Selinexor in Treating Patients With Abiraterone Acetate and/or Enzalutamide Refractory Metastatic Castration-Resistant Prostate Cancer
Condition: Castration Levels of Testosterone; Hormone-Resistant Prostate Cancer; Metastatic Prostate Carcinoma in the Soft Tissue; Prostate Carcinoma Metastatic in the Bone; PSA Progression; Stage IV Prostate Adenocarcinoma AJCC v7
MeSH terms: Carcinoma; Prostatic Neoplasms
Intervention: Selinexor
Intervention description: Given PO
Phase: Phase 2
Study type: Interventional
Primary purpose: Treatment
Intervention model: Single Group Assignment
Masking: None (Open Label)
Enrollment: 14.0
Sex: Male
Minimum age: 18 Years
Healthy volunteers: No

Summary:

      This phase II trial studies selinexor in treating patients with prostate cancer that has
      spread to other parts of the body (metastatic), keeps growing even when the amount of
      testosterone in the body is reduced to very low levels (castration-resistant), and did not
      respond to treatment (refractory) with abiraterone acetate and/or enzalutamide. Selinexor may
      stop the growth of tumor cells by blocking some of the enzymes needed for cell growth.
    

Eligibility criteria:

        Inclusion Criteria:

          -  Histologically confirmed adenocarcinoma of the prostate

          -  Patients must have castrate levels of testosterone (< 50 ng/dL) on
             gonadotropin-releasing hormone (GnRH) analogues or have had prior orchiectomy; GnRH
             analogues must be continued while on study

          -  Tumor tissue submitted for molecular and genetic analysis through the companion
             Stand-up 2 Cancer (SU2C) radiologically guided biopsy of abiraterone and/or
             enzalutamide refractory mCRPC protocol

               -  Patients who consent to participate in the companion biopsy protocol and are
                  subsequently determined to be ineligible for biopsy are eligible to participate
                  in the current protocol

          -  Progressive disease as demonstrated by a rising PSA (at least two determinations)
             prior to study entry, and/or radiographic evidence of tumor progression in soft tissue
             according to modified Response Evaluation Criteria In Solid Tumors (RECIST) criteria
             or identification of new lesions by bone scan (i.e., >= 2 new lesions)

          -  Primary resistance or acquired resistance (i.e., acquired resistance will be defined
             as disease progression following a period of response defined as >= 50% decline in PSA
             within 12 weeks of starting therapy and not otherwise meeting criteria for primary
             resistance) to any of the following agents/combinations of therapy:

          -  Abiraterone acetate; primary resistance to abiraterone will be defined as:

               -  No PSA decline

               -  PSA decline less than 50% after 12 weeks of abiraterone therapy

               -  PSA progression within 12 weeks of abiraterone acetate (AA) treatment (by
                  Prostate Cancer Working Group-2 [PCWG2] criteria), after initial response to
                  therapy

               -  Objective progression, by RECIST criteria for soft tissue lesions and by modified
                  PCWG2 criteria for bone lesions within 12 weeks of starting abiraterone treatment

               -  Unequivocal clinical progression (per the treating provider's discretion) within
                  12 weeks of starting abiraterone treatment

          -  Enzalutamide; primary resistance to enzalutamide will be defined as:

               -  No PSA decline

               -  PSA decline less than 50% after 12 weeks of enzalutamide therapy

               -  PSA progression within 12 weeks of enzalutamide treatment (by PCWG2 criteria),
                  after initial response to therapy

               -  Objective progression, by RECIST criteria for soft tissue lesions and by modified
                  PCWG2 criteria for bone lesions within 12 weeks of starting enzalutamide
                  treatment

               -  Unequivocal clinical progression (per the treating provider's discretion) within
                  12 weeks of starting enzalutamide treatment

          -  Other second-generation investigational anti-androgen/androgen-receptor targeted
             therapies, including apalutamide (ARN-509); primary resistance will be defined as:

               -  No PSA decline

               -  PSA decline less than 50% after 12 weeks of enzalutamide therapy

               -  PSA progression within 12 weeks of enzalutamide treatment (by PCWG2 criteria),
                  after initial response to therapy

               -  Objective progression, by RECIST criteria for soft tissue lesions and by modified
                  PCWG2 criteria for bone lesions within 12 weeks of starting enzalutamide
                  treatment

               -  Unequivocal clinical progression (per the treating provider's discretion) within
                  12 weeks of starting enzalutamide treatment

          -  Combination therapy with abiraterone, enzalutamide and/or other second- generation
             investigational anti-androgen/androgen-receptor targeted therapies, including ARN-509;
             primary resistance to combination therapy will be defined as:

               -  No PSA decline

               -  PSA decline less than 50% after 12 weeks of abiraterone and enzalutamide therapy

               -  PSA progression within 12 weeks of abiraterone and enzalutamide treatment (by
                  PCWG2 criteria), after initial response to therapy

               -  Objective progression, by RECIST criteria for soft tissue lesions and by modified
                  PCWG2 criteria for bone lesions within 12 weeks of starting abiraterone and
                  enzalutamide treatment

               -  Unequivocal clinical progression (per the treating provider?s discretion) within
                  12 weeks of starting abiraterone and enzalutamide treatment

          -  Sequenced therapy, including any of the following:

               -  Abiraterone acetate followed by enzalutamide

                    -  Primary resistance will be defined per criteria for abiraterone monotherapy
                       primary resistance

               -  Enzalutamide followed by abiraterone acetate

                    -  Primary resistance will be defined per criteria for enzalutamide monotherapy
                       primary resistance

               -  Other second-generation investigational anti-androgen/androgen- receptor targeted
                  therapies, including ARN-509

                    -  Primary resistance will be defined per criteria for other investigational
                       anti-androgen monotherapy primary resistance

          -  Presence of 1 or more bone metastasis

          -  Eastern Cooperative Oncology Group (ECOG) performance status 0 or 1

          -  Prior and ongoing zoledronic acid or denosumab therapy is allowed

          -  Prior therapy with radium-223 is allowed

          -  Discontinuation of prior therapy for mCRPC: a washout period of 28 days for the
             following therapies is required: abiraterone, enzalutamide, fluconazole, itraconazole,
             flutamide, bicalutamide, nilutamide, and other experimental hormonal agents (ARN509,
             orteronel [TAK-700], etc.), sipuleucel-T (Provenge), other experimental vaccines
             (PROSTVAC-V/F, etc.), strontium-89, samarium, and radium-223 chloride

          -  Leukocytes > 3,000/mcL

          -  Absolute neutrophil count > 1,500/mcL

          -  Platelets > 125,000/mcL

          -  Hemoglobin >= 5.59 mmol/L or 9 g/dL; up to 5% deviation is tolerated; transfusions and
             growth factors are allowed

          -  Total bilirubin within normal institutional limits

          -  Aspartate aminotransferase (AST)(serum glutamic oxaloacetic transaminase [SGOT]) < 3 X
             institutional upper limit of normal

          -  Alanine aminotransferase (ALT)(serum glutamate pyruvate transaminase [SGPT]) < 3 X
             institutional upper limit of normal

          -  Creatinine within normal institutional limits OR creatinine clearance > 60 mL/min/1.73
             m^2 for patients with creatinine levels above institutional normal

          -  Ability to understand a written informed consent document, and the willingness to sign
             it

          -  Life expectancy of at least 12 weeks

          -  Able to swallow and retain oral medication

        Exclusion Criteria:

          -  Untreated brain metastases; brain metastases =< 1 cm and not associated with any focal
             neurologic deficits are allowed

          -  Prior docetaxel or other chemotherapy for mCRPC; patients who have received docetaxel
             for metastatic hormone-sensitive prostate cancer are eligible

          -  Active or symptomatic viral hepatitis or chronic liver disease

          -  Clinically significant heart disease as evidenced by myocardial infarction, or
             arterial thrombotic events in the past 6 months, severe or unstable angina, or New
             York Heart Association (NYHA) class II-IV heart disease or known cardiac ejection
             fraction measurement of < 50 % at baseline

          -  Patients with significantly diseased or obstructed gastrointestinal tract or
             uncontrolled vomiting or diarrhea or other gastrointestinal disorders (medical
             disorders or extensive surgery) that may interfere with the absorption of the study
             agents

          -  Pure small cell carcinoma of the prostate or any mixed histology cancer of the
             prostate (eg: neuroendocrine) that contains < 50% adenocarcinoma, as observed on
             biopsy obtained at the time of diagnosis or on any subsequent biopsies

          -  Any ?currently active? second malignancy, other than non-melanoma skin cancer;
             patients are not considered to have a "currently active? malignancy, if they have
             completed therapy and are considered by their physician to be at least less than 30%
             risk of relapse over next year

          -  Any condition, which in the opinion of the investigator, would preclude participation
             in this trial

          -  Active psychiatric illnesses/social situations that would limit compliance with
             protocol requirements

          -  Patients in whom urgent treatment with docetaxel is indicated, per clinician
             discretion; this includes, but is not limited to patients with symptomatic visceral
             metastatic disease

          -  Uncontrolled infection or concomitant medical illness that is not adequately
             controlled with current medical management, as determined per clinician discretion

          -  Active bleeding disorders or evidence of evidence of chronic or acute disseminated
             intravascular coagulation (DIC)

          -  Severely compromised immunological state, including known human immunodeficiency virus
             (HIV)

          -  Any acute toxicities due to prior anti-cancer treatments and/or radiotherapy that have
             not resolved to a National Cancer Institute (NCI) Common Terminology Criteria for
             Adverse Events (CTCAE) grade of =< 1 (except alopecia)

          -  Prior radiation therapy completed < 3 weeks or single fraction of palliative
             radiotherapy < 14 days prior to first dose of KPT-330 (selinexor)

          -  Initiation of bisphosphonate therapy < 4 weeks prior to first dose of KPT-330;
             patients receiving bisphosphonate or denosumab therapy must be on stable doses for at
             least 4 weeks prior to first dose of KPT-330

          -  Men unable or unwilling to employ 2 forms of highly effective contraception throughout
             the study and for 8 weeks after the end of study treatment