Patient case: 81-year-old male with Prostate cancer. Genetic variant: PTEN Inactivating. Other conditions: Hypertension, Depression.

Clinical trial: Docetaxel and PROSTVAC for Metastatic Castration-Sensitive Prostate Cancer

Summary: Background:
  Metastatic castrate-sensitive prostate cancer is cancer that has spread beyond the prostate area. It can be controlled by lowering the amount of testosterone in the body. This is called androgen deprivation therapy (ADT). The vaccine PROSTVAC might help the immune system kill cancer cells. Researchers want to add PROSTVAC and docetaxel chemotherapy to ADT. They think this may work better against prostate cancer than ADT alone.
  Objective:
  To test if adding PROSTVAC and docetaxel to ADT works better against prostate cancer than ADT alone.
  Eligibility:
  Men ages 18 years and over with metastatic castrate-sensitive prostate cancer
  Design:
  Participants will be screened with:
  Physical exam
  Medical history
  Blood tests
  Possible CT, MRI, or bone scan: Participants lie in a machine. The machine takes pictures of the body.
  Electrocardiogram: Soft electrodes are stuck to the skin to record heart signals.
  Participants will have 2 optional tumor biopsies during the study.
  Participants will join 1 of 2 groups. Both groups will get:
  ADT
  Docetaxel by vein
  Steroids by mouth or vein before each docetaxel infusion
  PROSTVAC injection
  Both groups first have ADT. One to 4 months after, they have:
  Group A:
  Docetaxel every 3 weeks for 6 cycles
  PROSTVAC 3 weeks after the last infusion
  Booster injections 2 weeks later and then every 3 weeks, for 6 boosters total
  Group B:
  PROSTVAC
  Booster 2 weeks later
  Docetaxel hours later
  Docetaxel and the booster every 3 weeks for 6 cycles
  Participants will have a visit 4-5 weeks after the last treatment. They will then have visits every 12 weeks.
  Participants will be followed for up to 15 years. This includes physical exams every year for 5 years.

Detailed description: Background:
  -  A phase III trial demonstrated that combining docetaxel and androgen deprivation therapy (ADT) significantly improved survival (57.6 vs 44.0 months (HR=0.56, (0.44-0.70), p <0.0001) for men with metastatic castration sensitive prostate cancer (mCSPC).
  -  PROSTVAC (developed by the National Cancer Institute [NCI] and licensed to Bavarian Nordic Immunotherapeutics, Mountain View, CA) is a therapeutic cancer vaccine for prostate cancer. Early studies have demonstrated immunologic efficacy and suggested clinical benefit. A phase III trial has completed accrual.
  -  Preclinical and clinical studies support the potential synergy in the combination of docetaxel and PROSTVAC. The potential to combine docetaxel with vaccine in mCSPC could improve upon the survival advantage that has been previously seen.
  Objectives:
  Primary
  -To determine if PROSTVAC combined with docetaxel is able to induce greater antigen spreading (i.e. a broader immune response) with greater associated response score compared to docetaxel alone after 19 weeks.
  Key Eligibility Criteria:
  -  Must have castrate sensitive prostate cancer (rising PSA and testosterone over 100) or is within 134 days of starting ADT (Arm A or B) or within 28 days of start ADT (Arm C)
  -  Histopathological confirmation of prostate cancer
  -  Patients must have metastatic disease
  -  Patients must have a performance status of 0 to 2 according to the ECOG criteria
  -  Patients must have adequate bone marrow, hepatic, and renal function
  Design
  -  This is a randomized trial of ADT followed by simultaneous docetaxel 75 mg/m(2) q3 weeks x 6 cycles + PROSTVAC q3 weeks x 6 cycles versus ADT followed by sequential docetaxel 75 mg/m(2) q3 weeks x 6 cycles followed by PROSTVAC q3 weeks x 6 cycles in men with newly diagnosed mCSPC.
  -  Patients who have not started ADT or who have been on ADT for less than 28 days will be assigned to treatment with PROSTVAC for 6 injections followed by docetaxel 75 mg/m2 q3 weeks x 6 cycles.

Eligibility: -  INCLUSION CRITERIA:
  -  Histopathological confirmation of prostate cancer by the Laboratory of Pathology of thE NCI or Pathology Department of the Walter Reed National Military Medical Center is required prior to entering this study.
  -  Patients must have metastatic disease, defined as at least one lesion on bone scan or at least one lesion that can be accurately measured in at least one dimension (longest diameter to be recorded for non-nodal lesions and short axis for nodal lesions) as greater than or equal to 20 mm with conventional techniques or as greater than or equal to 10 mm with spiral CT scan, MRI, or calipers by clinical exam. (Patients who have metastatic disease by these criteria prior to ADT, but then have changes after ADT that diminish the size of these lesions or changes on bone scan are still eligible.)
  -  Patients must have a performance status of 0 to 2 according to the ECOG criteria
  -  Patients must have adequate bone marrow, hepatic, and renal function with:
  -  ANC greater than or equal to 1500/microL, without CSF support
  -  Platelets greater than or equal to 100,000/microL
  -  AST(SGOT) less than or equal to 2.5 times upper limit of normal (ULN);
  -  ALT(SGPT) less than or equal to 2.5 times upper limit of normal (ULN);
  -  Total serum bilirubin less than or equal to 1.5 times upper limit of normal (ULN), OR in patients with Gilbert s syndrome, a total bilirubin less than or equal to 3.0)
  -  Serum albumin greater than or equal to 2.8 g/dL
  -  Serum phosphorus, calcium, magnesium, and potassium greater than or equal to LLN
  -  Lipase < 2.0 times the upper limit of normal and no radiologic or clinical evidence of pancreatitis
  -  Creatinine less than or equal to 1.5 times institutional upper limits of normal
  OR
  Creatinine clearance of greater than or equal to 50 ml/min/1.73 m(2) for patients with creatinine levels above institutional normal by 24 hour urine.
  -  Willing to travel to the NIH for follow-up visits
  -  18 years of age or older.
  -  Able to understand and sign informed consent.
  -  May have had up to 24 months of ADT (testosterone suppression therapy in the nonmetastatic setting) and are at least 12 months removed from treatment
  -  Men treated or enrolled on this protocol must also agree to use adequate contraception, prior to the study, for the duration of study participation, and 4 months after completion. Sexually active subjects and their female partners must agree to use medically accepted barrier methods of contraception (e.g., male or female condom) during the course of the study and for 4 months after the last dose of study drug(s), even if oral contraceptives are also used. All subjects of reproductive potential must also agree to use both a barrier method and a second method of birth control during the course on the study and for 4 months after the last dose of study drug(s). Should a woman become pregnant or suspect she is pregnant while her partner is participating in this study, she should inform her treating physician immediately.
  -  Must have started ADT for metastatic disease within 134 days (for Arm A and B) or within 28 days (for Arm C).
  EXCLUSION CRITERIA:
  -  Immunocompromised status due to:
  -  Human immunodeficiency virus (HIV) positivity.
  -  Active autoimmune diseases such as Addison s disease, Hashimoto s thyroiditis, systemic lupus erythematosus, Sj(SqrRoot)(Delta)gren syndrome, scleroderma, myasthenia gravis, Goodpasture syndrome or active Grave s disease. Patients with a history of autoimmunity that has not required systemic immunosuppressive therapy or does not threaten vital organ function including CNS, heart, lungs, kidneys, skin, and GI tract will be allowed.
  -  Other immunodeficiency diseases
  -  Chronic administration (defined as daily or every other day for continued use > 14 days) of corticosteroids deemed systemic by investigator within 28 days before the first planned dose of PROSTVAC. Use of inhaled steroids, nasal sprays, and topical creams for small body areas is allowed.
  -  Evidence of rising PSA on ADT
  -  Serious intercurrent medical illness that, in the judgment of the investigator, would interfere with patient s ability to carry out the treatment program.
  -  Other medications used for urinary symptoms including 5-alpha reductase inhibitors (finasteride and dutasteride) and alternative medications known to alter PSA (e.g. phytoestrogens and saw palmetto)
  -  History of allergic reactions attributed to compounds of similar chemical or biologic composition to poxviral vaccines (e.g., vaccinia vaccine)
  -  Known allergy to eggs, egg products, aminoglycoside antibiotics (for example, gentamicin or tobramycin).
  -  History of atopic dermatitis or active skin condition (acute, chronic, exfoliative) that disrupts the epidermis
  -  Previous serious adverse reactions to smallpox vaccination
  -  Unable to avoid close contact or household contact with the following high-risk individuals for three weeks after the Day 1 vaccination: (a) children less than or equal to 3 years of age, (b) pregnant or nursing women, (c) individuals with prior or concurrent extensive eczema or other eczemoid skin disorders, or (d) immunocompromised individuals, such as those with HIV.
  -  Receipt of an investigational agent within 28 days (or 60 days for an antibody-based therapy) before the first planned dose of study drugs.
  -  Patients who test positive for HBV or HCV
  -  Uncontrolled hypertension (SBP>170/ DBP>105)
  -  Patients who have had prior chemotherapy for prostate cancer.
  -  The subject has had evidence within 2 years of the start of study treatment of another malignancy which required systemic treatment (with the exception of nonmelanoma skin cancers or carcinoma in situ of the bladder).
  -  The subject has active brain metastases or epidural disease.
  -  Patients with greater than or equal to grade 2 peripheral neuropathy at baseline.
  -  Patients with history of splenectomy

Relevance to patient case: not relevant