Hormone Therapy, Radiation Therapy, and Steroid 17alpha-monooxygenase TAK-700 in Treating Patients With High-Risk Prostate Cancer

RATIONALE: Androgens can cause the growth of prostate cancer cells. Drugs, such as steroid 17alpha-monooxygenase TAK-700, when used with other hormone therapy, may lessen the amount of androgens made by the body. Radiation therapy uses high energy x rays to kill tumor cells. This may be an effective treatment for prostate cancer when combined with hormone therapy. Studying quality-of-life in patients having cancer treatment may help identify the intermediate- and long-term effects of treatment on patients with prostate cancer.

PURPOSE: This randomized phase III trial is studying the use of hormone therapy, including TAK-700, together with radiation therapy in treating patients with prostate cancer.

OBJECTIVES:

Primary

* To evaluate the difference in overall survival of patients with clinically localized prostate cancer with unfavorable prognostic features between a) standard treatment (androgen-deprivation therapy \[ADT\] + radiotherapy) and b) standard treatment with the addition of 24 months of steroid 17alpha-monooxygenase TAK-700 (TAK-700).

Secondary

* To characterize differences between the treatment groups with respect to incidence of unexpected grade ≥ 3 adverse events and/or clinically significant decrement in patient-reported quality of life (QOL) among subjects treated with TAK-700.
* To compare rates and cumulative incidence of biochemical control (freedom from PSA failure), local/regional progression, and distant metastases.
* To compare rate and cumulative incidence of clinical failure, defined as prostate-specific antigen (PSA) \> 25 ng/mL, documented local disease progression, regional or distant metastasis, or initiation of ADT.
* To compare prostate cancer-specific survival and other-cause mortality.
* To compare the change in severity of fatigue as measured by the Patient-Reported Outcome Measurement Information System (PROMIS) fatigue short form.
* To compare changes in patient-reported QOL as measured by Expanded Prostate Cancer Index Composite (EPIC).
* To assess quality-adjusted survival using the EQ-5D.
* To compare nadir and average serum testosterone at 12 and 24 months during treatment.
* To compare changes in hemoglobin A1C, fasting glucose, and fasting insulin during 24 months of systemic treatment and during the first three years of follow-up.
* To compare changes in fasting lipid levels during 24 months of treatment and during the first three years of follow-up.
* To compare changes in body mass index (BMI) during 24 months of treatment and during the first three years of follow-up.
* To compare the incidence of adverse events ascertained via CTCAE version 4.
* To compare the rate of recovery of testosterone to \> 230 ng/dL (accepted threshold for supplementation) after 12 and 24 months of follow-up.
* To compare the median time to recovery of testosterone to \> 230 ng/dL during the first five years of follow-up.
* To assess cumulative incidence of relevant clinical survivorship endpoints including new diagnosis of type 2 diabetes, coronary artery disease, myocardial infarction, stroke, pulmonary embolism, deep vein thrombosis, or osteoporotic fracture.

OUTLINE: This is a multicenter, randomized study. Patients are stratified according to risk group (see Disease Characteristics) and type of radiation therapy (RT) boost (intensity-modulated RT (IMRT) vs brachytherapy). Patients are randomized to 1 of 2 treatment arms.

After completion of study therapy, patients are followed every 3 months for 2 years, every 6 months for 1 year, and then annually thereafter.

Eligibility Criteria:
Inclusion Criteria:

1. Histologically confirmed diagnosis of adenocarcinoma of the prostate within 180 days prior to registration at high risk for recurrence as determined by one of the following combinations:

   * Gleason Score (GS) ≥ 9, PSA ≤ 150 ng/mL, any T stage
   * GS ≥ 8, PSA \< 20 ng/mL, T stage ≥ T2
   * GS ≥ 8, PSA ≥ 20-150 ng/mL, any T stage
   * GS ≥ 7, PSA ≥ 20-150 ng/mL, any T stage
2. History/physical examination within 60 days prior to registration.
3. Clinically negative lymph nodes as established by imaging \[abdominal and/or pelvic computerized tomography (CT) or abdominal and/or pelvic magnetic resonance imaging (MRI)\], nodal sampling, or dissection within 90 days prior to registration.

   •Patients with lymph nodes equivocal or questionable by imaging are eligible if the nodes are \< 2.0 cm.
4. No distant metastases (M0) on bone scan within 90 days prior to registration (18F-Na bone scan is an acceptable substitute).

   •Equivocal bone scan findings are allowed if plain films are negative for metastasis.
5. Baseline serum prostate-specific antigen (PSA) value performed with an FDA-approved assay (e.g., Abbott, Hybritech), obtained prior to any luteinizing hormone-releasing hormone (LHRH) or anti-androgen therapy, within 180 days of randomization.
6. Androgen deprivation therapy (ADT), such as LHRH agonists (e.g., goserelin, leuprolide), anti-androgens (e.g., flutamide, bicalutamide), estrogens (e.g., DES), or surgical castration (orchiectomy), may have been started prior to registration, provided that registration is within 50 days of beginning ADT. Please note: If the patient has started ADT he will not be eligible to participate in the quality of life component of this study.
7. Prior testosterone administration is allowed if last administered at least 90 days prior to registration.
8. Zubrod Performance Status 0-1 within 21 days prior to registration
9. Age ≥ 18
10. Complete blood count (CBC)/differential obtained within 14 days prior to registration on study, with adequate bone marrow function defined as follows:

    * Absolute neutrophil count (ANC) ≥ 1,800 cells/mm3
    * Platelets ≥ 100,000 cells/mm3
    * Hemoglobin ≥ 8.0 g/dl (Note: The use of transfusion or other intervention to achieve Hgb ≥ 8.0 g/dl is acceptable.)
11. Serum creatinine \< 2.0 mg/dl and creatinine clearance (can be calculated) \> 40 mL/minute within 21 days prior to registration
12. Bilirubin \< 1.5x upper limit of normal (ULN) and alanine aminotransferase (ALT) or aspartate aminotransferase (AST) \< 2.5x ULN within 21 days prior to registration
13. Serum testosterone within 21 days prior to registration
14. Chemistry (including sodium, potassium, chloride, bicarbonate (carbon dioxide), blood urea nitrogen (BUN), glucose, calcium, magnesium and phosphorous) and liver panels (including albumin and alkaline phosphatase) obtained within 21 days prior to registration
15. Fasting glucose, fasting insulin, lipid panel \[cholesterol, triglyceride, high-density lipoprotein (HDL), low-density lipoprotein (LDL)\], and Hemoglobin A1C within 21 days prior to registration
16. Screening calculated ejection fraction of ≥ to institutional lower limit of normal by multiple gated acquisition (MUGA) scan or by echocardiogram (ECHO).
17. Baseline electrocardiogram (ECG) within 180 days prior to registration
18. Patients, even if surgically sterilized (ie, status post vasectomy), who:

    1. Agree to practice effective barrier contraception during the entire study treatment period and for 4 months (120 days) after the last dose of study drug, or
    2. Agree to completely abstain from intercourse.
19. Patient must be able to provide study-specific informed consent prior to study entry.

Exclusion Criteria:

1. PSA \> 150
2. Definite evidence of metastatic disease.
3. Pathologically positive lymph nodes or nodes \> 2.0 cm on imaging.
4. Prior radical prostatectomy, cryosurgery for prostate cancer, or bilateral orchiectomy for any reason.
5. Prior invasive malignancy (except non-melanoma skin cancer) unless disease-free or not requiring systemic therapy for a minimum of 3 years.
6. Prior systemic chemotherapy for prostate cancer (Note that prior chemotherapy for a different cancer is allowed).
7. Prior radiotherapy, including brachytherapy, to the region of the prostate that would result in overlap of radiation therapy fields.

   •Any patient undergoing brachytherapy must have transrectal ultrasound confirmation of prostate volume \<60 cc, American Urological Association (AUA) score ≤15 within 60 days of registration, and no history of prior transurethral resection of the prostate (TURP); prior TURP is permitted for patients who receive external beam radiation therapy \[EBRT\] only).
8. Previous hormonal therapy for \> 50 days.
9. Known hypersensitivity to TAK-700 or related compounds
10. A history of adrenal insufficiency
11. History of myocardial infarction, unstable symptomatic ischemic heart disease, ongoing arrhythmias of Grade \> 2 \[NCI CTCAE, version 4.02\] (U.S. Department of Health and Human Services, National Institutes of Health National Cancer Institute, 2009), thromboembolic events (eg, deep vein thrombosis, pulmonary embolism, or symptomatic cerebrovascular events), or any other cardiac condition (e.g., pericardial effusion restrictive cardiomyopathy) within 6 months prior to registration. Chronic stable atrial fibrillation on stable anticoagulant therapy is allowed.
12. New York Heart Association Class III or IV heart failure.
13. ECG abnormalities of:

    1. Q-wave infarction, unless identified 6 or more months prior to screening
    2. QTc interval \> 460 msec
14. Patients who are sexually active and not willing/able to use medically acceptable forms of contraception; this exclusion is necessary because the treatment involved in this study may be significantly teratogenic.
15. Prior allergic reaction to the drugs involved in this protocol.
16. Study entry PSA obtained during the following time frames:

    1. 10-day period following prostate biopsy;
    2. following initiation of hormonal therapy.
17. Cushing's syndrome
18. Severe chronic renal disease (serum creatinine \> 2.0 mg/dl and confirmed by creatinine clearance \< 40 mL/minute)
19. Chronic liver disease (bilirubin \> 1.5x ULN, ALT or AST \> 2.5x ULN)
20. Chronic treatment with glucocorticoids within one year
21. Uncontrolled hypertension despite appropriate medical therapy within 21 days prior to registration (blood pressure of greater than 150 mm Hg systolic and 90 mm Hg diastolic at 2 separate measurements no more than 60 minutes apart during Screening visit)
22. Unwilling or unable to comply with the protocol or cooperate fully with the investigator and site personnel.
23. Major surgery within 14 days prior to registration
24. Serious infection within 14 days prior to registration
25. Uncontrolled nausea, vomiting, or diarrhea \[Common Terminology Criteria for Adverse Events (CTCAE) grade ≥ 3\] despite appropriate medical therapy at the time of registration
26. Known gastrointestinal (GI) disease or GI procedure that could interfere with the oral absorption or tolerance of TAK-700, including difficulty swallowing tablets