A Phase II Trial of Adjuvant PROSTVAC-V/F in Subjects at High Risk for Relapse After Radical Prostatectomy
Phase: PHASE2
Conditions: Prostatic Neoplasms
Sponsor: Medical University of South Carolina

 
 
 
 
 
 
 
 
 
 
 
 
 
A PHASE II TRIAL OF ADJUVANT PROSTVAC-V/F IN SUBJECTS AT HIGH RISK FOR 
RELAPSE AFTER RADICAL PROSTATECTOMY 
 
MUSC 102377 
NCT02772562 
 
 
Principal Investigator: 
 
Michael Lilly, MD 
 
 
 
 
 
Professor of Medicine 
Division of Hematology-Oncology 
Medical University of South Carolina 
BSB102, 173 Ashley Street 
Charleston, SC  29425 
Email:  lillym@musc.edu 
 
 
 
Co-investigators: 
 
 
Thomas Keane, MD 
 
 
 
 
 
Professor and Chair, Department of Urology 
 
 
 
 
 
Medical University of South Carolina 
 
 
 
 
 
 
 
 
 
 
 
Stephen Savage, MD 
 
 
 
 
 
Professor of Urology 
 
 
 
 
 
Medical University of South Carolina 
 
 
 
 
 
 
Chanita Hughes Halbert, PhD 
 
 
 
 
 
Professor and Endowed Chair 
 
 
 
 
 
Department of Psychiatry & Behavioral Sciences 
 
 
 
 
 
Medical University of South Carolina 
 
 
Statisticians:  
 
 
Hong Li, PhD 
 
 
 
 
 
Associate Professor, Hollings Cancer Center 
 
 
 
 
 
Medical University of South Carolina 
 
 
 
 
 
 
 
 
 
 
 
Zhenyu Jia, PhD 
 
 
 
 
 
Department of Mathematics 
 
 
 
 
 
University of Akron 
 
                                                           Yeonhee Park, PhD 
                                                           Assistant Professor, Hollings Cancer Center 
                                                           Medical University of South Carolina 
 
 
 
 
 
 
 

Phase II Trial of Adjuvant PROSTVAC V/F Following Radical Prostatectomy                v. 4/22/2020 
 
 
 
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Coordinating Office:   
Sponsor-Investigator Support Unit 
 
 
Hollings Cancer Center 
 
 
86 Jonathan Lucas St., Suite 373 
 
 
Phone : 843-792-0275 
 
 
Fax : 843-792-5123 
 
 
Email : gibsond@musc.edu, smiler@musc.edu  
 
 
Version History:   
Version 15.0 dated April 22, 2020 
Version 14.0 dated March 23, 2020  
Version 13.0 dated November 11, 2019 
Version 12 dated May 16, 2019 
Version 11 dated May 6, 2019 
Version 10 dated January 4, 2019 
Version 9 dated July 19, 2018 
Version 8 dated March 19, 2018 
Version 7 dated May 11, 2017 
Version 6 dated February 14, 2017 
Version 5 dated January 26, 2017 
Version 4.2 dated December 29, 2016 
Version 4.1 dated December 14, 2016 
Version 4 dated November 22, 2016 
Version 3 dated September 19, 2016 
Version 2.2 dated July 7, 2016 
Version 1.5 April 28, 2016 
Version 1.4 March 2, 2016 
 

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TABLE OF CONTENTS 
 
DEFINITION OF TERMS USED ................................................................................................ 7 
PROTOCOL SYNOPSIS ........................................................................................................... 9 
2 
BACKGROUND AND RATIONALE ..................................................................................13 
2.1 
Research Hypothesis ........................................................................................................................ 13 
2.2 
Background for use of Prostvac-V/F .............................................................................................. 13 
2.2.1 
High-risk PCa ......................................................................................................................................... 13 
2.2.2 
Adjuvant Radiation, Chemotherapy, or Androgen Deprivation Therapy For High Risk PCa ..... 13 
2.3 
Study Rationale .................................................................................................................................. 14 
2.3.1 
Prostate Cancer Immunotherapy ......................................................................................................... 14 
2.3.2 
PSA as a Target Antigen ...................................................................................................................... 15 
2.3.3 
PSA-3-epitope modification .................................................................................................................. 15 
2.3.4 
Poxviral Vaccine Approach .................................................................................................................. 16 
2.3.5 
Vaccinia Virus ......................................................................................................................................... 16 
2.3.6 
Fowlpox Virus ......................................................................................................................................... 16 
2.3.7 
Prime-Boost ............................................................................................................................................ 16 
2.3.8 
TRICOM costimulatory molecules ....................................................................................................... 17 
2.4 
PROSTVAC-V/F for Prostate Cancer Immunotherapy ................................................................. 17 
2.4.1 
PROSTVAC-V/F Developmental Program ......................................................................................... 17 
2.4.2 
Summary of Findings from Human Clinical Studies ......................................................................... 18 
2.4.3 
Poxviral PSA Vaccine Clinical Trials ................................................................................................... 18 
2.4.4 
Clinical Safety of Recombinant Poxvirus-Based Vaccines .............................................................. 19 
2.5 
Potential Benefits and Risks to Human Subjects ........................................................................ 22 
2.6 
BACKGROUND FOR study of sociobiological responses to stress in prostate cancer ....... 23 
2.6.1 
Biological Pathways to Racial Disparities in Prostate Cancer Outcomes .................................................. 23 
2.6.2 
Clinical Model for Study of Stress Effects on Prostate Cancer and Immune Responses .......................... 25 
3 
STUDY OBJECTIVES ......................................................................................................26 
3.1 
Primary Objective .............................................................................................................................. 26 
3.2 
Secondary Objectives ....................................................................................................................... 26 
3.3 
Sub-Study Objectives .................................................................................................................................. 27 
4 
INVESTIGATIONAL PLAN ...............................................................................................27 
4.1 
Study Design and Duration .............................................................................................................. 27 
4.2 
Patient Population ...................................................................................................................................... 27 
4.3 
Inclusion Criteria ................................................................................................................................ 28 

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4.4 
Exclusion Criteria ........................................................................................................................................ 28 
4.5 
Eligibility For the Optional Sub-study .......................................................................................................... 30 
4.6 
Subject Enrollment and Registration ............................................................................................. 30 
4.7 
Discontinuation of Subjects from study ...................................................................................................... 30 
5 
TREATMENTS ..................................................................................................................31 
5.1 
Study Treatment:   PROSTVAC-V/F ................................................................................................ 31 
5.1.1 
Identification, Packaging, and Labeling .............................................................................................. 31 
5.1.2 
Storage, Handling, and Dispensing ..................................................................................................... 31 
5.2 
Selection and Timing of Dose for Each Subject ........................................................................... 32 
5.2.1 
PROSTVAC-V/F Treatment ................................................................................................................. 32 
6 
CONCOMITANT TREATMENTS ......................................................................................32 
6.1 
Prohibited and/or Restricted Treatments ................................................................................................... 32 
6.2 
Other Restrictions and Precautions ............................................................................................................ 33 
6.3 
Treatment Compliance ...................................................................................................................... 33 
7 
STUDY ASSESSMENTS AND PROCEDURES ................................................................33 
7.1 
Therapeutic Trial Procedures .......................................................................................................... 33 
7.2 
Optional Sub-Study Procedures .................................................................................................................. 34 
7.3 
Off-study Assessments .................................................................................................................... 34 
7.4 
Safety Assessments .......................................................................................................................... 35 
7.5 
Efficacy Assessments ....................................................................................................................... 35 
7.5.1 
Primary Efficacy Assessment .............................................................................................................. 35 
7.5.2 
Secondary Efficacy Assessments ....................................................................................................... 35 
8 
CORRELATIVE STUDIES ................................................................................................36 
8.1 
Research Blood Collections ......................................................................................................................... 36 
8.1.1 
Measurement of Antigen-Specific T-Cell Functions ................................................................................. 36 
8.1.2 
Measurement of Anti-Forssman Antibodies ............................................................................................ 37 
8.1.3 
Measurement of IgG Allotypes GM and KM ............................................................................................. 38 
8.1.4 
GR Genotyping ...................................................................................................................................... 3938 
8.2 
Formulin Fixed Paraffin Embedded tissue ............................................................................................... 3938 
8.3 
Quality of Life Patient Questionnaires ........................................................................................................ 39 
8.4 
Sub-study Social Determinants Survey: ...................................................................................................... 39 

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8.5 
Optional Sub-Study Trier Social Stress Test ............................................................................................. 4039 
8.6 
Allostatic Load ............................................................................................................................................ 41 
9 
ADVERSE EVENT REPORTING ......................................................................................42 
9.1 
Investigator Responsibilities ........................................................................................................... 42 
9.2 
Definition of Adverse Events (AE) .................................................................................................. 42 
9.3 
Collecting and Recording Adverse Events ................................................................................... 43 
9.4 
Assessment of Adverse Events ...................................................................................................... 43 
9.5 
Definition of Expected and Unexpected Events ........................................................................... 44 
9.5.1 
Expected Events .................................................................................................................................... 44 
9.5.2 
Unexpected Events ............................................................................................................................... 44 
9.6 
Assessment of Relationship to Study Drug (Causality) ............................................................. 44 
9.7 
Severity of Adverse Events (Grading) ........................................................................................ 4544 
9.8 
Definition of Serious Adverse Events ............................................................................................ 45 
9.9 
Events of Special Interest ........................................................................................................................ 4645 
9.9.1 
Appearance of Satellite Lesions ............................................................................................................ 4645 
9.9.2 
Pregnancy of a Female Partner ........................................................................................................... 46 
9.9.3 
Accidental Transmission of Vaccinia Virus ........................................................................................ 46 
9.10 
Expedited Reporting Requirements for Serious Adverse Events and Events of Special 
Interest ............................................................................................................................................................... 46 
10 
STATISTICAL CONSIDERATIONS ..................................................................................47 
10.1 
Statistical Considerations for the Primary Objective .................................................................. 47 
10.2 
Secondary Objectives ............................................................................................................................. 49 
10.2.1 
Comparison of Observed RFS with Predicted RFS ..................................................................... 49 
10.2.2 
Description of Treatment Toxicities ................................................................................................ 49 
10.2.3 
Correlative Laboratory Studies........................................................................................................ 49 
10.3 
Sociobiological Response to Stress OPtional sub-study Objectives ..................................................... 5049 
10.4 
Populations for Analyses ................................................................................................................. 50 
10.5 
Additional Analyses ...................................................................................................................... 5150 
11 
ETHICAL CONSIDERATIONS ..........................................................................................51 
11.1 
Good Clinical Practice ...................................................................................................................... 51 
11.2 
Institutional Review Board ............................................................................................................... 51 

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11.3 
Institutional Biosafety Committee (IBC) ........................................................................................ 51 
11.4 
Informed Consent .............................................................................................................................. 52 
11.5 
Compliance with the Protocol ......................................................................................................... 52 
11.6 
Records Retention ......................................................................................................................... 5352 
11.7 
Data collection .................................................................................................................................... 53 
11.8 
SubStudy Data Collection ................................................................................................................... 5453 
12 
REFERENCES ..................................................................................................................55 
APPENDIX A:  SCHEDULED PROCEDURES AND ASSESSMENTS .....................................65 
APPENDIX B:  SOURCE DATA FOR RFS ..............................................................................67 
APPENDIX C: PROCEDURE FOR OBTAINING VIG AND CIDOFOVIR FOR TREATMENT OF 
SERIOUS ADVERSE REACTIONS CAUSED BY THE SMALL POX VACCINE. .....................72 
APPENDIX D:  PHONE CONTACT GUIDE ..............................................................................73 
 
 
 

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DEFINITION OF TERMS USED 
ADT 
 
 
androgen deprivation therapy 
AE 
 
 
adverse event 
AL 
 
 
allostatic load 
ALT 
 
 
alanine transaminase 
APC 
 
 
antigen-presenting cells 
AST 
 
 
aspartate transaminase 
BNI 
 
 
Bavarian Nordic, Inc, formerly known as BNIT 
BUN 
 
 
blood urea nitrogen 
CBCD  
 
complete blood count with differential 
CDC 
 
 
center for disease control 
CEA 
 
 
carcinoembryonic antigen 
CFR 
 
  
Code of Federal Regulations  
cGMP  
 
good manufacturing practice 
CMP  
 
complete metabolic panel 
CRF 
 
 
case report form 
CTCAE 
 
 
Common Terminology Criteria for Adverse Events 
CTSA  
 
Clinical and Translational Science Award 
CTEP  
 
Cancer Therapy Evaluation Program 
CTL 
 
 
Cytotoxic T-lymphocytes 
DCTD  
 
NCI Division of Cancer Treatment and Diagnosis 
DSMC  
 
Data Safety Monitoring Committee 
ECOG  
 
Eastern Cooperative Oncology Group 
eCRF  
 
electronic case report form 
EM 
 
 
erythema multiforme 
EV 
 
 
eczema vaccinatum 
FDA 
 
 
US Food and Drug Administration 
GCP 
 
 
Good Clinical Practice 
GR 
 
 
glucocorticoid receptor 
HCC 
 
 
Hollings Cancer Center 
IB 
 
 
Investigator’s Brochure 
IBC 
 
 
Institutional Biosafety Committee 
ICF 
 
 
informed consent form 
ICH 
 
 
International Conference on Harmonisation 
IES 
 
 
Impact of Events Scale 
IGKC  
 
immunoglobulin  constant 
IM 
 
 
intramuscular 
INR 
 
 
international normalized ratio 
IRB 
 
 
International Review Board 
ISEL 
 
 
Interpersonal Support Evaluation List 
IV 
 
 
intravenous 
LLN 
 
 
lower limit of normal 
mCRPC 
 
metastatic castration-resistant prostate cancer 
MHC  
 
major histocompatibility complexes 
MUSC  
 
Medical University of South Carolina 
NCI 
 
 
National Cancer Institute 
 
PAP 
 
 
prostatic acid phosphatase 
PBL 
 
 
peripheral blood leukocytes 
PBMC  
 
peripheral blood mononuclear cells 
Pca 
 
 
prostate cancer 
PFS 
 
 
progression-free survival 
PI 
 
 
Principal Investigator 

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PSA 
 
 
prostate specific antigen 
PV 
 
 
progressive vaccinia 
PVE 
 
 
postvaccinial encephalitis 
QOL 
 
 
quality of life 
RBC 
 
 
red blood cell 
RECIST 
 
Response Evaluation Criteria in Solid Tumors 
REDCap 
 
Research Electronic Data Capture 
RFS 
 
 
relapse free survival 
SAE 
 
 
serious adverse event 
SES 
 
 
socio-economic status 
SIS Unit 
 
Sponsor-Investigator Support Unit 
SNP 
 
 
single nucleotide polymorphism 
SNS 
 
 
sympathetic nervous system 
SR 
 
 
stress response 
SUD 
 
 
subjective units of distress 
subQ  
 
subcutaneous injection 
SWOG  
 
Southwest Oncology Group 
TAA 
 
 
tumor-associated antigens 
TAA 
 
 
tumor-specific antigens 
TRICOM 
 
triad of co-stimulatory molecules 
TTP 
 
 
time-to-progression 
TSST  
 
Trier Social Stress Test 
ULN 
 
 
upper limit of normal 
VAMC  
 
Ralph H. Johnson Veteran’s Administration Medical Center 
VIG 
 
 
Vaccinia Immune Globulin 

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PROTOCOL SYNOPSIS 
Protocol Title: 
A PHASE II TRIAL OF ADJUVANT PROSTVAC-V/F IN SUBJECTS AT HIGH RISK FOR 
RELAPSE AFTER RADICAL PROSTATECTOMY 
Site Numbers & Names: 
1. 
Hollings Cancer Center, Medical University of South Carolina, Charleston, SC 
2. 
Ralph Johnson VA Medical Center, Charleston, SC 
Research Hypothesis: 
The hypothesis is that, in patients at high risk for relapse of PCa after radical prostatectomy, 
treatment with the PROSTVAC-V/F vaccine will improve Relapse Free Survival (RFS) 
compared with that expected for similar subjects given no adjuvant therapy. 
Study Schema: 
 
PROSTVAC-V   2 x 108pfu subQ x 1,  
followed by PROSTVAC-F 1 x 109 pfu subQ x 6 
Study Objectives: 
 
1. The primary endpoint is to determine the probability of RFS at 2 years after 
prostatectomy, and to compare it to RFS probability for historical control subjects 
without adjuvant treatment. 
 
2.  Secondary objectives are as follows: 
 
a) Compare observed RFSs to the predicted RFS values for the subjects as if they 
had received no adjuvant therapy.  The predicted (“virtual”) RFS for each subject 
will be calculated by standard algorithms.    
b) Relate serial measurement of immunologic parameters, SNPs to RFS 
c) Describe the toxicity for the treatment in this patient population 
Study Design:
The study will be a Phase II, open-label trial conducted at two centers in the United States.  
Accrual Goal: 
30 evaluable subjects out of 33 total enrollees  
Accrual Rate: 
(Number of subjects 
expected per month) 
1.85 subjects per month x 18 months = 33 subjects.   
Assuming an in-evaluability rate of about 10%, this will give us 30 evaluable subjects. 
Correlative Studies: 
 
1. Lymphocyte, monocytes subsets 
2. Immunoglobulin, FcR SNPs 
3. Plasma IL6, IL10, VEGF 
4. Exon sequencing on tumor from FFPE tissue 
Optional Study :  
Potential patients will be approached to participate in an optional sub-study looking at 
sociobiological responses to stress in prostate cancer survivors. 

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Inclusion Criteria: 
1. Age >21  
2. Completed radical prostatectomy for pathologically-verified adenocarcinoma of the 
prostate of the prostate no more than 120 days prior to enrollment.  The following 
procedures are acceptable:  radical retropubic prostatectomy (RRP),  laparoscopic 
prostatectomy (with or without robotic assistance: RALP),  radical perineal 
prostatectomy (RPP)  
3. Post-operative PSA must be undetectable < 0.2 ng/mL by 120 days after 
prostatectomy. 
4. Pts must have one or more of the following: 
a. 
pT3b or pT4 primary tumor 
b. 
Gleason score 8-10 
c. 
pN1 lymph node disease 
d. 
positive surgical margins 
e. 
pre-operative PSA of > 10 ng/mL 
f. 
presence of any tertiary Gleason 5 component on the prostatectomy pathology 
report 
 
Note:  Pts with pT3a disease who lack one of the criteria in 4a-f, and who refuse 
adjuvant radiation, may also be enrolled. 
5. ECOG PS 0-1 
6. Adequate hematologic, renal, liver function per parameters described in section 4.3.6     
7. Subject of fathering potential must use an adequate method of contraception to avoid 
conception throughout the study and for at least 4 weeks after the last dose of study 
drug to minimize the risk of pregnancy.   
8. Subjects must have had a negative bone scan, and CT of abdomen and pelvis within 
26 weeks prior to registration. Additional forms of imaging (Prostascint scan, MRI) may 
be substituted for a CT scan of the abdomen and pelvis if clinically indicated.  

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Exclusion Criteria: 
1. 
Pure small cell carcinoma of the prostate 
2. 
Radiographically-demonstrable metastases prior to, or at the time of enrollment 
3. 
Diagnosis of cancer requiring systemic therapy in the past 5 years 
4. 
Presence of any major medical condition which, in the opinion of the principal 
investigator, precludes participation in the study 
5. 
Neoadjuvant or adjuvant therapy of any kind  
6. 
Chronic administration (defined as daily or every other day for continued use > 14 
days) of systemic glucocorticoids within 28 days of the first planned dose of 
PROSTVAC-V/F. Use of inhaled steroids, nasal sprays, and all topical preparations 
(creams, solutions, gels, ointments, etc,) for up to 5% of the body surface area is 
allowed. 
7. 
Use of systemic immunosuppressant agents including anti-metabolites, 
glucocorticoids, TNFα antagonists, antibodies to IL6 or IL6R, calcineurin inhibitors, 
mTOR antagonists  
8. 
Prior history of serious toxicity or systemic reaction to vaccinia immunization such as 
myopericarditis, progressive vaccinia infection or eczema vaccinatum. 
9. 
Inflammatory or exfoliative skin diseases such as eczema, psoriasis that disrupt 
epidermis 
10. Active infections requiring systemic therapy 
11. Serologic evidence of HIV/AIDS. 
12. Positive hepatitis C serology or active hepatitis B infection.  
13. History of allergy to eggs, egg products, aminoglycoside antibiotics 
14. History of myocardial disease, such as myocarditis, cardiomyopathy, congestive 
heart failure, ischemic cardiomyopathy 
15. Prior solid organ or stem cell transplant 
16. History of or active autoimmune disease (e.g., autoimmune neutropenia, 
thrombocytopenia, or hemolytic anemia, systemic lupus erythematosis, Sjogren’s 
syndrome, scleroderma, myasthenia gravis, Goodpasture’s syndrome, or Addison’s 
disease).  Persons with vitiligo, Hashimoto’s thyroiditis, or Graves disease are not 
excluded.  
17. Vaccination with live attenuated vaccine within 28 days prior to day 1 of PROSTVAC-
V/F administration or vaccination with a killed vaccine within 14 days prior to day 1 of 
PROSTVAC-V/F. 
18. Inability to avoid close contact or household contact with the following high-risk 
individuals for three weeks after the Day 1 vaccination or until the vaccination site 
heals completely: (a) children ≤ 3 years of age, (b) pregnant or nursing women, (c) 
individuals with prior or concurrent extensive eczema or other eczemoid skin 
disorders, or (d) immunocompromised individuals, such as those with HIV. 
19. Any condition which, in the opinion of the investigator, would prevent full participation 
in this trial (including the Long-Term Follow-Up), or would interfere with the evaluation 
of the trial endpoints.
Criteria for Evaluation: 
 
1. 
Definition of Relapse: Relapse will be determined if any of the following conditions 
are met 
a. increase in PSA to > 0.2 ng/mL (confirmed >30 days later) after completion of 
all PROSTVAC V/F doses.  
b. development of radiographically-demonstrable metastases  
c. institution of new prostate cancer therapy 
d. death 
Note, RFS at two years will be met if a patient has met none of the above criteria 
two years post-surgery.  RFS as a time to event endpoint will be measured as the 
time in days from surgery to any of the above conditions being met. 
2. Toxicity criteria by the National Cancer Institute Common Toxicity Criteria for Adverse 
Events (CTCAE) version 4.0 

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Statistics for Main Study: 
Statistical considerations: 
 
Primary Objective:  The primary endpoint will be a binary indicator of relapse status at the 
2 year follow-up visit.  Enrollment and treatment initiation must take place no more than 
120 days after prostatectomy.  Two-year RFS will be estimated as a proportion with an 
exact 95% confidence interval.  RFS will also be treated as a time-to-event variable and 
Kaplan-Meier curves will be created; median and 95% confidence intervals will be 
reported. 
 
The data from this trial will be compared with results from historical control data obtained 
from a multi-institutional database which includes high-risk, post-prostatectomy subjects 
without adjuvant therapy (n = 243), and from a published clinical trial (n = 98).  The 
estimated 2-year probability of RFS of high-risk subjects after prostatectomy is 0.6.  We 
define an “interesting” improvement in RFS to be 30% (i.e. increase in the probability of 
RFS from 0.6 to 0.78).  Assuming a one-sided alpha = 0.1, with 30 patients in a group, we 
have 80% power to detect this difference based on an exact binomial test. Thus if among 
30 evaluable subjects, at least 24 are recurrence free at 24 months, we will reject the null 
hypothesis (2-year RFS=0.60) and conclude that the PROSTVAC intervention improves 
RFS relative to the RFS of similar patients receiving no adjuvant therapy. 
 
Secondary objectives:  a) A secondary objective will be a comparison of observed RFS 
times with the predicted RFS times for the treatment cohort using the Duke and CaPSURE 
nomograms.  The comparison will be performed using the logrank test of the observed and 
predicted RFSs.       
 
b) Biochemical and genomic measurements will be graphically displayed to evaluate their 
distributions.  Transformations will be taken as appropriate.  Cox regression will be used to 
estimate hazard ratios measuring the association between these measures and RFS.  
95% confidence will be estimated for the hazard ratios as appropriate.   
 
c) Toxicities will be tabulated by CTCAE grade and type.   
 
 
 

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2 
BACKGROUND AND RATIONALE 
2.1 RESEARCH HYPOTHESIS 
The hypothesis is that the PROSTVAC V/F vaccine will promote the development of an effective 
immune response leading to long-term disease control in subjects with PCa at high-risk for 
relapse after prostatectomy. 
 
2.2 BACKGROUND FOR USE OF PROSTVAC-V/F 
2.2.1 High-risk PCa 
PCa is the most common malignancy among men and the second leading cause of cancer death 
in men in the United States. The lifetime risk of developing PCa in the United States is 1 in 6, 
whereas the lifetime risk of death due to PCa is 1 in 34. Treatment options for PCa confined to 
the gland include watchful waiting, prostatectomy, and radiotherapy. While many cases of early 
and localized PCa can be cured by radical prostatectomy, one third of patients experience a 
recurrence of disease. These patients can be identified by clinical parameters through the use of 
widely-available nomograms (1,2).  These high-risk features include 1) T3 or T4 primary PCa, 2) 
one or more lymph nodes containing metastatic PCa, 3) an initial PSA >10 ng/mL, 4) involvement 
of the seminal vesicles, margins, or extraprostatic tissue with cancer.  Subjects with these features 
are at risk for clinically significant recurrence and poor outcomes.   
2.2.2 Adjuvant Radiation, Chemotherapy, or Androgen Deprivation Therapy For High 
Risk PCa                  
Systemic adjuvant therapy, using cytotoxic agents or hormone manipulation, has been shown to 
improve overall survival following surgery for subjects with clinical localized cancers of the breast, 
lung, colon, and other sites. However, adjuvant therapy for subjects treated with radical 
prostatectomy for PCa has not been widely studied or consistently applied. While traditional local 
therapies provide adequate control for the vast majority of PCa patients, a substantial minority of 
patients relapses and is at risk for a fatal outcome.  Adjuvant therapy for subjects treated with 
radical prostectomy for PCa has not been widely studied or consistently applied. 
 
Post-prostatectomy adjuvant therapy for PCa has largely consisted of radiation therapy or ADT. 
Recent large, prospective, randomized studies demonstrate that external beam radiation to the 
prostatic fossa can delay biochemical failure, and improve disease-specific survival in subsets of 
patients with T3a disease, especially those subjects with positive surgical margins (3,4). However, 
studies are inconsistent as to whether radiation clearly improves outcomes for more advanced 
cases (pT3b or pN1).  In addition radiation can cause significant side effects such as bowel 
toxicity, increased frequency of strictures, and possibly, secondary malignancies. 
 
Few data exist on the role of adjuvant chemotherapy for patients at high risk of relapse after 
prostatectomy.  The initial studies failed to show clear benefit, however, due to the lack of active 
agents (5-7).  In the past decade the taxanes have been identified as cytotoxic agents with 
significant anti-tumor activity in PCa (8,9).  Attempts have been made to develop chemotherapy 
regimens with adjuvant activity against PCa.  Three large-scale, phase III studies of adjuvant 

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chemotherapy have been launched, but have been difficult to complete.  The SWOG 9921 study 
compared adjuvant ADT with ADT plus six cycles of mitoxantrone.  The study was terminated 
short of the planned accrual due to an excess of acute leukemia cases in the chemotherapy arm 
(10).  TAX3501 was a multicenter trial comparing ADT with ADT plus six cycles of docetaxel.  This 
study too was terminated after only a small proportion of the total enrollment was accrued.  The 
Veterans Affairs Cooperative Studies Program is sponsoring CSP553, a randomized study 
comparing prostatectomy versus prostatectomy plus docetaxel for patients with high-risk, 
localized PCa.  Accrual has been completed, but no report has been published.   One phase II 
trial of adjuvant weekly single-agent docetaxel has been presented (11).  In this trial 77 post-
prostatectomy subjects at high risk for relapse or disease progression were treated.  Compared 
with the predicted PFS for the patients if they had not received adjuvant chemotherapy, there was 
little or no improvement in PFS from chemotherapy. 
 
The results from studies of adjuvant ADT are also variable. The only randomized, prospective 
study of adjuvant ADT was the E3886 trial reported by Messing, et al. (12,13).  This study 
demonstrated that ADT given immediately after prostatectomy (rather than waiting for clinical 
relapse) improves progression-free, disease-specific, and overall survival in PCa patients with 
positive lymph nodes. Older analyses of adjuvant ADT for other subgroups are ambiguous (14). 
Recent prospective (15) and retrospective (16) analyses are consistent with a beneficial effect 
from adjuvant ADT in a wide spectrum of high-risk patients, possibly better than would be 
expected from observation alone.  However, ADT is associated with significant side effects.  
These include increased body fat, insulin resistance, loss of libido, increased cardiac events, and 
potentially delay in or prevention of recovery of sexual function after prostatectomy.   Furthermore, 
it is not clear that adjuvant ADT “cures” PCa patients. Progression-free survival curves from the 
E3886 trial show continuing relapses over time, without a clear plateau or “break” in the downward 
slope of group survival curves, such as would be seen with a curative treatment. 
 
2.3 STUDY RATIONALE 
The rationale is based on the observation that PROSTVAC V/F vaccine can generate an effective 
immune response against prostate cancer in subsets of patients with advanced disease.  
Therefore it would be most likely to have the maximum effect when applied at an early stage of 
cancer, when the tumor bulk is low, when there is not androgen deprivation, and when the patient 
is in good physical condition.  We propose to use PROSTVAC V/F in subjects at high risk of 
relapse shortly after radical prostatectomy. 
 
2.3.1 Prostate Cancer Immunotherapy 
Therapeutic cancer vaccines have been investigated in both castration-sensitive and castration-
resistant disease (17).  Prostate cancer is an ideal disease for treatments that stimulate the 
immune system to target cancer cells.  Prostate cancer may progress slowly (even in advanced 
disease), allowing time for the immune system to be stimulated, and to mount an active immune 
response.  It is not a highly chemosensitive disease, so patients are generally not heavily 
pretreated with cytotoxic agents, and their immune systems are more intact.  Prostate cells have 
a unique and specific marker, PSA, which is secreted into the blood, and can be detected with 
even low levels of tumor burden.  Several other gene products are unique to prostate cells, and 

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prostate cancer cells over-express TAA, making for multiple targets suitable for immunotherapy 
responses (18,19).  Many patients with prostate cancer have low levels of cytolytic T-cells capable 
of recognizing PSA, and this minimal response can be enhanced with immune stimulation by 
therapeutic cancer vaccines (20).  Finally, because the prostate is a nonessential organ, targeting 
PSA- or TAA-specific immune cells to prostatic tissue is unlikely to have a significant negative 
clinical impact. 
 
The first FDA approved prostate cancer immunotherapy, Provenge (sipuleucel-T), is now 
available (approved 29 April 2010).  Provenge is a cell-based vaccine consisting of autologous 
PBMCs that have been activated ex-vivo with a recombinant protein representing a fusion of PAP 
(prostatic acid phosphatase) and GM-CSF. Early clinical work demonstrated prolongation of 
overall survival (21), and up-regulations of cellular immunity and reductions in PSA and PAP 
levels (22).  The Phase 3 IMPACT study of 512 subjects with metastatic castration-resistant 
prostate cancer met its primary endpoint of prolongation of overall survival.  Provenge was 
approved for use in metastatic castration-resistant prostate cancer based on an increase in 
median survival of 4.1 to 4.5 months (23). 
2.3.2 PSA as a Target Antigen 
PSA is a promising target antigen for immunotherapy of prostate cancer. PSA is a ~34,000 dalton 
glycoprotein that is produced in normal, benign, and cancerous prostate epithelia, but not in other 
normal tissues (24,25). Because PSA is expressed essentially only in prostatic epithelial cells 
(normal and malignant), and the prostate gland is nonessential, this antigen is an enticing choice.  
The fact that PSA is secreted and not membrane-bound limits its use as a target for humoral 
immunity, but not its use as a target of specific cellular immune system attack. Cells, including 
tumor cells, present endogenously expressed proteins on their surface in the form of peptide- 
MHC. CTLs recognize and are activated by specific peptides in the context of the appropriate 
MHC class I molecule on APC. This activation can in turn lead to killing of tumor targets by the 
peptide-specific CTLs.  The use of PSA as a target to elicit tumor-specific T-cell-mediated lysis 
has been validated in vitro.  Correale et al. demonstrated in vitro killing of a PSA-peptide-pulsed 
HLA-A2+ human cell line by a PSA-specific human CTL cell line, and lysis was blocked by an 
antibody directed against MHC class I molecules (26). It has also been shown that PSA-specific 
CTLs could be generated that lyse PSA-expressing prostate cancer cells (26,27). The 
identification of these peptide epitopes further provides a means of identifying cytolytic T-cells 
resulting from immunization as an in vitro monitoring tool. 
2.3.3 PSA-3-epitope modification 
Protein antigens are presented to CTLs as small peptides (approximately 9–10 amino acids long) 
bound to class I molecules of the MHC. One strategy to increase the immunogenicity of a self-
antigen such as PSA is to modify selected epitopes within the protein sequence to enhance their 
binding to MHC class I alleles. The stabilized binding enables more sustained and potent immune 
cell activation. One such epitope, designated PSA-3 (amino acids 154–163), which is specific for 
the MHC class I A2 allele, was modified by the introduction of a single amino acid change (I to L) 
at position 2 in the epitope (designated L155) (27); (28). A number of in vitro studies suggest that 
PSA carrying this modification will be more immunogenic in HLA-A2 individuals than the native 
(unmodified) PSA polypeptide (27)(28)). 

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2.3.4 Poxviral Vaccine Approach 
Poxviruses are large multi-enveloped DNA viruses which encode about 200 genes. Poxviral 
vectors are able to accommodate multiple transgenes, and are able to deliver PSA and multiple 
immunostimulatory genes directly or indirectly to APCs. The activated APCs process and present 
the PSA antigen, leading to PSA specific T-cell activation (29,30). PSA as a soluble protein is 
weakly immunogenic, especially in the tumor-bearing host. Vaccine strategies must induce 
greater activation of T-cells than is being achieved endogenously in the host. The poxviral system 
achieves this by generating a natural inflammatory context for facilitating activation of immune 
cells, and inducing PSA-specific immune responses. Extensive pre-clinical studies in 
experimental murine models have demonstrated the therapeutic utility of using poxviral vaccines 
to break tolerance (31-33).  Another advantage of poxviral vaccines is that they are well tolerated 
by the patients. The relative safety of PSA-based poxviral vectors has been well established in 
previous trials (34-36). 
2.3.5 Vaccinia Virus 
Vaccinia virus has been used for over 200 years as a vaccine for smallpox and has a well-
established safety and adverse event profile (37,38). The virus actively replicates in human cells, 
and generates a strong inflammatory response, resulting in the presentation of high levels of 
antigen to the immune system over a period of one to two weeks, supporting a potent immune 
stimulation.  Subsequently, the immune response specific to vaccinia then eliminates the virus. 
Host immune responses to vaccinia restrict its replication and thus limit its ability to be re-used 
for subsequent vaccinations.  Consequently, vaccinia-based vaccines, although potent 
immunological priming agents, can be used to immunize an individual only once or twice. 
2.3.6 Fowlpox Virus 
Fowlpox virus is a member of the genus Avipox, which is evolutionarily divergent from vaccinia 
virus and serologically non cross-reactive (39,40). Immune responses to vaccinia are essentially 
non cross-reactive with fowlpox, and do not block infection and immunization with fowlpox-based 
vectors. Hence vaccinia-primed immune responses can be boosted with fowlpox vectors.  In 
addition, fowlpox vectors do not replicate in human cells (only in avian cells), and are therefore 
much less of a safety risk than vaccinia-based vectors. Fowlpox vectors mediate a limited 
infection in human cells, with early viral and transgene expression, but late gene expression is 
blocked, and no infectious particles are produced. Thus minimal viral surface antigen is made, 
and minimal neutralizing antibody immune responses are induced. This enables multiple boosting 
with the fowlpox-based vectors. 
2.3.7 Prime-Boost 
Recombinant vaccinia and fowlpox vectors are most effective when used in combination in prime-
boost regimens. By priming with recombinant vaccinia virus and then boosting repeatedly with 
the corresponding recombinant fowlpox virus, maximum immune responses to the expressed 
tumor antigens can be obtained. This phenomenon has been demonstrated in animal models 
(41,42) and has been supported by the results from the completed Phase 1 and Phase 2 trials 
conducted by the NCI, ECOG, and Therion.   

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2.3.8 TRICOM costimulatory molecules 
Destruction of immunological targets requires T-cell lymphocyte recognition, via the T-cell 
receptor, of antigenic peptides presented in the context of MHC molecules on APCs.  In addition 
to this antigen-specific signal, a second, antigen-independent signal is required for T-cell 
activation (43,44). This second signal is provided by the interaction of specific ligands on the T-
cell surface with “costimulatory” molecules expressed on APCs.  The most extensively studied 
pathway of costimulation is that involving the interaction of the costimulatory molecule B7.1 
expressed on APCs with CD28 and CTLA4 on the T-cell (45,46).  A number of additional 
costimulatory molecules on APCs have been identified; these include ICAM-1 and LFA-3, whose 
ligands are LFA-1 and CD2, respectively, on the surface of T-cells (47-49).  Proper engagement 
of the T-cell receptor and costimulatory receptor requires the expression of both antigen and 
costimulatory molecules, respectively, in the same cell. Therefore, co-expression of costimulatory 
molecules using a single recombinant vector presents the potential of cooperation among these 
proteins to enhance T-cell activation.  Recombinant vectors co-expressing three costimulatory 
molecules, LFA-3, ICAM-1, and B7.1, designated TRICOM™ (TRICOM), have been shown to 
have synergistic effects on antitumor responses as compared to vectors expressing individual 
costimulatory molecules (50).  Mice immunized with a recombinant vaccinia virus co-expressing 
carcinoembryonic antigen (CEA) and murine TRICOM exhibited greater immune responses and 
antitumor responses than mice immunized with a recombinant vaccinia virus co-expressing CEA 
and murine B7.1.  Enhanced anti-tumor immunity was also observed in mice that were transgenic 
(tolerant) for CEA (50).  PROSTVAC-V and PROSTVAC-F have, therefore, been designed to 
simultaneously express PSA together with B7.1, LFA-3, and ICAM-1. 
 
2.4 
PROSTVAC-V/F FOR PROSTATE CANCER IMMUNOTHERAPY 
2.4.1 PROSTVAC-V/F Developmental Program  
BNI is developing PROSTVAC-V/F for the treatment of prostate cancer (34). The PROSTVAC 
vaccine product is comprised of two biologic agents, PROSTVAC-V and PROSTVAC-F. These 
are two different poxvirus vectors, recombinant vaccinia and fowlpox viruses, encoding the genes 
for PSA with the L155 mutation in combination with a triad of human costimulatory molecules, 
B7.1, ICAM-1, and LFA-3 (TRICOM™; TRICOM). They are used to introduce TAAs and 
costimulatory molecules into patients with metastatic prostate cancer. The vaccinia and fowlpox 
viruses encoding PSA and TRICOM are used in a prime-boost vaccination regimen to optimize 
immune responses against prostate cancer tumor cells. 
 
The proposed treatment is a PSA-based immunization strategy. PROSTVAC-V/F is a viral vector-
based product that is administered over seven subcutaneous vaccinations, over a five month 
period. It is intended to generate immune responses to prostate specific antigens and prostate 
cancer cells. It uses poxviral vectors to introduce modified PSA to the patient in an immunogenic 
manner to break self-tolerance and generate immune responses directed against prostate cancer 
cells.  
 
PROSTVAC-V/F is an outcome of more than 15 years of poxviral vector development and 
evaluation by the NCI, the former Therion Biologics Corporation (Therion), and BNI. Over 570 

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patients have been treated with related PSA-containing poxviral vectors, and over 300 patients 
have been treated with the current PROSTVAC-V/F regimen.   A large database (see 
Investigator’s Brochure) exists from safety evaluations in animals and in humans for PROSTVAC-
V/F. BNIT-PRV-301 will evaluate the efficacy of PROSTVAC-V/F in men with asymptomatic or 
minimally symptomatic, mCRPC. 
 
2.4.2 Summary of Findings from Human Clinical Studies 
Clinical investigation of the PROSTVAC-V/F vaccine product in the United States was initiated in 
2002 by Therion under BB-IND 10428.  Therion manufactured all PROSTVAC-V/F product and 
conducted two clinical trials on PROSTVAC-V/F, including a Phase 1 trial evaluating the safety 
and immunogenicity of PROSTVAC-V/F in 10 subjects, and a randomized, placebo-controlled 
Phase 2 trial evaluating the safety and efficacy (as defined by TTP) of PROSTVAC-V/F in 
approximately 125 men with castration-resistant metastatic prostate cancer.  Both trials were 
conducted in the US only.  Therion also manufactured the PROSTVAC-V/F product for all the NCI 
and ECOG trials. 
 
2.4.3 Poxviral PSA Vaccine Clinical Trials 
The use of poxviral vectors to stimulate an immune response to PSA has been evaluated in 
several clinical trials. In a Phase 1 clinical trial using an earlier version of a PSA-based vaccine 
(devoid of any costimulation), Eder et al. used three monthly vaccinations of recombinant vaccinia 
(rV)-PSA (51). Six out of 10 subjects with rising PSA following local therapy who received the 
highest tested dose, with GM-CSF, had a time of PSA progression of greater than six months. 
Four of these 6 subjects still showed no progression, with the longest time of follow-up greater 
than 24 months. This was suggested to be evidence of clinical activity (51). Five of 7 HLA-A2+ 
subjects in this final dose level had at least a 2-fold increase in PSA-specific T-cells in PBMCs as 
a result of vaccination, as measured by the ELISPOT assay, indicating that tolerance to self-
antigens could be circumvented with these vaccine strategies. Another Phase 1 study of rV-PSA 
also demonstrated that immune responses could be elicited in subjects with metastatic hormone-
refractory prostate cancer and that immune cells taken from these subjects could specifically lyse 
PSA-expressing cancer cells in vitro (52). 
 
ECOG previously conducted and reported a randomized Phase 2 study in which 64 subjects with 
rising PSA following definitive local therapy with no evidence of disease on imaging studies were 
randomized to receive four vaccines with rV-PSA (designated V) and/or rF-PSA (designated A for 
avipox) (53). The arms were thus VAAA, AAAA and AAAV. PSA PFS was about 9 months in the 
latter arm, and about 18 months in the VAAA arm, lending further support to the use of vaccinia 
priming and avipox vector boosting.   
 
Vaccinia and fowlpox vectors containing the gene for human PSA with a single amino acid 
substitution (designated PSA (L155)) along with genes encoding TRICOM have been tested in 
two fully accrued Phase 1 clinical trials with 25 subjects with metastatic prostate cancer (36,54). 
There were no dose-limiting toxicities on these studies attributed to vaccine.  One of these studies 
in subjects with mCRPC has shown that subjects treated with PSA/TRICOM who were evaluable 

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for immune response had an increase in PSA-specific T-cells after treatment; and 9 of 15 subjects 
had decreases in PSA velocity (36).   
 
The Therion-sponsored Phase 2 trial randomized subjects with mCRPC 2:1 in favor of vaccine 
vs. an empty fowlpox vector as control. 125 subjects with mCRPC and Gleason scores ≤ 7 were 
enrolled (122 treated). Subjects randomized to receive vaccine (82 subjects) were given 
subcutaneous rV-PSATRICOM prime with monthly boosts of rF-PSA-TRICOM, while control 
subjects (40 subjects) were given subcutaneous injections of fowlpox. Although no difference in 
TTP was seen in the short-term, in an interim analysis at two years of follow-up, median overall 
survival was 24.4 months in the vaccine arm compared to 16.6 months in the control arm, 
suggesting that although disease progression occurred at similar times in both groups, there 
appeared to be a long-term benefit for some subjects treated with PSA/TRICOM (30,55).  The 
overall survival results after a final survey (median follow-up 4 years) were recently completed. 
The formal overall survival update revealed that PROSTVAC-V/F immunotherapy was associated 
with a significant survival benefit. PROSTVAC-V/F-treated subjects had a longer median survival 
(25.1 months versus 16.6 months controls), and an increased survival at 3 years post study (25 
of 82 subjects, 30%; versus 7 of 40 control subjects, 17%). Statistical analysis of the Kaplan-
Meier curves revealed an estimated hazard ratio of 0.56 (95% CI 0.37-0.85), and a stratified log 
rank of P=0.006 (23).   
 
In an NCI Phase 2 study (NCI no.5911) of PSA/TRICOM, 32 subjects with metastatic CRPC were 
treated with an rV-PSA-TRICOM prime and monthly boosts of rF-PSA-TRICOM. In that trial, 47% 
of subjects had a decrease in PSA velocity, 38% had a PSA decline. Median time to progression 
was 2.8 months. One subject at 8 months experienced a decrease in his hilar adenopathy 
associated with declining PSA (> 30%). He remained on study for 12 months. Another subject 
had a decrease of 29% in his adenopathy (by RECIST) associated with a decline in his PSA (> 
30%). Another subject who enrolled on study with a super-scan on bone scan had a >70% decline 
in his PSA and remains on trial more than 4 years after enrollment. Overall, 13 of 29 evaluable 
subjects had a > 2-fold increase in PSA-specific T-cells.  In addition, 5 subjects had a > 6-fold 
increase in PSA-specific T-cells, which was associated with a trend to improved overall survival 
(p = 0.055) (56); (57). 
2.4.4 Clinical Safety of Recombinant Poxvirus-Based Vaccines 
2.4.4.1 Vaccinia Virus 
Vaccinia virus causes a transient infection, with elimination of viral components over several 
weeks. Host cells infected with vaccinia virus are short lived (days) and die by a mixed form of 
apoptosis/necrosis.  Vaccinia replicates in the cytoplasm of infected cells, and viral DNA does not 
integrate into the host cell DNA. Vaccinia virus is known to be shed from the wound site in 
traditional dermal scarification based vaccination. 
The use of vaccinia virus for worldwide eradication of smallpox provides a safety database with 
number of observations in the millions. Geographical differences in strains of vaccinia virus used 
as well as differences in reporting practices, diagnostic and follow-up criteria between countries 
are a cause of some discrepancies in the incidences of adverse events reported, but the overall 
picture of vaccinia virus safety is very well known. An additional set of data is provided by recent 
vaccination campaign of military and civilian vaccinations in the US. 
 

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A number of events post vaccination are expected and considered to be normal: fever, myalgia, 
headache, fatigue, chills, nausea, soreness and erythema at the vaccination site, local 
lymphadenopathy.  Satellite lesions around the vaccination site have been reported as well as 
local edema. These symptoms are self-limiting, last for around three weeks after vaccination and 
rarely are a cause for serious concern (58,59). Mild adverse reactions that can occur post 
vaccination are bacterial superinfection of vaccination site, erythema EM and generalized vaccinia. 
Superinfection is a rare event with incidence from 0.14 to 55 cases per million according to 
different reports (60).  EM most often presents as papules, plaques or 20ocalized20 which may 
be symmetrical, may involve palms and soles. EM resolves spontaneously and requires no 
special care. A development of Stevens-Johnson syndrome with mucosal involvement is 
extremely rare, with only one case noted in the 2003-2004 vaccination campaign in the US (<1 
per 1,000,000) (59,61).  Generalized vaccinia results from viremic spread of vaccinia virus from 
the vaccination site. It presents as a generalized rash, which behaves like the vaccination site 
lesion, progressing through 20ocaliz, vesicular, pustular and scab-forming stages. The incidence 
is difficult to assess, since historically there was no strict definition to distinguish generalized 
vaccinia from other conditions where rash is a dominant symptom (severe chickenpox, smallpox, 
eczema vaccinatum, EM). Retrospective analysis of 2002 –2004 vaccinations suggests an 
incidence of ~50 cases per 1,000,000 (62). The rash appears within a week after vaccination and 
resolves within a week. Most instances do not require specific therapy (Fulginiti 2003).  Some of 
the post-vaccinia adverse events, although very rare, are serious and potentially life-threatening.  
They are described as follows. 
 
PV is the most serious complication known. It was almost always fatal prior to the introduction of 
VIG. PV occurs predominantly in persons with T-cell deficiencies or receiving treatments that 
result in T-cell deficiencies. The primary vaccination site fails to heal leading to a severe local 
reaction with necrosis, and viremic spread of vaccinia leads to generalized appearance of new 
lesions without reactive immunoinflammatory response (59,63).  PV is extremely rare; historical 
incidence is in the order of 1 case per 1,000,000. There were no reports of PV in the military and 
civilian vaccines in 2002 – 2004 vaccination campaigns (61). 
 
EV manifests as rash (popular, vesicular, pustular, erosive) that can be localized or generalized 
and predominantly occurs in the areas that have been affected by lesions of atopic dermatitis or 
other eczematous skin condition. Historically it occurred at a rate of ~1 case per 25,000 
vaccinations.  EV can occur in a vaccine recipient as well as in susceptible individuals in close 
contact. Two cases of EV from transmission have been recently reported, both in children of 
recently vaccinated US military personnel (64,65). In the military vaccination program in the US 
there were no reports of EV among 450,239 vaccinees, probably due to careful screening for 
contraindications (66). Review of civilian vaccinations did not detect any cases of EV (60).  EV 
can be prevented by thorough screening of at-risk individuals and education on importance of 
avoiding contacts with such persons and proper hygiene. 
 
PVE historical case-fatality rate is 25%. The historical (1963 – 1968) reported frequency of PVE 
in United States was reported at 2.9 cases per 1,000,000 (67)). PVE has higher prevalence and 
mortality rate in children compared to adults. Higher historical rates were reported in Europe 
compared to United States. Variability is attributed to differences in case definitions, clinical 
evaluations and differences in vaccine strains used by different countries (68). Pathogenesis is 

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still under investigation, although several compelling theories focus on autoimmune mechanism.  
Aside from vaccinia, measles and rabies vaccines have known association with PVE, as well as 
other viral and bacterial infections (69); (70), ). Review of 2002 – 2004 vaccinations in US reported 
three cases of PVE for the rate of 5 per 1,000,000. 
 
Recent vaccination campaign in the US revealed a higher than historically observed incidence of 
myocarditis or pericarditis among 21ocalize.  Predominant symptoms were chest pain, shortness 
of breath and fatigue, typically mild and transient.  Among military contingent, 88% of cases 
occurred in men with the incidence of 16.11 per 100,000 for primary vaccines and 2.07 per 
100,000 in revaccinees (71). In civilian population women accounted for 67% of cases and the 
majority of events (86%) were reported in revaccinees (37,72). Variability between the two sets 
of data may be explained by differences in demographics of 21 ocalize, case detection, 
ascertainment and reporting practices (Morgan 2008). Myocarditis and pericarditis has been long 
associated with a number of viral infections, although there are very few reports of confirmed 
viremia. A few cases have been reported following DTP and influenza vaccinations (73,74).  It is 
currently assumed that injury to the heart post viral infection is more of an immune inflammatory 
than direct nature (75,76). 
 
A review of data from 2002 – 2004 vaccinations in US reported ~1 case of autoinoculation per 
6,500 vaccinations with 17% of ocular cases, none with corneal involvement (61).  Vaccinia 
keratitis is the most serious consequence of autoinoculation, since lesions on the cornea threaten 
eyesight.  Diseased or injured conjunctiva and cornea may increase the risk of this complication.  
Vaccinia keratitis will respond to treatment with topical antiviral agents and interferon and can be 
prevented with use of occlusive bandages over the scarification site and by subject education 
(77).   Transmission of vaccinia to close contacts is another known complication.  Contact vaccinia 
may manifest as progressive vaccinia, eczema vaccinatum or accidental infection of eye, mouth, 
genital areas. A review of several national and state surveys between 1962 and 1968 gives 
frequency for EV at 8 – 27 per 1,000,000, and for accidental infections at 3 – 44 per 1,000,000 
(78).  The rate of contact vaccinia in 2002 – 2004 was <10 cases per 100,000. Education of 
21ocalize in proper care for the vaccination site, proper hand hygiene and avoidance of contact 
with at risk individuals seems to be a reasonable and effective prophylactic against contact 
vaccinia.  PROSTVAC-V/F immunization is subcutaneously administered, which greatly reduces 
injection site reactions, and skin surface wound formation/viral shedding.  PROSTVAC-V/F is also 
given to vaccinia preimmune persons. Both of these factors reduce the potential for inadvertent 
infection versus traditional smallpox vaccine programs. 
2.4.4.2 Fowlpox Virus 
Fowlpox virus has been investigated and used in vaccine design for at least two decades. As a 
pox virus, it offers the advantages of a large genome but provides an additional safety assurance 
by not being able to replicate in mammalian cells. Fowlpox virus-based vaccines have been tested 
in both animals and humans for HIV, malaria and cancer. No safety concerns have been raised 
and the adverse events associated with the use of fowlpox vector have been limited to mild 
injection site reactions (40,79). 
2.4.4.3 Safety of Recombinant Poxvirus Vectors in Cancer Immuntherapy 
Since 1991, 10 recombinant vaccinia-based vaccines and 8 recombinant fowlpox-based 
vaccines produced by Therion for the treatment of various cancers have been evaluated in 

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human clinical trials sponsored by CTEP, DCTD, NCI. Over 1,000 cancer subjects, most with 
metastatic disease, have been treated to date with these poxvirus-based vaccines in 29 CTEP-
sponsored or Therion-sponsored clinical trials (80). These trials represent a large component of 
the relevant safety database that supported the initiation of the Phase 3 trial of PROSTVAC-V/F.  
Significant safety experience in humans includes: (a) vaccinia- and/or fowlpox-based vaccines 
safely administered by a variety of routes including intradermal (by injection or scarification), 
subQ,  IM, IV, and intra-tumoral at doses up to 2 x 109 Inf. U. (vaccinia) or 6 x 109 Inf. U. 
(fowlpox); (b) vaccinia-based and fowlpox-based vaccines containing costimulatory molecules, 
alone or in combination with CEA or PSA antigens, administered without serious adverse 
effects, as outlined below. 
 
Poxviral vectors containing PSA, either alone or with B7.1 or TRICOM, have been evaluated in 
13 different Phase 1 (5 trials) and 2 (8 trials) comprising over 400 vaccinated subjects with 
advanced prostate cancer. In addition, there are three other fully enrolled, and two open studies 
using PROSTVACV/F treatment, for an additional 100 treated subjects. There have only been 
two serious adverse events thought to be possibly due to the PROSTVAC-V/F treatment (both in 
the same subject): the subject had a myocardial infarction and it was found that he had Grade 4 
thrombotic thrombocytopenic purpura, thought to be possibly related to study drug, approximately 
3.5 weeks after receiving the fourth dose of his vaccine. This resolved with therapeutic apheresis 
treatment, however, the subject continued to do poorly (for a more detailed description of this 
case, see Investigator’s Brochure). Thrombotic thrombocytopenic purpura has not been reported 
as an adverse event in large scale studies of smallpox vaccination with vaccinia. 
 
2.5 
POTENTIAL BENEFITS AND RISKS TO HUMAN SUBJECTS 
The intent of vaccination with PROSTVAC-V/F is to induce an immune response to PSA, and 
other prostate- and tumor-specific antigens. In the randomized, placebo controlled Phase 2 trial, 
an over-all survival benefit among patients who received PROSTVAC-V/F was observed. It is 
unknown whether PROSTVAC-V/F will provide this benefit to subjects participating in this trial, as 
this product is still currently in development. Benefits of this trial also include the potential boosting 
(or acquisition) of protective immunity against smallpox. 
 
Based on clinical experience with PROSTVAC-V/F in Phase 2, adverse reactions are expected 
to be minimal. A local injection site reaction is typical, and comparable to those seen with other 
modern vaccines. Potential adverse reactions attributable to the administration of PROSTVAC-
V/F at ≥ 50% frequency include injection site reactions (pain, swelling, induration, and redness), 
and at ≥ 10% frequency include headache, fatigue, myalgia, and nausea; the majority of events 
of Grade 1 and 2 in severity. 
 
The priming vaccination with PROSTVAC-V is with a vaccinia-based replicating virus.  Special 
wound pre-cautions are required.  The vaccinia virus has been used in millions of people to 
eliminate smallpox. In this trial it is given subcutaneously, not by dermal scarification, and local 
injection site reactions are much less severe, and viral shedding is minimal. However, there are 
still risks of inadvertent infection of other body sites (through scratching), or transfer of infection 
to others. Special bandage precautions are required, and subjects need to avoid contact with 
small children <3 years of age, individuals who are immunocompromised or are receiving 

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immunosuppressive therapies, and pregnant or lactating women (for 3 weeks). With smallpox 
vaccine programs in vaccinia-naïve subjects immunized by dermal scarification, inadvertent 
inoculation occurred approximately 1/6,000 vaccinations.  Subjects in this trial will be given 
detailed instructions on proper care of the injection site and rules of hygiene to prevent inadvertent 
inoculations and transmission of vaccinia virus.   
 
In the recent series of military and civilian vaccinations, vaccinia immunization has been reported 
to induce myopericarditis.  Symptoms of chest pain were typically mild and transient, but occurred 
in 1/1,000 subjects. The incidence of this complication is lower in re-vaccinees.  To prevent 
potential exacerbation of existing chronic problems, this protocol excludes subjects with known 
history of heart disease from participating in the trial. In addition, there are rare risks of severe 
and possibly life-threatening adverse reactions.  These include eczema vaccinatum (~1/25,000, 
usually with history of underlying skin disorder) or progressive vaccinia infections (~1/300,000, 
usually with underlying immunodeficiency), or post-vaccinial encephalitis (~1/500,000, usually 
infants or small children).  These were observed after the administration of conventional smallpox 
vaccines, and have not been seen in prior studies of PROSTVAC-V/F or related PSA (or other 
tumor antigen-containing vaccinia virus vaccines) administered to vaccinia pre-immune cancer 
subjects Under the proposed protocol, age restriction, exclusion of all preexisting conditions with 
features of immune suppression and skin disorders minimize the risk of such rare complications.  
To minimize risk, potential subjects who have a known allergy to eggs, egg products, 
aminoglycoside antibiotics, or other pre-existing medical conditions known to be risk factors for 
SAEs will be excluded from participation.  In view of the anticipated mild side effects, the potential 
risks for the subject seem to be limited and to justify the potential benefit of participating in this 
trial. 
 
2.6 
BACKGROUND FOR STUDY OF SOCIOBIOLOGICAL RESPONSES TO STRESS IN 
PROSTATE CANCER 
2.6.1 Biological Pathways to Racial Disparities in Prostate Cancer Outcomes  
Despite increased access to early detection and the availability of more effective therapeutic 
strategies, African Americans with prostate cancer continue to experience excess rates of 
morbidity and mortality from this disease.  A vast array of genomic and epigenomic studies of 
prostate cancer cells, or peri-tumoral stroma, have identified differences among racial groups.  An 
emerging hypothesis about prostate cancer disparities is that social conditions and physiological 
responses to social stressors influence biological processes, and are important to the aggressive 
behavior, and poor response to treatment, among African Americans (81).  This hypothesis is 
supported by animal studies showing that chronic stress promotes tumor development and 
progression in various rodent cancer models (82,83) including prostate cancer models (84).  
Chronic stress has also been shown to augment the normal age-related senescence of the 
immune system, enhancing the low of T cell diversity and increasing systemic inflammation 
(85,86).  
 
The mechanisms through which socio-economic stressors affect several and varied phenotypes 
in cancer patients are not clear.  The postulated mechanisms derive from the HPA axis (1) or the 
SNS (87) in most studies.  In the former case, chronically elevated cortisol has been identified as 

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a mediator of stress, acting through the polymorphic GR.   In the latter case, norepinephrine is 
thought to regulate VEGF- and PKA-dependent signaling pathways, leading to increased 
proliferation and migration.  Recent work has also implicated stress-induced loss of TP53 function 
(88).  These pathways are not mutually exclusive, and multiple signaling events may be involved 
in mediating stress effects. 
 
A variety of social conditions and SES factors may be involved in promoting cancer.  Data are 
most advanced for breast cancer.  Social support and perceptions of loneliness are critical to the 
breast cancer recovery process and morbidity and mortality from disease.  Women who have high 
levels of social support have a decreased risk of breast cancer mortality, even if they are 
diagnosed with advanced stage disease, whereas social isolation increase the likelihood of breast 
mortality (89).   In addition chronic economic stressors and living in in stressful social 
environments may contribute to an increased risk of developing advanced breast cancer and triple 
negative disease.   How these stressors function in the setting of prostate cancer is much less 
clear.  Several studies have examined the extent of perceived stress in prostate cancer patients, 
generally relating these parameters to QOL measurements, or biochemical analyses of stress, or 
immune system mediators.  Hoyt et al (90) found that prostate cancer patients who used avoidant 
coping strategies had a greater dysregulated cortisol response.  Fabre et al (91) has shown that 
cortisol moderates the effects of adverse life events on testosterone; among those who had high 
cortisol, the number of stressful life events was positively correlated with total testosterone levels.  
Similarly, stressful life events were positively correlated with PSA among men with high cortisol 
levels, but were negatively associated with PSA among those who had low cortisol (92).   While 
stress management methods generally improve QOL, no studies have related stress in prostate 
cancer patients to an actual anti-cancer effect, or to the development of an anti-cancer immune 
response.   
 
Even fewer studies have examined the effect of race on stress levels and effects in prostate 
cancer patients.   In a study of multiple socioeconomic stressors, Coker (93) noted a modest 
association of coping-intensity (“John Henryism”) with prostate cancer incidence in African 
Americans (HR 1.63), but the same effect was noted in Caucasians.  Jenkins (94) noted that 
African Americans were more likely to have concerns about sexual function after primary prostate 
cancer therapy than were Caucasians.  Depression is more likely to be worsened by a prostate 
cancer diagnosis in African Americans than in Caucasians (95), and African Americans are more 
likely to have experienced traumatic stress than Caucasians (96).  African American prostate 
cancer survivors generally had poorer mental health QOL than Caucasian, though this difference 
was erased if there was perceived social support ((97).  Dr. Hughes-Halbert and colleagues have 
recently reported on emotional and physical well-being among African American and Caucasian 
prostate cancer patients.  The former had a significantly better emotional well-being than the 
latter, a finding at odds with the prior reports of Eton ((98) and Chattre (99).  Dr. Hughes-Halbert 
has also studied the emotional and stress responses of prostate cancer patients shortly after the 
diagnosis.  There were no racial differences in the level of stress or coping mechanisms (100,101).   
 
Despite advances in prostate cancer treatment and increased access to early detection, African 
American men continue to experience disparities in morbidity and mortality from this disease.   
Based on data from animal studies, racial disparities in prostate cancer outcomes may involve 
physiological responses to social stressors that activate biological processes involved in the 

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initiation and progression of cancer.  Until these physiological mechanisms have been examined 
in human samples, the understanding of the biological basis of disparities in prostate cancer 
outcomes will be limited.  Stress reactivity has not been examined among prostate cancer patients 
at any stage.   
2.6.2 Clinical Model for Study of Stress Effects on Prostate Cancer and Immune 
Responses 
Studying stress response (SR) in conjunction with the immunotherapy clinical trial offers many 
advantages for identifying SR and other potential immune modulators.  An optional sub-study will 
be made available for patients being screened to the PROSTVAC therapeutic intervention of this 
study. The goals of the sub-study will be to address critical empirical questions related to 
underlying physiological processes within the context of allostatic load (AL), by examining the 
mechanistic underpinnings of immune and stress responses.  AL is an indicator of biological 
dysregulation in response to psychological and social stress and is used as a marker of 
psychological and social stressor impact on biological functioning (102).  The trial is highly feasible 
and immune responses are likely to be seen in half or more of subjects, providing a wide range 
on immune response parameters for comparisons. 
 
The sub-study will be the first to use a biobehavioral model to examine biological, psychological, 
and behavioral pathways that contribute to disease processes and outcomes in this population.  
Investigators will do this by characterizing stress reactivity among prostate cancer patients based 
on both biological factors that include individual variation in genetic variants in the GR receptor 
gene and chronic SES stressors.   The sub-study is unique in seeking to relate stress 
measurements to clinical and immunologic responses. In addition to having a significant impact 
in terms of understanding the ways in which biological and psychological pathways may contribute 
to racial disparities in prostate cancer outcomes, the research is highly relevant to precision 
medicine.   
 
The optional sub-study will involve correlative analyses will demonstrate another distinct feature 
by studying the pathways within the setting of a clinical trial of prostate cancer immunotherapy.  
The clinical trial itself was designed and powered to detect a therapeutic effect in prostate cancer 
patients.  It is not a trial designed to measure an irrelevant immune response in normal volunteers 
or non-cancer patients.  Hence, the psychologic insights will be derived from, and applicable to, 
a “real world” setting.  The PROSTVAC vaccine has been in development for several years, and 
randomized Phase II trials in patients with advanced disease have shown an improvement in 
overall survival.  The PROSPECT trial, designated by the FDA as the registration trial, completed 
worldwide accrual in December, 2014.  Interim analyses will be made in early 2017, with the hope 
for FDA approval in late 2017 or early 2018.  The present trial focuses on a different population, 
a minimally-treated population after prostatectomy.  The physiologic, and likely psychologic, 
conditions of these subjects are markedly different from those in the PROSPECT trial.  MUSC 
investigators will make comparisons between measurement of SR and other psychologic 
parameters, and clinical (relapse-free survival), genomic (IgG allotypes), and immunologic (anti-
Forssman antibody, antigen-restricted effector T cell populations) measurements.  Thus, if the 
vaccine turns out not to have the desired clinical effect, the investigators will still be able to 
examine the relationship between stress and immune response development. 

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Another important aspect of this clinical trial and optional sub-study will be to define the 
acceptability of stress reactivity measurements in this patient population.  The trial will not be 
powered to detect subtle differences in SR between racial groups.  However, an accurate power 
analysis to establish recruitment goals for a large-scale trial is not possible without initial data on 
the acceptability of psychologic testing in men with prostate cancer, and the range of SR values 
to be expected.  Project investigators will use the Trier Social Stress Test (TSST) (103) to induce 
a stress response among the clinical trial participants.  The TSST is a standardized psychological 
stress challenge which has been used extensively in research studies.  A meta-analysis supports 
that it is the gold standard for evoking an HPA axis stress response in a laboratory setting (104). 
The ACTH and cortisol changes induced by the TSST reflect the sequence of HPA axis activity. 
That is, ACTH peaks first, at the end of the 15-minute stressor, and returns to baseline level within 
40 minutes.  Total plasma cortisol peaks 20 minutes after ACTH, and returns to baseline about 
an hour after initiation of the stressor. Most of the studies of these tools in cancer patients have 
been in breast cancer and leukemia survivors.  Men may be less willing to accurately share their 
feelings, to participate in role-playing tests, and to learn coping strategies.  Indeed, there are no 
published studies on the use of the Trier Social Stress Test in men with prostate cancer.  The 
data developed during this study will provide a solid foundation for planning large scale studies 
and will identify core measures of social, psychological, and behavioral factors that are important 
to measure as part of precision medicine research and health disparities. 
 
3 
STUDY OBJECTIVES 
3.1 
PRIMARY OBJECTIVE 
The primary objective is to determine if PROSTVAC-V/F has significant anti-tumor effect when 
used as a post-surgical adjuvant therapy in subjects at high risk of relapse after prostatectomy.  
The probability of RFS at 2 years after prostatectomy will be compared with RFS data from similar, 
published, historical patient series.   
3.2 
SECONDARY OBJECTIVES 
There are four secondary objectives.   
 
To compare observed RFSs for the study population with the predicted RFSs for the study 
population. The predicted RFS values will be calculated from each patient’s clinical and 
pathologic data by standard algorithms (Duke and CaPSURE).  The observed and 
predicted RFSs will be presented as Kaplan-Meier plots and comparisons will be perofmed 
using the logrank test. 
 
To compare the observed RFS with the RFSs of a historical comparison group of MUSC 
prostatectomy patients.  These patients will be matched to the experimental group for 
race, Gleason score, and pathological stage.  The observed, historical RFSs will be 
presented as Kaplan-Meier plots and comparisons will be performed using the logrank 
test. 
 
To describe associations between the RFS values and various immunologic, genetic, and 
biochemical parameters on research blood and tissue specimens.   
 
To describe the toxicity of PROSTVAC-V/F in this patient population. 

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3.3 
SUB-STUDY OBJECTIVES 
There are three objectives for the sociobiological response sub-study that is being conducted as 
part of this trial. 
 
 
To evaluate the effects of stress reactivity on the development of an effective anti-tumor 
immune response in this patient population 
 
To evaluate the difference in terms of stress reactivity based on SES, perceptions of 
social stressors, and AL between racial subgroups. 
 
To evaluate the difference between racial subgroups for the magnitude and distribution 
of stress responses with biological (AL) and immunologic measure of vaccine effect. 
4 
INVESTIGATIONAL PLAN 
4.1 
STUDY DESIGN AND DURATION 
This will be a Phase II study of adjuvant PROSTVAC-V/F in subjects at high risk for relapse after 
radical prostatectomy.  The study will be carried out at MUSC and the VAMC.  The coordinating 
center will be at the Sponsor-Investigator Support Unit.  Additional sites may be recruited as 
needed to ensure accrual.  
 
We anticipate a two year period of accrual and an equal period of follow up for each subjects, or 
approximately four years total, from the point of completions of approvals and contracts. 
 
The study population will be post-prostatectomy patients whose pathology reports documents one 
or more high risk features, including one or more of the following:  pT3b or pT4, pN1, pT3a (without 
adjuvant radiation), positive margins, pre-operative PSA >10 ng/mL, Gleason score 8-10.  Each 
site PI will be responsible for reviewing all prostatectomy cases to determine the patient’s eligibility 
and interest in participating in the study.   
 
Forty evaluable subjects (total 44 subjects) will be enrolled.   Subjects will be treated with 
PROSTVAC-V/F alone.  Subjects will be followed for relapse for two years after prostatectomy. 
 
Prior to any study specific activities, the patient must be aware of the nature of his/her disease 
and willingly consent to the study after being informed of study procedures, the experimental 
therapy, possible alternatives, risks and potential benefits.  IRB approval of this protocol and 
accompanying consent is required. 
 
4.2 
PATIENT POPULATION 
This study will be conducted at MUSC and the VAMC.  There are approximately 80 radical 
prostatectomies performed yearly at MUSC (30% African American), and 70 at the VAMC (70% 
African American).  Both institutions have extensive experience with prostate cancer clinical trials, 
and investigators have been particularly successful in recruiting African American subjects.  
Therapeutic trial accruals in the HCC include approximately 25% African American subjects, 
reflecting a close match to the 30% prevalence of African Americans in the population of South 
Carolina.  This study will aim to enroll equal numbers of African American and Caucasian subjects. 

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4.3 
INCLUSION CRITERIA 
1. Age >21  
 
2. Completed radical prostatectomy for pathologically-verified adenocarcinoma of the prostate 
no more than 120 days prior to start of treatment.  The following procedures are acceptable:  
radical retropubic prostatectomy (RRP), laparoscopic radical prostatectomy (with or without 
robotic assistance; LAPD), radical perineal prostatectomy (RPP). 
 
3. Post-operative PSA < 0.2 ng/mL by 120 days after prostatectomy 
 
4. Must have one or more of the following: 
 
pT3b or pT4 primary tumor 
 
Gleason score 8-10 
 
pN1 lymph node disease 
 
positive surgical margins 
 
pre-operative PSA of > 10 ng/mL 
 
presence of any tertiary Gleason 5 component on the prostatectomy pathology report. 
 
Note:  Patients with pT3a disease who lack one of the above criteria, and who refuse 
adjuvant radiation, may also be enrolled. 
 
5. ECOG performance status 0-1 
 
6. Adequate hematologic, renal, liver 
function per parameters in Table 1  
      
7. Subject of fathering potential must 
agree to use an adequate method of 
contraception to avoid conception 
throughout the study and for at least 4 
weeks after the last dose of study 
drug to minimize the risk of 
pregnancy.   
 
8. Subjects must have had a negative bone scan, and CT of abdomen and pelvis within 26 
weeks prior to registration.  Additional forms of imaging (Prostascint scan, MRI) may be 
substituted for a CT scan of the abdomen and pelvis if clinically indicated. 
 
4.4 
 EXCLUSION CRITERIA 
1. Pure small cell carcinoma of the prostate 
 
2. Radiographically-demonstrable metastases at any time prior to the time of enrollment 
 
Table 1.  Organ Function Criteria 
 
Total bilirubin < 1.5x ULN  
 
Hepatic enzymes (AST, ALT ) ≤ 2.5 x ULN  
 
Serum sodium, potassium,  and calcium  > 
LLN 
 
Serum Creatinine < 1.5 x ULN  
 
Hemoglobin ≥ 9 gm/dL 
 
Neutrophil count ≥ 1000/mcL 
 
Platelets ≥ 100,000/mcL 

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3. Diagnosis of cancer requiring systemic therapy in the past 5 years 
4. Presence of any major medical condition which, in the opinion of the investigator, precludes 
participation in the study 
 
5. Neoadjuvant or adjuvant therapy of any kind  
6. Chronic administration (defined as daily or every other day for continued use > 14 days) of 
systemic glucocorticoids within 28 days of the first planned dose of PROSTVAC-V/F. Use of 
inhaled steroids, nasal sprays, and all topical preparations (creams, solutions, gels, 
ointments, etc.) for up to 5% of the body surface area is allowed. 
 
7. Use of systemic immunosuppressant agents including anti-metabolites, glucocorticoids, 
TNF antagonists, antibodies to IL6 or IL6R, calcineurin inhibitors, mTOR antagonists  
 
8. Prior history of serious toxicity or a systemic reaction to vaccinia immunization such as 
myopericarditis progressive vaccinia infection, or eczema vaccinatum. 
 
9. Inflammatory or exfoliative skin diseases such as eczema, psoriasis that disrupt epidermis 
 
10. Active infections requiring systemic therapy 
 
11. Serologic evidence of HIV/AIDS. 
 
12. Positive hepatitis C serology or active hepatitis B infection.  
 
13. History of allergy to eggs, egg products, aminoglycoside antibiotics 
 
14. History of myocardial disease, such as myocarditis, cardiomyopathy, congestive heart failure, 
ischemic cardiomyopathy 
 
15. Prior solid organ or stem cell transplant 
 
16. History of or active autoimmune disease (e.g., autoimmune neutropenia, thrombocytopenia, 
or hemolytic anemia, systemic lupus, localized lupus, Sjogren’s syndrome, scleroderma, 
myasthenia gravis, Goodpasture’s syndrome, or Addison’s disease).  Persons with vitiligo, 
Hashimoto’s thyroiditis, or Graves disease are not excluded.   
 
17. Vaccination with live attenuated vaccine within 28 days prior to day 1 of PROSTVAC-V/F 
administration or vaccination with a killed vaccine within 14 days prior to day 1 of 
PROSTVAC-V/F.   
 
18. Inability to avoid close contact or household contact with the following high-risk individuals 
for three weeks after the Day 1 vaccination or until the vaccination site heals completely: (a) 
children ≤ 3 years of age; (b) pregnant or nursing women; (c) individuals with prior or 
concurrent extensive eczema or other eczemoid skin disorders; or (d) immunocompromised 
individuals, such as those with HIV. 

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19. Any condition which, in the opinion of the investigator, would prevent full participation in this 
trial (including Follow-Up), or would interfere with the evaluation of the trial endpoints. 
 
4.5 
ELIGIBILITY FOR THE OPTIONAL SUB-STUDY 
Patients who are being screened for the therapeutic clinical trial will also be approached for 
participation into the optional sub-study evaluating sociobiological response to stress. Refusal to 
participate in the sub-study will not impact the patient’s eligibility to participate in the therapeutic 
intervention.  
Should a patient consent to the optional sub-study, the patient may proceed with the optional 
baseline interventions for the optional sub-study as outlined within the protocol’s study calendar.  
 
4.6 
SUBJECT ENROLLMENT AND REGISTRATION 
The SIS Unit will provide patient registration services for the optional sub-study and for the main 
study.   
 
The SIS Unit will conduct a patient eligibility audit review of all eligibility source documents prior 
to patient registration.  After obtaining signed informed consent(s) and completion of required 
baseline assessments, eligible subjects will be registered.  A unique subject number will be 
assigned to each patient.  The SIS Unit will issue a patient registration confirmation email to the 
enrolling study team at the time of registration.  This confirmation will include the patient’s 
assigned treatment regimen and study ID number.  If the patient consented to the optional sub-
study, the ID used for that portion of the study will be the subject’s study ID.  Patient registrations 
may occur between 8AM and 5PM EST, Monday through Friday.   
 
4.7 
DISCONTINUATION OF SUBJECTS FROM STUDY 
Subjects must discontinue study treatment and withdraw from the study or optional sub-study for 
any of the following reasons: 
 
Withdrawal of informed consent (subject’s decision to withdraw for any reason) 
 
PCa relapse at any time after completion of PROSTVAC administration (see 7.5 for 
definition)  
 
Any clinical adverse event (AE), laboratory abnormality, or intercurrent illness which, in 
the   opinion of the investigator, indicates that continued participation in the study is not in 
the best interest of the subject 
 
Termination of the study by BNI 
 
Loss of ability to freely provide consent through imprisonment or involuntarily incarceration 
for    treatment of either a psychiatric or physical (e.g., infectious disease) illness 
 
Initiation of any form of non-protocol cancer treatment 
 
Initiation of scheduled narcotics for pain treatment 

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 
Unacceptable toxicity defined as any grade 3-4 possibly or definitely related non-
hematologic toxicity that does not improve to grade 1 or resolve within 28 days or any 
possibly or definitely related grade 3-4 hematologic toxicity that does not improve to grade 
1 or resolve with 14 days.   
General or specific changes in the patient's condition render the patient unacceptable for 
further treatment in the judgment of the investigator. 
5 
TREATMENTS 
5.1 STUDY TREATMENT:   PROSTVAC-V/F 
Subjects must start study drug within 120 days after surgery. 
5.1.1 Identification, Packaging, and Labeling 
PROSTVAC-V/F is comprised of two components. PROSTVAC-V is a replication-competent 
vaccinia virus which has been engineered to encode the sequences for a modified human PSA 
and a TRICOM. PROSTVAC-F is a fowlpox virus which does not replicate in human cells and has 
been engineered to encode the same sequences present in PROSTVAC-V. A full description of 
the PROSTVAC-V/F product and PROSTVAC-V/F pre-clinical and clinical support are contained 
in the IB.  Study vaccine for this trial contains no preservatives or adjuvants and is supplied in 
single-dose 2 ml clear, borosilicate glass injection vials with rubber injection stoppers covered by 
a plastic-aluminum flip cap. 
 
Active Ingredient:  
 
PROSTVAC-V:  PROSTVAC-V-PSA-TRICOM in aqueous solution for injection  
 
PROSTVAC-F:  PROSTVAC-F-PSA-TRICOM in aqueous solution for injection 
 
Product Description: PROSTVAC-V/F is comprised of two recombinant pox viruses: a 
recombinant vaccinia virus (PROSTVAC-V) and a recombinant fowlpox virus (PROSTVAC-F).   
Both recombinant pox viruses contain genes for human PSA, B7.1, ICAM-1, and LFA-3. The PSA 
gene used in these recombinants has an alteration in an HLA-A2 specific epitope (replacement 
of isoleucine with leucine at amino acid position 155; designated L155). In PROSTVAC-V, all four 
genes are inserted into the genome of a derivative of the Wyeth strain of vaccinia virus (strain 
NYCBH).  In PROSTVAC-F, all four genes are inserted into the genome of a plaque-purified 
isolate of the POXVAC-TC vaccine strain of fowlpox virus.   
 
The PROSTVAC-V/F study vaccines are manufactured at IDT’s GMP facility in Dessau-
Rosslau, Germany in compliance with cGMPs. The formulations do not contain adjuvants or 
preservatives. The study drug substance is thawed and formulated by dilution in PBS in 10% 
glycerol. 0.7 ml of the formulated material is dispensed aseptically into sterile 2 mL clear 
borosilicate glass vials, the vials are sealed with rubber injection stoppers and plastic/aluminum 
flip-caps, and a label is affixed to the vial. PROSTVAC-V/F study vaccine vials are then 
packaged in 6-vial cartons with an outer carton label. 
5.1.2 Storage, Handling, and Dispensing 
Storage*: −70°C or below 

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Storage conditions and stability claims for the final PROSTVAC-V/F product are based on long-
term manufacturing experience with PROSTVAC-V/F by Therion, the initial manufacturer. The 
stability data for PROSTVAC-V/F shows virus titer stability for four years when stored at −80°C 
(± 10°C). 
 
PROSTVAC-V/F will be ordered by participating sites directly from the manufacturer. 
 
5.2 
SELECTION AND TIMING OF DOSE FOR EACH SUBJECT 
5.2.1 PROSTVAC-V/F Treatment 
 
All subjects will receive PROSTVAC V/F in the same dose and schedule. 
 
Drug Administration:  Doses of PROSTVAC-V/F will be drawn into labeled syringes by a 
research pharmacist or designee for use by the clinic staff.   PROSTVAC-V will be administered 
by the designated study staff once by subQ injection on one side (upper arm or upper outer thigh) 
on Day 1.  PROSTVAC-F will be administered by the study staff six times by subQ injection on 
Days 15, 28, 57, 85, 113 and 141.  Vaccination with PROSTVAC-F will begin on one side (upper 
arm or upper outer thigh), and subsequent immunization sites should be rotated to the opposite 
side and/or limb if possible.  The doses will contain the following: 
o 
0.5 ml containing at least 2 x 108 Infectious Units (Inf.U) PROSTVAC-V 
o 
0.5 ml containing at least 1 x 109 Inf.U PROSTVAC-F 
 
Subjects should be informed on how to care for the wound after each injection of the study 
agent.   
 
Dose Modification or Interruptions:  There will be no modification or delays in dosing of 
PROSTVAC V/F for toxicity  If there are unresolved toxicities related to PROSTVAC V/F at the 
time the next dose is due, the patient should be taken off study.  PROSTVAC V/F treatment 
should be initiated within 120 days after prostatectomy.  If there is a delay due to scheduling, 
within the +/- 7 days window, it will be at the investigator’s discretion whether to have the 
subject continue.   
 
6 
CONCOMITANT TREATMENTS 
6.1 
PROHIBITED AND/OR RESTRICTED TREATMENTS 
 
Subjects may not receive any other form of anti-cancer therapy during this study except 
for    PROSTVAC V/F.   
 
Daily use of finasteride, dutasteride, is not permitted during this study 
 
Use of supplements reported to delay progression of prostate cancer (vitamin D3 over 
1000IU   daily, pomegranate juice or extract, lycopene) is not permitted. 
 
Testosterone, estrogen agonists (estradiol, diethylstilbesterol), progesterone agonists, or 
DHEA-containing medicines or supplements is not permitted during the study. 

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6.2 
OTHER RESTRICTIONS AND PRECAUTIONS 
 
Subjects should not start treatment with any immunosuppressive agents during study.  
This includes daily oral or parenteral glucocorticoids, antimetabolites, calcineurin 
inhibitors, mTOR inhibitors, cytokine antagonists. 
 
Subjects should not receive live attenuated vaccine within 28 days prior to PROSTVAC-
V/F administration or a killed vaccine within 14 days prior to or after completion of 
PROSTVAC-V/F. 
6.3 
TREATMENT COMPLIANCE 
Treatment compliance for PROSTVAC V/F will be ensured by administration of the agent in the 
treating physician’s office or infusion center.   
 
7 
STUDY ASSESSMENTS AND PROCEDURES 
Scheduled treatments, procedures, and assessments are shown in the table contained in 
Appendix A. 
7.1 
THERAPEUTIC TRIAL PROCEDURES 
A variety of clinical assessments are made during the screening period and while the subject is 
on study.  These include the following.  Specific details about the timing of these procedures can 
be found in the study calendar (Appendix A): 
 
 
Patients will be given instructions on how to care for the injection site after each 
injection of PROSTVAC-V and PROSTVAC-F.   
 
History and physical examination.  The history includes a review of the prostatectomy 
pathology report to ensure that it includes the following information:  date of surgery, 
subject’s age at surgery, pre-op PSA, Gleason score, margin status, extraprostatic 
extention, seminal vesicle status, lymph node status.  A measurement of the PSA at 
45 or more days after surgery is also necessary, if the post-prostatectomy PSA nadir 
is not < 0.2 ng/mL before then. 
 
CBCD 
 
CMP (sodium, potassium, chloride, bicarbonate, BUN, creatinine, glucose, albumin, 
alkaline phosphatase, AST, ALT, calcium);  
 
Lipid Panel (total cholesterol, HDL cholesterol, triglycerides, LDL cholesterol, non-HDL 
cholesterol).  Lipid panel will only be done at baseline and requires patients to be 
fasting.  If a fasting blood draw cannot be done at screening (prior to registration), it 
may be done on day 1 prior to agent administration.    
 
PSA 
 
Testosterone 
 
C-reactive protein 
 
HIV, Hep B and Hep C serology screening, unless known negative within previous 2 
years prior to registration. 

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 
Scans:  Technetium bone scan (but not 18F-fluoride PET scan);  CT scan of abdomen, 
pelvis (a Prostascint scan or MRI of abdomen, pelvis can be substituted).  Scans can 
be done up to 26 weeks prior to start of treatment. 
 
Correaltive research will include the following: 
 
 
FACT-P, AUA SS, and SHIM quality of life questionnaires 
 
Collection of blood for research (refer to Section 8):  
 
10 mL blood in a sodium heparin tube 
 
7 mL blood in a lithium heparin tube 
 
21 mL blood in a EDTA tube 
 
7 mL blood in a serum (clot) tube 
 
FFPE tissue, if available:  5 thick (20 micron) sections on plastic slides for genomic 
analysis, plus 5 additional thin (5 micron) sections 
 
Social Determinants Survey:  Patients will be given the option to complete the survey via 
telephone administration or in-person during the clinic visit of their first vaccine treatment. 
Surveys that are completed over the telephone will administered by a trained research 
assistant from MUSC to obtain information on SES and to measure social factors (e.g., 
perceived loneliness), perceived stress, behavioral factors (i.e. exercise and diet), shared 
decision-making with providers, and knowledge and perceptions about precision 
medicine. Surveys completed during the clinic visit will be self-administered.  The survey 
will take 30 minutes to complete.  
 
7.2 
OPTIONAL SUB-STUDY PROCEDURES 
For patients who provide consent for the optional sub-study the following additional procedure will 
be completed after providing consent to the optional sub-study and prior to the first PROSTVAC 
treatment. 
 
TSST:  70 minute stress test that includes saliva samples, blood pressure and heart rate 
monitoring and subjective units of distress (SUD) scale. More information about the TSST 
procedures is outlined in Section 8. 
 
7.3 
OFF-STUDY ASSESSMENTS 
Off study assessments will consist of those procedures indicated for day 730 if the patient’s 
participation ends at that time, or at any earlier time.  These include: 
 
 
clinical examination (history and physical examination);  
 
assessment of toxicity or adverse events;  
 
CBCD;  
 
CMP 
 
bone scan and CT scan of abdomen, and pelvis (a Prostascint scan or MRI of abdomen, 
pelvis can be substituted).  Scans will not be repeated at the off-study point if they have 
been performed in the preceding 2 months. 
 
PSA;  

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35 
 
 
total testosterone;  
 
research assessments 
o Blood samples-See Section 8 for details 
o Quality of Life questionnaires  
 
7.4 
SAFETY ASSESSMENTS 
Safety assessments will be performed continuously throughout the entire study, and will occur at 
every clinic visit, as indicated in Appendix A.  At the minimum assessments will include a complete 
history and physical examination, and the following laboratory studies:  CBCD, CMP, and 
testosterone.     
 
Toxicities will be defined by the CTCAE v 4.0. 
 
7.5 
EFFICACY ASSESSMENTS 
Efficacy assessments will primarily be performed by measurement of PSA and by physical 
assessment.  Imaging studies (CT scans of the abdomen and pelvis, and bone scans) will be 
performed at baseline (up to 16 weeks prior to treatment) and at the end of the study (or within 
the preceding 2 months before end of study).  Otherwise, scans will be performed only if clinically 
indicated for evaluation of relapse or off study.  Additional forms of imaging (Prostascint scan, 
MRI) may be substituted for a CT scan of the abdomen and pelvis if clinically indicated.  However, 
the imaging method used at baseline will be used for follow up scans.  Compliance with therapy 
may be considered a component of the efficacy assessment.  Compliance with PROSTVAC-V/F 
will be monitored at each visit by interviewing the patient and reviewing the infusion center records 
for administration. 
 
Both primary and secondary efficacy assessment involve measurement of RFS.  Recurrence will 
be defined as the occurrence of any of the following: : 
 
Institution of new prostate cancer therapy 
 
First detection of a PSA level ≥ 0.2 ng/mL (confirmed > 30 days later) after 
completion of all PROSTVAC V/F vaccine doses  
 
Development of radiographically-demonstrable metastases  
 
Death 
RFS at two years will be met if a patient has met none of the above criteria two years post-surgery.  
RFS as a time to event endpoint will be measured as the time in days from surgery to any of the 
above conditions being met. 
7.5.1 Primary Efficacy Assessment 
The primary study endpoint is recurrence-free status at 2 years after prostatectomy.  RFS will be 
defined as in Section 10.2.  Observed probability of RFS will be compared with the same 
parameter obtained from similar historical patient series. 
7.5.2 Secondary Efficacy Assessments 
The secondary efficacy assessment will consist of a comparison of the observed RFS values with 
predicted RFS values calculated for the enrolled subjects by the Duke and CaPSURE algorithms.  

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36 
 
The RFS values will be plotted using Kaplan-Meier methods, and the observed and predicted 
RFS values will be compared using the logrank test. 
 
8 
CORRELATIVE STUDIES 
8.1 
RESEARCH BLOOD COLLECTIONS 
A variety of analyses will be performed on the research blood samples collected for this study.  
To evaluate biological responses to vaccinations, plasma, serum, as well as whole blood samples 
will be collected from all enrolled subjects.  Plasma will be analyzed for the development of 
antibodies to the vaccinia and fowlpox virus vectors, the PSA insert, other prostate specific 
antigens, as well as tumor associated antigens. Serum will also be profiled for changes in cytokine 
and chemokine expression and circulating tumor markers.   Immune function analysis will be 
performed by isolation of PBMCs for immune function assays.  PBMCs will be evaluated for PSA 
antigen-specific responses by ELISPOT and flow cytometric-based methods.  Determinant 
spreading to other prostate antigens and tumor-associated antigens will also be examined.  All 
evaluations will be performed at laboratories using standardized procedures. Subject samples 
may be kept for up to one year past the end of the trial for assay development, implementation, 
and data review. These described analyses will generate a large dataset that will potentially 
enable the identification of new biomarkers of disease prognosis and/or vaccine response. 
 
Research assessments will not be made in real time, since they will require analyses that will be 
performed only in “batch mode” when samples are available.  Research samples will be collected 
as indicated and stored for future assays, in accordance with MUSC and VAMC policies.   
 
All patients will be expected to provide blood for research purposes per the timepoints outlined 
within the study calendar (Appendix A). Each research blood collection will require 38mL of 
anticoagulated peripheral whole blood.  
 
Research Blood Collection 
Timepoints 
At each blood collection, collect the following 
Amount of Blood 
Tube type 
Baseline 
Day 85 
Day 225 
Day 730 or off study 
10 mL  
sodium heparin tube 
7 mL 
lithium heparin tube 
21 mL 
(three 7 mL tubes) 
EDTA tube 
7mL 
Blood (clot) tube 
 
8.1.1 Measurement of Antigen-Specific T-Cell Functions 
Peripheral blood samples will be collected in EDTA vacutainer tubes prior to vaccination, one 
week after the third immunization, and one week following final PROSTVAC administration. Red 
blood cells will be lysed with ACK buffer for isolation of peripheral blood leukocytes (PBL). PBLs 
will be frozen in 90% FBS/10% DMSO using a controlled-rate freezer, and immediately stored in 
liquid nitrogen.  Phenotypic characterization and detection of prostate specific antigen (PSA)-
speciﬁc cytokine production from T cells within previously cryopreserved PBL will be performed 

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37 
 
simultaneously. Brieﬂy, PBLs will be stimulated at 5x106 cells per test with peptide pools 
consisting of sequential 15mer peptides overlapping by 11 amino acids spanning the compete 
human PSA protein at 1µg/ml/peptide (Miltenyi), 1% DMSO negative control or polyclonal 
activation via 50 ng/mL phorbol myristate acetate (PMA) and 1 µg/ml ionomycin for 6 hours.  
Brefeldin A (10 mg/mL) will be present for the last 5 hours. Samples will be labeled to exclude 
dead cells by incubation with amine reactive UV Live/Dead dye (Molecular Probes). 
Subsequently, T cell memory subsets will be phenotyped by staining for surface antigens using 
monoclonal antibodies speciﬁc for CD3, CD4, CD8, CD45RA, CD45RO, CCR7 and CD64L 
allowing for detection of naïve, stem cell memory, central memory, effector memory and terminally 
differentiated effector CD4+ and CD8+ T cells. Cells are then ﬁxed and permeabilized by treatment 
with BD Cytoﬁx/Cytoperm solution (BD Pharmingen) followed by labeling with monoclonal 
antibodies speciﬁc for IFN-γ, IL-17A, IL-4, and IL-10 for 30 min at 4⁰C in the presence of 
permeabilizing staining buffer to identify predominant TH1, TH17, TH2 and Treg cytokines, 
respectively. Cells will be collected immediately on a BD Fortessa X-20 flow cytometer capable 
of detection of up to 18 parameters (Beckman Dickinson). At least 300,000 events will be collected 
and data analyzed using FlowJo software. Values 3-fold higher than the DMSO background are 
scored as positive. 
 
The proposed assay provides state-of-the-art immune monitoring of vaccine-induced PSA-
specific immunity via multiparametric flow cytometry. Utilizing cutting-edge techniques, project 
investigators will simultaneously measure T cell memory status and determine the overall cytokine 
profile of vaccine-induced CD8+ and CD4+ T cell subsets. Detailed characterization of antitumor 
immunity will allow for the identification of immune correlates of protection from disease 
progression.  
8.1.2 Measurement of Anti-Forssman Antibodies 
Antibodies to heterophile antigens such as the glycolipid Forssman antigen commonly develop 
during certain infections.  A recent report documented the appearance of antibodies to Forssman 
antigen during treatment of prostate cancer patients with PROSTVAC (32).  Antibodies appeared 
in a high proportion of subjects (64%) and in high titer.  Moreover, the appearance of anti-
Forssman antibodies correlated with overall survival after vaccination, and the antibody titer was 
directly proportional to length of survival.  The appearance of anti-Forssman antibodies during 
PROSTVAC therapy may represent a generalized activation of the immune system, or possibly 
antigen spreading.  Project investigators will use a competitive immunoassay to detect anti-
Forssman antibodies in serum from trial subjects before treatment, after the third injection, and 
after the final injection.  Sheep RBCs will be purchased from commercial sources and used as a 
source of Forssman antigen.  Washed RBCs will be incubated with serial dilutions of patient 
plasma, and with a FITC-labelled anti-Forssman monoclonal antibody.  Binding of the labelled 
antibody will be measured by flow cytometery.  Increasing amounts of anti-Forsmman antibody in 
patient plasma will compete with the labelled antibody and reduce its binding, leading to 
decreased signal in the flow histogram.  The amount of bound, labelled antibody will be quantified 
as the difference in maximum fluorescence intensity of the histogram curves, with irrelevant, 
isotype-matched antibody as a negative control, and labelled anti-Forssman antibody only (no 
competitor) as the positive controls.  The result will be expressed as serum titer that inhibits 
binding of the labelled antibody probe by 90%.   

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8.1.3 Measurement of IgG Allotypes GM and KM 
Polymorphic hereditary antigenic determinants present on IgG heavy chains are called GM 
allotypes (33, 34). These determinants are inherited as autosomal codominant genes according 
to Mendelian laws. They are encoded by three very closely linked genes—immunoglobulin heavy 
chain G1 (IGHG1), IGHG2, and IGHG3—on chromosome 14q32. GM alleles are expressed on 
the constant region of Υ1, Υ2, and Υ3 chains. There are currently 18 serologically testable GM 
specificities—four on Υ1 (1/a, 2/x, 3/f, 17/z), one on Υ2 (23/n), and 13 on Υ3 (5/b1, 6/c3, 10/b5, 
11/b0, 13/b3, 14/b4, 15/s, 16/t, 21/g1, 24/c5, 26/u, 27/v, 28/g5). Linkage disequilibrium in the GM 
gene complex within a racial group is almost absolute and the determinants are transmitted as a 
group—haplotypes. 
 
Polymorphic hereditary antigenic determinants present on Υ-type light chains are called KM 
allotypes. Three alleles—KM 1, KM 1,2, and KM 3—segregate at the immunoglobulin Υ constant 
(IGKC) locus on chromosome 2p12. KM 1 allele, without KM 2, is rare; 98% of the individuals 
positive for KM 1 are also positive for KM 2. Thus, positivity for KM 1 includes both KM 1 and KM 
1,2 alleles (33,34). 
 
Immunoglobulin GM genes are one of the most powerful tools for genetic characterization of 
human populations. For instance, unless there is genetic admixture, GM 3 is not found in 
African Americans; GM 6 is present only in people of African ancestry; GM 1 is polymorphic only 
in people of European ancestry. Their racially associated prevalence makes them especially 
suitable for investigations involving racial disparity in prostate cancer. Furthermore, these 
markers have been shown to contribute to both cellular and humoral immunity to several tumor-
associated antigens in a racially restricted manner ((105-112)(113-115)). Thus, this project 
could potentially identify racially-specific genetic correlates of PROSTVAC vaccine efficacy.  
Immunoglobulin GM and KM genotyping may provide an import co-variant to measure along 
with stress responses.  Because of almost absolute linkage disequilibrium between particular 
GM allotypes within a race, not all markers need to be typed to determine the major haplotypes 
segregating in a population. 
 
 
8.1.4 TSC22D3/GILZ Genotyping 
 
Psychological stress negatively influences cancer mortality, but the underlying molecular 
mechanisms are not known. Stress increases the secretion of glucocorticoids, which 
upregulates the transcriptional factor TSC22D3, also known as glucocorticoid-induced leucine 
zipper (GILZ). In mice, TSC22D3 acts as a “checkpoint” for anti-cancer immune responses. In 
humans, the gene encoding GILZ is located on human chromosome Xq22.3. Several single 
nucleotide polymorphisms (SNPs) have been identified in this gene. Using TaqMan® 
genotyping assays from Applied Biosystems Inc. and DNA from the trial participants, we will 
genotype for the following SNPs with appreciable minor allele frequencies: 
 
rs12858266, rs17254207, rs3747406, rs6523975, rs6523976 
 
These SNPs may influence the qualitative and quantitative expression of the 
TSC22D3/GILZ protein, resulting in interindividual differences in stress-induced 

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39 
 
immunosuppression. We will determine whether these genetic markers are associated with 
allostatic load, stress reactivity, and the relapse risk in the vaccinees. 
Thus, the SNPs to be genotyped in this project could be potential genetic modifiers of 
psychosocial stress and the outcome of immunotherapy in prostate cancer 
 
8.1.5 GR Genotyping 
Trial participants will be genotyped for variants in the Bcll polymorphism (rs41423247) by 
collecting whole blood for genetic analysis.  Blood samples will be stored at -80C for batch DNA 
extraction and genetic testing. Genomic DNA extraction from frozen blood will be done using the 
Purelink DNA extraction kit (QiaGen). Genotyping will be done using RFLP analysis and verified 
by sequencing at the MUSC Genomics Center.   
 
8.2 
FORMULIN FIXED PARAFFIN EMBEDDED TISSUE 
An attempt will be made to acquire FFPE tissue from all subjects, since study enrollment will be 
in close temporal proximity to the acquisition of the prostatectomy specimen.   Should tissue be 
available for research, the study requires 5 thin (5 micron) sections on glass slides for H&E and 
IHC staining.   
 
8.3 
QUALITY OF LIFE PATIENT QUESTIONNAIRES 
All study participants will be administered three questionnaires: FACT-P, AUA SS, and SHIM. The 
questionnaires will be used to assess the impact of therapy on the patient’s perception of their 
quality of life the intervals as indicated within the study calendar. Questionnaires may be mailed 
to the subject in pre-metered envelope if they are unable to come into the clinic to complete them 
(ie: due to COVID19 travel restrictions). The subject will complete the questionnaires at home and 
then mail the completed questionnaires back to the main site in the provided envelope.  
 
8.4 
SUB-STUDY SOCIAL DETERMINANTS SURVEY:  
For patients who consent to the main study, SES, social factors, behavioral factors, shared 
decision-making, knowledge and perceptions of precision medicine, and perceived stress 
measurements will be obtained by self-report. Patients will have the option to be administered the 
survey over the telephone, or they can complete the survey during their clinic visit of the first 
vaccine treatment.  This survey will provide a numeric readout.  Investigators will measure chronic 
SES stressors in terms of income, employment status, and financial strain.  The Life Events 
Questionnaire (LEQ; (116)) is a validated measure that captures life events across multiples 
areas.  The Health, Work (e.g., difficulty finding a job); Residence (e.g., difficulty finding housing), 
and Financial subscales of the LEQ will be used for the purposes of the current study.  In addition, 
the validated Perceived Stress Scale (117) and the Everyday Discrimination Scale ((118)) will be 
used to capture perceived stress and discriminatory stress, respectively.   
 
Investigators will use the short form of the Loneliness Scale (119) and Interpersonal Support 
Evaluation List (ISEL; (120)) to measure social isolation and support, respectively.  Financial 
strain will be measured by a validated Likert-style item that asks participants if they have some, 
just enough, or not enough money left over at the end of the month.  Cancer-related stressors will 

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40 
 
be measured in terms of perceived stress about being diagnosed with prostate cancer and clinical 
stressors) and perceived risk and control about prostate cancer recurrence.   Perceived risk and 
control will be measured using items from previous research on cancer recurrence among breast 
cancer survivors ((121)). Items relating to knowledge and perceptions of precision medicine were 
adapted from previous research on genetically targeted care (123). Health behavior items 
measuring moderate exercise and diet behaviors were taken from the validated NCI-HINTS (124). 
Investigators will also measure clinical stressors in terms of stage and grade of prostate cancer 
diagnosis and the presence of surgery-related side effects.  Clinical stressors will be abstracted 
from medical records. 
 
8.5 
OPTIONAL SUB-STUDY TRIER SOCIAL STRESS TEST  
For patients who consent to the optional sub-study, the TSST ((103)) will be used to induce and 
measure a stress response.  The TSST is a standardized psychological stress challenge which 
has been used extensively in research studies.  A meta-analysis supports that it is the gold 
standard for evoking an HPA axis stress response in a laboratory setting ((104)). The ACTH and 
cortisol changes induced by the TSST reflect the sequence of HPA axis activity. That is, ACTH 
peaks first, at the end of the 10-minute stressor, and returns to baseline level within 40 minutes.  
Total plasma cortisol peaks 20 minutes after ACTH, and returns to baseline about an hour after 
initiation of the stressor. The TSST will be administered at the South Carolina Clinical and 
Translational Research Institute (SCTR) at MUSC.   
 
Effort will be made to ensure that the experimental procedures and assessments for the TSST 
are collected at the same time point for each participant to control for changes in cortisol levels 
due to time of day (diurnal patterns). However, should a time variation occur, this will be 
considered a deviation, and patients will have to be rescheduled for their TSST. A time lapse of 
no more than 15 minutes will be permissible for conducting the TSST. The times of procedures 
will be collected within the source worksheets and any time delays will be recorded. 
 
Because of the logistics for scheduling and the TSST assessment, the timeframe for conducting 
the assessment may be prior to the main study registration. The TSST must be administered after 
the patient provides consent to the optional sub-study and any time before the patient begins 
PROSTVAC treatment. The TSST experimental stress challenge should begin at 4:00 pm.  During 
the TSST, participants are told at 4:00 pm that he will soon perform to an audience which includes 
a speech and arithmetic task. The topic of the speech is why he should be hired for a particular 
job (the individual’s “dream job”). The participant will deliver the speech as though speaking to a 
group of hiring managers.  The experimenter then tells the participant that  
he has five minutes to prepare the speech, and starts the countdown clock (which is placed in 
view of the individual). The experimenter leaves the room to allow the participant to prepare. At 
4:33 pm, the participant is escorted by the experimenter to an interview room, where three 
individuals unfamiliar to the participant (the audience) are seated; the individual is instructed by 
one audience member (the spokesperson) to stand and begin his prepared speech (without 
notes).   
 
The speech is delivered for five minutes. At the end of the speech task (4:44 pm), the individual 
is instructed to serially subtract 13 from 1,022 as quickly and accurately as possible. If the 

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41 
 
participant makes a mistake, he is told to begin again at 1,022. The mental math recitation 
continues for five minutes, at the end of which time, the spokesperson instructs the individual to 
stop. The experimenter enters the room and escorts the participant back to the initial room. The 
TSST, in total, spans 10 minutes. The first post-stressor assessment occurs immediately following 
the task (or control condition) at 4:46 p.m. and the last post-stressor assessment occurs at 5:10 
p.m. 
 
Investigators will measure stress reactivity using saliva samples that are collected prospectively 
during the TSST (see Figure 3).  The change in cortisol level may be expressed in several ways, 
such as change from pretest to maximum increase, area-under-the-curve, or an index 
incorporating multiple values.  If needed, heart rate, BP can similarly quantified.  Data on cortisol, 
heart rate, blood pressure will be used to generate allostatic load during an acute stress response.  
An 11-point scale (0-10) will be used for the Subjective Units of Distress variable (SUD). 
Investigators will also measure heart rate variability (HRV) and blood pressure using standard 
medical equipment and procedures during the TSST.  
 
8.6 
ALLOSTATIC LOAD 
Allostatic load will be determined based on laboratory results and clinical measures that will 
include the following; blood pressure, heart rate, total cholesterol, HDL cholesterol, body mass 
Figure 3. TSST Procedures and Timeline 
TIME 
EXPERIMENTAL PROCEDURE 
STRESS ASSESSMENT 
4:00-4:15pm 
 Acclimation period  
(15 minute duration) 
Patient 
arrives 
and 
given 
relaxation tools (i.e. spa video, 
magazine, nature scenes) 
4:16 
Baseline  
(immediately  following acclimation period) 
Laboratory Stress measurements 
Take cortisol, BP, HR, and 
assess SUD 
4:28pm 
Immediately before TSST (12 minutes following 
baseline) 
Laboratory Stress measurements 
Take cortisol, BP, HR, assess 
SUD, and explain the task and 
give participant paper to write 
notes  
4:33- 4:44pm 
(5 minutes following 2nd lab measurements) 
TSST  
  
5 minutes 
Interview  task 
  
5 minutes 
Arithmetic task 
  
Post TSST stress assessments (12 minute increments) 
4:46pm 
Post TSST  
(2 minutes following TSST) 
Post-TSST Assessment 
Cortisol, BP, HR, SUD 
4:58pm 
12 mins post TSST 
Post-TSST Assessment 
Cortisol, BP, HR, SUD 
5:10pm 
24 mins post TSST 
Final Post-TSST Assessment 
Cortisol, BP, HR, SUD 
Note: Patients more than 15 minutes late are unable to participate in the TSST and would need to be rescheduled. 

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42 
 
index (BMI), C-reactive protein (CRP),  DHEAS and interlukin-6 (IL-6). Cortisol will also be 
measured for those participating in the optional sub-study.  We will use established methods to 
determine allostatic load.  These methods use established clinical cutoffs to categorize 
biomarkers as being within normal ranges.  For instance, a systolic blood pressure ≥ 140mm/Hg 
and CRP ≥ 3mg/L are values that are outside of normal ranges. The values for each biomarker 
will be coded into a dichotomous variable (1=above normal cutoff and 0=below normal cutoff).  
Scores for allostatic load will be calculated by summing dichotomous values for each biomarker. 
 
9 
ADVERSE EVENT REPORTING 
For the purposes of this trial, “study vaccine” is defined as PROSTVAC-V/F.  
 
9.1 
INVESTIGATOR RESPONSIBILITIES 
Investigators are responsible for monitoring the safety of subjects who have entered this study 
and for assuring appropriate medical care is provided.  Investigators are responsible for providing 
subjects who experience adverse events, especially SAEs that cause subjects to discontinue 
participation in the study, with appropriate medical care. Frequency of follow-up of any particular 
adverse event is left to the discretion of the investigator. Duration of follow-up and requirement 
for immediate SAE reporting (within 24 hours of becoming aware of the event) are described 
below. 
 
9.2 
DEFINITION OF ADVERSE EVENTS (AE) 
An AE is any untoward (unfavorable, harmful, or pathologic) medical occurrence in a subject 
administered an investigational product even if the event does not necessarily have a causal 
relationship with this treatment. An AE can therefore be any unfavorable and unintended sign 
(including an abnormal laboratory finding), symptom, or disease temporally associated with the 
use of a medicinal (investigational) product whether or not related to the investigational product 
(ICH E2A II/A/1, 21 CFR 312.32). 
 
For the purpose of this clinical study, AEs include only treatment-emergent events which are 
either new or represent detectable exacerbations of pre-existing conditions. AEs may include, but 
are not limited to: 
 
Subjective or objective symptoms spontaneously offered by the subject and/or observed 
by the Investigator or study staff including laboratory abnormalities of clinical significance.  
 
AEs not previously observed in the subject that emerge during the protocol-specific AE 
reporting period, including signs or symptoms associated with prostate cancer that were 
not present before the AE reporting period  
 
Complications that occur as a result of protocol-mandated procedures and interventions. 
 
For the purposes of this study, the following exceptions to the definitions above will NOT be 
considered an AE: 
 
 
Pre-existing condition: A pre-existing condition (documented on the medical history CRF) 
is not considered and AE unless the severity, frequency, or character of the event worsens 
during the study period. 

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 
Preplanned hospitalization: A planned hospitalization is not considered an SAE, but 
rather a therapeutic intervention. However, if during the pre-planned hospitalization an 
event occurs, which prolongs the hospitalization or meets any other SAE criteria, the event 
will be considered an SAE. Surgeries or interventions that were under consideration, but 
not performed before enrollment in the study will not be considered serious if they are 
performed after enrollment in the study for a condition that has not changed from its 
baseline level. Hospitalizations for social reasons or due to long travel distances are also 
not SAEs.  
 
 
Diagnostic testing and procedures:  Testing and procedures should not be reported as 
AEs or SAEs, but rather the cause for the test or procedure should be reported. 
 
9.3 
COLLECTING AND RECORDING ADVERSE EVENTS 
The Investigator will monitor the occurrence of AE for each subject during the course of the study. 
All AEs (as defined above) reported by the subject, observed by the Investigator, or documented 
in medical records will be listed on the AE CRF, whether believed by the Investigator to be related 
or unrelated to the study vaccine. 
 
All AEs must be reviewed, graded and causality determined by an Investigator listed on the form 
FDA 1572 at the research center reporting the event(s). Collection of AEs begins at the time the 
subject starts study treatment and continues for 28 days following administration of the last dose 
of study medication.  If an SAE is present at the end of the reporting period, the SAE (and 
associated AEs and concomitant medications) should be followed to resolution or until the 
Investigator assesses the subject as stable, or the subject is lost to follow-up or withdraws consent. 
Resolution/stable means the subject has returned to baseline state of health or the Investigator 
does not expect any further improvement or worsening of the event. 
Adverse event terms should be recorded concisely, using CTCAE v. 4 terms.  When possible, a 
diagnosis (i.e., disease or syndrome) rather than the component signs and symptoms should be 
recorded on the CRF (e.g., congestive heart failure rather than dyspnea, rales, and cyanosis).  
However, signs and symptoms considered unrelated to syndromes or diseases are to be recorded 
as individual adverse events on the CRF (e.g., if congestive heart failure and severe headache 
are observed at the same time, each event is to be recorded as an individual adverse event). The 
adverse event should not be recorded as a procedure or clinical measurement (i.e., a laboratory 
or vital sign).  The underlying reason for the procedure or the abnormal clinical measurements, 
and, whenever possible, a diagnosis, should be recorded. 
 
Death is considered to be an outcome of an adverse event. The cause of death should be 
recorded on the AE CRF (e.g., congestive heart failure with an outcome of death rather than the 
term “death”). 
 
9.4 
ASSESSMENT OF ADVERSE EVENTS 
Investigators will assess the occurrence of AEs and SAEs at all subject evaluation time points 
during the study. All AEs and SAEs whether volunteered by the subject, discovered by study 

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personnel during questioning, or detected through physical examination, clinically significant 
laboratory test, or other means will be recorded in the subject’s medical record and on the AE 
CRF and, when applicable, on the SAE report form. 
 
Each recorded AE or SAE will be described by its duration (i.e., start and end dates), severity,  
suspected relationship to the investigational product, and any actions taken.  Any SAE that occurs 
after the subject signs informed consent, irrespective of the treatment received by the subject, 
must be reported to the SIS Unit within 24 hours of the investigator learning of the event.   
 
9.5 
DEFINITION OF EXPECTED AND UNEXPECTED EVENTS 
9.5.1 Expected Events 
Expected events are those that have been previously identified as resulting from administration 
of the investigational product. For the purpose of this study, an AE is considered expected when 
it appears in the current adverse event list, the IB, the package insert or is included in the ICF as 
a potential risk.  Injection site reactions such as pain, redness, swelling, induration, and pruritus, 
or systemic injection reactions such as fever ≥ 104°F; myalgia, headache, nausea, fatigue lasting 
less than 72 hours are expected events for PROSTVAC-V/F.   
 
If, however, the investigator considers an expected event to be unexpectedly severe or more 
frequent than usual for a patient with prostate cancer following prostatectomy the event will be 
captured on the AE CRF.  Similarly, if the event is associated with PROSTVAC-V/F, and is 
unexpectedly severe, it will also be recorded on the AE CRF. 
9.5.2 Unexpected Events 
Unexpected events are those considered unexpected when it varies in nature, intensity or 
frequency from the information provided in the current adverse event list, the IB, the package 
insert or when it is not included the ICF as a potential risk.  
 
9.6 
ASSESSMENT OF RELATIONSHIP TO STUDY DRUG (CAUSALITY) 
Investigators are required to assess the causal relationship (i.e., whether there is reasonable 
possibility that the study drug caused the event) using the following definitions: 
 
 
Unrelated: Another cause of the AE is more plausible; a temporal sequence cannot be 
established with the onset of the AE and administration of the investigational product; or, 
a causal relationship is considered biologically implausible. 
 
 
Possibly Related: There is clinically plausible time sequence between onset of the AE 
and administration of the investigational product, but the AE could also be attributed to 
concurrent or underlying disease, or the use of other drugs or procedures. Possibly related 
should be used when the investigational product is one of several biologically plausible 
AE causes. 
 
 
Definitely Related: The AE is clearly related to use of the investigational product. 

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45 
 
 
9.7 
SEVERITY OF ADVERSE EVENTS (GRADING) 
AEs will be categorized and graded by the Investigator through use of the CTCAE v 4.0 five-point 
scale, Grades 1 to 5 with unique clinical descriptions of severity for each referenced AE.   
 
Should a subject experience any AE not listed in the CTCAE v4.0, the following grading system 
should be used to assess severity: 
9.8 
DEFINITION OF SERIOUS ADVERSE EVENTS 
An SAE is an untoward medical occurrence that at any dose: 
 
Results in death (the AE actually causes or leads to death) 
 
Is life-threatening (“life-threatening” is defined as an AE in which the subject was at risk of 
death at the time of the event. It does not refer to an event which hypothetically might have 
caused death if it were more severe. If either the Investigator or the Sponsor believes that 
an AE meets the definition of life-threatening, it will be considered life-threatening). 
 
Requires in-patient hospitalization or prolongation of existing hospitalization 
 
Results in persistent or significant disability/incapacity (the AE results in substantial 
disruption of the subject’s ability to conduct normal life functions) 
 
Results in a congenital anomaly/birth defect 
 
Is medically significant 
 
Medical and scientific judgment should be exercised in deciding whether other situations, such 
as important medical events that may not be immediately life-threatening or result in death or 
hospitalization but may jeopardize the subject or may require intervention to prevent one of the 
other outcomes listed in the definition above, should also be considered serious.  If either the 
Sponsor or the Investigator believes that the event is serious, the event will be considered serious.   
 
Table 2.  Adverse Event Grading Criteria 
CTCAE Grade
Equivalent To
Definition
Grade 1 
Mild AE 
Experiences which are usually transient, requiring no 
special treatment, and no disruption of normal daily activity 
Grade 2 
Moderate AE 
Experiences which introduce some level of nconvenience 
or concern to the subject, and which may interfere with 
daily activities, but are usually ameliorated by simple 
therapeutic maneuvers 
Grade 3 
Severe AE 
Experiences which are unacceptable or intolerable, 
significantly interrupt the subject’s usually daily activity, 
and require systemic drug therapy or other treatment 
Grade 4 
Life threatening / disabling 
AE 
Experience which causes the subject to be in imminent 
danger of death 
Grade 5 
Death related to AE 
 
Experiences resulting in subject death 
 

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9.9 
EVENTS OF SPECIAL INTEREST 
9.9.1 Appearance of Satellite Lesions 
If a patient appears with a lesion that is not at the original injection site, the incident will be 
reported to the Sponsor-Investigator within 24 hours of occurrence using the SAE CRF in 
REDCap.  The subject will be instructed to return to the clinic and the appropriate safety 
protocol will be followed.  The lesion will be swabbed per instructions from BNI and sent to the 
designated lab for testing.  If the lesion comes back positive, it will be reported to the FDA and 
NIH as outlined in setion 9.10.  
 
9.9.2 Pregnancy of a Female Partner 
For the purposes of this study, pregnancy of a female partner will be captured using a modified 
SAE report form, however; the event is not considered an SAE but will be reported to the 
appropriate regulatory authorities in the annual safety update. Partner pregnancies will be 
followed through the term of the pregnancy or pregnancy termination and the birth of the child 
after the female partner has signed the Pregnant Partner Informed Consent Form. Subjects and 
their partners will be counseled as to any possible known risks to either the partner or the child. 
9.9.3 Accidental Transmission of Vaccinia Virus 
Accidental transmission of vaccinia virus to a clinic staff member or a member of the subject’s 
family or personal contacts must be reported to the Investigator as soon as possible, but no later 
than 24hours after he/she becomes aware. The Investigator must contact the BNI study Medical 
Monitor if there are specific questions in regard to the potential vaccinia reaction.  A swab of the 
suspected lesion may be obtained from the study subject for confirmatory testing prior to 
administration of VIG.  The Investigator should refer to the Management Plan for Potential Serious 
Vaccinia Reaction for recognition, diagnosis and treatment of a rare potential serious vaccinia 
reaction.  This plan also describes when VIG is indicated for use and administration procedures.  
For further information or for a supply of VIG in the United States, contact the CDC at (877) 554-
4625.  If VIG treatment is warranted, the person receiving VIG must sign the Consent Form to 
Administer Vaccinia Immune Globulin (VIG) PRIOR to administration of VIG. 
 
9.10 EXPEDITED REPORTING REQUIREMENTS FOR SERIOUS ADVERSE EVENTS AND 
EVENTS OF SPECIAL INTEREST 
All events described in section 9.8 and 9.9 must be submitted to the SIS Unit within 24 hours of 
the investigator learning of the event following the SOPs outlined in the CTO 102377 Operations 
Manual.  
 
The SIS Unit will be responsible for processing these events for reporting to the applicable 
regulatory and oversight authorities including the IRB, DSMC and FDA. 
 
All SAEs and events of special interest must be reported to Bavarian Nordic, Inc. within 24 hours 
by fax or email to:  
 
Bavarian Nordic, Inc. 
Attn: Drug Safety and Pharmacovigilance Designee 
Fax: 888-465-1219 

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Email:  pharmacovigilance@bavarian-nordic.com 
 
 
Any suspected, unexpected SAE, skin lesion positive for vaccinia, pregnancy of a female 
partner, or accidental transmission of vaccinia virus must be reported to the FDA as soon as 
possible and no later than 7 days (for a death or life-threatening event) or 15 days (for all other 
SAEs) after the investigator’s or institution’s initial receipt of the information.  
 
10 STATISTICAL CONSIDERATIONS 
We will compare RFS at two years for the patients treated with PROSTVAC to that of untreated 
historical controls.  A secondary efficacy objective will be a comparison of the observed RFSs 
for the treated subjects with the calculated RFSs for the same subjects as if they had not 
received adjuvant therapy . 
 
10.1 STATISTICAL CONSIDERATIONS FOR THE PRIMARY OBJECTIVE 
Endpoint: The primary endpoint will be a binary indicator of relapse status at the 2 year follow-
up visit after prostatectomy.  Due to interval-censoring, using a time-to-event RFS outcome may 
lead us to anti-conservative estimates due to some patients having follow-up weeks to months 
after the 2 year anniversary of their surgery and recurrences defined at those later timepoints 
would not be captured in an estimate of 2 year RFS based on a Kaplan-Meier approach.   
A time-to-event analysis of RFS will also be performed, but not for making inferences for the 
primary objective. Patients who do not have data available for a two-year follow-up will be 
censored at the last visit at which they were known to be recurrence-free.  Patients who drop out 
will be replaced for up to 4 patients.  However, those who choose to discontinue treatment prior 
to a recurrence (or other event defined in Section 4.6) but wish to remain in the study, will be 
followed through 24 months to evaluate their disease status based on the intent-to-treat principle.  
These subjects will not be replaced.   
 
Analysis Plan: The primary endpoint will be a binary indicator of relapse status at the 2 year 
follow-up visit after prostatectomy.  Two-year RFS will be estimated as a proportion with an exact 
95% confidence interval.  RFS will also be treated as a time-to-event variable and Kaplan-Meier 
curves will be created and median and two year RFS will be reported with 95% confidence 
intervals. 
 
Sample Size Justification: To estimate the likelihood of RFS at 2 years for subjects at high risk 
of relapse, we extracted data from two sources.  The first source is a database of high risk subjects 
that we have previously used in published research (122).  The database contains clinical 
synopses of 243 subjects treated with radical prostatectomy (retropubic, laparoscopic, and 
perineal) for high-risk prostate cancer.  These subjects were treated by multiple surgeons at 
several academic medical centers.  None received any adjuvant therapy.  High-risk features 
included one or more of the following criteria:   pre-operative PSA > 10 ng/mL; Gleason score 8-
10; positive surgical margins, seminal vesicles, extraprostatic extension, or lymph nodes; 
persistently detectable PSA >45 days after surgery.  Relapse-free survival was defined as the 
interval (days) from prostatectomy to the first of the following:  a) PSA of ≥ 0.2 ng/mL (confirmed) 

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>30 days later, b) appearance of lesions consistent with metastases on imaging studies, or c) 
institution of new prostate cancer therapy.  The observed 1yr probability of RFS was 0.751 and 
the 2yr probability of RFS was 0.645. 
 
An additional source of data for RFS was the ECOG E3886 study (13), in which subjects with 
node-positive prostate cancer after radical prostatectomy (n = 98) were randomized to immediate 
ADT, or ADT at the time of clinical relapse.  This analysis was performed by Dr. Yu-Hui Chen 
(ECOG statistical office) at our request, in 2010.  Relapse was defined as the first of the following:  
a) the appearance of local or distant metastases identified by imaging or physical examination, b) 
the first increase in PSA > 0.1 ng/mL following a post-prostatectomy PSA nadir of < 0.1ng/mL or 
c) death from any cause.  The RFS probability curve is shown in Appendix B.  The observed 1yr 
probability of RFS was 0.73 and the 2yr probability of RFS was 0.56. 
 
While the two groups differ somewhat in the disease status of the subjects, as well as frequency 
and manner of follow up, the probabilities of RFS agree quite closely.  For the purposes of our 
power analysis and sample size, we will assume that the true probability of RFS at 2 years, for 
patients similar to our proposed study population, is 0.60. 
 
We define an “interesting” reduction in the risk of relapse to be 30% (i.e., increase in the probability 
of RFS from 0.6 to 0.78).  Assuming a one-sided alpha = 0.1, with 30 evaluable patients, we have 
80% power to detect this difference based on an exact binomial test. Thus if among 30 evaluable 
subjects, at least 24 are recurrence free at 24 months, we will reject the null hypothesis (2 year 
RFS=0.60) and conclude that the PROSTVAC intervention improves RFS relative to the current 
standard of care in this patient population (one-sided p-value ≤ 0.025). Anticipating a final sample 
size of 30 patients with 10% drop out rate, we plan to enroll 33 patietns for this study. 
 
Interim Analysis: An interim analysis for futility will be performed through Simon’s minimax two-
stage design (Simon, 1989) when a total number of 19 patients are evaluable. The design is 
described as follows: 
 
Stopping criteria: Stop the study if there are 11 or fewer recurrence free among the first 
19 evaluable patients. Otherwise, additional patients will be accrued resulting in a total 
evaluable sample size of 30. 
 
Decision rule at N=30 evaluable patients: Reject the null hypothesis if there are 22 or more 
recurrence free among the 30 evaluable patients. We claim that the PROSTVAC intervention 
improves RFS relative to the current standard of care in this patient population. This design 
controls the type I error rate at 0.1 and yields the power of 0.8. 
 
Safety Monitoring:  Continuous safety monitoring will be performed with early stopping rules in 
the case of unacceptable risk to the subjects, defined as evidence in favor of a risk of a grade 3 
or greater toxicity deemed to be possibly related to treated of 25% vs. an acceptable rate of 10%.   
Stopping criteria are shown in the table below.  The stopping rules are based on a likelihood ratio.  
Specifically, the likelihood ratio is calculated based on a hypothesized 10% event rate (safe) vs, 
a 25% event rate (unsafe) and likelihood ratios in excess of 8 (in favor of an event rate of 25%) 

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49 
 
are considered sufficient evidence to stop the trial.  For example, 7 events in 33 patients yields 
an event rate of 0.21, which has a likelihood ratio of 9.21 favoring a rate of 25% vs. 10%. 
 
Stop if:  
Likelihood Ratio 
Observed Event Rate 
3 events in ≤6 patients 
≥ 9.04 
≥ 0.50 
4  events in ≤12 patients 
≥ 9.08 
≥ 0.33 
5  events in ≤18 patients 
≥ 9.13 
≥ 0.28 
6  events in ≤24 patients 
≥ 9.17 
≥ 0.25 
7  events in ≤33 patients 
≥ 9.21 
≥ 0.23 
 
10.2 SECONDARY OBJECTIVES 
10.2.1 Comparison of Observed RFS with Predicted RFS   
A secondary endpoint will be a comparison of the observed RFSs with the predicted (“virtual”) 
RFS for the same patients based on clinical and pathologic information collected at baseline.  The 
predicted RFSs will be constructed with published and validated algorithms (Duke and 
CaPSURE).  The observed RFSs of the treated subjects are compared with the predicted RFSs 
as if the same subjects had not been treated.  The comparison is performed using the logrank 
test of the observed and predicted RFSs.  These represent the estimated RFSs for patients with 
those clinical characteristics if they did not receive any adjuvant therapy. 
 
RFSs will be displayed graphically using Kaplan-Meier curves.  We then use the log rank test to 
compare the virtual or estimated RFSs values of the test patients with the observed values 
following PROSTVAC-V/F. 
 
The comparative analysis (observed vs predicted RFS) will be performed repeatedly during the 
course of the study, whenever an additional 5 subjects relapse or reach the end of the 2-year 
follow up period.   
10.2.2 Description of Treatment Toxicities   
Toxicities will be tabulated by CTCAE grade and type.   
10.2.3 Correlative Laboratory Studies 
Biochemical and genomic measurements will be summarized both graphically and numerically 
using descriptive statistics.  Transformations will be performed based on the observed 
distribution of the endpoints.  Cox regression will be used to estimate hazard ratios measuring 
the association between these measures and RFS.  95% confidence will be estimated for the 
hazard ratios as appropriate.   
For the amount of antibody forcement antigen, graphical displays such as scatterplots of optical 
density of particular color and dilution will be made for pre- and post-vaccination. To investigate 
if the distributions of pre- and post-vaccination are different, Kolmogorov-Smirnov test will be 
performed. The reverse sigmoidal curves will fit to estimate model paprameters such as slope 
and 50% of maximum effect for the antibody measurement. Depending on the curve results, 
different percentages of maximum effect (e.g., 65-75%) will be investigated as well. Moreover, 
those interest of immune parameters will be compared between pre- and post-vaccination. The 

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difference of the immune parameters will be used for measuring the association between these 
measures and time to relapse/stress.  
 
10.3 SOCIOBIOLOGICAL RESPONSE TO STRESS OPTIONAL SUB-STUDY OBJECTIVES 
The investigators expect around 70-80% of patients will consent for the sub-study, which leads 
to the sample size around 30-40 patients for the analysis. Through this sub-study, the 
investigators will explore the relation between stress responses and clinical outcomes for the 
entire patient population and for racial subgroups. The following statistical plan will be used. 
 
Aim 1: To evaluate the effects of stress reactivity on the development of an effective anti-tumor 
immune response in this patient population. 
 
We will perform the following analyses to better understand how stress reactivity affects the 
anti-tumor immune response: 1) correlation analysis between the anti-tumor immune response 
and stress reactivity measures; 2) logistic regression in which we will regress the anti-tumor 
immune response of each patient on stress reactivity adjusting for covariates (e.g. age, 
perceived stress). 
 
Aim 2: To evaluate the difference in terms of stress reactivity based on SES, perceptions of 
social stressors, and AL between racial subgroups. 
 
Descriptive statistics of stress reactivity measures will be summarized for the entire patient 
population and for each racial group. Wilcoxon rank sum test or a Fisher’s exact test will be 
used to explore the potential statistical significance among those measures (e.g. SR, clinical 
history, psychosocial factors (e.g., life stress events, social isolation), and genetic variants in the 
GR receptor gene) between racial subgroups. In addition, a discriminant analysis (e.g. quadratic 
discriminant analysis or nearest neighbor approach) for the entire patient population and for 
each racial group will be used to classify patients as high or low stress responders based on 
changes in cortisol during the TSST. Cross validation will be used to exam the misclassification 
rates.  
 
Aim 3: To evaluate the difference between racial subgroups for the magnitude and distribution 
of stress responses with biological (AL) and immunologic measure of vaccine effect. 
 
Descriptive statistics will be summarized for the AL measurements (e.g. median) at each time 
point (baseline, day 85, day 225, and day 730 or off study) for the entire patient population and 
for each racial group. We will compare the mean difference between two consecutive time 
points between two racial groups using a Wilcoxon rank sum test. A linear mixed model will also 
be fitted in which we will regress AL measurements on racial group, time, stress reactivity (may 
consider interaction terms) to explore the AL response profile difference. The outcome of RFS 
will be evaluated using Kaplan-Meier estimates and the statistical significance of difference in 
RFS between racial groups will be tested by a logrank test.  In addition, a cox regression model 
will be explored. 
 
10.4 POPULATIONS FOR ANALYSES 
Subjects evaluable for toxicity or efficacy will be those who receive at least one dose of 
PROSTVAC-V.   
 

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10.5 ADDITIONAL ANALYSES 
Demographic and clinical parameters will be tabulated.  Critical parameters to be recorded include 
age at time of surgery, date of surgery, race, primary Gleason score, secondary Gleason score, 
pathologic stage, surgical margin status, extraprostatic extension status, seminal vesicle status, 
lymph node status, pre-operative PSA level, post-operative PSA level (> 6 wks after surgery).  
Formalin-fixed paraffin-embedded tissue from the prostatectomy specimen will be archived for 
future “omic” analyses to correlate with RFS.   
11 ETHICAL CONSIDERATIONS 
11.1 GOOD CLINICAL PRACTICE 
This study will be conducted in accordance with GCP, as defined by the International ICH and in 
accordance with the ethical principles underlying the US CFR, Title 21, Part 50 (21CFR50).  The 
study will be conducted in compliance with the protocol. The protocol, any amendments, and the 
subject informed consent will receive IRB approval before initiation of the study. 
 
All potential serious breaches must be reported to the institutional IRB and DSMC.  A serious 
breach is a breach of the conditions and principles of GCP in connection with the study or the 
protocol, which is likely to affect, to a significant degree, the safety or physical or mental integrity 
of the subjects of the study or the scientific value of the study. 
 
Study personnel involved in conducting this study will be qualified by education, training, and 
experience to perform their respective tasks. This study will not use the services of study 
personnel where sanctions have been invoked or where there has been scientific misconduct or 
fraud (e.g., loss of medical licensure; debarment). Systems with procedures that ensure the 
quality of every aspect of the study will be implemented. 
 
11.2 INSTITUTIONAL REVIEW BOARD 
Before study initiation, the investigator must have written and dated approval/favorable opinion 
from the IRB for the protocol, consent form, recruitment materials, and any other written 
information to be provided to subjects. The investigator should also provide the IRB with a copy 
of the IB or product labeling, information to be provided to subjects, and any updates. The 
investigator should provide the IRB with reports, updates, and other information (e.g., expedited 
safety reports, amendments, and administrative letters) according to regulatory requirements or 
institution procedures. 
11.3 INSTITUTIONAL BIOSAFETY COMMITTEE (IBC)  
This protocol and any accompanying material provided to the subject (such as subject information 
sheets, ICF, or descriptions of the study used to obtain informed consent) will be submitted by 
the investigator to a legally constituted and chartered IBC. Additional materials, such as the IB, 
will be submitted to the IBC according to the specific Committee and federal (NIH) requirements. 
Each site will be approved by the IBC in accordance with local procedures and country-specific 
regulatory requirements. Documentation of IBC approval must be in place prior to drug shipment 
to the site. 

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At the discretion of the specific IBC and within federal requirements, IBC oversight of individual 
sites may be terminated provided (1) all subjects at that site have completed dosing by at least 
28 days, and (2) all investigational materials have been fully accounted for and either returned to 
BNI, destroyed on site, or shipped to a duly licensed destruction facility and a shipping and 
inventory reconciliation records have been filed in the Pharmacy Manual. 
11.4 INFORMED CONSENT 
The ICF and process must comply with the US regulations (§ 21 CFR Part 50), as well as state 
and local laws. The ICF will document the study-specific information the Investigator or his/her 
designee provides to the subject and the subject’s agreement to participate. 
 
The Investigator, or designee (designee must be listed on the Delegation of Authority log), must 
explain in terms understandable to the subject the purpose and nature of the study, study 
procedures, anticipated benefits, potential risks, possible adverse effects, and any discomfort 
participation in the study may entail. Investigators must ensure that subjects are clearly and fully 
informed about the purpose, potential risks, and other critical issues regarding clinical studies in 
which they volunteer to participate. Freely given written informed consent must be obtained from 
every subject before clinical study participation, including informed consent for any screening 
procedures conducted to establish subject eligibility for the study.  This process must be 
documented in the subject’s source record. Each subject must provide a signed and dated 
informed consent before any study-related (nonstandard of care) activities are performed. The 
original and any amended signed and dated consent forms must remain in each subject’s study 
file at the study site and be available for verification by study monitors at any time. A copy of each 
signed consent form must be given to the subject at the time that it is signed by the subject. 
 
The rights, safety, and well-being of the study subjects are the most important considerations and 
should prevail over interests of science and society. 
11.5 COMPLIANCE WITH THE PROTOCOL 
A complete list of Investigator responsibilities are outlined in the clinical trial research agreement 
and the Statement of Investigator FDA Form 1572, both of which are signed by the Investigator 
before commencement of the study. In summary, the Investigator will conduct the study according 
to the current protocol; will read and understand the IB; will obtain IRB approval to 
conduct the study; will obtain informed consent from each study participant; will maintain and 
supply to the Sponsor or designee, auditors and regulatory agencies adequate and accurate 
records of study activity and drug accountability for study-related monitoring, audits, IRB reviews 
and regulatory inspections; will report SAEs to the Sponsor or designee and IRB according to the 
specifics outlined in this protocol; will personally conduct or supervise the study; and will ensure 
that colleagues participating in the study are informed about their obligations in meeting the above 
commitments. 
 

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11.6 RECORDS RETENTION 
The Investigator must keep a record that lists all subjects considered for enrollment (including 
those who signed consent but were not enrolled) in the study. For those subjects subsequently 
excluded from enrollment, the reason(s) for exclusion is to be recorded. 
 
The Investigator/study staff must maintain adequate and accurate records to enable the conduct 
of the study to be fully documented and the study data to be subsequently verified.  Essential 
documentation includes, but is not limited to, the Investigator Brochure, signed protocols and 
amendments, IRB approval letters (dated), signed FDA Form 1572 and Financial Disclosures, 
signed ICFs (including subject confidentiality information), drug dispensing and accountability 
records, shipping records of investigational product and study-related materials, signed 
(electronically), dated and completed CRFs, and documentation  of CRF corrections, SAE forms 
transmitted to BNI or designee and notification of SAEs and related reports, source 
documentation, normal laboratory values, decoding procedures for blinded studies, curricula vitae 
for study staff, and all relevant correspondence and other documents pertaining to the conduct of 
the study. 
 
All essential documentation will be retained by the Investigator for at least 2 years after the date 
the last marketing application is approved for the drug for the indication for which it is being 
investigated and until there are no pending or contemplated marketing applications; or, if no 
application is to be filed or if the application is not approved for such indication, until 2 years after 
formal discontinuation of clinical development of the drug.  
11.7 DATA COLLECTION 
Electronic CRFs will be used to collect the clinical study data and must be completed for each 
enrolled subject with all required study data accurately recorded such that the information 
matches the data contained in medical records (e.g., physicians’ notes, nurses’ notes, clinic charts 
and other study-specific source documents). Authorized study site personnel (i.e., listed on the 
Delegation of Authority form) will complete eCRFs designed for this study according to the 
completion guidelines that will be provided. The Investigator will ensure that the eCRFs are 
accurate, complete, legible, and completed within 7 days of each subject’s visit. At all times, the 
Investigator has final responsibility for the accuracy and authenticity of all clinical data. 
 
All data should be substantiated by clinical source documents organized within a patient 
research record. ICH Good Clinical Practices are to be followed.  
 
Electronic data for on study and follow-up patient data is submitted via the electronic system 
called REDCap.  REDCap is managed from MUSC as a consortium partner under their CTSA. 
REDCap is a secure, Web-based application designed to capture and manage research study 
data. 
 
The system has been reviewed for 21CFR Part 11 compliance and has been deemed “21CFR 
11 Capable.” Users of the REDCap system are limited to members of the IRB approved 
research team who are delegated data management responsibilities and those tasked with 
assuring quality control and quality assurance. 

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11.8 SUBSTUDY DATA COLLECTION 
A data integration core has been established to integrate biological data (i.e., allostatic load) 
with information collected on social, psychological, behavioral, and clinical variables collected 
through the social determinants survey, MUSC’s EPIC electronic health records (EHR), and 
MUSC’s electronic data warehouse (EDW). This will be accomplished through several data 
integration strategies that will harmonize diverse types of data on psycho-social factors and 
biological biomarkers.  These strategies include using natural language processing (NLP) 
techniques to identify social factors and patient stressors. Key data elements from the EHR and 
EDW will be extracted using NLP to establish discrete fields for patient demographics, 
encounter details, vitals, diagnostic history, medications, and laboratory results. Textual patient 
summaries such as clinical notes containing patient’s social history will also be extracted from 
the EHR and EDW and analyzed via NLP. The Data Integration Core will also use data mining 
strategies to determine the temporal links between allostatic load and disease risk and 
outcomes in order to validate the associations observed in the study. All longitudinal patient 
data will be extracted from EDW via dynamic data pull (DDP) and from EHR using medical 
record numbers (MRNs) and stored in MUSC’s REDCap data capture system and then merged 
with experimental data, and anonymized to create the main data repository. Anonymization will 
be performed by IRB certified honest brokers during integration of the data into the main data 
repository. Investigators will only have access to anonymized datasets. On a quarterly basis, 
data will be updated by honest brokers with any newly acquired clinical data items. Investigators 
will utilize the datasets to perform correlation analyses in order to examine linkages between 
biological, social, and clinical factors. 

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APPENDIX A:  SCHEDULED PROCEDURES AND ASSESSMENTS 
 
 
  
Days on studyf 
Therapeutic trial procedures 
Procedurec 
Prea 
Active/On Treatment 
1n 
15 
29 
57 
85 
113 
141 
Follow Uph, p 
225 
309 
393 
477 
561 
645 
730g 
Informed Consent 
Xc 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Full Physical Exam 
X 
Focused Phyical Exam 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Full Medical History 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Interim Medical 
Historyo
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
AE assessment 
X 
X  
X 
X 
X 
X 
X 
X 
CBCD 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
CMP 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
PSA 
Xm 
Xm  
  
  
X 
  
  
X 
X 
X 
X 
X 
X 
X 
X 
Testosterone 
X 
  
  
  
  
  
  
CRP 
X 
  
  
  
  
  
X 
Lipid Panel 
 
Xk 
 
 
 
 
 
 
 
 
 
 
 
 
 
CT (abdomen/pelvis) 
Xb 
  
  
  
  
  
  
  
  
  
  
  
  
  
Tc-bone scan 
Xb 
  
  
  
  
  
  
  
  
  
  
  
  
  
HIV test 
Xl 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Hep B and C testing 
Xl 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treatment 
PROSTVAC-V 
  
X 
  
  
  
  
  
  
  
  
  
  
  
  
  
PROSTVAC-F 
  
  
X 
X 
X 
X 
X 
X 
  
  
  
  
  
  
  
Correlative 
Research 
FACT-P 
Xi,q 
  
  
  
 Xq 
  
 Xq 
  
  
  
  
 Xq 
AUA 
Xi,q 
  
  
  
 Xq 
  
 Xq 
  
  
  
  
 Xq 
SHIM 
Xi,q 
  
  
  
 Xq 
  
 Xq 
  
  
  
  
 Xq 
Social Determinants 
Questionnaire
 
Xi, 
 
 
 
 
 
 
 
 
 
 
 
 
 
Research bloode 
Xi, 
  
  
  
 X 
  
X 
  
  
  
  
  
X 
Research FFPE tissue 
Xj 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Optional 
Sub-Study 
Optional Sub-study 
Consent 
Xd 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Trier Stress Test 
Xi 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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v. 11/11/2019 
 
 
 
 
 
 
 
66 
 
 
a. 
Screening Assessments (“Pre”) may be done up to 30 days prior to registration unless otherwise noted.   
b. 
Radiographic assessments may be done up to 26 weeks prior to registration.  PSA at screening is required to document eligibility for post-operative PSA and may be done greater than 
30 days prior to registration.  
c. 
The informed consent for the main study can be obtained more than 30 days prior to registration but must be obtained before any research procedures are completed 
d. 
The optional sub-study consent must be obtained prior to conducting the Trier Stress Test. The optional sub-study is voluntary and does not impact the patient’s ability to participate in 
the main therapeutic portion of the trial.  
e. 
See section 8 for blood draw volume and tube type requirements. 
f. 
all specified times are +/- 7 days  
g. 
or off-study day 
h. 
follow up will begin after the last day of study drug administration.   
i. 
Research blood, social determinants questionnaire and quality of life questionnaires may be completed any time after informed consent is signed and prior to Day 1 drug administration. 
j. 
If available:  Send 5 thin (5 micron) sections on glass for H+E and IHC staining.  These can be sent at any time after consent has been signed.   
k. 
Lipid panel requires patients to be fasting and can be done any time after informed consent is signed and prior to day 1 agent administration. 
l. 
HIV, Hep B and Hep C serology screening, unless known negative within previous 2 years prior to registration.     
m. PSA confirming eligibility can be done outside of the 30 day window.  However, if PSA confirming eligibility was done greater than 30 days prior to day 1, it should be repeated prior to day 
1 agent administration to ensure PSA is < 0.2ng/mL 
n. Day 1 assessments completed within 24 hours of screening assessments do not need to be repeated.   
o. Interim medical history includes any changes to the patient’s medical history and/or any clinical changes since the previous clinic visit. 
p. For non-local patients in follow up, all attempts should be made to have subject return to the clinic for all follow up visits, but specifically day 225 and day 703.  However, clinical care 
procedures (PSA, CMP, CBCD, focused physical exam and interim medical history – to include AE assessment and conmed assessment) may be done locally and the records provided.  
At a minimum, a PSA must be done and results provided to the study team.  If a clinic visit is not done during follow up, the study team may conduct a phone interview (using the phone 
contact guide, Appendix D) in leiu of an clinic visit to assess adverse events, current cancer therapy and PSA level.  Quality of life surveys may also be conducted over the phone by the 
study team if the subject does not return to clinic.  
q. 
Questionnaires may be mailed to the subject in pre-metered envelope if they are unable to come into the clinic to complete them (ie: due to COVID19 travel restrictions). The subject will 
complete the questionnaires at home and then mail the completed questionnaires back to the main site in the provided envelope. 
 
 
 

Phase II Trial of Adjuvant PROSTVAC V/F Following Radical Prostatectomy 
 
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APPENDIX B:  SOURCE DATA FOR RFS 
See next page for additional source of data for RFS  

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APPENDIX C: PROCEDURE FOR OBTAINING VIG AND CIDOFOVIR FOR TREATMENT OF 
SERIOUS ADVERSE REACTIONS CAUSED BY THE SMALL POX VACCINE. 
Information in this document is taken from the Smallpox fact sheet – Information for Clinicians and 
Public Health Professionals.  The fact sheet can be reviewed in full here:   
https://emergency.cdc.gov/agent/smallpox/vaccination/pdf/mgmt-adverse-reactions-clinic.pdf  
Indications for VIG/cidofovir release: 
 
Vaccinia Immune Globulin (VIG) and cidofovir are indicated for the treatment of certain serious 
smallpox vaccine adverse events, including progressive vaccinia, eczema vaccinatum, 
generalized vaccinia (severe form or if underlying illness), and inadvertent inoculation (if judged 
to be severe due to the number of lesions, toxicity of affected individual, or significant pain). VIG 
is recommended as the first line of therapy. Cidofovir may be considered as a secondary 
treatment, and will only be released by CDC after all inventories of VIG have been exhausted, 
after a patient fails to improve with VIG treatment, or as a last effort for a patient who is 
otherwise near death.  
 
VIG and cidofovir are available for civilians through the CDC under Investigational New Drug 
(IND) protocols for treatment of specific smallpox vaccine reactions. Based on the anticipated 
number of adverse events resulting from the planned vaccination program for healthcare 
workers, CDC’s supply of VIG should be adequate.  
Process for obtaining VIG/cidofovir under Investigational New Drug Protocol (IND): 
1. Contact the South Carolina Department of Health:  Physicians should first contact their State 
Health Department when seeking consultation for civilian patients experiencing a severe or 
unexpected adverse event following smallpox vaccination or when requesting VIG or cidofovir.   
2. If further consultation is required, or VIG or cidofovir is recommended, the physician will be 
referred to the CDC Clinical Information Line (CIL) at 1- 877-554-4625. The nurses staffing 
the CIL will take basic information and then expedite the call to the CDC Smallpox Vaccine 
Adverse Events Clinical Consultation Team. The CDC Clinical Consultation Team will provide 
in-depth consultation and will facilitate VIG or cidofovir release as appropriate.  
3. According to FDA regulations, VIG or cidofovir released from the CDC must be administered 
according to their investigational new drug protocols (IND). The IND mandates that the treating 
physician must become a co-investigator. The responsibilities of the co-investigator are primarily 
to complete follow-up forms describing the clinical status of the patient being treated with VIG 
and/or cidofovir, including the prompt report of any significant adverse reaction in the recipient. 
Detailed information on the requirements of the IND will be shipped with the products.  
Shipment of VIG/cidofovir  
 
VIG/cidofovir will be shipped by the National Pharmaceutical Stockpile (NPS). The CDC 
Smallpox Vaccine Adverse Events Clinical Consultation Team will coordinate the shipment of 
VIG/cidofovir with NPS. The cost of VIG and cidofovir and the cost of shipping will be covered 
by the U.S. Government. Arrival of shipments should be expected within 12 hours of the 
approval for release.  

Phase II Trial of Adjuvant PROSTVAC V/F Following Radical Prostatectomy 
 
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73 
 
 
 
 
APPENDIX D:  PHONE CONTACT GUIDE 
This form is to be used if a patient does not come back to HCC for follow up visits after the day 141 
PROSTVAC-F administration. 
 
Study ID/Initials:_______________________ Date:_________________Timepoint:_________________ 
 
 Call conducted (complete information below) 
 Patient could not be contacted after ____ attempts. 
 
1. Are you experiencing any side effects? 
 
[Document any side effects reported by the subject.  Severity to be confirmed by a study-approved 
investigator.  Attribution to done by a study-approved investigator.] 
 
Side Effect 
Severity 
Attribution 
Investigator 
Initials
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
2. Are you receiving any form of prostate cancer treatment? 
☐Yes 
☐No 
 
 
Date treatment was started:________________________ 
 
3. What is your most recent PSA value?________________ng/dL 
 
4. Day 225 and Day 730 only:  May we ask you some quality of life questions? ☐Yes 
☐No 
 
[If yes – administer the quality of life questionnaires] 
 
Recorder’s signature and date:  ________________________________________ 
 
 
Investigator’s signature and date:________________________________________