Phase II Trial of a DNA Vaccine Encoding Prostatic Acid Phosphatase (pTVG-HP) and Nivolumab in Patients With Non-Metastatic, PSA-Recurrent Prostate Cancer
Phase: PHASE2
Conditions: Prostate Cancer
Sponsor: University of Wisconsin, Madison

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Phase II Trial of a DNA Vaccine Encoding Prostatic Acid Phosphatase (pTVG-HP) and 
Nivolumab in Patients with Non-Metastatic, PSA-Recurrent Prostate Cancer  
 
UW 18008 
 
 
 
 
Trial Registration Number:  NCT 03600350 
 
Investigational Agent: 
 
 
 
BB IND 12109 - pTVG-HP DNA encoding human prostatic acid phosphatase  
 
 
Study Supporters: 
 
 
 
Bristol-Myers Squibb – Nivolumab 
 
 
Madison Vaccines Inc. (MVI) – pTVG-HP 
 
 
 
STUDY SITE INFORMATION 
 
Study Sites: 
 
University of Wisconsin Carbone Cancer Center (UWCCC) 
 
 
 
1111 Highland Avenue 
 
 
 
Madison, WI 53705 
 
 
 
 
Johns Hopkins School of Medicine (JHU) 
 
 
 
Baltimore, MD 21287 
 
 
Sponsor Investigator: Douglas G. McNeel, M.D., Ph.D. 
UWCCC 
7007 Wisconsin Institutes for Medical Research 
1111 Highland Ave.  
Madison, WI 53705 
Tel:  (608) 263-4198 
Fax:  (608) 265-0614 
 
 
 
dm3@medicine.wisc.edu 
 
 
UWCCC Local Principal Investigator : 
 
  
 
Hamid Emamekhoo, MD 
 
 
 
UWCCC 
 
 
 
7009 Wisconsin Institutes for Medical Research 
 
 
 
1111 Highland Ave. 
 
 
 
Madison, WI 53705 
 
 
 
Tel : (608) 263-3398 
 
 
 
Fax : (608) 265-5146 
 
 
 
emamekhoo@wisc.edu 
 
 

 
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Other UWCCC Investigators:  
 
 
 
 
 
 
 
Christos Kyriakopolous, M.D. – Clinical Investigator 
 
 
 
Glenn Liu, M.D. – Clinical Investigator 
 
 
 
Joshua Lang, M.D. – Clinical Investigator 
Robert Jeraj, Ph.D. – Medical Physics, Quantitative Total Bone Imaging 
 
 
 
Scott Perlman, M.D. – Nuclear Medicine 
 
JHU Principal Investigator:  
 
 
 
Channing Paller, MD 
 
 
 
Associate Professor, 
 
 
 
Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins 
 
 
 
Viragh Floor 9, Box 7 
 
 
 
201 N. Broadway, Room 9162 
 
 
 
Baltimore, MD 21287 
 
 
 
Phone: 410-955-8239 
 
 
 
Email: cpaller1@jhmi.edu 
 
 
Study Coordinator: 
Mary Jane Staab, R.N. B.S.N. 
 
 
 
UWCCC 
 
 
 
600 Highland Ave. K6/5 CSC 
 
 
 
Madison, WI  53792 
 
 
 
Tel:  (608) 263-7107 
 
 
 
mjs@medicine.wisc.edu 
 
Study Biostatistician: Jens Eickhoff, Ph.D. 
 
 
 
UWCCC 
 
 
 
600 Highland Ave.  K6/434 CSC 
 
 
 
Madison, WI  53792 
 
 
 
Tel:  (608) 265-5376 
 
 
 
eickhoff@biostat.wisc.edu 
 
 
Projected Start Date:  
 
 
 
 
May 1, 2018 
 
Projected End of Accrual Date (First Stage):  
 
October 31, 2019 
 
 
Projected End of Study Date (First Stage): 
 
 
October 31, 2020 
 
Projected End of Long-Term Follow-Up (First Stage): 
October 31, 2022 
 
 
 

 
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TABLE OF CONTENTS 
 
 
1. Introduction ........................................................................................................................... 7 
 
2. Background and Rationale .................................................................................................... 9 
 
3. Objectives ........................................................................................................................... 14 
 
4. Vaccine and Nivolumab Preparation .................................................................................. 15 
 
5. Patient Selection.................................................................................................................. 17 
 
6. Experimental Design ........................................................................................................... 19 
 
7. Definition and Management of Limiting Toxicities and Adverse Events .......................... 21 
 
8. Plan of Treatment ................................................................................................................ 28 
 
9. Response Monitoring .......................................................................................................... 34 
 
10. 
Reporting Adverse Events ................................................ Error! Bookmark not defined. 
 
11. 
Statistical Considerations ................................................................................................ 37 
 
12. 
Administrative Considerations ........................................................................................ 41 
 
13. 
Data and Safety Monitoring Plan .................................................................................... 43 
 
14. 
Potential Risks and Benefits, and Procedures to Minimize Risk .................................... 49 
 
15. 
Study Data Management and Procedural Issues .............................................................. 52 
 
16. 
Roles and Responsibilities of Study Personnel at UWCCC ............................................ 56 
 
17. 
References ....................................................................................................................... 57 
 

 
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SYNOPSIS: 
 
Purpose:  To evaluate the safety of an investigational DNA vaccine, pTVG-HP, a plasmid DNA 
encoding human prostatic acid phosphatase (PAP), in combination with nivolumab, and the 
efficacy of this combination in decreasing serum PSA in patients with non-metastatic, non-castrate 
prostate cancer (clinical stage D0/M0). 
 
 Primary Objectives: 
 
1. To evaluate the safety and tolerability of pTVG-HP DNA vaccine and nivolumab in 
patients with clinical stage D0/M0 prostate cancer 
2. To determine the PSA complete response rate (PSA < 0.2 ng/mL)  
 
Secondary Objectives: 
 
1. To evaluate 2-year metastasis-free survival rate 
2. To evaluate median radiographic progression-free survival  
3. To evaluate changes in PSA doubling time or slope 
4. To evaluate PSA response rate (< 50% of baseline) 
5. To determine whether GM-CSF is required as a vaccine adjuvant for pTVG-HP vaccine 
when used in combination with nivolumab 
 
Laboratory/ Exploratory Biomarker Objectives: 
 
1. To determine if antigen-specific T-cell and/or IgG responses are elicited with treatment 
2. To determine if the development of PAP-specific T-cell immune responses are associated 
with PSA response (decline > 50%)  
3. To determine if antigen spread (the development of immune responses to other cancer-
associated proteins) is associated with PSA response (decline > 50%)  
4. To determine if Quantitative Total Bone Imaging (QTBI) by NaF PET/CT can identify 
bone lesions in this patient population not detected by standard bone scintigraphy  
5. To determine whether the presence of lesions detected by NaF PET/CT at baseline is 
associated with early disease progression (within 1 year) by standard radiographic 
imaging methods (CT and bone scintigraphy) 
6. To determine if growth rates, and changes in growth rates, determined by NaF PET/CT are 
associated with PSA doubling time and changes in PSA doubling time 
 
 

 
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Study Scheme: 
 
 
 
 
 
 

 
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Study Calendar: 
 
 
 
Vaccine / Treatment 
Visit: 
 
 
Pre-Screen 
(within 4 wks registration) 
Screen/Randomization 
(within  2 weeks of day 1) 
Day 1 (wk 0) –  V1 
Week 2 – V2 (+/- 3 d)d 
Week 4 – V3 (+/- 3 d) 
Week 6 -  V4 (+/- 3 d) 
Week 8 – V5 (+/- 3 d) 
Week 10  - V6 (+/- 3 d) 
Week 12 – V7 (+/- 3 d) 
Week 16 – V8 (+/- 3 d) 
Week 20 – V9 (+/- 3 d) 
Week 24 – V10 (+/- 3 d) 
Week 28 – V11 (+/- 3 d) 
Week 32 – V12 (+/- 3 d) 
Week 36 – V13 (+/- 3 d) 
Week 40 – V14 (+/- 3 d) 
Week 44 –  V15 (+/- 3d) 
Week 48 – V16 EOT (+/- 
3d)
Week 60 – V17 (+/- 14d)k 
Week 72 – V18 (+/- 14d)k 
Week 84 – V19 (+/- 14d)k 
Week 96 – EOS (+/- 14d)k 
28-day Follow Up (+/- 
7d)hp
Annual Long-Term F/U 
History & Physical Exam 
Consenting 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
History 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Physical Examm 
 
Xn 
X 
 
X 
 
X 
 
X X X X X X X X X X X X X X X  
Toxicity assessmenta 
 
X 
X X X X X X X X X X X X X X X X X X X X X  
Lab Tests 
CBCb 
 
X 
Xg 
 
X 
 
X 
 
X X X X X X X X X X X X X X X  
Chemistry panelc 
 
X 
Xg 
 
X 
 
X 
 
X X X X X X X X X X X X X X X  
Serum testosterone 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
PSAl and PAP 
 
X 
Xg 
 Xo  
X 
 
X X X X X X X X X X X X X X X  
Procedures / Treatments 
CT abdomen/pelvisf 
X 
 
 
 
 
 
 
 
 
 
 Xe  
 
 
 
 Xe  Xe  Xe  
 
Bone scan 
X 
 
 
 
 
 
 
 
 
 
 Xe  
 
 
 
 Xe  Xe  Xe  
 
NaF-PET/CT 
 
Xq,r 
 
 
 
 
 
 Xq,r  
 Xq,r  
 
 
 
 
 
 
 
 
 
 
 
Nivolumab 
 
 
X X X X X X X X X X X X X X X 
 
 
 
 
 
 
 
pTVG-HP immunization 
 
 
X X X X X X X X X X X X X X X 
 
 
 
 
 
 
 
rhGM-CSF adjuvantj 
 
 
 
 
X X X X X X X X X X X X X 
 
 
 
 
 
 
 
Blood for immune 
studies 
 
X 
 
 
X 
 
 
 
X 
 
 
X 
 
 
X 
 
 
X 
 
 
 
 Xi  
a Study coordinator or research nurse review of systems 
b CBC to include differential and platelets 
c Chemistry panel includes Chem7 (sodium, potassium, bicarbonate, BUN, creatinine, glucose), ALT, AST, total 
bilirubin, alkaline phosphatase, amylase, TSH (thyroid stimulating hormone), and LDH 
d Time interval (+/- 3 days) is from last visit 
e Can be +/- 7 days of this visit 
f CT of chest only as clinically indicated 
g If not performed within 7 days of this visit 
h 28 days +/- 7d after off-study date, if prior to week 48, otherwise this visit not required 
i If not already collected within previous 60 days 
j Only use GM-CSF adjuvant if serum PSA at week 4 (V3) is higher than that obtained at day 1 (V1). 
k Can be +/- 14 days of this visit 
l PSA values used for screening/eligibility should all be from same clinical laboratory; for day 1 and subsequent 
visits, all PSA values should be from same lab, but not necessarily from same lab as used for screening  
m Physical exam to include vital signs and ECOG status 
n Physical exam does not need to be repeated on Day 1 if obtained within 14 days prior to the visit 
o PSA obtained at week 4 and used to determine whether GMCSF will be added can be obtained within 7 days of the 
visit 
p  Patients will be followed for adverse events for 90 days after the last dose of nivolumab 
q NaF PET/CT within +/- 7 days of study visit, exceptions may be allowed with prior approval from the study PI.   The 
same PET/CT scanner should be used for each individual subject.  
r  NaF PET/CT should NOT be done within 2 days of GM-CSF injection.  
 

 
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1. 
Introduction 
 
Prostate cancer is the most common tumor among men, and the second leading cause of male 
cancer-related death in the United States [1].  Despite advances in screening and early detection, 
nearly 30,000 U.S. men are estimated to die as a result of prostate cancer in 2017 [1].  Treatment 
with surgery and radiation remain effective for presumed organ-confined disease, however 
approximately one third of these patients will have progressive or metastatic disease at 10 years 
[2].  A retrospective review of patients with prostate cancer treated with prostatectomy 
demonstrated that with evidence of a rise in serum PSA after definitive therapy, so-called “stage 
D0” (or M0) disease, patients ultimately developed radiographically apparent metastatic disease 
within a median of 8 years [3].  Prostate cancer, once it becomes metastatic, is not curable and is 
generally treated initially with androgen ablation therapy with an average three-year progression-
free survival before the disease becomes refractory to hormonal manipulations.  Many patients 
with this stage D0/M0 disease (rising PSA after definitive treatment, and without evidence of 
radiographically-apparent metastatic disease) are often treated with androgen deprivation.  
Androgen deprivation in this context could be by orchiectomy or treatment with LH-RH agonists, 
with or without a nonsteroidal anti-androgen.  Observation is also an option, in particular given 
the potentially long natural history of this stage of disease.  In patients with rising serum PSA after 
definitive therapy, without radiographic evidence of metastases and not on androgen deprivation 
therapy, the rate of rise of the serum PSA blood test (PSA doubling time, PSA DT, or PSA slope) 
may be the most important prognostic indicator.  Several recent retrospective reports have 
highlighted that patients with rapid PSA DT in this stage of disease have a markedly shorter time 
to the development of metastases and death [4-7].  In a prospective analysis, the most important 
contributors to metastatic disease progression were the PSA DT, the original Gleason score, and 
the baseline PSA at the start of prospective monitoring [5].  Consequently, this clinical stage 
D0/M0 disease represents a high-risk population of patients for whom there is not a standard 
therapy, for whom observation is typically employed, and whose progression-free survival can be 
estimated based on known factors, including PSA DT [7].  This represents a population for whom 
new treatments without the side effects associated with androgen deprivation could be evaluated.  
 
Vaccine-based strategies, also known as active immunotherapies, are particularly appealing as 
potentially safe and less costly treatments that have the potential to eradicate micrometastatic 
disease and prevent the progression from limited-stage disease to metastatic disease, or at least 
slow this progression.  Once a patient is diagnosed with presumably organ-confined prostate 
cancer, the gland is usually removed by prostatectomy or destroyed in vivo with radiation.  Hence, 
an immune response directed at the prostate following such procedures, to elicit a prostate tissue-
specific rejection, might have therapeutic benefit to destroy micrometastatic disease, the goal of 
active immunotherapies.  The target of such therapy would not need to be specific to malignant 
prostate tissue, but could be to any prostate tissue.  We and others have investigated prostatic acid 
phosphatase (PAP) as a prostate tumor vaccine antigen.  PAP is a well-defined protein whose 
expression is essentially restricted to normal and malignant prostate tissue [8].  It is also one of 
only a few known prostate-specific proteins for which there is a rodent homologue, which thereby 
provided an animal model for evaluating vaccine strategies and assessing toxicity [9].  Data from 
independent labs has demonstrated that, in a rat model, vaccine strategies targeting PAP can result 
in PAP-specific CD8+ T-cells, the presumed population mediating tumor cell destruction, and anti-
tumor responses [10-13].  An autologous antigen-presenting cell vaccine loaded ex vivo with a 
PAP derivative protein (sipuleucel-T, Dendreon Corporation, Seattle, WA) demonstrated 

 
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improved overall survival in patients with advanced castration-resistant metastatic prostate cancer 
in a placebo-controlled randomized phase III trial, leading to the FDA approval of sipuleucel-T in 
2010 [14].  Together, these results demonstrate that the PAP protein is a reasonable target antigen 
for immunotherapy trials of prostate cancer.  However, the use of autologous cell-based vaccines 
is labor-intensive and costly.  The development of novel, more feasible, immunization strategies 
would provide a significant advantage to the development of immunotherapeutic treatments for 
prostate cancer.   
 
Based on previous studies in rat models using a plasmid DNA vaccine encoding PAP, we 
conducted a phase I/II trial in patients with high-risk stage D0 prostate cancer using this same 
DNA vaccine (pTVG-HP).  No significant adverse events were observed in 22 subjects treated 
over a 12-week period of time.  Moreover, several patients developed evidence of PAP-specific 
CD8+ T-cells, and several patients experienced a prolongation in the PSA doubling time, 
demonstrating immunological efficacy and possible clinical efficacy [15].  IFNγ-secreting immune 
responses to PAP detectable at multiple times months after immunization were detectable in 
individuals with evidence of prolonged PSA doubling time [16].  A second trial was conducted in 
patients with castration-resistant, non-metastatic prostate cancer (clinical stage D0.5/M0) that 
evaluated treatment over a 2-year period of time and with different schedules of administration.  
That trial similarly demonstrated safety, and the induction of durable Th1-biased immune 
responses specific for the PAP target antigen [17].  These findings have justified further evaluation 
of this vaccine in a randomized phase II clinical trial (NCT01341652), evaluating whether 
vaccination with pTVG-HP versus placebo increases the 2-year metastasis-free survival of patients 
with high-risk PSA-recurrent, non-metastatic prostate cancer (stage D0) at high-risk for metastatic 
progression as defined by a PSA doubling time of less than 12 months.  That trial has completed 
accrual, and is expected to be completed in 2018.   
 
We have further explored means to increase the immunogenicity of DNA vaccines in murine 
models, and found that DNA vaccination elicited PD-L1 expression in tumors as a result of tumor-
specific T cells elicited with vaccination that secrete IFNγ.  Combining vaccination with anti-PD-
1 or anti-PD-L1 antibody treatment resulted in a greater anti-tumor response and eradication of 
tumors in some animals [18]. We have recently identified that this also occurs following human 
immunization using cryopreserved blood samples collected from patients with advanced prostate 
cancer treated with pTVG-HP.  Using in vitro and trans vivo methods, we found that immune 
responses to PAP were detected and/or augmented when combined with PD-1 blockade [19].  
Moreover, we detected increased expression of PD-L1 on circulating tumor cells following DNA 
vaccination, and we found that higher expression correlated with the development of persistent 
antigen-specific IFNγ-secreting T-cell immunity [19].  These data suggested that combining PD-
1 blockade with pTVG-HP should elicit superior anti-tumor effects in patients.  We have now 
completed accrual to the first part of a pilot clinical trial using pTVG-HP in combination with 
pembrolizumab, in patients with metastatic, castration-resistant prostate cancer (mCRPC, 
NCT02499835). In this trial, patients received both agents, together or in sequence, over a 12-to-
24-week course.  We identified that treatment elicited PAP-specific Th1-biased immunity in some 
patients, and anti-tumor responses as measured by declines in serum PSA, and objective 
radiographic tumor responses as measured by CT imaging, were only detected in individual 
receiving the combination of agents (not sequentially).  These are encouraging findings, notably 
because PD-1 blockade with either nivolumab or pembrolizumab alone has not demonstrated 
single-agent clinical activity in patients with advanced prostate cancer in previous phase I trials 

 
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[20, 21], and PSA declines and objective radiographic responses are rare following vaccine 
therapies.  The current trial will further evaluate this treatment approach in patients with early 
recurrent prostate cancer, a stage that we have most studied using vaccines as monotherapy.  The 
ability to drive PSA to undetectable levels, possibly curing or significantly delaying the metastatic 
recurrence of prostate cancer prior to the need for androgen depriving therapies, could be a 
substantial and clinically meaningful advance in the therapy of this disease.  This will be conducted 
as a pilot, safety and feasibility multiple-institution study in this population.   
 
 
2. 
Background and Rationale 
 
A. 
PAP is a tumor antigen in prostate cancer and CTL are necessary to destroy prostate tissue 
 
PAP was first identified in 1938 and was initially used as a serum marker for the detection of 
prostate cancer [8, 22].  PAP expression in normal and malignant prostate cells is well-
documented, and is still used in immunohistochemical staining to establish a prostate origin of 
metastatic carcinoma [23].  The ubiquitous expression of PAP in prostate tissue makes it an 
appealing antigen as a potential “universal” target for immune-directed therapies of prostate 
cancer, unlike specific oncogenes that may or may not be expressed by a particular tumor.  
Moreover, it has been demonstrated that some patients with prostate cancer have preexisting 
antibody and T-cell responses to PAP, suggesting that tolerance to this “self” protein can be 
circumvented in vivo [24, 25].  In particular, the demonstration of Th1-like immune responses 
specific for PAP suggest that an immune environment permissive of an anti-tumor response can 
exist in patients even without immunization. 
 
Results from researchers at Dendreon Corporation have demonstrated that PAP is a human prostate 
tumor vaccine antigen.  They have reported that CTL specific for HLA-A2 peptide epitopes 
derived from PAP could be expanded from the peripheral blood of HLA-A2-expressing normal 
donors, and that some peptide-specific CTL lines generated were capable of lysing an HLA-A2-
expressing prostate cancer cell line [26].  They then initiated human clinical trials targeting PAP 
using autologous antigen-presenting cell vaccines pulsed with a protein conjugate of human PAP 
and GM-CSF.  In a phase II follow-on trial with the PAP-GM-CSF treatment approach, one of 21 
patients experienced a complete response [27].  These trials formed the basis for a double-blinded 
phase III randomized clinical trial designed initially to evaluate the time to disease progression in 
patients with asymptomatic, androgen-independent prostate cancer.  In that study, D9901, 127 
patients were randomized to three infusions, two weeks apart, of sipuleucel-T (n=82) or placebo 
(n=45) [28].  The median time to progression was found to be 11.7 weeks on the treatment arm 
compared with 10.0 weeks on the placebo arm (p=0.052, log-rank test), not meeting its original 
endpoint [28].  However, that trial demonstrated a significant increase in median survival (25.9 
months for patients treated with sipuleucel-T, compared with 21.4 months in patients treated with 
placebo, p=0.01 log-rank test), with 34% of patients treated with sipuleucel-T alive at 36 months 
compared with 11% of patients treated on the placebo arm (p=0.005, chi-square analysis).  
Consequently, a confirmatory phase III trial was conducted with overall survival as the primary 
endpoint.  That trial demonstrated a significant increase in overall survival [14], and was consistent 
with results from previous trials [29], leading to the FDA approval for this treatment in 2010.  
Interestingly, few “PSA responses” used in the assessment of cytotoxic treatments for prostate 
cancer were observed, despite increases in overall survival.  The results from the Dendreon trials 

 
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underscore the rationale for targeting PAP as a vaccine antigen, and the importance of clinical 
progression endpoints in the design of anti-tumor vaccine trials.  Moreover, the development of 
less costly and cumbersome immunization approaches to elicit responses to the PAP antigen could 
be advantageous, as could their application to an earlier stage of disease. 
 
B. 
DNA vaccines can elicit antigen-specific Th1/CTL immune responses 
 
Over the last decade, there has been considerable interest in the development of plasmid DNA-
based vaccines, a strategy that offers several distinct advantages over other methods of antigen 
delivery.  DNA can be rapidly and inexpensively purified, and there are no problems with 
solubility as there frequently are with peptides and recombinant protein vaccines.  In addition, 
because the DNA in nucleic acid vaccines has been demonstrated to be taken up and expressed by 
host tissues and presented by host antigen-presenting cells (APC) directly [30-32], antigen 
presentation occurs through naturally processed epitopes.  DNA vaccines can therefore be 
theoretically employed in an HLA-independent fashion unlike peptide-based vaccines that are 
necessarily HLA-restricted.  This strategy is ideal in the HLA-diverse human situation.  In many 
ways, this method of immunization is similar to the use of viral immunization vectors, however 
without the additional foreign antigens introduced with a viral vector and consequently less of a 
risk of an overwhelming immune response to the vector itself [12, 33].  Of importance in tumor 
immunization models, several groups have demonstrated that immunization with plasmid DNA 
encoding a target antigen is a potent means of eliciting Th1-biased immune responses [34] and 
CD8+ T-cells specific for the targeted antigen [30, 35-38].  In animal models, the use of an 
intradermal route of vaccine administration, in particular, tends to promote this Th1/CTL-biased 
immune response [34, 39, 40].   
 
C. 
GM-CSF can function as an immunological adjuvant for DNA vaccines 
 
Granulocyte-macrophage colony-stimulating factor (GM-CSF) has been studied extensively by 
many groups in animal and human models as a vaccine adjuvant [41].  GM-CSF is a known growth 
and differentiation factor for human dendritic cells [42, 43].  Dendritic cells are specialized 
antigen-presenting cells (APC) that are believed to be responsible for stimulating naïve T-cell 
responses and to be the best cells at augmenting secondary immune responses [44].  They are 
known to cross present antigens encoded by DNA vaccines and taken up by bystander cells [45].  
The dermis is a site for skin dendritic cells (Langerhans’ cells) that are important in initiating 
immune responses by migrating to draining lymph nodes after antigen exposure for presentation 
of antigen to T-cells [46].  In human studies, soluble GM-CSF has been used as a vaccine adjuvant 
for a hepatitis B vaccine.  In this phase I study, doses of 20-80 µg GM-CSF were administered just 
prior to and at the same site as the hepatitis B protein vaccination.  Of 81 subjects treated with 
GM-CSF, 15 developed anti-HBs after only 1 injection (10 had protective titers) while only 1 of 
27 patients vaccinated without GM-CSF produced a weak and transient antibody response [47].  
GM-CSF-expressing autologous cells have also been demonstrated in murine and human studies 
to be able to elicit immune responses to autologous antigens [48-50]. GM-CSF has also been 
demonstrated to be a potent adjuvant for plasmid DNA vaccines.  Several groups have 
demonstrated in animal models that plasmid DNA encoding GM-CSF can enhance the immune 
response generated to a target antigen when co-immunized with plasmid DNA encoding the 
antigen [39, 51, 52].  We have previously used recombinant human GM-CSF as a vaccine adjuvant 
for DNA vaccines, however its use has been dispensable in preclinical murine and rat studies, 

 
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suggesting it may or may not be required as an adjuvant for human use.  This is being more 
formally evaluated in a separate trial (NCT02411786).  In the current trial, GM-CSF will be used 
as an adjuvant in patients without evidence of PSA decline, to determine whether it required as an 
adjuvant for the pTVG-HP vaccine when used in combination with nivolumab.   
 
D. 
PD-1 blockade and cancer treatment 
 
The PD-1 receptor-ligand interaction is a major pathway hijacked by tumors to suppress immune 
control.  The normal function of PD-1, expressed on the cell surface of activated T-cells under 
healthy conditions, is to down-modulate unwanted or excessive immune responses, including 
autoimmune reactions. PD-1 (encoded by the gene Pdcd1) is an immunoglobulin (Ig) superfamily 
member related to cluster of differentiation 28 (CD28) and cytotoxic T-lymphocyte-associated 
protein 4 (CTLA-4) that has been shown to negatively regulate antigen receptor signaling upon 
engagement of its ligands (PD-L1 and/or PD-L2) [53, 54]. 
 
A major mechanism by which tumors can avoid immune detection is by expression of PD-L1 or 
PD-L2, ligands for a receptor on T cells (PD-1), activation of which can decrease T-cell function 
and lead to immune tolerance.  There is currently great enthusiasm to specifically develop PD/PD-
L blockade inhibitors given the relative paucity of adverse events observed with these agents in 
clinical trials, and long-term disease response observed in some instances in early phase clinical 
trials.  Targeting PD-1, in particular, should be a universal therapy, as it targets the T-cell 
compartment rather than the tumor directly.  However, clinical trial experience to date suggests 
that patients with some solid tumor types (notably renal cell cancer, melanoma and non-small cell 
lung cancer) experience more benefit than patients with other histologies, including prostate cancer 
[20, 21].  This disparity suggests that differences are due to differences in the T-cells of responding 
and non-responding patients.  In particular, higher frequencies of tumor-infiltrating lymphocytes 
(TIL) are typically observed in patients with renal cell cancer and melanoma than prostate cancer 
[55].  In addition, early phase clinical trials using PD-1 or PD-L1 inhibitors have identified that 
the expression of at least one of the ligands for PD-1 (PD-L1) on the target tumor cell by biopsy 
is associated with clinical response to therapy [21].  This is expected, given that tissue-infiltrating 
T cells can induce the expression of PD-L1 via the expression of IFNγ, and ligand binding of PD-
1 leads to decrease in T-cell effector function.  It has been demonstrated that prostate cancers can 
express PD-L1, and can have infiltrating PD-1-expressing T cells [56].  Taken together, these 
results suggest that the efficacy of anti-tumor immunotherapy could be increased for prostate 
cancer by combining agents able to increase the number of tumor-specific T cells, such as through 
vaccination, and by PD-1/PD-ligand blockade.   
 
The structure of murine PD-1 has been resolved [57].  PD-1 and its family members are type I 
transmembrane glycoproteins containing an Ig-variable–type (IgV-type) domain responsible for 
ligand binding and a cytoplasmic tail responsible for the binding of signaling molecules.  The 
cytoplasmic tail of PD-1 contains 2 tyrosine-based signaling motifs, an immunoreceptor tyrosine-
based inhibition motif, and an immunoreceptor tyrosine-based switch motif.  Following T-cell 
stimulation, PD-1 recruits the tyrosine phosphatases, SHP-1 and SHP-2, to the immunoreceptor 
tyrosine-based switch motif within its cytoplasmic tail, leading to the dephosphorylation of 
effector molecules such as CD3 zeta (CD3ζ), protein kinase C-theta (PKCθ), and zeta-chain-
associated protein kinase (ZAP70), which are involved in the CD3 T-cell signaling cascade [54, 
58-60].  The mechanism by which PD-1 down-modulates T-cell responses is similar to, but distinct 

 
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from, that of CTLA-4, because both molecules regulate an overlapping set of signaling proteins 
[61, 62].  As a consequence, the PD-1/PD-L1 pathway is an attractive target for therapeutic 
intervention in multiple types of cancer, including prostate cancer.  
 
Nivolumab is a potent human immunoglobulin G4 (IgG4) monoclonal antibody (mAb) with high 
specificity of binding to the programmed cell death 1 (PD-1) receptor, thus inhibiting its interaction 
with programmed cell death ligand 1 (PD-L1) and programmed cell death ligand 2 (PD-L2).  
Based on preclinical in vitro data, nivolumab has high affinity and potent receptor blocking activity 
for PD-1.  Nivolumab has an acceptable safety profile and has been FDA approved for the 
treatment of several malignancy types, including melanoma, renal cell cancer, non small cell lung 
cancer, Hodgkin lymphoma, squamous cell head and neck cancer, urothelial cancers, microsatellite 
instability-high metastatic colorectal cancer, and heptocellular cancer.  For more details on specific 
indications refer to the Investigator brochure. 
 
E. 
DNA vaccine with PD pathway blockade elicits anti-tumor responses in murine models 
and a pilot human clinical trial 
 
Given our findings in human trials that some patients did not develop evidence of immune 
response, and even those that did still showed evidence of disease progression, we have sought to 
evaluate methods to increase the efficacy of DNA vaccines and evaluate potential mechanisms of 
tumor escape.  As described above, we have identified that immunization elicits CD8+ T cells, 
which, upon secretion of IFNγ, leads to increased PD-L1 expression in tumors [18].  Moreover, 
efforts to increase the immunogenicity of vaccination by encoding epitopes with greater affinity 
for MHC class I led to an inferior anti-tumor response that was mediated by increased and 
prolonged expression of PD-1 on antigen-specific CD8+ T cells [18, 63].  The anti-tumor efficacy 
of vaccination could be increased by blocking the PD-1/PD-L1 interaction at the time of 
immunization [18, 63].  The importance of these findings for human tumor immunotherapy has 
recently been demonstrated in a pilot clinical trial (NCT02499835, manuscript in preparation).  
The goal of this trial was to determine if it was better to first elicit a PD-1-regulated T cell response 
with vaccination, and then block PD-1 (by using vaccine followed by PD-1 blockade), or to block 
PD-1 at the time T cells are activated with vaccination prior to them being able to be deregulated 
in the PD-L1-expressing tumor environment (by using vaccine delivered concurrently with PD-1 
blockade).  26 patients with castration-resistant, metastatic prostate cancer were randomized to 
receive the pTVG-HP DNA vaccine, administered every 2 weeks x 6, followed by pembrolizumab 
administered every 3 weeks x 4 over 24 weeks, or to receive these agents concurrently on the same 
schedule over 12 weeks.  As shown in Figure 1, PSA declines were observed almost exclusively 
in patients treated with the concurrent schedule.  PSA declines were observed in approximately 
half of individuals treated with the concurrent schedule.   
 
F. 
NaF PET/CT and Quantitative Total Bone Imaging (QTBI) 
 
In the setting of PSA recurrence after definitive therapy, this stage D0/M0 being evaluated, it is 
assumed that patients have metastatic disease that is simply below the level of current methods 
of detection. We and others have demonstrated that NaF PET/CT provides a more sensitive 
method of detecting bone metastases in patients with more advanced prostate cancer {Morisson, 
2013 #4088}, suggesting that this method may be more sensitive in detecting minimal residual 
disease in the setting of PSA recurrence.  Moreover, NaF PET/CT can provide a more 

 
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quantitative assessment of total bone involvement, an assessment that cannot be determined from 
standard bone scintigraphy{Morisson, 2013 #4088}, when combined with advanced image 
analysis, such as in Quantitative Total Bone Imaging (QTBI), developed at University of 
Wisconsin Carbone Cancer Center.  QTBI can be used to evaluate changes in total prostate 
cancer bone involvement over time, effectively a measure of tumor growth rate in bone. Our 
group explored the role of NaF PET/CT in a similar patient cohort in a subset of patients enrolled 
in a randomized phase II trial of pTVG-HP versus GM-CSF adjuvant in patients with non-
metastatic prostate cancer (NCT01341652). Among 34 patients who had NaF PET/CT scans, 
only 4 of 34 did not have a lesion identified at baseline, and only 1 of 34 patients had no lesions 
at any time point. Although the median number of lesions detected and change in total activity 
(SUVtotal) was not significantly different for the two treatment cohorts, the median SUVtotal 
increased 50.4% in the GM-CSF arm and decreased 23.0% in the pTVG-HP arm [manuscript 
under preparation].    
 
 In this study we wish to further explore, whether these methods could be used to identify 
individuals at particularly high risk for early disease progression and to evaluate whether 
treatment with a DNA vaccine in combination with nivolumab can affect the tumor growth rate 
analogous to changes in PSA doubling time.  Moreover, we wish to determine whether the 
pattern of disease progression (continued growth of all lesions, or rapid growth of individual 
lesions) differs among patients based on their response to treatment.  
 
G. 
Summary 
 
Given these findings, the current protocol aims to expand on these findings, and determine if the 
efficacy of anti-tumor vaccination can be improved by combination with PD-1 blockade in patients 
with early recurrent disease, specifically in a population with minimal residual disease that should 
theoretically be more amenable to anti-tumor vaccination.  This trial will also evaluate whether 
GM-CSF is required as a vaccine adjuvant when using this combination, and gather safety and 
PSA response data using nivolumab alone for two cycles in patients with this earlier stage of 
disease.  The hypothesis to be tested is that vaccination with PD-1 blockade will elicit a greater 
magnitude of tumor-specific CD8+ T cells, and this will result in an objective anti-tumor effect as 
measured by PSA declines, possibly PSA complete responses that are durable, and absence of 
metastatic progression at two years in patients who experience substantial (> 50%) PSA declines.  
The ability to drive PSA to undetectable levels, possibly curing or significantly delaying the 
metastatic recurrence of prostate cancer prior to the need for androgen depriving therapies, would 
be a “game changing” advance in the therapy of this disease.  This will be conducted as a pilot, 
multiple-institution safety and feasibility trial.  Identification of PSA responses (defined as PSA 
decline > 50%), and complete responses (PSA decline to < 0.2 ng/mL), and delays in the time to 
disease progression will serve as evidence of clinical activity be used for planning future 
confirmatory clinical trials.   

 
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3. 
Objectives 
 
A. 
Primary Objectives 
 
1. To evaluate the safety and tolerability of pTVG-HP DNA vaccine and nivolumab in 
patients with clinical stage D0/M0 prostate cancer 
 
2. To determine the PSA complete response rate (PSA < 0.2 ng/mL)  
 
 
B. 
Secondary Objectives 
 
1. To evaluate 2-year metastasis-free survival rate 
 
2. To evaluate median radiographic progression-free survival  
 
3. To evaluate changes in PSA doubling time or slope 
 
4. To evaluate PSA response rate (< 50% of baseline) 
 
5. To determine whether GM-CSF is required as a vaccine adjuvant for pTVG-HP vaccine 
when used in combination with nivolumab 
 
 
Laboratory/Exploratory Biomarker Objectives: 
 
1. To determine if antigen-specific T-cell and/or IgG responses are elicited with treatment 
 
Figure 1:  Changes in serum PSA – 
patients treated with pTVG-HP and 
pembrolizumab. 
 
26 
patients 
were 
randomized to treatment with pTVG-HP 
delivered 6 times over 12 weeks either 
concurrently with pembrolizumab (blue, 
delivered 4 times over 12 weeks), or 
sequentially (red, DNA vaccination over 
12 weeks followed by pembrolizumab 
treatment over subsequent 12 weeks).  
Shown is the greatest change in serum 
PSA from baseline (p=0.013, Fisher’s 
exact test, for any PSA decrease with 
respect to treatment arm). Green asterisks 
indicate those individuals that developed 
immune response to the PAP target 
antigen. 

 
Version 10/03/19 
15 
 
 
2. To determine if the development of PAP-specific T-cell immune responses are 
associated with PSA response (decline > 50%)  
 
3. To determine if antigen spread (the development of immune responses to other cancer-
associated proteins) is associated with PSA response (decline > 50%) 
 
4. To determine if Quantitative Total Bone Imaging (QTBI) by NaF PET/CT can identify 
bone lesions in this patient population not detected by standard bone scintigraphy  
 
5. To determine whether the presence of lesions detected by NaF PET/CT at baseline is 
associated with early disease progression (within 1 year) by standard radiographic 
imaging methods (CT and bone scintigraphy) 
 
6. To determine if growth rates, and changes in growth rates, determined by NaF PET/CT 
are associated with PSA doubling time and changes in PSA doubling time 
 
 
4. 
Vaccine and Nivolumab Preparation 
 
A. 
Anti-PD-1 monoclonal antibody (Nivolumab, Opdivo®)  
 
Nivolumab (Opdivo®, Bristol Myers Squibb) is a human programmed death receptor-1 (PD-1)-
blocking antibody indicated for the treatment of patients with multiple different types of cancer.  
While this agent is commercially available, its use is investigational under this protocol.  A fixed 
dose will be used based on the approved dosing of 240 mg IV every 2 weeks for several 
malignancies.  This dose will be used for all treatments, even during the period of monthly 
administrations, given that nivolumab is being used in combination rather than as a single-agent 
therapy.  Nivolumab is supplied in 100 mg (10 mL of a 10mg/mL solution in a single-dose vial) 
quantities.  For each administration, three 100-mg vials will be used to achieve the 240 mg fixed 
dose.   
 
The most common adverse reactions (reported in > 20% of patients) included fatigue, cough, 
nausea, pruritis, rash, decreased appetite, constipation, arthralgia, and diarrhea.  Immune-mediated 
adverse reactions have also been observed, including immune-mediated pneumonitis, colitis, 
hepatitis, hypophysitis, nephritis, hyperthyroidism and hypothyroidism.  The management of 
suspected adverse reactions is discussed in Section 7 below.  
 
B. 
Plasmid DNA vaccine 
 
 
pTVG-HP 
 
pTVG4 vector containing cDNA for human PAP 
 
The sequence of the pTVG-HP plasmid has been confirmed by standard DNA sequencing to 
confirm its identity.  A bacterial strain was transformed with this plasmid and transferred to the 
National Gene Vector Laboratories (NGVL) manufacturing facility (Center for Biomedicine and 
Genetics, City of Hope/Beckman Research Institute, Duarte, CA) from which a master cell bank 
was prepared.  This master cell bank was shipped in 2008 to the Waisman Clinical 
Biomanufacturing Facility (WCBF) at the University of Wisconsin.  Several GMP-grade lots of 

 
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plasmid DNA have been prepared at the WCBF.  The biological activity of each lot has been tested 
by production of PAP following transfection of reporter cells in vitro.  Lots were also tested for 
appearance, plasmid homogeneity, DNA identity by restriction endonuclease evaluation, protein 
contamination, RNA contamination, genomic DNA contamination, sterility, endotoxin, and pH, 
and criteria for each of these have been established for future lot release.  The vaccine will be 
supplied in single-use vials containing 0.6 mL 0.2 mg/mL pTVG-HP in phosphate-buffered saline.  
Vials will be stored at –80°C (or -20°C if further stability testing confirms that this is appropriate) 
until the day of use.   
 
C. 
GM-CSF 
 
GM-CSF (Leukine®, Sargramostim), will be obtained from Berlex Laboratories (Montville, NJ), 
or other commercial pharmaceutical vendors, and may be used as a vaccine adjuvant, provided 
without cost to subjects participating in this trial. GM-CSF, as described above, is a growth factor 
that supports the survival, clonal expansion and differentiation of hematopoietic progenitor cells 
including dendritic antigen presenting cells.  In preliminary animal experiments and human clinical 
trials GM-CSF has been shown to be safe and serve as an effective adjuvant for the induction of 
antibody and T-cell responses to the immunized antigen [41, 64].  The use of GM-CSF is 
associated with little toxicity [42, 47, 65].  GM-CSF is a sterile, white, preservative-free, 
lyophilized powder supplied in 250 µg-dose vials.   
 
Recombinant human GM-CSF (rhGM-CSF), when administered intravenously or subcutaneously 
is generally well tolerated at doses ranging from 50 to 500 µg/m2/day.  Severe toxic manifestations 
are extremely rare in patients treated with rhGM-CSF.  Diarrhea, asthenia, rash and malaise were 
the only events observed in more than 5% of the rhGM-CSF group compared with the placebo 
group in phase III controlled studies of patients undergoing autologous bone marrow 
transplantation.  In uncontrolled phase I/II studies for various indications, the adverse effects 
reported most frequently were fever, chills, nausea, vomiting, asthenia, headache and pain in the 
bones, chest, abdomen, joints, or muscles.  Most of these systemic events reported with rhGM-
CSF administration were mild to moderate in severity and rapidly reversed by the administration 
of analgesics or antipyretics.  Other events reported infrequently were dyspnea, edema, local 
injection site reactions, and rash.  Thrombosis and cardiac arrhythmia have also been reported, and 
there have been infrequent reports of tissue sloughing, leukemic progression, congestive heart 
failure, hepatomegaly, and intracranial bleeding; and isolated reports of Guillain-Barré syndrome 
and increased histiocytes.  Neutropenia, although usually a pre-existing condition in the patients 
receiving rhGM-CSF, has been reported in association with administration.  There was an 
increased frequency of severe thrombocytopenia in patients receiving concurrent chemotherapy 
and radiotherapy with GM-CSF.  Eosinophilia and other blood abnormalities may occur. 
 
There have been rare reports of 1) sequestration of granulocytes in the lungs with respiratory 
symptoms; 2) a syndrome characterized by respiratory distress, hypoxia, flushing, orthostatic 
hypotension, and partial loss of consciousness; 3) peripheral edema, pericardial or pleural 
effusions, and capillary leak of fluid; and 4) serious allergic or anaphylactic reactions. 
 
Administration of rhGM-CSF may aggravate fluid retention in patients with pre-existent edema, 
capillary leak syndrome, or pleural or pericardial effusions.  In some patients with pre-existing 
renal or hepatic dysfunction, elevation of the serum creatinine or bilirubin and hepatic enzymes 

 
Version 10/03/19 
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has occurred during the administration of rhGM-CSF.  Dose reduction or interruption of rhGM-
CSF administration has resulted in a decrease to pretreatment values.  Occasional transient and 
reversible supraventricular arrhythmia has been reported in uncontrolled studies, particularly in 
patients with a previous history of cardiac arrhythmia. 
 
Stimulation of marrow precursors with rhGM-CSF may result in a rapid rise in white blood cell 
count.  Dosing should be stopped if the ANC exceeds 20,000/cm3.  rhGM-CSF may stimulate the 
growth of myeloid malignancies; therefore, caution must be exercised in its use in these 
malignancies or myelodysplastic syndromes. 
 
Because GM-CSF will only be administered at most once every two weeks on the current protocol, 
most of these side effects are not anticipated.  In previous vaccine studies using rhGM-CSF as an 
adjuvant in an identical fashion, local skin reactions consisting of erythema and induration have 
occurred in many patients.  These resolved without need for treatment over a 2-3 week period for 
some, and over 2-3 days for most.  Transient leukopenia (lasting only a couple of hours) has been 
observed in some patients, and resolved without treatment and without clinical sequelae [66].  
Furthermore, the generation of a transient immune response to rhGM-CSF following its use as a 
vaccine adjuvant has been observed, however no clinical sequelae were noted, and the significance 
of this observation is not clear at present [65]. 
 
D. 
Vaccine preparation and administration 
 
Vials will be thawed, and the plasmid DNA will be used by itself or will be used to reconstitute 
the GM-CSF, on the day of administration.  Specifically: 
 
For each of the immunizations:  0.25 mL of 0.2 mg/mL pTVG-HP will be drawn into each of two 
tuberculin syringes.  This effectively provides a 100-µg dose of DNA.  If GM-CSF is used as an 
adjuvant, 0.6 mL of 0.2 mg/mL pTVG-HP will be withdrawn and used to reconstitute 250 µg GM-
CSF.  0.25 mL will then be drawn into each of two tuberculin syringes.  This effectively provides 
a 100-µg dose of DNA and 208 µg GM-CSF. 
  
The vaccine with or without GM-CSF will then be administered intradermally on the deltoid area 
of the lateral aspect of the arm (left arm, preferentially) in two adjacent sites, with the total syringe 
contents (0.25 mL) administered at each site. 
 
 
5. 
Patient Selection 
 
A. 
Inclusion Criteria 
  
1. 
Patients must be at least 18 years of age with a histologic diagnosis of 
adenocarcinoma of the prostate 
2. 
Patients must have undergone radical prostatectomy 
3. 
Patients must have completed local therapy by surgery and any adjuvant/salvage 
radiation therapy at least 3 months prior to entry, with removal or ablation of all 
visible disease, including seminal vesical and/or local lymph node involvement. 

 
Version 10/03/19 
18 
 
 
4. 
Patients must have biochemically recurrent, non-metastatic (by CT and bone scan) 
clinical stage D0/M0 disease defined by the following:   
• Patients must have evidence of detectable serum PSA with at least 4 serum PSA 
measurements available, from the same clinical laboratory, at least two weeks 
apart up to one year, and the final serum PSA value must be > 2.0 ng/mL.   
• PSA doubling time, calculated from most recent 4 serum PSA values (collected 
up to one year prior to enrollment, at least 2 weeks apart, and all from the same 
clinical laboratory), must be a positive number (i.e. evidence of PSA rise over 
time).  
• PSA doubling time will be calculated using the Memorial Sloan-Kettering 
Cancer Center nomogram: 
(http://www.mskcc.org/applications/nomograms/prostate/PsaDoublingTime.as
px). 
• Patients must not have definitive evidence of metastases as determined by CT 
of the abdomen/pelvis and bone scintigraphy (bone scan).  Note: patients with 
lesions detectable by highly sensitive methods (e.g. NaF PET imaging or PSMA 
PET imaging) will be considered eligible as long as these lesions do not meet 
size criteria on CT imaging (visceral lesions suspicious for metastases or lymph 
node > 15 mm in short axis) and/or are not independently observed on bone 
scan.    
5. 
Patients with a prior history of a second malignancy are eligible provided they have 
been treated with curative intent and have been free of disease greater than three 
years.  There will be no exclusion for patients with a history of basal cell carcinoma, 
squamous cell skin cancer, superficial bladder cancer, or other in situ carcinoma 
that has been adequately treated. 
6. 
Patients who are sexually active must use a reliable form of contraception while on 
study and for 4 weeks after the last immunization.  
7. 
ECOG performance score < 2 and life expectancy of at least 12 months. 
8. 
Patients must have normal hematologic, renal and liver function as defined by:  
WBC > 3000/mm3, hematocrit > 30%, platelet count > 100,000/mm3, serum 
creatinine < 1.5 mg/dl or a calculated creatinine clearance > 60 cc/min, AST or 
ALT < 3.0x ULN, and serum bilirubin < 2.0 mg/dl (except participants with Gilbert 
Syndrome, who can have total bilirubin < 3.0 mg/dL), within 4 weeks prior to first 
immunization. 
9. 
Patients must be informed of the experimental nature of the study and its potential 
risks and must sign an IRB-approved written informed consent form indicating 
such an understanding.   
10. 
Willingness to provide blood samples for immune studies, per study calendar, up 
to one year after study, even if off study treatment. 
 
B. 
Exclusion Criteria 
 
1. 
Small cell or other variant prostate cancer histology 
2. 
Patients cannot have evidence of immunosuppression or have been treated with 
immunosuppressive therapy, such as chemotherapy or chronic treatment dose 
corticosteroids (greater than the equivalent of 10 mg prednisone per day), within 3 
months of the first vaccination. 

 
Version 10/03/19 
19 
 
 
3. 
Seropositive for HIV, hepatitis B (HBV) or hepatitis C (HCV) per patient history 
due to the immunosuppressive features of these diseases. 
4. 
Prior treatment with an LHRH agonist or nonsteroidal antiandrogen, except in the 
following circumstances:  Neoadjuvant/adjuvant androgen deprivation therapy 
administered with radiation therapy or at the time of prostatectomy is acceptable, 
provided that there was no evidence of PSA progression while on treatment.  In this 
situation, patients must not have received more than 24 months of androgen 
deprivation treatment.  Other treatment with androgen deprivation therapy is 
prohibited.   
5. 
Serum testosterone at screening < 50 ng/dL. 
6. 
Patients must not be concurrently taking other medications or supplements with 
known hormonal effects, including PC-SPES, megestrol acetate, finasteride, 
ketoconazole, estradiol, or Saw Palmetto.  All other medications with possible anti-
cancer effects must be discussed with the PI prior to study entry. 
7. 
Patients previously treated with herbal supplements as described in 5.B.6 or other 
potential or experimental therapies for prostate cancer must have discontinued these 
treatments and completed at least a 4 week washout prior to beginning treatment. 
8. 
Patients must not have evidence of bone metastases or lymph node involvement as 
determined by bone scan or CT scan of the abdomen and pelvis within 4 weeks of 
study registration.   Note:  Advanced imaging modalities (such as NaF-PET/CT, 
choline PET/CT, fluviclovine, or PSMA PET scans) will NOT be used to determine 
evidence of metastases for eligibility purposes or for defining disease progression.  
9. 
Patients must not have been treated with a prior DNA vaccine therapy for prostate 
cancer. 
10. 
Patients must not have known psychological or sociological conditions, addictive 
disorders or family problems, which would preclude compliance with the protocol. 
11. 
Patients must not have known allergic reactions to GM-CSF. 
12. 
Patients with unstable or severe intercurrent medical conditions or laboratory 
abnormalities that would impart, in the judgment of the PI, excess risk associated 
with study participation or study agent administration. 
13. 
Patients cannot have concurrent enrollment on other phase I, II, or III 
investigational therapeutic treatment studies. 
 
 
6. 
Experimental Design 
 
This will be a single-arm, multiple-institution, two-stage phase II trial designed to evaluate the 
safety and effect of serial intradermal vaccinations of a DNA vaccine encoding PAP with or 
without rhGM-CSF, and co-administered with nivolumab, on serum PSA in patients with PSA-
recurrent, non-metastatic, non-castrate prostate cancer.  A total of 20-41 patients will be accrued, 
treated over a maximum of one year each, and followed for up to two years for evidence of 
radiographic progression.  All subjects will be followed an additional 2 years after their last 
treatment for evidence of delayed adverse events.  The treatment will be as follows: 
 
 
 

 
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Nivolumab 240 mg IV every two weeks x 6 beginning day 1, then every four weeks x 9 
beginning week 12 
pTVG-HP (100 µg) administered intradermally (i.d.) every two weeks x 6 beginning day 
1, then every four weeks x 9 beginning week 12 
rhGM-CSF (208 µg) administered intradermally (i.d.) every two weeks x 4 beginning week 
4, then every four weeks x 9 beginning week 12  NOTE:  Only administered to 
patients for whom serum PSA obtained week 4 > serum PSA obtained at day 1.   
 
A. 
Study Arm Assignment and Toxicity Assessment 
 
Patients with non-metastatic prostate cancer, with evidence of rising PSA, and a calculable PSA 
doubling time with at least 4 serum PSA values collected over a one-year period of time, will be 
invited to participate.  Given the absence of significant adverse events observed in a previous phase 
I study, no adverse events > grade 2 are anticipated attributable to vaccine alone.  Similarly, given 
the absence of grade 4 events observed among 26 patients with advanced castration-resistant 
metastatic prostate cancer treated with this vaccine in combination with pembrolizumab, we do 
not anticipate toxicity that has not been observed with nivolumab alone.  While not common, 
previous immune-associated toxicities have been observed with nivolumab, including immune-
mediated pneumonitis, colitis, hepatitis, hypophysitis, nephritis, hyperthyroidism, and 
hypothyroidism.  Hence these may be anticipated events.  All study patients will be evaluated for 
evidence of toxicity over time, and further accrual to the trial will halt and be reviewed by the 
UWCCC DSMC if the toxicity rate is deemed to be excessive.  A toxicity rate of 30% for Grade 
3 events or 10% Grade 4 events given an attribution of at least possibly related to study treatment 
will be considered excessive.  Grade 3 limited site reactions (lasting < 48 hours) and fevers/chills 
(lasting < 48 hours) will be excluded from this assessment as expected possible adverse events of 
limited duration.   
 
Continuous toxicity monitoring based on repeated significance testing with a Pocock boundary 
will be applied after the first 5 patients have been accrued and evaluated for toxicity.  A toxicity 
rate p0 of at most 15% of Grade ≥ 3 toxicity events will be considered as acceptable while a toxicity 
rate p1=35% or more will be considered as unacceptably high. Assuming a boundary probability 
of 0.1 under p0, the stopping boundaries of the repeated significance testing procedure within an 
arm are as follows: 2/5, 3/9, 4/12, 5/17, 6/21, 7/26, 8/31, 9/35, or 10/40. If the number of Grade ≥ 
3 toxicities exceeds the boundaries, accrual will be temporarily suspended and the study will be 
reviewed for safety, dose modification and safety modification, and the study will be reviewed for 
safety by the UW DSMC (data and safety monitoring committee).  Once the study is suspended, 
it would only be reopened if modifications could be made, and approved by the DSMC and the 
UW-IRB, to assure that patient safety is reestablished.  If not, the study would be closed.   
 
B. 
Endpoints 
 
The primary endpoints for the trial will be safety, tolerability, and PSA complete response (PSA 
CR) rate.  A PSA CR will be defined as a serum PSA <0.2 ng/mL, with a confirmatory PSA <0.2 
ng/mL at least 4 weeks later, as per PCWG2 recommendations [67].  To qualify as a PSA CR, 
there must be no evidence of radiographic progression.  Patients will come off study at the time of 
appearance of metastatic disease (radiographic progression), at the time of undue toxicity (as 
defined below), or at the discretion of the patient and treating physician that other therapies for 

 
Version 10/03/19 
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prostate cancer are warranted.  Patients should be discouraged from discontinuing protocol 
treatment for PSA rise only.  Patients will continue to have blood drawn for immune studies, as 
per study calendar, up to one year after screening, even if off study prior to that time.   
 
All subjects will undergo radiographic imaging (CT of abdomen and pelvis and bone scan) prior 
to treatment, and at 6-month intervals (or as clinically indicated).  The appearance of lesions 
consistent with metastatic disease will be used to define radiographic progression, and from these 
the 2-year metastatic progression-free survival will be calculated for each treatment arm, as well 
as the median progression-free survival.  NOTE:  Lesions detected by 18F-NaF-PET/CT or other 
advanced imaging (such as NaF-PET/CT, choline PET/CT, fluviclovine, or PSMA PET scans) 
only will not be used to define metastatic disease or disease progression.  MRI imaging may 
substitute for CT, but the same type of imaging must be used to determine eligibility and 
progression.  RECIST 1.1 criteria will be used to define metastatic disease (appearance of a 
visceral lesion > 10 mm by CT or MRI, lymph node > 15 mm in short axis, or appearance of new 
lesions on bone scan consistent with metastatic disease).  The 2-year metastasis-free survival will 
be determined by investigator review of radiographic studies (CT/MRI and bone scintigraphy) 
performed 2 years after study initiation in subjects who have not already met criteria for 
radiographic progression. 
 
PSA doubling times will be calculated from four available serum PSA values obtained up to one 
year from the same clinical laboratory prior to study enrollment, up to and including the baseline 
value, and used to determine a pre-treatment PSA doubling time (PSADT).  Similarly, a post-
treatment doubling time will be calculated from: 
 
(1) All PSA values obtained from the same clinical laboratory using the same PSA assay 
beginning with the PSA value at day 1 (week 0) and continuing until the end-of study (or 
month 24) value (PSADT0-24). 
 
(2) All PSA values obtained from the same clinical laboratory using the same PSA assay 
beginning with the PSA value at day 85 (month 3) to the day 253 (month 9) value (PSADT3-
9).  
 
These time points for PSADT assessment were chosen to correspond to those being obtained in a 
randomized phase 2 trial using the pTVG-HP vaccine alone (NCT01341652).   
 
 
7. 
Definition and Management of Limiting Toxicities and Adverse Events 
 
A treatment-limiting toxicity will be defined as any Grade 3 or greater toxicity (using the NCI 
Common Terminology Criteria version 4), or a specific Grade 2 event as described below that 
affects agent dosing, with an attribution of at least possibly related to the study or treatment 
procedures, and occurring between the pre-study visit and within one month of the final study 
vaccine treatment or within 90 days of the last treatment with nivolumab (whichever is later).  If a 
patient develops Grade 3 toxicity with an attribution of at least possibly related to nivolumab and 
unlikely related (or unrelated) to pTVG-HP, the nivolumab treatment will be held until the toxicity 
resolves to Grade 1 or less, with the vaccine schedule continuing as per protocol.  In general, if a 
patient develops a second Grade 3 event (or any Grade 4 event) believed to be at least possibly 

 
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due to nivolumab, but unlikely related (or unrelated) to pTVG-HP vaccine, no further nivolumab 
treatments will be given.  However, Grade 3 or 4 events that would not limit continued treatment 
or intervention (e.g. lymphopenia or asymptomatic elevations of amylase or lipase) will not require 
holding the dosing or discontinuation of nivolumab. The specific management for nivolumab-
associated adverse events (and the indications for delaying or discontinuing nivolumab treatment) 
are shown in the table below.  In the absence of adverse events attributed to DNA vaccine, the 
patient will continue with DNA vaccine administration only as per protocol.  However, if a patient 
develops a Grade 3 toxicity with an attribution of at least possibly related to pTVG-HP vaccine, 
both vaccine and nivolumab treatment will be held until the toxicity resolves to Grade 1 or less.  If 
a patient develops a second Grade 3 event (or any Grade 4 event) believed at least possibly related 
to pTVG-HP vaccine, no further treatments (nivolumab or vaccine) will be given.  The patient will 
remain on study, however, with collection of radiographic and laboratory data as per protocol.  The 
rationale for these modifications is that patients could continue to benefit in terms of anti-tumor 
response and this could in fact be related to the development of other autoimmune toxicities, and 
patients who have toxicity from nivolumab could still potentially benefit from continued DNA 
vaccination.  While rare overall, autoimmune events observed following nivolumab treatment of 
patients with melanoma typically resolved and did not necessarily lead to discontinuation of 
treatment.    
 
AEs associated with nivolumab exposure may represent an immunologic etiology. These immune-
related AEs (irAEs) may occur shortly after the first dose or several months after the last dose of 
nivolumab treatment and may affect more than on body system simultaneously.  Therefore, early 
recognition and initiation of treatment is critical to reduce complications.  Based on existing 
clinical study data, most irAEs were reversible and could be managed with interruptions of 
nivolumab, administration of corticosteroids and/or other supportive care.  For suspected irAEs, 
ensure adequate evaluation to confirm etiology or exclude other causes.  Additional procedures or 
tests such as bronchoscopy, endoscopy, skin biopsy may be included as part of the evaluation.  
Based on the severity of irAEs, it may be necessary to withhold or permanently discontinue 
nivolumab and administer corticosteroids.  In general, if IV corticosteroids are used, these can be 
switched to oral dose equivalent (e.g. prednisone), and then tapered, once sustained clinical 
improvement is observed.  Dose modification and toxicity management guidelines for irAEs 
associated with nivolumab are provided in the following Table:  
 
Dose modification and toxicity management guidelines for immune-related AEs associated with nivolumab  
Immune-
related AEs 
Toxicity grade 
or conditions 
(CTCAEv4.0) 
Management  
Monitor and follow-up  
Diarrhea / 
Colitis 
Grade 1 (<4 
stools per day 
over baseline; 
asymptomatic 
colitis) 
Continue per protocol 
Symptomatic treatment 
Close monitoring for worsening 
symptoms 
Educate patient to report worsening 
immediately 
If worsens, treat as grade 2 or 3/4 
Grade 2 (4-6 
stools per day 
over baseline; IV 
fluids required < 
24 hours; not 
interfering with 
ADL. Colitis: 
Delay nivolumab per protocol 
 
Symptomatic treatment 
If improves to grade 1, resume 
nivolumab per protocol 
 
If persists > 5-7 days or recurs: 
0.5-1.0 mg/kg/day methylprednisolone 
or oral equivalent 

 
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abdominal pain, 
blood in stool 
When resolves to grade 1, taper 
steroids over at least one month, 
consider prophylactic antibiotics, and 
resume nivolumab 
 
If worsens or persists >3-5 days with 
oral steroids, treat as grade 3/4   
Grade 3-4 (> 7 
stools per day 
over baseline; IV 
fluids > 24 
hours; interfering 
with ADL.  
Colitis: severe 
abdominal pain, 
medical 
intervention 
required, 
peritoneal signs. 
Grade 4: life 
threatening, or 
perforation 
Discontinue nivolumab 
 
1.0 to 2.0 mg/kg/day 
methylprednisolone or IV other 
corticosteroid equivalent 
 
Add prophylactic antibiotics for 
opportunistic infections 
 
Consider lower endoscopy 
 
If improves, continue steroids to grade 
1, then taper over at least one month 
 
If persists > 3-5 days, or recurs after 
improvement: 
Add infliximab 5 mg/kg (if no 
contraindication).  Note: infliximab 
should not be used if perforation or 
sepsis 
Renal 
Grade 1 
(creatinine > 
ULN and > 
baseline, but < 
1.5x baseline 
Continue as per protocol 
 
Monitor creatinine weekly 
If returns to baseline, monitor 
creatinine as per protocol 
 
If worsens, treat as grade 2 or ¾ 
Grade 2-3 
(creatinine >1.5x 
baseline and < 
6x ULN 
Delay nivolumab 
 
Monitor creatinine daily 
 
0.5 to 1.0 mg/kg/day  
methylprednisolone or oral 
equivalent 
 
Consider bx or renal consult 
If returns to grade 1: 
Taper steroids over at least 1 month, 
consider prophylactic antibiotics, 
resume nivolumab and creatinine 
monitoring as per protocol 
 
If elevation persists > 7 days: 
Treat as grade 4 
Grade 4 
(creatinine > 6x 
ULN) 
Discontinue nivolumab 
 
Monitor creatinine daily 
 
1.0 to 2.0 mg/kg/day 
methylprednisolone or IV other 
corticosteroid equivalent 
 
Consult nephrologist, consider 
biopsy 
If returns to grade 1: 
Taper steroids over at least 1 month, 
and add prophylactic antibiotics for 
opportunistic infections 
 
 
Pneumonitis 
Grade 1 
(radiographic 
changes only) 
Consider delay of nivolumab 
 
Monitor symptoms every 2-3 days 
 
Consider pulmonary and ID 
consults 
Reimage at least every 3 weeks 
 
If worsens, treat as grade 2 or 3/4 
Grade 2 (mild to 
moderate new 
symptoms) 
Delay nivolumab  
 
Pulmonary and ID consults 
Re-image every 1-3 days 
 
If improves:  

 
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Monitor symptoms daily, possible 
hospitalization 
 
1.0 mg/kg/day methylprednisolone 
or oral equivalent 
 
Consider bronchoscopy, lung biopsy 
When symptoms improve to near 
baseline, taper steroids over at least 1 
month, and then resume nivolumab as 
per protocol.  Consider prophylactic 
antibiotics 
 
If not improved after 2 weeks or 
worsening:  
Treat as grade 3/4 
Grade 3/4 
(severe new 
symptoms, 
new/worsening 
hypoxia; life 
threatening) 
Discontinue nivolumab 
 
Hospitalize 
 
Pulmonary and ID consults 
 
2-4 mg/kg/day methylprednisolone 
or IV equivalent 
 
Add prophylactic antibiotics for 
opportunistic infections 
 
Consider bronchoscopy, lung biopsy 
If improves to baseline: 
Taper steroids over at least 6 weeks 
 
If not improving after 48 hours or 
worsening: 
Add additional immunosuppression 
 
 
Hepatic / 
Liver 
Function 
Test 
Elevation 
Grade 1 (AST or 
ALT > ULN to 
3x ULN and/or 
total bili > ULN 
to 1.5x ULN) 
Continue nivolumab as per protocol 
Continue LFT monitoring as per 
protocol 
 
If worsens, treat as grade 2 or 3/4  
Grade 2 (AST or 
ALT >3.0 to < 
5x ULN and/or 
total bili > 1.5 to 
< 3x ULN) 
Delay nivolumab 
 
Increase monitoring LFTs to every 
3 days 
If returns to baseline: 
Resume routine monitoring and resume 
nivolumab 
 
If elevation persist > 5-7 days or 
worsens: 
0.5 – 1 mg/kg/day methylprednisolone 
or oral equivalent and when LFT 
returns to grade 1 or baseline, taper 
steroids over at least 1 month, consider 
prophylactic antibiotics, and resume 
nivolumab as per protocol 
Grade 3/4 (AST 
or ALT > 5x 
ULN or total bili 
> 3x ULN 
Discontinue nivolumab 
NOTE: May be delayed rather than 
discontinued if AST/ALT < 8xULN 
or total bili < 5x ULN 
 
Increase LFT monitoring to every 1-
2 days 
 
1.0 to 2.0 mg/kg/day 
methylprednisolone or IV 
equivalent  
NOTE:  2 mg/kg/day recommended 
for grade 4 
 
Add prophylactic antibiotics for 
opportunistic infections 
Consult gastroenterologist 
If returns to grade 2: 
Taper steroids over at least 1 month 
 
If does not improve in >3-5 days, 
worsens, or rebounds: 
Add mycophenolate mofetil 1 g bid 
If no response within an additional 3-5 
days, consider other 
immunosuppressants 

 
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Endocrino-
pathies 
Asymptomatic 
TSH elevation 
Continue nivolumab as per protocol 
If TSH < 0.5 x LLN or > 2x ULN, or 
consistently out of range in 2 
measurements, include free T4 at 
subsequent cycles and treat as clinically 
indicated.  Consider endocrinology 
consult 
 
Symptomatic 
endocrinopathy 
Evaluate endocrine function 
Consider pituitary scan (MRI) 
 
Grade 3 drug-related 
endocrinopathies, adequately 
controlled with only physiologic 
hormone replacement do not require 
discontinuation. Adrenal 
insufficiency requires 
discontinuation regardless of control 
with hormone replacement. 
 
Grade 4 drug-related 
endocrinopathy AEs, such as, 
hyper- or hypothyroidism, or 
glucose intolerance, that resolve or 
are adequately controlled with 
physiologic hormone replacement 
(corticosteroids, thyroid hormones) 
or glucose-controlling agents, 
respectively, may not require 
discontinuation.  
 
Grade 4 drug-related adrenal 
insufficiency or hypophysitis 
requires discontinuation regardless 
of control with hormone 
replacement. 
 
 
Suspicion of 
adrenal crisis 
(e.g. severe 
dehydration, 
hypotension, 
shock out of 
proportion to 
current illness) 
Discontinue nivolumab for any 
drug-related grade 3 or 4 adrenal 
insufficiency 
Rule out sepsis 
Stress dose of IV steroids with 
mineralocorticoid activity 
IV fluids 
Consult endocrinologist 
 
Dermatolo-
gic (Skin 
rash) 
Grade 1-2 
(covering < 30% 
BSA) 
 
Continue nivolumab 
Symptomatic therapy (e.g. 
antihistamines, topical steroids) 
If persists >1-2 weeks or recurs: 
Consider skin biopsy 
Delay nivolumab 
Consider 0.5-1.0 mg/kg/day 
methylprednisolone or oral equivalent. 
Once improving, taper steroids over at 
least 1 month, consider prophylactic 
antibiotics, and resume nivolumab as 
per protocol 
 
If worsens:  Treat as grade 3/4  
Grade 3-4 
(covering >30% 
BSA or with life 
Delay or discontinue nivolumab 
Consider skin biopsy 
Consult dermatology 
If improves to grade 1: 
Taper steroids over at least 1 month 
and add prophylactic antibiotics 

 
Version 10/03/19 
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threatening 
consequences) 
1.0-2.0 mg/kg/day 
methylprednisolone or IV 
equivalent 
Resume nivolumab as per protocol 
 
NOTE:  If SJS/TEN is diagnosed, 
permanently discontinue nivolumab 
Neurologic 
Grade 1 
(asymptomatic 
or mild 
symptoms, 
intervention not 
indicated) 
Continue nivolumab as per protocol 
Continue monitoring.   
 
If worsens, treat as grade 2 or 3/4  
Grade 2 
(moderate 
symptoms, 
limiting 
instrumental 
ADL) 
Delay nivolumab as per protocol 
Treat symptoms as clinically 
indicated 
Consider 0.5 to 1.0 mg/kg/day 
methylprednisolone or oral 
equivalent 
If improves to baseline: 
Resume nivolumab as per protocol 
 
If worsens: 
Treat as grade 3/4  
Grade 3/4 
(severe 
symptoms; 
limiting self-care 
ADL; life 
threatening) 
Discontinue nivolumab 
Neurology consult 
Treat symptoms as clinically 
indicated 
1.0 – 2.0 mg/kg/day 
methylprednisolone or IV 
equivalent 
Add prophylactic antibiotics 
If improves to grade 2: 
Taper steroids over at least 1 month 
 
If worsens or atypical presentation: 
Consider IVIG or other 
immunosuppressive therapies as 
clinically indicated 
All other 
immune-
related AEs 
Grade 3, or 
intolerable/ 
persistent Grade 
2 
Delay nivolumab as per protocol 
Consider corticosteroid therapy 
Ensure adequate evaluation to confirm 
etiology or exclude other causes;  
Resume nivolumab as per protocol if 
symptoms resolve 
 
Grade 4 or 
recurrent Grade 
3  
Discontinue nivolumab 
1.0 to 2.0 mg/kg/day 
methylprednisolone or IV 
equivalent 
Add prophylactic antibiotics 
Taper steroids over at least 1 month 
after improvement in symptoms 
 
Any infusional drug, including nivolumab, may cause severe or life threatening infusion-reactions 
including severe hypersensitivity or anaphylaxis. Signs and symptoms usually develop during or 
shortly after drug infusion and generally resolve completely within 24 hours of completion of 
infusion. Dose modification and toxicity management guidelines for infusion reactions are 
provided in the Table below: 

 
Version 10/03/19 
27 
 
 
NCI CTCAE Grade 
Treatment 
Premedication at Subsequent 
Dosing 
Grade 1 
Mild reaction; infusion 
interruption not 
indicated; intervention 
not indicated 
Increase monitoring of vital signs as medically 
indicated until the participant is deemed medically 
stable in the opinion of the investigator. 
None 
Grade 2 
Requires therapy or 
infusion interruption but 
responds promptly to 
symptomatic treatment 
(e.g., antihistamines, 
NSAIDs, narcotics, IV 
fluids); prophylactic 
medications indicated 
for ≤24 hrs 
Stop Infusion. 
Additional appropriate medical therapy may 
include but is not limited to: 
IV fluids 
Antihistamines 
NSAIDs 
Acetaminophen 
Narcotics 
Increase monitoring of vital signs as medically 
indicated until the participant is deemed medically 
stable in the opinion of the investigator. 
If symptoms resolve within 1 hour of stopping 
drug infusion, the infusion may be restarted at 
50% of the original infusion rate (e.g. from 100 
mL/hr to 50 mL/hr).  Otherwise dosing will be 
held until symptoms resolve and the participant 
should be premedicated for the next scheduled 
dose. 
Participants who develop Grade 2 toxicity 
despite adequate premedication should be 
permanently discontinued from further 
nivolumab treatment 
Participant may be 
premedicated 1.5h (± 30 
minutes) prior to infusion of 
nivolumab with: 
Diphenhydramine 50 mg po (or 
equivalent dose of 
antihistamine). 
Acetaminophen 500-1000 mg 
po (or equivalent dose of 
analgesic). 
Grades 3 or 4 
Grade 3: 
Prolonged (i.e., not 
rapidly responsive to 
symptomatic medication 
and/or brief interruption 
of infusion); recurrence 
of symptoms following 
initial improvement; 
hospitalization indicated 
for other clinical 
sequelae (e.g., renal 
impairment, pulmonary 
infiltrates) 
Grade 4: 
Life-threatening; pressor 
or ventilatory support 
indicated 
Stop Infusion. 
Additional appropriate medical therapy may 
include but is not limited to: 
Epinephrine** 
IV fluids 
Antihistamines 
NSAIDs 
Acetaminophen 
Narcotics 
Oxygen 
Pressors 
Corticosteroids 
Increase monitoring of vital signs as medically 
indicated until the participant is deemed medically 
stable in the opinion of the investigator. 
Hospitalization may be indicated. 
**In cases of anaphylaxis, epinephrine should be 
used immediately. 
Participant is permanently discontinued from 
further nivolumab treatment. 
No subsequent dosing 
Appropriate resuscitation equipment should be available at the bedside and a physician readily available during the period of 
drug administration. 
For further information, please refer to the Common Terminology Criteria for Adverse Events v4.0 (CTCAE) at 
http://ctep.cancer.gov 
  
 

 
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Nivolumab may be interrupted for situations other than treatment-related AEs such as medical / 
surgical events or logistical reasons not related to study therapy. Participants should be placed back 
on study therapy within 3 weeks of the scheduled interruption, unless otherwise discussed with the 
Sponsor. The reason for interruption should be documented in the patient's study record. 
 
 
8. 
Plan of Treatment 
 
The following section describes the schedule for prescreening, treatment, and clinical and 
laboratory evaluations.  When a chemistry panel is indicated the following tests are performed:  
Chem 7 (including sodium, potassium, bicarbonate, BUN, creatinine, and glucose), ALT, AST, 
total bilirubin, alkaline phosphatase, amylase, thyroid stimulating hormone (TSH) and LDH.  
Whenever a CBC is indicated, this will include differential and platelet count.  This plan is 
summarized in the Schema. 
 
A. 
Prescreen (performed within 4 weeks of study registration unless otherwise noted) 
 
 
1. 
Confirm potential eligibility by history, pathology, diagnosis, and serial serum PSA 
levels; no exclusions by history 
2. 
CT scan of abdomen and pelvis, bone scan 
3. 
Sign consent form (to be done within 4 months prior to study registration) 
 
B. 
Screening Evaluation (performed within 2 weeks of study Day 1; can coincide with 
prescreen evaluation) 
 
1. 
Physical examination, including vital signs, symptoms assessment, and ECOG 
performance score  
2. 
Evaluation of blood cell counts (CBC with platelets), chemistry panel, serum 
prostate specific antigen (PSA), serum PAP, serum testosterone. 
3. 
20 ml peripheral blood (red-top tubes) for sera to evaluate baseline antibody 
responses, and 200 ml peripheral blood (green-top heparinized tubes) for T-cell 
response evaluation.  
4. 
NaF PET/CT (scan within +/- 7 days of study visit, exceptions may be allowed with prior 
approval from the study PI.).  NOTE:  This PET scan is for research purposes only, 
will not be used to determine eligibility, and will not be used for clinical response 
evaluation or treatment decisions. NaF PET/CT should NOT be obtained within 2 
days of GM-CSF injection.  
 
C. 
First treatment visit (day 1) 
 
1. 
Physical examination, including vital signs, symptoms assessment, and ECOG 
performance score (not required if already obtained within 14 days) 
2. 
Blood draw CBC, chemistry panel, PSA and PAP.  May be done up to 7 days in 
advance of Day 1, and could coincide with screening evaluation.  
3. 
pTVG-HP immunization intradermally on the deltoid area of the lateral arm 
(preferentially left arm) with 0.25 mL administered at each of two adjacent sites 
4. 
Following vaccination, subjects will be observed for 60 min. for adverse events 

 
Version 10/03/19 
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5. 
Nivolumab 240 mg, administered intravenously over 30 minutes 
 
D. 
Second treatment visit (week 2, 14 +/- 3 days after day 1 visit) 
 
1. 
Symptoms assessment  
2. 
pTVG-HP immunization intradermally on the deltoid area of the lateral arm 
(preferentially left arm) with 0.25 mL administered at each of two adjacent sites 
3. 
Following vaccination, subjects will be observed for 60 min. for adverse events 
4. 
Nivolumab 240 mg, administered intravenously over 30 minutes 
 
E. 
Third treatment visit (week 4, 14 +/- 3 days after week 2 visit) 
 
1. 
Physical examination, including vital signs, symptoms assessment, and ECOG 
performance score  
2. 
Blood draw CBC, chemistry panel, PSA and PAP.  NOTE: for this visit the PSA 
can be obtained up to 7 days prior to the visit in order to have the results available 
to determine whether  rhGM-CSF will be co-administered. 
3. 
10 ml peripheral blood (red-top tube) for sera to evaluate baseline antibody 
responses, and 100 ml peripheral blood (green-top heparinized tubes) for T-cell 
response evaluation  
4. 
pTVG-HP immunization intradermally on the deltoid area of the lateral arm 
(preferentially left arm) with 0.25 mL administered at each of two adjacent sites 
5. 
NOTE:  If serum PSA obtained at this visit is higher than that obtained at day 1 
visit, then rhGM-CSF (208 µg) will be co-administered with the pTVG-HP 
immunization as adjuvant for this and all subsequent immunizations 
6. 
Following vaccination, subjects will be observed for 60 min. for adverse events 
7. 
Nivolumab 240 mg, administered intravenously over 30 minutes 
 
F. 
Fourth treatment visit (week 6, 14 +/- 3 days after week 4 visit) 
 
1. 
Symptoms assessment 
2. 
pTVG-HP immunization intradermally on the deltoid area of the lateral arm 
(preferentially left arm) with 0.25 mL administered at each of two adjacent sites: 
NOTE:  If serum PSA obtained at week 4 was higher than that obtained at day 1 
visit, then rhGM-CSF (208 µg) will be co-administered with the pTVG-HP 
immunization as adjuvant for this and all subsequent immunizations 
3. 
Following vaccination, subjects will be observed for 60 min. for adverse events 
4. 
Nivolumab 240 mg, administered intravenously over 30 minutes 
 
G. 
Fifth treatment visit (week 8, 14 +/- 3 days after week 6 visit) 
 
1. 
Physical examination, including vital signs, symptoms assessment, and ECOG 
performance score  
2. 
Blood draw CBC, chemistry panel, PSA and PAP.   
3. 
pTVG-HP immunization intradermally on the deltoid area of the lateral arm 
(preferentially left arm) with 0.25 mL administered at each of two adjacent sites  
NOTE:  If serum PSA obtained at week 4 was higher than that obtained at day 1 

 
Version 10/03/19 
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visit, then rhGM-CSF (208 µg) will be co-administered with the pTVG-HP 
immunization as adjuvant for this and all subsequent immunizations 
4. 
Following vaccination, subjects will be observed for 60 min. for adverse events 
5. 
Nivolumab 240 mg, administered intravenously over 30 minutes 
 
H. 
Sixth treatment visit (week 10, 14 +/- 3 days after week 8 visit) 
 
1. 
Symptoms assessment 
2. 
pTVG-HP (+/- GM-CSF adjuvant) immunization intradermally on the deltoid area 
of the lateral arm (preferentially left arm) with 0.25 mL administered at each of two 
adjacent sites NOTE:  If serum PSA obtained at week 4 was higher than that 
obtained at day 1 visit, then rhGM-CSF (208 µg) will be co-administered with the 
pTVG-HP immunization as adjuvant for this and all subsequent immunizations 
3. 
Following vaccination, subjects will be observed for 60 min. for adverse events 
4. 
Nivolumab 240 mg, administered intravenously over 30 minutes 
 
I. 
Seventh treatment visit (week 12, 14 +/- 3 days after week 10 visit) 
 
1. 
Physical examination, including vital signs, symptoms assessment, and ECOG 
performance score  
2. 
Blood draw CBC, chemistry panel, PSA and PAP.   
3. 
10 ml peripheral blood (red-top tube) for sera to evaluate baseline antibody 
responses, and 100 ml peripheral blood (green-top heparinized tubes) for T-cell 
response evaluation  
4. 
pTVG-HP (+/- GM-CSF adjuvant) immunization intradermally on the deltoid area 
of the lateral arm (preferentially left arm) with 0.25 mL administered at each of two 
adjacent sites NOTE:  If serum PSA obtained at week 4 was higher than that 
obtained at day 1 visit, then rhGM-CSF (208 µg) will be co-administered with the 
pTVG-HP immunization as adjuvant for this and all subsequent immunizations 
5. 
Following vaccination, subjects will be observed for 60 min. for adverse events 
6. 
Nivolumab 240 mg, administered intravenously over 30 minutes 
7. 
NaF PET/CT (NaF PET/CT within +/- 7 days of week 12 study visit, exceptions may be 
allowed with prior approval from the study PI  ).  NOTE:  This PET scan is for research 
purposes only and will not be used for clinical response evaluation or treatment 
decisions. This study will be performed only at designated sites. NaF PET/CT 
should NOT be obtained within 2 days of GM-CSF injection. 
 
J. 
Eighth treatment visit (week 16, 28 +/- 3 days after week 12 visit) 
Ninth treatment visit (week 20, 28 +/- 3 days after week 16 visit) 
 
1. 
Physical examination, including vital signs, symptoms assessment, and ECOG 
performance score  
2. 
Blood draw CBC, chemistry panel, PSA and PAP.   
3. 
pTVG-HP (+/- GM-CSF adjuvant) immunization intradermally on the deltoid area 
of the lateral arm (preferentially left arm) with 0.25 mL administered at each of two 
adjacent sites NOTE:  If serum PSA obtained at week 4 was higher than that 

 
Version 10/03/19 
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obtained at day 1 visit, then rhGM-CSF (208 µg) will be co-administered with the 
pTVG-HP immunization as adjuvant for this and all subsequent immunizations 
4. 
Following vaccination, subjects will be observed for 60 min. for adverse events 
5. 
Nivolumab 240 mg, administered intravenously over 30 minutes 
 
K. 
Tenth treatment visit (week 24, 28 +/- 3 days after week 20 visit) 
 
1. 
Physical examination, including vital signs, symptoms assessment, and ECOG 
performance score  
2. 
Blood draw CBC, chemistry panel, PSA and PAP (can be performed +/- 7 days of 
this visit) 
 
3. 
CT scan of abdomen and pelvis, and bone scan (can be performed +/- 7 days of this 
visit) 
4. 
10 ml peripheral blood (red-top tube) for sera to evaluate baseline antibody 
responses, and 100 ml peripheral blood (green-top heparinized tubes) for T-cell 
response evaluation (can be performed +/- 7 days of this visit) 
 
5. 
pTVG-HP (+/- GM-CSF adjuvant) immunization intradermally on the deltoid area 
of the lateral arm (preferentially left arm) with 0.25 mL administered at each of two 
adjacent sites NOTE:  If serum PSA obtained at week 4 was higher than that 
obtained at day 1 visit, then rhGM-CSF (208 µg) will be co-administered with the 
pTVG-HP immunization as adjuvant for this and all subsequent immunizations 
6. 
Following vaccination, subjects will be observed for 60 min. for adverse events 
7. 
Nivolumab 240 mg, administered intravenously over 30 minutes 
8. 
NaF PET/CT (NaF PET/CT within +/- 7 days of week 24 study visit, exceptions may be 
allowed with prior approval from the study PI.).  NOTE:  This PET scan is for research 
purposes only and will not be used for clinical response evaluation or treatment 
decisions. This study will be performed only at designated sites. NaF PET/CT 
should NOT be obtained within 2 days of GM-CSF injection. 
 
L. 
Eleventh treatment visit (week 28, 28 +/- 3 days after week 24 visit) 
Twelfth treatment visit (week 32, 28 +/- 3 days after week 28 visit) 
 
1. 
Physical examination, including vital signs, symptoms assessment, and ECOG 
performance score  
2. 
Blood draw CBC, chemistry panel, PSA and PAP.   
3. 
pTVG-HP (+/- GM-CSF adjuvant) immunization intradermally on the deltoid area 
of the lateral arm (preferentially left arm) with 0.25 mL administered at each of two 
adjacent sites NOTE:  If serum PSA obtained at week 4 was higher than that 
obtained at day 1 visit, then rhGM-CSF (208 µg) will be co-administered with the 
pTVG-HP immunization as adjuvant for this and all subsequent immunizations 
4. 
Following vaccination, subjects will be observed for 60 min. for adverse events 
5. 
Nivolumab 240 mg, administered intravenously over 30 minute 
 
 
 

 
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32 
 
 
M. 
Thirteenth treatment visit (week 36, 28 +/- 3 days after week 32 visit) 
 
1. 
Physical examination, including vital signs, symptoms assessment, and ECOG 
performance score  
2. 
Blood draw CBC, chemistry panel, PSA and PAP.   
3. 
10 ml peripheral blood (red-top tube) for sera to evaluate baseline antibody 
responses, and 100 ml peripheral blood (green-top heparinized tubes) for T-cell 
response evaluation  
4. 
pTVG-HP (+/- GM-CSF adjuvant) immunization intradermally on the deltoid area 
of the lateral arm (preferentially left arm) with 0.25 mL administered at each of two 
adjacent sites NOTE:  If serum PSA obtained at week 4 was higher than that 
obtained at day 1 visit, then rhGM-CSF (208 µg) will be co-administered with the 
pTVG-HP immunization as adjuvant for this and all subsequent immunizations 
5. 
Following vaccination, subjects will be observed for 60 min. for adverse events 
6. 
Nivolumab 240 mg, administered intravenously over 30 minutes 
 
N. 
Fourteenth treatment visit (week 40, 28 +/- 3 days after week 36 visit) 
Fifteenth treatment visit (week 44, 28 +/- 3 days after week 40 visit) 
 
1. 
Physical examination, including vital signs, symptoms assessment, and ECOG 
performance score  
2. 
Blood draw CBC, chemistry panel, PSA and PAP.   
3. 
pTVG-HP (+/- GM-CSF adjuvant) immunization intradermally on the deltoid area 
of the lateral arm (preferentially left arm) with 0.25 mL administered at each of two 
adjacent sites NOTE:  If serum PSA obtained at week 4 was higher than that 
obtained at day 1 visit, then rhGM-CSF (208 µg) will be co-administered with the 
pTVG-HP immunization as adjuvant for this and all subsequent immunizations 
4. 
Following vaccination, subjects will be observed for 60 min. for adverse events 
5. 
Nivolumab 240 mg, administered intravenously over 30 minute 
 
O. 
End of treatment period visit (week 48, 28 +/- 3 days after week 44 visit) 
 
1. 
Physical examination, including vital signs, symptoms assessment, and ECOG 
performance score  
2. 
Blood draw CBC, chemistry panel, PSA and PAP (can be performed +/- 7 days of 
this visit).  
3. 
CT scan of abdomen and pelvis, and bone scan (can be performed +/- 7 days of this 
visit) 
4. 
10 ml peripheral blood (red-top tube) for sera to evaluate baseline antibody 
responses, and 100 ml peripheral blood (green-top heparinized tubes) for T-cell 
response evaluation  (can be performed +/- 7 days of this visit) 
 
P. 
Week 60 visit (84 +/- 14 days after week 48 visit) 
 
1. 
Physical examination, including vital signs, symptoms assessment, and ECOG 
performance score  
2. 
Blood draw CBC, chemistry panel, PSA and PAP.   
 

 
Version 10/03/19 
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Q. 
Week 72 visit (84 +/- 14 days after week 60 visit) 
 
1. 
Physical examination, including vital signs, symptoms assessment, and ECOG 
performance score  
2. 
Blood draw CBC, chemistry panel, PSA and PAP.   
3. 
CT scan of abdomen and pelvis, and bone scan (can be performed +/- 7 days of this 
visit) 
 
R. 
Week 84 visit (84 +/- 14 days after week 72 visit) 
 
1. 
Physical examination, including vital signs, symptoms assessment, and ECOG 
performance score  
2. 
Blood draw CBC, chemistry panel, PSA and PAP.   
 
S. 
Week 96 visit (84 +/- 14 days after week 72 visit) – END OF STUDY 
 
1. 
Physical examination, including vital signs, symptoms assessment, and ECOG 
performance score  
2. 
Blood draw CBC, chemistry panel, PSA and PAP.   
3. 
CT scan of abdomen and pelvis, and bone scan (can be performed +/- 7 days of this 
visit) 
 
T. 
28-Day Follow Up Visit (28 +/- 7 days after Off-study date, if prior to week 48) 
 
Patients will come off study at the time of disease progression, undue toxicity, or at the 
discretion of the patient and/or treating physician that it is not in the interest of the patient 
to continue treatment.  A separate follow-up visit is not required for patients completing 
the week 48 evaluation, however for patients coming off study prior to week 48, 28-day 
follow up visit will include the following: 
 
1. 
Physical examination, symptoms assessment, and ECOG performance score. 
2. 
Blood draw for CBC, chemistry panel, serum PSA and PAP  
3. 
IF NOT ALREADY COLLECTED WITHIN PREVIOUS 60 DAYS:  10 ml 
peripheral blood (red-top tubes) for sera to evaluate antibody responses, and 100 
ml peripheral blood (green-top heparinized tubes) for T-cell response evaluation 
 
U. 
Long-term Follow-Up 
 
Subjects will be contacted by telephone (if not already being seen in clinic) annually 
for 2 years following the last DNA vaccination to collect clinical information to 
identify any potential long-term risks.  This information has been requested by FDA 
for all gene delivery trials to assess potential long-term risks.  The specific 
information to be collected annually will include:   
 Date of contact 
 Current medications 
 Hospitalizations (dates and reasons for hospital admission) 

 
Version 10/03/19 
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 Stage of prostate cancer, treatments for prostate cancer, and recent 
serum PSA level 
 New cancer diagnoses 
 New autoimmune disorders 
 New hematologic or neurologic disorders 
 Other new medical diagnoses 
 Date of death if patient deceased 
 
 
9. 
Response Monitoring 
 
A. 
Radiographic Monitoring – Primary Endpoint 
 
CT scans of the abdomen and pelvis and bone scans will be obtained at 6-month intervals, or at 
times clinically indicated at the discretion of the treating physician.  Progression is defined as the 
appearance of metastases by radiographic imaging using the same criteria as for defining study 
eligibility – RECIST 1.1 criteria (appearance of a visceral lesion > 10 mm by CT or MRI, lymph 
node > 15 mm in short axis, or appearance of new lesions on bone scan consistent with metastatic 
disease).   
 
PSA rise will not be used to define disease progression, however PSA progression will be 
determined, as per Section 13 below.   
 
B. 
Immunological Monitoring 
 
Blood (up to 220 mL) will be collected pre-immunization, and at weeks 4,12, 24, 36, and 48 after 
study start for immunological monitoring.  From the heparinized blood peripheral blood 
mononuclear cells (PBMC) will be prepared by density centrifugation over Ficoll-Paque using 
standard techniques (included in separate laboratory manual).  PBMC will be cryopreserved in 
liquid nitrogen using 90% autologous serum collected at the time of blood draw, or 90% fetal calf 
serum, and 10% DMSO.  Sera will be prepared from the red-top tubes and stored in aliquots at –
80°C for antibody analyses.   
 
(1) Quantitative assessment of PAP-specific CD8+ T-cell effector immunity 
 
PAP-specific IFNγ- and granzyme B-secreting T-cell precursor frequency quantification by 
ELISPOT: ELISPOT will be used as the preferred methodology, as it permits analysis of low-
frequency events (LOD < 1:10,000 cells) and also permits simultaneous analysis of cryopreserved 
batched specimens.  Specifically, cryopreserved PBMC from subjects at the various time points 
will be rapidly thawed, and then transferred to 96-well nitrocellulose microtiter (ELISPOT) plates 
previously coated with monoclonal capture antibodies specific for IFNγ or granzyme B.  105 cells 
per well will be cultured in the presence of media (RPMI 1640 supplemented with L-glutamine, 
penicillin/streptomycin, ß-mercaptoethanol and 10% human AB serum) only (no antigen), 2 µg/ml 
PAP protein, 2 µg/ml PSA protein (negative control), 250 ng/ml tetanus toxoid, or 2.5 µg/ml PHA 
(positive mitogenic control) for 24-48 hours.  Plates will then be washed with PBS containing 
0.05% Tween-20 and incubated for 2.5 hours at room temperature with 50 µl/well PBS containing 
5 µg/ml biotinylated detection antibodies for either IFNγ or granzyme B.  After incubation, wells 

 
Version 10/03/19 
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will be washed with PBS, and further incubated with 100 µl/well streptavidin-labeled alkaline 
phosphatase (BioRad, Hercules, CA) and then developed with 100 µl/well BCIP/NBT colorimetric 
substrate (BioRad).  The colorimetric reaction will be stopped by rinsing the plates under cool tap 
water, and wells will be allowed to dry completely before spots are enumerated with an ELISPOT 
automatic plate reader.  Fluorometric assays of detection may be substituted for those described 
above, and include the evaluation of other cytokines.  
 
REPORTING AND RESPONSE DEFINITION:  Results will be presented as previously reported 
as the mean (+/- standard deviation) number of spot-forming-units (sfu) per 106 cells (frequency), 
calculated by subtracting the mean number of spots obtained from the no antigen control wells 
from the mean number obtained in the experimental wells, normalized to 106 starting PBMC, from 
3- to 8-well replicate assays [17].  Comparison of experimental wells with control, no antigen, 
wells will be performed using a two-sample t-test, with p < 0.05 (two-sided) defined as a significant 
antigen-specific T-cell response.  A significant antigen-specific response resulting from 
immunization will then be defined as a PAP-specific response detectable at least twice post 
treatment that is significantly higher than to media only (as above), at least 3-fold higher than the 
mean baseline value, and with a frequency > 10 per 106 PBMC.   
 
(2) Quantitative assessment of antigen-specific antibody immunity 
 
Enzyme-linked immunosorbent assay (ELISA) for the detection of antibodies responses to PAP:  
The presence of a coexisting humoral immune response to PAP will be evaluated by ELISA using 
an indirect method similar to that described previously [24].  Specifically, Immulon-4 ELISA 
plates (Dynex Technologies Inc.) will be coated with 2 µg/ml purified PAP protein (Research 
Diagnostics, Inc.) in 0.1 M NaHCO3/Na2CO3 buffer (pH 9.6) overnight at 4oC.  After blocking 
with PBS/1% BSA for 1 hour at room temperature, wells will be washed with PBS + 0.05% 
Tween-20 (PBS-Tween) and then incubated for 1 hour with human sera diluted 1:25, 1:50, 1:100 
and 1:200.  After washing, plates will then be sequentially incubated with a peroxidase-conjugated 
anti-human IgG detection antibody (Amersham), followed by peroxidase enzyme TMB substrate 
(Kierkegaard and Perry Laboratories).  The color reaction will be stopped with 1N H2SO4 and the 
optical density measured at 450 nm.  Antibody titers for PAP-specific IgG antibodies will be 
determined as previously described [24]. 
 
REPORTING AND RESPONSE DEFINITION:  These are not strictly quantitative assays.  IgG 
response will be reported graphically demonstrating sera dilution curves, and by titer – defined as 
the highest sera dilution at which IgG responses are detectable above the mean + 3 standard 
deviations of the negative control.  A positive IgG response resulting from immunization will be 
defined as an antigen-specific IgG titer at least 4-fold higher than the baseline titer detectable at 
the 6-month post-treatment time point (or other post-treatment time point evaluated). 
 
(3) Assessment of antigen-spread to other prostate-associated antigens 
 
High-throughput immunoblot (HTI):  An exploratory objective of the study will be to determine 
if patients treated develop “off-target” prostate cancer antigen-specific immune responses as 
evidence of antigen spread.  Future studies may evaluate T-cell responses to non-targeted antigens.  
However, the primary evaluation will be to evaluate IgG responses to a panel of prostate-associated 
antigens as we have previously reported in patients treated with vaccines or other immune-

 
Version 10/03/19 
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modulating agents [68-70].  IgG specific for 126 antigens, including 29 cancer-testis antigens [71, 
72] and 97 prostate antigens frequently immunologically recognized [73-76] will be identified by 
screening a high-density phage array expressing these individual antigens, as we have previously 
reported [68, 70, 71].  An alternative to this approach may include the evaluation of responses to 
panels of protein or peptide antigens fixed to support membranes provided by commercial vendors.  
The primary analysis will be conducted using sera obtained at 6 months, and compared with IgG 
responses identified at baseline, to determine whether IgG specific for individual antigens are 
elicited over time.  Other time points will be assessed to determine the durability and kinetics of 
immune response development, and confirmatory ELISA studies will be performed where feasible.   
 
REPORTING AND RESPONSE DEFINITION:  A positive IgG response will be defined as an 
immunoreactive spot to a defined antigen, scored by at least 3 of 4 independent reviewers, and 
detectable to at least 2 of 3 replicates per immunoblot membrane as previously described [68, 77], 
or by statistically defined criteria using commercial antigen sources.  An IgG response resulting 
from immunization will be defined as an immunoreactive antigen identified at the 6-month (or 
other post-treatment time for subsequent analyses) time point that was not identified at the pre-
treatment time point.   
 
C. 
Serum PSA Doubling Time Evaluation 
 
See Section 11 for further details.  Serum PSA doubling-time (or PSA slope) response will be 
considered a secondary endpoint.  The pre-treatment serum PSA doubling time will be calculated 
from four serum PSA values available from the same clinical laboratory using the same assay for 
the period up to one year prior to study treatment, not on other treatments for prostate cancer, up 
to and including the PSA value obtained at screening, using the Memorial Sloan-Kettering 
Cancer Center nomogram 
(http://www.mskcc.org/applications/nomograms/prostate/PsaDoublingTime.aspx). The post-
treatment PSA doubling time will be calculated using the same nomogram from:  
 
(1) All PSA values obtained from the same clinical laboratory using the same PSA assay 
beginning with the PSA value at day 1 (week 0) and continuing until the end-of study (or 
month 24) value (PSADT0-24). 
 
(2) All PSA values obtained from the same clinical laboratory using the same PSA assay 
beginning with the PSA value at week 12 (month 3) to the week 36  (month 9) value 
(PSADT3-9).  
 
An increase in the PSA doubling time to at least double the baseline value, and at least 15 months, 
will be considered a PSA doubling time “response” [7]. 
 
 
D. 
Quantitative Total Bone Imaging (QTBI) using NaF PET/CT 
 
An assessment of small volume bone metastatic disease (potentially not detected by standard 
bone scintigraphy) and tumor growth rates will be conducted using QTBI. Patients selected to 
participate in the NaF PET/CT part of the study will be assessed at baseline, week 12, and week 
24 by NaF PET/CT. Metastatic prostate cancer lesions in bone will first be localized and 
identified based on functional NaF PET uptake, assisted with the anatomical information 

 
Version 10/03/19 
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provided by CT scans. Segmentation will be performed using an automatic segmentation method 
(e.g. a fixed SUV threshold), and adjusted with physician guidance. Scans from different time 
points will be registered to one another using an articulated registration technique employing a 
rigid registration of skeletal elements (bones) from CT followed by registration optimization by 
combining with deformable registration of bones and lesions from NaF PET/CT. The lesions 
between pre-treatment and follow-up scans will be matched to establish longitudinal 
correspondence of the lesions. For each patient, comprehensive treatment response metrics will 
be calculated, consisting of SUVtotal (total disease burden), SUVmax (maximum intensity lesion), 
SUVmean (average intensity), the number of lesions, and total volume of bone lesions. In addition, 
imaging response metrics will be calculated for each individual lesion. This methodology will 
specifically be used to assess the growth rate of bone metastatic disease by evaluating changes 
from baseline to month 3 and from month 3 to month 6.  In terms of logistics, each of the clinical 
centers has the capacity and expertise to perform NaF PET imaging.   
 
NaF-PET/CT IMAGING PROCEDURES:  To ensure uniformity as well as optimal data interpretation, a standardized 
image acquisition protocol will be utilized and the overall imaging analyses will be conducted centrally under the 
supervision of Dr. Robert Jeraj, PhD (co-investigator) at the University of Wisconsin Image Analysis Core (IMAC) 
facility, with all analysis blinded to study treatment arm.  Please refer to the Standard Operating Procedures (SOP) 
document for NaF-PET/CT procedures, which will be adhered to at both sites, for details of image acquisition, image 
analysis, image interpretation, image submission for central review, and other imaging-related details.   
 
 
10. 
Statistical Considerations 
 
A. 
Overview 
 
This will be a single-arm, multiple-institution, two-stage phase II trial designed to evaluate the 
safety and effect of serial intradermal vaccinations of a DNA vaccine encoding PAP with or 
without rhGM-CSF, and co-administered with nivolumab, on serum PSA in patients with PSA-
recurrent, non-metastatic, non-castrate prostate cancer. 
 
B. 
Objectives 
 
Primary Objectives: 
 
1. To evaluate the safety and tolerability of pTVG-HP DNA vaccine and nivolumab in 
patients with clinical stage D0/M0 prostate cancer 
2. To determine the PSA complete response rate (PSA < 0.2 ng/mL)  
 
Secondary Objectives 
 
1. To evaluate 2-year metastasis-free survival rate 
2. To evaluate median radiographic progression-free survival  
3. To evaluate changes in PSA doubling time or slope 
4. To evaluate PSA response rate (< 50% of baseline) 
5. To determine whether GM-CSF is required as a vaccine adjuvant for pTVG-HP vaccine 
when used in combination with nivolumab 
 

 
Version 10/03/19 
38 
 
 
Laboratory/Exploratory Biomarker Objectives: 
 
1. To determine if antigen-specific T-cell and/or IgG responses are elicited with treatment 
2. To determine if the development of PAP-specific T-cell immune responses are associated 
with PSA response (decline > 50%) To determine if antigen spread (the development of 
immune responses to other cancer-associated proteins) is associated with PSA response 
(decline > 50%) 
3. To determine if antigen spread (the development of immune responses to other cancer-
associated proteins) is associated with PSA response (decline > 50%)  
4. To determine if Quantitative Total Bone Imaging (QTBI) by NaF PET/CT can identify 
bone lesions in this patient population not detected by standard bone scintigraphy  
5. To determine whether the presence of lesions detected by NaF PET/CT at baseline is 
associated with early disease progression (within 1 year) by standard radiographic 
imaging methods (CT and bone scintigraphy) 
6. To determine if growth rates, and changes in growth rates, determined by NaF PET/CT are 
associated with PSA doubling time and changes in PSA doubling time 
 
C. 
Study Design and Sample Size Calculation 
 
The primary efficacy endpoint is the PSA complete response (PSA < 0.2 ng/mL) rate.  A confirmed 
PSA CR will be defined as one in which serum PSA at least 4 weeks later is < 0.2 ng/mL, as per 
PCWG2 recommendations [67].  In this patient population, the PSA CR rate is expected to be less 
than 5% with standard care.  Hence, the null hypothesis that the PSA complete response rate is at 
most 5% will be tested against the alternative hypothesis that the rate is greater than 5%. A PSA 
complete response rate of 20% or more, on the other hand, will be considered sufficient evidence 
to consider further clinical trial investigation.  In order to ensure sufficient accuracy in the 
estimation of PSA complete response, an adequate number of patients should be enrolled in this 
study.  However, in order to avoid treating patients with a potentially ineffective therapy, a Simon 
optimal two-stage design with one interim analysis for efficacy will be utilized.  
 
In the first stage, 21 patients will be enrolled and evaluated for PSA response. If a PSA complete 
response is observed in at most one out of the 21 patients, then study will be terminated after the 
first stage. Otherwise, an additional 20 patients will be enrolled in the second stage for a total of 
41 patients.  
 
Assuming that the number of subjects with a PSA complete response is binomially distributed and 
using a Simon-optimal two-stage design, this design has a significance of 5% and 90% power for 
detecting a true success (PSA complete response) probability of 20%.  If the true PSA complete 
response rate is only 5%, the study will be terminated after the first stage with 66% probability. 
The expected sample size is 27 under this scenario. If, however, the true efficacy response rate is 
20%, the study will be terminated early with only 6% probability with an expected sample size of 
40 patients.  The two-stage procedure has 98% power to detect an efficacy response rate of 25% 
and 71% power to detect an efficacy response rate of only 15%. The operating characteristic of the 
proposed balanced two-stage design are summarized in the following table:   
 
Table 1 Operating characteristics of the Simon-optimal two-stage design 
True PSA complete response rate  Probability of 
Power  
Expected  

 
Version 10/03/19 
39 
 
 
early stop after 
 stage 1 
sample size 
5% 
66% 
6% 
27 
10% 
36% 
35% 
34 
15% 
16% 
71% 
38 
20% 
6% 
90% 
40 
25% 
2% 
98% 
41 
 
A sample size of 21 patients for the first stage and 41 patients in total will be also adequate for 
estimating toxicity rates with sufficient accuracy.  Specifically, toxicity rates will be estimated 
with a standard error of less than 10% with a sample size of 21 for the first stage and the 
corresponding 95% confidence intervals will be no wider than 40%.  Analogously, with a total 
sample size of up to 41 patients, toxicity rates will be estimated with a standard error of less than 
8% and the corresponding 95% confidence intervals will be no wider than 32%.  
 
 
D. 
Analysis 
 
(1) 
General 
This section outlines the statistical analysis strategy and procedures for the study.  Descriptive 
statistics will primarily be generated to summarize the data.  For continuous variables, descriptive 
statistics may include the number of subjects reflected in the calculation (n), mean, standard 
deviation, median, minimum, and maximum; frequencies and percentages may be displayed for 
categorical data. A detailed Statistical Analysis Plan (SAP) will be generated before the data 
analysis will be conducted.    
 
(2) 
Analysis of Primary Endpoints 
 
PSA complete response: PSA complete responses will be analyzed by descriptive statistics and 
summarized in tabular format (frequency tables).  The PSA complete response rate will be 
estimated using the Whitehead’s bias adjustment method which takes into account the sequential 
testing procedure of the proposed two-stage design.  The table below shows the estimated 
objective response rates, the p-values and 90% confidence intervals for various scenarios: 
 
Table 2: Estimated PSA complete response rates, p-values and confidence intervals 
Number of 
PSA complete 
responses 
Estimated PSA 
complete response 
rate† 
 
p-value 
Lower 95% 
CI bound 
Upper 95% 
CI bound 
0 
0.0% 
1.0000 
0.0% 
0.0% 
1 
5.7% 
0.6590 
0.2% 
13.3% 
2 
5.9% 
0.2830 
1.7% 
20.7% 
3 
8.5% 
0.2120 
2.6% 
20.8% 
4 
10.9% 
0.1140 
3.7% 
21.3% 
5 
13.2% 
0.0460 
5.1% 
22.7% 
6 
15.4% 
0.0140 
6.7% 
24.8% 

 
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7 
17.7% 
0.0040 
8.4% 
27.2% 
8 
20.0% 
0.0010 
10.1% 
29.8% 
9 
22.3% 
0.0000 
12.0% 
32.5% 
10 
24.6% 
0.0000 
13.9% 
35.2% 
† Estimated using Whitehead's bias-adjustment approach 
 
For example, if at the end of the study, PSA complete response efficacy responses are observed in 
5 out of the 41 patients, then the estimated (bias adjusted) response rate is 13.2% with a 95% 
confidence intervals ranging form 5.1% to 22.7%.  
 
A minimum of 5 complete PSA responses are required to reject the null hypothesis which warrants 
further clinical investigation. 
 
Toxicity and adverse events: Subjects will be evaluated at each visit by a review of systems based 
on the most recent version of the NCI common toxicity criteria.  Toxicities will be summarized by 
type and severity in tabular format.  Toxicity rates (grade 2, grade 3, grade 4, grade ≥ 2, grade ≥ 
3, etc.) will be calculated and reported along the corresponding 95% confidence intervals.  The 
95% confidence intervals will be constructed using the Wilson score method. 
 
(3) Analysis of Secondary Endpoints 
 
2-year metastasis-free Survival Rate: The 2-year metastasis-free survival rate will be estimated 
using the Kaplan-Meier method and reported along with the corresponding two-sided 95% 
confidence interval.  
 
Median radiographic progression-free survival: Radiographic progression-free survival will be 
estimated using the Kaplan-Meier method. The Brookmeyer-Crowley method will be used to 
construct the 95% confidence interval of the median radiographic progression-free survival.   
 
PSA doubling time: PSA doubling time will be estimated for each patient using linear regression 
analysis. Specifically, PSA doubling time will be calculated as log(2) divided by the slope 
parameter of the regression of log(PSA) on time. PSA doubling times and slopes will be 
summarized in terms of means, medians, standard deviation, and 95% confidence interval. 
Changes in PSA doubling time and slopes will be evaluate using a paired t-test or nonparametric 
Wilcoxon Signed Rank test.  
 
(4) 
Exploratory Objectives 
 
The number of antigen-specific T-cell and/or IgG responses will be summarized in terms of means, 
standard deviations, medians and ranges for each assessment time point. Changes from baseline 
will be evaluated using a nonparametric Wilcoxon Signed Rank test. A negative binomial or 
overdispersed Poisson model (depending on the model fit) will be utilized to evaluate whether 
antigen-specific T-cell and/or IgG responses are elicited with treatment. Univariate and 
multivariate logistic regression analysis will be conducted to examine whether the development of 
PAP-specific T-cell immune responses and antigen spread are associated with PSA response.  
 

 
Version 10/03/19 
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Results from the QTBI analysis will be used to determine (1) whether QTBI by NaF PET/CT 
can identify bone lesions in this patient population not detected by standard bone scintigraphy, (2) 
whether the presence of lesions detected by NaF PET/CT at baseline is associated with early 
disease progression (within 1 year) by standard radiographic imaging methods (CT and bone 
scintigraphy), and (3) whether growth rates, and changes in growth rates, determined by NaF 
PET/CT are associated with PSA doubling time and changes in PSA doubling time. Sensitivity of 
QTBI by NaF PET/CT to identify bone lesions will be summarized in tabular format and compared 
to sensitivity of standard bone scintigraphy using a paired McNemar’s test. Univariate and 
multivariate Cox proportional hazard regression analyses will be conducted to evaluate the 
associations between presence of lesions detected by NaF PET/CT at baseline and time to disease 
progression. Analogously, univariate and multivariate logistic regression analyses will be 
performed to evaluate the associations between presence of lesions detected by NaF PET/CT at 
baseline and 1-year PFS rate. The associations between  changes in QTBI parameters (SUVmax, 
SUVmean, SUVtotal) and changes in PSA doubling time will be evaluated using linear mixed 
effects modeling with subject specific random effects. 
 
 
11. 
Administrative Considerations 
 
A. 
Specimen Handling 
 
Upon entry into the study, each subject will be assigned a unique identification number.  All 
materials collected on that subject will be labeled with that number only, for reasons of 
confidentiality.  Lymphocytes collected will be stored in liquid nitrogen, and sera will be aliquoted 
and stored at –80°C in research laboratories at the investigator sites, and shipped in bulk to the 
central UWCCC laboratory for immune analysis.  
 
B. 
Future Use of Samples 
 
Not all of the blood components obtained during this study may be required for the tests that are 
part of the clinical trial.  Following the conclusion of the study, the samples may be used for future 
cancer research at University of Wisconsin or other sites.  This research will help to understand 
disease subtypes, drug response and toxicity, and possibly identify new drug targets or biomarkers 
that predict subject response to treatment.  Patients will be given the option to opt out of the sample 
banking process. 
 
Samples will be coded with the subject’s unique study identification number and date sample 
was drawn, which can be linked back to individually identifiable information.  The link between 
the unique subject identification number and the identifiable information will be stored in a secure 
location in a password protected computer, with only appropriately trained staff having access to 
this link. Samples will be stored in the research laboratory of the University of Wisconsin Carbone 
Cancer Center in Madison, Wisconsin.  This is a secure facility and only appropriate people will 
have access to the blood samples.   
 
C. 
Institutional Review Board 
 

 
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In accordance with federal regulations (21 CFR 312.66), an Institutional Review Board (IRB) that 
complies with the regulations in 21 CFR 56 must review and approve this protocol and the 
informed consent form prior to the initiation of the study at each investigator site.  In addition, the 
study cannot be instituted without FDA approval of the vaccine formulations.  Finally, the trial 
will be conducted with adherence to this protocol, following good clinical practice (GCP) 
guidelines, and in compliance with other applicable regulatory requirements.  Any modifications 
to the protocol must follow the procedure as outlined in Section 17 below. 
 
As the Coordinating Center for a trial, it is UWCCC’s responsibility for oversight of regulatory 
documentation for each participating site including verifying that the participating has an IRB and 
a Federal wide assurance to cover its activities. After UW Health Sciences Institutional Review 
Board (HS-IRB) grants initial approval, the UWCCC GU Oncology Group staff will provide the 
approved protocol, and consent form to the participating site.  The participating site will use the 
UW HS-IRB approved consent document as a template.  No substantial changes, including 
changes to the risk language will be allowed without first receiving approval from the UWCCC 
GU Oncology Group. 
 
Each participating site must receive local IRB approval of both the current protocol and consent 
prior to activation of the study at their site.  The local IRB approval notice, approved HIPAA and 
consent will be forwarded to the UWCCC GU Oncology Group at the contact listed below either 
by mail, fax or email.  Once all of the UWCCC administrative requirements are completed, the 
UWCCC GU Oncology Group will issue an activation notice for the site and subjects can be 
enrolled into the study: 
 
In addition, the participating institution must provide the UWCCC GU Oncology Group with a 
copy of the institution’s approved continuing review.  Registration will be halted at the 
participating institution if a current continuing review approval is not on file at UWCCC.  
 
All local IRB approvals and informed consent documents should be forwarded to the UWCCC 
GU Oncology Group by email at uwcccgu@medicine.wisc.edu or fax at 608-265-5146 or regular 
mail at:  
UWCCC GU Oncology Group 
University of Wisconsin Carbone Cancer Center 
600 Highland Avenue, CSC K4/6 
Madison, WI 53792 
 
D. 
Consent 
 
The Principal Investigator or their associates must explain verbally and in writing the nature, 
duration, and purpose of the study and possible consequences of the treatment.  Patients must also 
be informed that they may withdraw from the study at any time and for any reason without 
jeopardizing their future treatment.  In accordance with Federal regulations (21 CFR 312), all 
patients must sign the IRB-approved consent form.   
 
Documentation of both the informed consent process and that the process occurred prior to a 
subject’s entry into the study should be recorded in the subject’s source documents.  The original 

 
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consent form, signed and dated by the subject and by the person consenting the subject prior to the 
subject’s entry into the study, must be maintained in the investigator’s study files at each site. 
 
 
12. 
Data and Safety Monitoring Plan 
 
A. 
Definitions 
Adverse events (AE) are defined as any unfavorable and unintended sign (including abnormal 
laboratory finding), symptom or disease temporally associated with a medical treatment or 
procedure, regardless of whether it is considered related to the treatment or procedure. Adverse 
events are categorized as definite, probable, possible, unlikely or unrelated in relation to the 
medical treatment or procedure performed.  
 
AEs include the following: 
1. An exacerbation, or an unexpected increase in frequency or intensity of a pre-existing 
condition (other than condition under investigation), including intermittent or episodic 
conditions. 
2. Significant or unexpected worsening or exacerbation of the condition/indication under 
investigation. 
3. A suspected drug interaction. 
4. An intercurrent illness. 
5. Any clinically significant laboratory abnormality. 
 
An AE does not include: 
1. Anticipated day-to-day fluctuations of any pre-existing conditions, including the disease under 
study. 
2. Signs and symptoms of the disease under study that do not represent a significant worsening 
or exacerbation. 
3. Expected progression of the disease under investigation. 
4. Abnormal laboratory findings that are grade 1 or 2 and are considered clinically insignificant. 
 
Serious adverse events (SAE) are any events occurring that result in any of the following 
outcomes: 
 
1. 
Subject death 
2. 
Life-threatening adverse event 
3. 
Inpatient hospitalization or prolongation of existing hospitalization 
4. 
Persistent or significant disability/incapacity 
5. 
Congenital anomaly or birth defect 
 
A life-threatening event is defined as any adverse event that places the subject, in the view of the 
investigator, at immediate risk of death from the reaction.  
 
 
Note: In addition to the above criteria, adverse events meeting any of the below criteria, although 
not serious per ICH definition, are reportable to the BMS in the same timeframe as SAEs to meet 

 
Version 10/03/19 
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certain local requirements. Therefore, these events are considered serious by BMS for collection 
purposes. 
• 
Is another important medical event 
• 
Is a new cancer (that is not a condition of the study) 
• 
Is associated with an overdose. 
 
Severity rating/grading scale  
Adverse events are classified by organ system and graded by severity according to the current 
NIH Common Terminology Criteria V. 5, as described in Appendix A. The defined grades use 
the following general guidelines: 
 
0          No adverse event or within normal limits 
1 
Mild adverse event 
2 
Moderate adverse event 
3 
Severe adverse event 
4 
Life-threatening or disabling adverse event 
5 
Fatal adverse event 
 
All adverse events will be recorded from time of treatment initiation through 30 days after the 
final dose of study treatment, as well as any time after these 30 days for events that are believed 
to be at least possibly related to study treatment. Please note: SAEs, regardless of relationship, 
occurring from the time of consent until 100 days after the final dose of nivolumab will be 
collected and reported as per section E.1. 
  
Appropriate clinical, diagnostic, and laboratory measures to attempt to delineate the cause of the 
adverse reaction in question must be performed and the results reported. All tests that reveal an 
abnormality considered to be drug- or vaccine-related will be repeated at appropriate intervals 
until the course is determined or a return to normal (or pre-treatment) values occurs.  Information 
will be recorded as noted above. 
 
B. 
Disease Oriented Team Meetings 
UWCCC site: This study undergoes review of subject safety at regularly scheduled Disease 
Oriented Team (DOT) meetings where the following are discussed as applicable: number of 
subjects enrolled, subject treatments given, dose holds/modifications, significant toxicities, 
response to treatment, and the subjects’ overall status. These discussions are documented in the 
DOT meeting minutes. 
 
C. 
UWCCC Data and Safety Monitoring Committee (DSMC) Study Progress Review 
and Oversight 
The review of Protocol Summary Reports (PSRs) enables the UWCCC DSMC to assess whether 
the study should continue, continue with modifications, be suspended, or be closed. Following 
their review, the UWCCC DSMC will notify the sponsor-investigator of their recommendation 
and the authority for continuing, modifying, suspending, or closing the protocol is the 
responsibility of the applicable sponsor-investigator, Principal Investigator, IRB, FDA or other 
regulatory authority associated with the protocol.  

 
Version 10/03/19 
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Based on the risk level of this study, as determined by the UWCCC Protocol Review and 
Monitoring Committee, PSRs must be submitted to the UWCCC DSMC by the UWCCC site on 
a quarterly basis. 
 
The UWCCC site is responsible for ensuring participating sites enter data used to populate the 
PSRs in a timely manner into the UWCCC instance of OnCore. This data includes: accrual 
information, Serious Adverse Events (SAEs), response to treatment, events reportable to IRB 
(e.g., non-compliance, unanticipated problems). 
 
a. 
 UWCCC DSMC Review of Auditing and/or Monitoring Reports 
Reports created through the auditing and/or monitoring activities at all sites are submitted in real-
time by the UWCCC site to the UWCCC DSMC. Summary data and/or query reports are 
submitted in lieu of detailed reports. Following the review of these reports, the committee may 
issue a request for corrective and/or preventive action(s), protocol suspension, or for-cause 
audit(s). 
 
b. 
 UWCCC DSMC Review of Non-compliance, Unanticipated Problems, and Other 
IRB Reportable Events 
UWCCC site: Reports of non-compliance, unanticipated problems, and other IRB reportable 
events are submitted to the IRB of record for the study and to the UWCCC DSMC, via an email 
to DSMC@carbone.wisc.edu, simultaneously. 
 
Non-UWCCC participating site(s): Reports of non-compliance, unanticipated problems, and 
other IRB reportable events are submitted to the IRB of record for the site at which the event 
occurred and to the UWCCC site, via an email to uwcccgu@medicine.wisc.edu, simultaneously. 
The UWCCC site forwards the event information to the UWCCC DSMC within 1 business day 
of receipt. 
 
c. 
Real-time UWCCC DSMC Review of Serious Adverse Events (SAEs) 
The UWCCC DSMC Chair, or designee, reviews all SAEs occurring on the study, regardless of 
site, to determine if immediate action is required. 
 
UWCCC site: The Principal Investigator (PI), or designee, notifies the following 
individuals/entities of SAEs as applicable: 
• 
Other investigators involved with the study at the UWCCC  
• 
IRB of record for the study conducted at the UWCCC, per the IRB’s reporting 
requirements 
• 
UWCCC DSMC (Refer to section D) 
• 
Sponsor-Investigator 
• 
UW Institutional Biosafety Officer [Andrea  Ladd:  AndreaLadd@wisc.edu ] 
 
Non-UWCCC participating sites: The site PI, or designee, notifies the following 
individuals/entities of SAEs as applicable: 
• 
Other investigators involved with the study at the site 
• 
IRB of record for the study conducted at the site, per the IRB’s reporting requirements 
Institutional Biosafety Committee of record for the participating site 
• 
UWCCC site via an email to uwcccgu@medicine.wisc.edu  

 
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UWCCC site (Sponsor-Investigator or designee): responsibilities are noted in section E 
 
D. 
Serious Adverse Event Reporting 
 
Serious Adverse Events Requiring 24-Hour Reporting 
UWCCC site: All Serious Adverse Events must be reported within 24 hours to the UWCCC 
DSMC Chair via an email to saenotify@uwcarbone.wisc.edu within one business day. The 
OnCore SAE Details Report must be submitted along with other report materials as appropriate 
(FDA Medwatch Form #3500, UWCCC routing form, UWCCC Sponsor-Investigator 
Determination Form for FDA Reporting of Safety Events, de-identified supporting 
documentation available at that time of initial reporting). The UWCCC DSMC Chair reviews the 
information and determines if immediate action is required. Within 5 calendar days, all available 
subsequent SAE documentation is submitted electronically, along with a 24 hour follow-up SAE 
Details Report, to saenotify@uwcarbone.wisc.edu. This information is entered and tracked in the 
UWCCC secure, password protected computer network. Refer to the current UWCCC SAE 
Standard Operating Procedure (SOP) and related documents to facilitate reporting. 
 
UWCCC site (Sponsor-Investigator): Refer to section E for sponsor-investigator responsibilities. 
 
Non-UWCCC participating site(s): All Serious Adverse Events must be reported within 24 hours 
to the UWCCC site via an email to uwcccgu@medicine.wisc.edu and a phone call (608-263-
7107) within one business day of the site being aware of the event. The OnCore SAE Details 
Report must be submitted along with other report materials as appropriate (FDA Medwatch 
Form #3500 and de-identified supporting documentation available at that time of initial 
reporting). The UWCCC site sends this information, along with the completed UWCCC 
Sponsor-Investigator Determination Form for FDA Reporting of Safety Events, to the UWCCC 
DSMC Chair via an email to saenotify@uwcarbone.wisc.edu within one business day of receipt. 
The DSMC Chair reviews the information and determines if immediate action is required. If 
immediate action is required, it is communicated by the UWCCC DSMC Chair to the UWCCC 
site, who is then responsible for contacting the non-UWCCC participating site. Within 5 calendar 
days, all available subsequent SAE documentation is submitted electronically, along with a 24 
hour follow-up SAE Details Report, to the UWCCC site via an email to 
uwcccgu@medicine.wisc.edu. The UWCCC site sends this information to the UWCCC DSMC 
Chair via an email to saenotify@uwcarbone.wisc.edu within one business day of receipt. This 
information is entered and tracked in the UWCCC secure, password protected computer network. 
 
E. 
Sponsor-Investigator Responsibilities for SAE Review 
The sponsor-investigator (i.e., IND holder), assumes the responsibilities of the study sponsor in 
accordance with FDA 21 CFR 312.32. In this capacity, the sponsor-investigator reviews all 
reports of serious adverse events occurring on the study at the UWCCC and non-UWCCC 
participating sites and makes a documented determination of 1) suspectedness (i.e., whether 
there is a reasonable possibility that the drug caused the AE); and 2) unexpectedness (the event is 
not listed in the Investigator’s Brochure or is not listed at the specificity or severity that has been 
observed) in the context of this study.  SAE with suspected causality to study drug and deemed 
unexpected are reported as IND Safety Reports by the sponsor-investigator, or designee, to the 
following within 15 calendar days unless otherwise designated below:  

 
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• 
FDA 
• 
All participating investigators on the study, and the external global sponsor (if 
applicable).  
• 
Other oversight committees (NIH OSP) 
• 
Study supporters within 1 day (For additional details, see section E.1): 
Madison Vaccines, Inc. 
Attn: Safety Manager 
Phone:  (608) 467-5269  
 
            Bristol Myers Squibb (BMS) 
            SAE Email Address:  Worldwide.Safety@BMS.com       
            SAE Facsimile Number:  +1 609-818-3804 
 
All fatal or life-threatening SAE that are unexpected and have suspected causality to the study 
drug will be reported by the sponsor-investigator, or designee, to the following within 7 calendar 
days unless otherwise designated below: 
• 
FDA 
• 
All participating investigators on the study, and the external global sponsor (if applicable) 
• 
Other oversight committees (NIH OSP) 
• 
Study supporters within 1 day (For additional details, see section E.1): 
Madison Vaccines, Inc. 
Attn: Safety Manager  
Phone:  (608) 467-5269 
 
Bristol Myers Squibb (BMS) 
SAE Email Address:  Worldwide.Safety@BMS.com       
      SAE Facsimile Number:  +1 609-818-3804 
 
a. 
UWCCC Sponsor-Investigator Reporting to the Industry Supporters: 
 
Madison Vaccines, Inc. 
All SAEs that occur from the signing of the study specific consent through the duration of the 
post- therapy adverse event collection period (30 days after the last treatment administration) of 
the study vaccine must be reported to Madison Vaccines Inc. within 24 hours of being made 
aware of the SAE. Notifications can be made via phone a copy of the FDA Med Watch form to: 
 
Madison Vaccines Inc. Attn: Safety Manager Phone:  (608) 467-5269 
 
Significant new information regarding an ongoing SAE and the resolution must be sent to 
Madison Vaccines Inc. within 3 business days of awareness of the new information via the same 
reporting mechanism. 
 
Bristol Myers Squibb (BMS): 
• 
All Serious Adverse Events (SAEs) that occur following the subject’s written consent to 
participate in the study until 100 days following discontinuation of dosing must be reported 
to BMS Worldwide Safety, whether related or not related to study drug.  If applicable, SAEs 

 
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must be collected that relate to any later protocol-specified procedure (eg, a follow-up skin 
biopsy). 
• Following the subject’s written consent to participate in the study, all SAEs, whether related 
or not related to study drug, are collected, including those thought to be associated with 
protocol-specified procedures. The investigator should report any SAE occurring after these 
aforementioned time periods, which is believed to be related to study drug or protocol-
specified procedure. 
• An SAE report should be completed for any event where doubt exists regarding its 
seriousness;  
• If the investigator believes that an SAE is not related to study drug, but is potentially related 
to the conditions of the study (such as withdrawal of previous therapy or a complication of a 
study procedure), the relationship should be specified in the narrative section of the SAE 
Report Form. 
• If the BMS safety address is not included in the protocol document (e.g. multicenter studies 
where events are reported centrally), the procedure for safety reporting must be 
reviewed/approved by the BMS Protocol Manager. Procedures for such reporting must be 
reviewed and approved by BMS prior to study activation. 
• An appropriate SAE form (e.g.  ex-US = CIOMS form or USA = Medwatch form) should be 
used to report SAEs to BMS. The BMS protocol ID number must be included on whatever 
form is submitted by the Sponsor/Investigator.  
o The CIOMS form is available at: http://www.cioms.ch/index.php/cioms-form-i  
o The Med Watch form is available at:  
https://www.fda.gov/downloads/AboutFDA/ReportsManualsForms/Forms/UCM0
48334.pdf 
• In accordance with local regulations, BMS will notify investigators of all reported SAEs that 
are suspected (related to the investigational product) and unexpected (ie, not previously 
described in the IB). An event meeting these criteria is termed a Suspected, Unexpected 
Serious Adverse Reaction (SUSAR). Investigator notification of these events will be in the 
form of a SUSAR Report.  
o Other important findings which may be reported by BMS as an Expedited Safety Report 
(ESR) include: increased frequency of a clinically significant expected SAE, an SAE 
considered associated with study procedures that could modify the conduct of the study, 
lack of efficacy that poses significant hazard to study subjects, clinically significant 
safety finding from a nonclinical (e.g. animal) study, important safety recommendations 
from a study data monitoring committee, or sponsor decision to end or temporarily halt 
a clinical study for safety reasons. 
o Upon receiving an ESR from BMS, the investigator must review and retain the ESR 
with the IB. Where required by local regulations or when there is a central IRB/IEC for 
the study, the sponsor will submit the ESR to the appropriate IRB/IEC. The investigator 
and IRB/IEC will determine if the informed consent requires revision. The investigator 

 
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should also comply with the IRB/IEC procedures for reporting any other safety 
information.  
o In addition to the Sponsor Investigator’s responsibility to report events to their local HA, 
suspected serious adverse reactions (whether expected or unexpected) shall be reported 
by BMS to the relevant competent health authorities in all concerned countries 
according to local regulations (either as expedited and/or in aggregate reports). 
SAEs, whether related or not related to study drug, and pregnancies in partners of study 
participants must be reported to BMS within 24 hours. SAEs must be recorded on either CIOMS 
or MedWatch form & pregnancies must be reported on a Pregnancy Surveillance Form or can be 
submitted on the aforementioned SAE form to BMS. 
Overdoses (either accidental or intentional dose that is considered both excessive and medically 
important) must be reported as an SAE. 
SAE Email Address:  Worldwide.Safety@BMS.com 
SAE Facsimile Number:  +1 609-818-3804 
If only limited information is initially available, follow-up reports are required. (Note: Follow-up 
SAE reports should include the same investigator term(s) initially reported.)  
If an ongoing SAE changes in its intensity or relationship to study drug or if new information 
becomes available, a follow-up SAE report should be sent within 24 hours to BMS (or designee) 
using the same procedure used for transmitting the initial SAE report.  
All SAEs should be followed to resolution or stabilization. 
 
13. 
Potential Risks and Benefits, and Procedures to Minimize Risk 
 
A. 
Potential Risks 
 
(1) From immunization with DNA plasmid encoding PAP 
 
Two potential toxicities might be predicted to occur from DNA-based vaccines.  The first would 
be immediate toxicity due to the vaccination itself, and a second would be due to immunological 
consequences of the vaccination targeting other unrelated tissues.  An intradermal route of 
administration will be used, and is preferred given the presence of Langerhans’ antigen-presenting 
cells in the dermis.  Intradermal administrations, however, carry a risk of immediate allergic 
reactions.  For that reason, subjects will be remain for 60 minutes following each treatment to 
evaluate the skin site of treatment and for any immediate allergic events.  Subjects will also be 
asked to keep a record of unusual site or other reactions for two days after immunization.  To date, 
in studies using pTVG-HP only without anti-PD-1, allergic reactions have been rare (grade 3 
angioedema observed in 1 of over 50 treated subjects, <5% individuals). 
 
 

 
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With respect to eliciting unwanted immunological reactions, PAP, a protein whose expression is 
essentially restricted to the prostate, does share homology with other tissue phosphatases, notably 
lysosomal acid phosphatase (LAP), most prevalent in pancreatic tissue.  No such toxicity has been 
reported in clinical trials targeting PAP by means of a dendritic cell vaccine, and the generation of 
PAP-specific CTL in rat models similarly did not elicit detectable evidence of autoimmune disease 
in non-prostate tissues.  Moreover, this was not seen in previous clinical trials with this DNA 
vaccine with over 100 subjects.  This could theoretically be potentiated, however, with the anti-
PD-1 therapy.  Consequently, in order to further evaluate this potential toxicity in humans, subjects 
will be evaluated at each visit by a review of systems based on the NCI common toxicity criteria.  
In addition, subjects will be examined and serum chemistries, including renal function tests, blood 
counts, liver function tests, and serum amylase, will be evaluated at 6-12 week intervals, as 
outlined above.  The serum amylase will be used as a serum marker to monitor for evidence of 
subclinical pancreatic inflammation.  Again, while no autoimmune treatment-limiting adverse 
events have been observed to date in other trials, it is conceivable that by using a checkpoint 
inhibitor such as anti-PD-1 with an immunization approach targeting the PAP antigen that more 
autoimmune events could be observed than with either agent alone.  For this reason, these blood 
tests will be continued to be monitored in this trial.   
 
While there has been a suggestion that the plasmid DNA could insert into the host chromosomal 
DNA, this has not been documented in any other study, and several laboratory investigations have 
suggested the possibility of this occurring is less than the spontaneous mutation rate, and therefore 
not a real risk [78].  Even should this occur, there is little reason to suspect that this would put 
subjects at any increased risk, and in this patient population with treated prostate cancer, there is 
little risk of transfer to offspring.  There are no known risks to blood donation during or after 
immunization, however subjects will be requested to not donate blood from study entry until 
completion of all study procedures. 
 
The DNA itself is not hazardous (in that it encodes no viral proteins, is not radioactive, and is not 
itself a carcinogen) and does not pose additional risk to subjects or study personnel.  However, 
standard precautions to reduce the risk of needle sticks to study personnel will be performed. 
 
(2) From intradermal treatment with rhGM-CSF 
 
GM-CSF, administered intradermally with the vaccine, is being used as a vaccine adjuvant, and 
has demonstrated safety from multiple other vaccine trials in humans.  Common side effects 
include erythema and induration at the site of immunization (lasting for several days), and a 
transient decrease in peripheral white blood cell counts (lasting for several hours), mild flu-like 
symptoms (lasting for several hours).  It has also been observed and reported that T-cell and 
antibody responses can occur to GM-CSF, but without any known clinical sequelae [65].  
Uncommon and rare side effects, which have been less frequently observed with daily 
administration of higher doses of GM-CSF, include: vomiting; diarrhea; fatigue; weakness; 
headache; decreased appetite; feeling of faintness; facial flushing; pain in the bones, muscles, 
chest, abdomen, or joints; blood clots or unusual bleeding symptoms; rapid or irregular heartbeat 
or other heart problems; kidney and liver dysfunction; fluid accumulation or worsening of pre-
existing fluid accumulation in arms and legs, in the lungs, and around the heart that may result in 
breathing problems and heart failure; allergic reactions; sloughing of skin; liver enlargement; 
Guillain-Barré syndrome; hypotension; loss of consciousness; dyspnea.  In a previous phase I trial 

 
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with this DNA vaccine and GM-CSF, two patients experienced chest and back pain, attributed to 
the GM-CSF, which lasted less than 10 minutes and occurred within one hour of receiving GM-
CSF.  For this reason, all subjects will be monitored for one hour after receiving each DNA 
immunization treatment. 
 
(3) From treatment with nivolumab 
 
Nivolumab (Opdivo®, Bristol Myers Squibb) is a human programmed death receptor-1 (PD-1)-
blocking antibody.  Given that PD-1 is expressed on T cells, and that ligation of PD-1 by one of 
its ligands causes inactivation of T-cell function, blocking PD-1 by means of an antibody such as 
nivolumab can release the function of T cells that may have reactivity to normal cells.  In fact, the 
goal of this therapy is to “unleash” T cells, and cytolytic CD8+ T cells in particular, that recognize 
tumor cells.  In this trial, the goal is to elicit a specific population of CD8+ T cells that recognize 
prostate tumors, and allow them to lyse prostate tumor by not permitting expression of the ligand 
PD-L1 on prostate tumors to inhibit their function.  But because PD-1 blockade is itself not 
specific, the release of T cells with specificity to other normal tissues can result, leading to 
autoimmune adverse events.  To date, while autoimmune adverse events have been relatively 
uncommon (occurring in <10% of patients with melanoma treated), multiple different immune 
adverse events have been observed.  These have included immune-mediated pneumonitis, colitis, 
hepatitis, hypophysitis, nephritis, hyperthyroidism and hypothyroidism.  Other clinically 
significant, immune-mediated adverse reactions have been observed in <1% of patients treated 
with nivolumab, including exfoliative dermatitis, uveitis, arthritis, myositis, pancreatitis, 
hemolytic anemia, partial seizures, adrenal insufficiency, myasthenic syndrome, optic neuritis, and 
rhabdomyolysis.  Most of these events resolved following discontinuation of nivolumab, or in 
some cases following treatment with systemic corticosteroids.  But because of these rare, but 
potentially serious immune adverse events, patients will be followed closely for unusual new 
symptoms.   
 
In addition to these immune-mediated adverse events, other common adverse reactions (reported 
in > 20% of patients) included fatigue, cough, nausea, pruritis, rash, decreased appetite, 
constipation, arthralgia, and diarrhea.   
 
(4) From blood tests 
 
Drawing blood may cause temporary discomfort and bruising at the site of venipuncture.  Skin 
infections, while possible, are extremely rare as a result of blood draws 
 
(5) 
From NaF PET/CT imaging 
 
The main potential risk to subjects is during and immediately after the tracer injection, not 
because of the tracer, but because of the saline, which represents greater than 99% of the 
injection volume, so risks associated with any injection apply.  The NaF PET/CT scan will be 
performed for at least 60 minutes after the injection, so there is a built-in 60 minute observation 
period for adverse events.  The 60-minute time period for collection of AE’s will also cover the 
risk of radiation, which is very low, and no different than a standard PET procedure. For this 
study, subjects will be assessed for adverse events (AE) starting from immediately after the 
injection of the Sodium Fluoride F-18 tracer for each of the NaF PET/CT scans until 60 minutes 

 
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after the injection.  All events assessed as at least possibly related to the study procedure (NaF 
tracer or NaF PET/CT scan) will be collected.   
 
(6) Confidentiality 
 
The research staff will make their best effort to keep samples and data confidential at all times.  
However, absolute confidentiality cannot be guaranteed.  There is a slight risk of breach of 
confidentiality which could be embarrassing or stigmatizing. 
 
B. 
Potential Benefits 
 
No benefits are guaranteed.  It is hoped that individual patients treated with the DNA vaccine and 
nivolumab will derive a clinical response indicated by a decrease in PSA and prolonged time to 
development of metastatic disease.  While no direct benefit is guaranteed, the results from this trial 
will guide the direction of future vaccine trials targeting PAP or potentially other antigens for the 
treatment of prostate cancer, and could suggest means by which anti-PD-1 therapies could be used 
in prostate cancer, as these agents have demonstrated substantial benefit for patients with other 
types of malignancies other than prostate cancer.  Thus, it is hoped that study participants and 
future patients will benefit from research participation in the current study. 
 
 
14. 
Study Data Management and Procedural Issues 
 
A. 
Study Enrollment Procedures – Recruitment and Informed Consent Process: 
 
(1) For Subjects enrolled at UWCCC  
 
Potentially eligible subjects at the UWCCC will be patients regularly followed or referred to the 
University of Wisconsin Hospital and Clinics, and seen in the Medical Oncology, Urology, or 
Radiation Oncology outpatient clinics at the University of Wisconsin.  No specific advertisement 
or recruiting tools will be used.  Subjects will be identified by their primary radiation, surgical, or 
medical oncologist, and informed about this study, alternatives to this study, and the possible risks 
and benefits.  Potentially eligible subjects will be informed that their decision to participate or not 
participate will in no way affect their ongoing medical care.  Subjects who are interested at that 
point in obtaining more information will then be introduced to one of the GU research nurses who 
will then present the study (review rationale, describe time commitment, discuss again possible 
risks and benefits, and answer procedural questions) to the subject and provide them with a consent 
form.  In order to allow research subjects time to review the consent form thoroughly with their 
family and referring or primary physician, the subject will be instructed to take the consent form 
home without signing.  If the patient wishes to proceed with enrollment, they are then asked to 
contact the GU research office (608) 263-7107.  To avoid the possibility of unintended coercion, 
incarcerated subjects and subjects unable to provide their own informed consent will not be 
considered eligible.  In addition, the research staff will call the patient to further discuss the study 
and its requirements.  Any questions the subject has will be addressed by the research staff or 
investigators, and the time commitment and alternatives to treatment will again be reviewed.  If 
the subject agrees to participate in the study, they will be instructed to return to clinic to meet with 
the research staff and to sign and date the consent form. Our research staff will sign and date the 

 
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consent form as the person obtaining consent.  No screening procedures done solely for purposes 
of the study will be obtained prior to the subject signing the consent form. 
 
(2) Enrollment Procedures For Subjects enrolled at Participating Institution: 
 
Eligible patients will be entered on study centrally at the University of Wisconsin by the Study 
Coordinator.  All sites should call the UWCCC GU Oncology Program at 608-263-7107 to verify 
a slot is available.   
 
To register a patient, the following documents should be completed by the research nurse or data 
manager and faxed 608-265-5146 or e-mailed to uwcccgu@medicine.wisc.edu to the Study 
Coordinator: 
• Copy of required laboratory tests and other source documents verifying eligibility 
• Signed patient consent form 
• HIPAA authorization form 
• Eligibility checklist 
 
The research nurse or data manager at the participating site will then call 608-263-7107 or e-mail 
uwcccgu@medicine.wisc.edu to verify eligibility.  To complete the registration process, the 
UWCCC will: 
• assign a patient study number 
• register the patient on study via UWCCC’s On-line Clinical Oncology Research Environment 
(ONCORE)  
• fax or e-mail the patient study number to the participating site 
 
B. 
Data Collection Procedures 
 
Electronic case report forms (e-CRFs) will be submitted to the UWCCC GU Oncology Office via 
UWCCC’s On-line Clinical Oncology Research Environment (ONCORE). Completion of the e-
CRFs will be done in accordance with the instructions provided by the UWCCC GU office in a 
study-specific data capture plan.  The e-CRFs are found in the study specific calendar that has been 
created in ONCORE.  The system will prompt the user to the forms that are required based upon 
the patient’s enrollment and treatment dates. 
 
Research personnel entering data into the ONCORE data base at both UWCCC and at the 
participating institution must have completed human subjects training and Health Insurance 
Portability and Accountability Act (HIPAA) training.  The UWCCC GU Oncology Office will 
verify that the required training has occurred. 
 
The Principal Investigator will be responsible for assuring that all the required data is entered onto 
the e-CRFs accurately and within 2 weeks of the date in which the previous cycle was completed.   
 
Periodically, monitoring and/or auditing visits will be conducted by staff from the UWCCC GU 
Oncology Office. The Principal Investigator at each participating center will provide access to 
his/her original records to permit verification of data entry. 
 

 
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All clinical safety and clinical response data will be collected by the study coordinators on 
electronic case report forms as noted in section 14.B. and maintained by the individual sites.  
 
The UWCCC will serve as the Coordinating Center responsible for initial study configuration and 
database setup and any future changes. 
 
Research data evaluating immune responses will be maintained in individual laboratory research 
charts.  All laboratory analysis conducted at the UWCCC will be maintained in research charts in 
the laboratory of Dr. McNeel and stored a minimum of 7 years.   
 
Adverse events, clinical responses, and issues related to disease progression are reviewed each 
week by the Genitourinary Malignancy clinical research Disease Oriented Working Group 
(DOWG), attended by GU medical oncologists, GU malignancy research nurses, data 
coordinators, and the GU malignancy program manager.  Minutes from these meetings are 
recorded, and bi-annual reports from this group are submitted to and reviewed by the UWCCC 
Data Safety and Monitoring Committee.  All clinical safety, immunological response, and clinical 
response data will be analyzed by the study statistician, with the University of Wisconsin 
Department of Biostatistics and Medical Informatics. 
 
All subject research charts will be maintained at individual treatment sites for a minimum of seven 
years after study completion.  All clinical information maintained in the UWCCC clinical trials 
database will be stored indefinitely.  All research samples and data derived from these specimens 
will be maintained indefinitely in the laboratory of Dr. McNeel.  All information with patient 
identifiers or medical history information will be kept in locked cabinets or secured databases 
available only to the study personnel to maintain patient confidentiality.   
 
C. 
Description of Procedures to Maintain Confidentiality of Research Specimens 
 
All specimens obtained for the immunological evaluation of this trial (blood specimens) will be 
delivered to the laboratory of Dr. McNeel.  Specimens received by Dr. McNeel’s lab will only be 
handled by laboratory personnel who have undergone HIPAA training and annual UWHC-
mandated blood-borne pathogen safety training.  Receipt of specimens will be entered into a 
database that will provide a unique code for each specimen.  All stored specimens (sera, peripheral 
blood mononuclear cells) will be labeled with this unique code and the date of preparation.  Thus, 
all patient identifiers will be removed from the final stored samples, and any data generated will 
contain only the unique code as identifier.  A database will be maintained to link individual coded 
specimens with an individual subject (name, hospital medical record number, date/time point) in 
order to be able to compare information from samples obtained at different time points from a 
specific individual, and ultimately for transfer of research data to the clinical trials database, if 
necessary.  This research database will only be available to the study investigators, not other 
laboratory personnel, to maintain confidentiality.  Subject sera will be maintained in Dr. McNeel’s 
laboratory, stored in aliquots at –20°C to –80°C.  Peripheral blood mononuclear cells will be stored 
in Dr. McNeel’s laboratory, stored in aliquots in liquid nitrogen. If warranted, samples may be sent 
to an external institution or a contract research organization for the purpose of collaboration and 
/or analysis.  
 

 
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Subjects will have the option to consent to future research using both their samples and data which 
may be used independently. Samples remaining after the primary analysis has been completed and 
available for future research will be “banked” and stored as they were for this study unless they 
are selected to be sent for research elsewhere, which may be within or outside of the University of 
Wisconsin. Subjects wishing to withdraw their banked samples will be required to contact the 
study team with their request , otherwise their samples may be used indefinitely for cancer 
research. All research samples and data derived from these specimens will be maintained 
indefinitely in the laboratory of Dr. McNeel.  All information with patient identifiers or medical 
history information will be kept in locked cabinets or secured databases available only to the study 
personnel to maintain patient confidentiality.  
 
D. 
Modifications of Protocol and Deviations from Protocol 
 
Any changes to the preceding protocol after approval by the University of Wisconsin IRB must be 
submitted as an amendment to this IRB with a description of specific changes.  All changes must 
be approved by the IRB before implementation.  If these changes were related to possible adverse 
events that could potentially affect subject safety, the consent form will also be modified, and 
submitted with the protocol to the IRB.  After approval, all enrolled subjects will be asked to 
review and sign the new consent form to proceed with treatment.  If these changes were related to 
a severe adverse event, or could affect the scientific integrity of the study, the events would also 
be reviewed internally by the DSMC, as described above, and the study could be placed on hold 
pending a protocol and consent form amendment, as described above, or study closure.  In addition, 
any information that might affect the immediate safety of currently enrolled subjects will be 
communicated with them directly as well. 
 
The UWCCC GU Oncology Group will forward a copy of all UW HS-IRB approved protocol and 
consent changes and new study information to the participating site.  The participating institution 
must provide the UWCCC GU Oncology Group with a copy of the institution’s approvals.  The 
UWCCC GU Oncology Group will maintain a copy of all amendments, consent forms and 
approvals from each participating institution.   
 
Note that any changes to the protocol will require approval from the UWCCC Study PI, Dr. Hamid 
Emamekhoo, and from the Sponsor Investigator, Dr. Douglas McNeel.  
  
Deviations from the study protocol, for reasons other than patient safety, are not permitted.  Any 
possible deviations, intended or not, will be documented in the subjects’ research chart.  Deviations 
that are unlikely to affect subject safety, such as missing a specific study lab draw, will be 
documented in the research chart and discussed with the study PI.  Deviations that could potentially 
affect subject safety, such as missing safety labs, will be documented, performed as soon as 
possible, and reviewed at the weekly GU clinical research (DOWG) meetings, with prompt 
reporting as soon as any deviation is identified to the IRB if there are concerns for patient safety 
or scientific integrity of the study.     
 
E. 
Withdrawal from Study Protocol 
 
Subjects are informed during the consenting process, and in the consent form, that their 
participation is voluntary and they may withdraw consent at any time and for any reason.  If 

 
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subjects wish to withdraw from the study, they will be asked, but not required, to perform the off-
study procedures/blood draws.  They will be again informed that their decision to participate or 
not participate at any time will not affect their routine medical care or any other benefits to which 
they were otherwise entitled.  In addition, subjects will be removed from study participation if 
there is a concern for patient safety, as described above, if they are unable to comply with study 
procedures, or if the study is terminated by local or national regulatory agencies. 
 
 
15. 
Roles and Responsibilities of Study Personnel at UWCCC 
 
Protocol sponsor: 
 
Dr. Douglas McNeel MD PhD, Professor of Medicine, is a genitourinary medical oncologist, with 
a clinical research and laboratory interest in immune-based therapies for prostate cancer.  He has 
served as the principal investigator for multiple other clinical trials, and has had formalized training 
in the ethics and conduct of clinical trials and human subjects protection.  He is overall responsible 
for the design of the trial, interpretation of the protocol as study sponsor, and its laboratory 
analysis, and holds physician INDs for the pTVG-HP DNA vaccines.  Because of his ownership 
interest in these vaccines that have been licensed by the WARF (Wisconsin Alumni Research 
Foundation, intellectual property manager for the University of Wisconsin) to a company that is 
seeking to commercialize them (Madison Vaccines, Inc), however, he will not be involved in any 
direct patient care aspects of this trial (recruitment, treatment of subjects on trial, review of imaging 
studies, or review of clinical laboratories as they pertain to the treatment of individual subjects).   
 
UWCCC Principal Investigator: 
 
Dr. Hamid Emamekhoo MD, Assistant Professor of Medicine, is a genitourinary medical 
oncologist with a primary interest in genitourinary cancer clinical trials research. He will be the 
UWCCC Principal Investigator for this study.  As UWCCC PI he will be responsible for activities 
involving direct patient care and interaction, including recruitment, consent, clinical care and 
adverse event reporting. The UWCCC local PI will also assume the role of principal investigator 
on the protocol and UW HS-IRB submission, working with the UW HS-IRB as the responsible 
investigator to obtain and maintain UW HS-IRB approval for the study.  The UWCCC local PI 
will also be responsible for reviewing significant adverse events that occur at UWCCC and will 
oversee the care provided by the UWCCC co-investigators on this study. 
 
Biostatistician: 
 
Dr. Jens Eickhoff, PhD is a biostatistician with a primary interest in cancer clinical trials, and 
significant experience with immunotherapy clinical trials.  He has been actively involved in the 
study design and he, or designee, will be primarily responsible for the statistical analysis of the 
study as proposed. 
 
 
 
 

 
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