IV Prosta...	Cytology Specim... Laboratory Biom...	18 Years -	University of Washington
Collecting and Studying Blood and Tissue Samples From Patients With Locally Recurrent or Metastatic Prostate or Bladder/Urothelial Cancer	NCT01050504	Localized Renal... Malignant Solid... Metastatic Mali... Metastatic Mali... Metastatic Rena... Recurrent Bladd... Recurrent Prost... Recurrent Renal... Stage IV Bladde... Stage IV Bladde... Stage IV Prosta...	Cytology Specim... Laboratory Biom...	18 Years -	University of Washington
Vaccine Therapy and Pembrolizumab in Treating Patients With Hormone-Resistant, Metastatic Prostate Cancer	NCT02499835	Hormone-Resista... Metastatic Mali... Metastatic Mali... Metastatic Pros... Prostate Adenoc... Recurrent Prost... Stage IV Prosta...	Pembrolizumab pTVG-HP Plasmid...	18 Years -	University of Wisconsin, Madison

Spots Global Cancer Trial Database for metastatic malignant neoplasm in the soft tissues