Clinical trial NCT02300610
Conditions: Bladder Cancer Carcinoma, Transitional Cell Renal Pelvis Cancer Ureter Cancer Urethra Cancer
Keywords: Ureteral Diseases Urinary Bladder Diseases Transitional Cell Carcinoma Bladder Carcinoma Renal Pelvis Ureter Urethra
Sponsor: H. Lee Moffitt Cancer Center and Research Institute
Start date: 2015-02-11; Completion date: 2019-04-19
Enrollment: 10 participants; Allocation: NON_RANDOMIZED; Intervention model: SEQUENTIAL

Brief summary:
The main purpose of this study is to find out the dose of enzalutamide that can be safely given with gemcitabine and cisplatin in patients with advanced bladder cancer. Researchers also want to find out the side effects of these drugs when given together. This study will also help in finding out the effect on tumor of the combination of enzalutamide, gemcitabine and cisplatin.

Detailed description:
For the phase 1 dose escalation phase, the starting dose of enzalutamide will be 80 mg orally once a day (Level 1). The dosing regimen of cisplatin and gemcitabine will be at standard doses of Gemcitabine at 1000 mg/m\^2 IV on days 1, 8 and cisplatin at 70 mg/m2 IV on day 1, repeated every 21 days for total of 6 cycles.

Three patients will be treated dose level 1 (enzalutamide 80 mg daily). If 0 patients experience dose limiting toxicity (DLT), dose escalation will be done to level 2 of enzalutamide 160 mg daily. If 1 patient experiences DLT, 3 more patients will be treated at the same dose level; if 1 of 6 experiences DLT, escalate the dose to next level, and if 2 or more of 6 experiences DLT, the dose level 1 (80 mg enzalutamide) will be the recommended dose for dose expansion cohort.

The cohort expansion will then be done by enrolling 12 patients with stage IV bladder cancer, who express androgen receptor (AR) staining of 1+ and above by immunohistochemistry (IHC), to determine the safety and tolerability of cisplatin and gemcitabine with the recommended dose level of enzalutamide (80 mg or 160 mg, depending upon the safety results from dose escalation part) in this expanded cohort of patients with AR + bladder cancer.

Enzalutamide would be continued after completion of 6 cycles of gemcitabine-cisplatin for patients exhibiting a response or stable disease, until they experience disease progression.

Arms: arm 1: Dose Escalation: Begin with Level 1 dose of enzalutamide (orally), with standard doses of cisplatin and gemcitabine via intravenous (IV). arm 2: Dose Expansion: Enzalutamide at recommended dose level with standard doses of cisplatin and gemcitabine.
Interventions: intervention 1: Enzalutamide intervention 2: Cisplatin intervention 3: Gemcitabine
Intervention descriptions: intervention 1: Enzalutamide orally once a day. Dose Escalation Level 1: 80 mg; Level 2: 160 mg. Dose Expansion at recommended dose level, after dose escalation. intervention 2: Cisplatin at 70 mg/m\^2 IV on day 1, repeated every 21 days for total of 6 cycles. intervention 3: Gemcitabine at 1000 mg/m\^2 IV on days 1, 8, repeated every 21 days for total of 6 cycles.

Protocol documents:
Prot_SAP_000.pdf: 
 
 
 
 TITLE: A Phase I/1b Study of Enzalutamide in Combination with Gemcitabine 
and Cisplatin in Bladder Cancer  
 
NCT02300610 
 
Version 3.0 
July 13, 2016 




 
 
 
2 
 
 
TABLE OF CONTENTS 
 
 
Page 
1. OBJECTIVES   .................................................................................................................. 5 
1.1    Primary objective 
............................................................................................................ 5 
1.2    Secondary Objectives ....................................................................................................... 5 
1.3    Exploratory Objectives 
................................
................................
..................................... 5 
 
2. BACKGROUND 
 .................................................................................................................. 5 
2.1    Bladder Cancer ................................................................................................................. 5 
2.2    Androgen Receptor and Bladder cancer 
................................
........................................... 6 
2.3    Enzalutamide……………………………………………………………… .................... 7 
 
3. PATIENT SELECTION ...................................................................................................... 8 
3.1    Inclusion Criteria  
................................
................................
............................................. 8 
3.2    Exclusion Criteria 
................................
................................
........................................... 10 
 
4. TREATMENT PLAN 
....................................................................................................... 12 
4.1    Drug Administration 
................................
................................
....................................... 12 
4.2    Definition of Dose-Limiting Toxicity............................................................................. 13 
4.3    Supportive Care Guidelines 
................................
............................................................ 14 
4.4    Duration of Therapy........................................................................................................ 15 
4.5    Duration of Follow Up 
.................................................................................................. 15 
4.6    Patient Replacement ....................................................................................................... 15 
4.7       Discontinuation criteria................................................................................................... 16 
 
5. DOSE DELAYS/DOSE MODIFICATIONS 
................................................................... 16 
5.1       Dose Modification Guidelines for Hematologic Toxicity 
.............................................. 16 
5.2    Dose Modification Guidelines for Non-Hematologic Toxicity 
...................................... 17 
 
6. PHARMACEUTICAL INFORMATION 
........................................................................ 18 
6.1    Enzalutamide. ................................................................................................................. 18 
6.2    Gemcitabine 
................................
................................
.................................................... 20 
6.3    Cisplatin 
................................
................................
.......................................................... 20 
 
7. CORRELATIVE/SPECIAL STUDIES 
................................
............................................ 21 
7.1    AR Expression 
................................
................................
................................................ 21 
7.2    pAKT Expression ........................................................................................................... 21 
7.3       Circulating Tumor Cells 
................................
................................
................................. 21 
 
8. STUDY CALENDAR 
................................
................................
......................................... 22 
 
9. MEASUREMENT OF EFFECT 
................................
....................................................... 24 
 


 
 
 
3 
10. REGULATORY AND REPORTING REQUIREMENTS 
............................................. 27 
10.1  Adverse Event ................................................................................................................ 28 
10.2  Reporting Adverse Event 
.............................................................................................. 28 
10.3  Investigator responsibilities 
................................
............................................................ 29 
10.4  Institutional review Board Approval 
................................
.............................................. 29 
10.5  Informed Consent ........................................................................................................... 29 
10.6  Study Records requirement 
............................................................................................ 30 
10.7 Patient Registration 
....................................................................................................... 30 
10.8 Data Management 
................................
................................
........................................... 31 
10.9 Study Monitoring and Auditing 
..................................................................................... 31 
 
11. STATISTICAL CONSIDERATIONS 
................................
.............................................. 32 
11.1  Study Design/Endpoints ................................................................................................. 32 
11.2  Sample Size…................................................................................................................. 33 
11.3  Analysis of secondary endpoints 
................................
.................................................... 33 
11.4  Analysis of exploratory endpoints 
................................
.................................................. 33 
 
12. PUBLICATIONS 
................................
................................
................................................ 34 
 
 
REFERENCES.......................................................................................................................... 35 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
 
 
4 
 
1. OBJECTIVES 
 
1.1.  Primary Objective 
   To determine the safety and tolerability of enzalutamide at doses of 80 mg and 160 mg 
each in combination with gemcitabine and cisplatin in advanced bladder cancer.  
   Once the safety of the combination is established, the phase 1 cohort will be expanded 
to an additional cohort of 12 patients with stage IV bladder cancer (phase 1b), who 
express androgen receptor (AR) by immunohistochemistry (IHC), to determine the 
safety and tolerability of enzalutamide and gemcitabine and cisplatin in this expanded 
cohort of patients with AR+ bladder cancer.   
 
1.2.  Secondary Objectives 
• To evaluate the response rate (RR) of enzalutamide in combination with 
gemcitabine and cisplatin in advanced bladder cancer. Evaluation of response 
would be based on Response Evaluation Criteria in Solid Tumors (RECIST) 
criteria for all solid tumors. 
• To evaluate progression free survival. 
• To evaluate overall survival.  
 
1.3    Exploratory Objectives 
• To determine if AR expression in bladder cancer correlates with outcome. For 
patients with positive AR expression on IHC, we will use Automated 
Quantitative Analysis (AQUA) for precise quantitative scoring and test for 
pAKT in addition to AR to better understand biological behavior of tumors, 
including responders and non-responders. 
• To evaluate whether circulating tumor cell (CTC) count measurements at 
baseline and on day 1 of cycle 3 correlate with disease burden, and treatment 
response respectively. AR expression in CTCs will also be evaluated and 
correlated with response.   
 
2. BACKGROUND 
 
2.1   Bladder Cancer  
 
Bladder cancer is the 4th most common malignancy in men and the 9th most common 
in women in the US, with an estimated 72,570 new case and 15,210 deaths in 2013. 
1 
Approximately 25% of patients initially present with muscle invasive disease, which 
is life threatening. Despite radical cystectomy, approximately 50% of patients develop 
disease  recurrence  and  require  subsequent  systemic  chemotherapy  within  5  years 
usually  in  the  first  2-3  years.  Transitional  cell  cancer  is  a  chemotherapy-sensitive 
malignancy  and  
systemic  chemotherapy with platinum based  
regimens  
is  an  
integral 
component of first-line therapy. However, durable responses are rarely seen and most 
patients  with  metastatic  disease  recur.  Combination  regimens  with  multiple 
conventional cytotoxics, have been developed. Methotrexate, vinblastine, doxorubicin, 
and cisplatin (M-VAC) combination chemotherapy demonstrated a median survival of 


 
 
 
5 
13 months, however the regimen was quite toxic. A follow-up phase 3 trial comparing 
M-VAC  with  the  combination  of  gemcitabine  and  cisplatin  (GC)  was  conducted, 
demonstrating  similar  efficacy  (ORR  of  49%  versus  46%),  and  time  to  disease 
progression (7.4 months in both arms), and similar median survivals (14.8 months vs. 
13.8  months),  respectively.  Patients  in  the  GC  arm  also  experienced  less adverse 
events.
2 There are no standard 2nd line therapy options and taxane bases regimens are 
frequently employed with low response rates and very little options after progression 
on  taxanes.  Majority  of  patients  with  metastatic  urothelial  cancer  will  die  of  their 
disease  in  less  than  two  years.  Effective  treatment  of  bladder  cancer  is  an  unmet 
medical need and novel treatment strategies are urgently required.  
 
 
2.2   Androgen Receptor and Bladder cancer 
 
Androgen  receptor  (AR) signaling  has  been  reported  to  play  a  critical  role  in  the 
development of prostate cancer and anti-androgen therapy is effective in stopping the 
growth and progression of prostate cancer.(10-13)  
 
The higher incidence of urothelial cancer of urinary bladder in men could be related to 
AR being involved in the development of bladder cancer. The AR, a member of the 
nuclear receptor superfamily, is a ligand-dependent transcriptional factor that mediates 
the  biologic  effects  of  androgens.  AR  expression  has  been  demonstrated  
in  various 
bladder cancer cell lines, expression of the AR  by  
immunohistochemistry (IHC) has 
been demonstrated in normal bladder epithelium, bladder smooth muscle and neuronal 
cells.
3,4 Early studies using androgen-binding assays suggested the expression of AR 
in bladder tumors.
5 Recent studies showed AR expression in more than half of bladder 
cancers using immunohistochemistry (IHC).
6 
 
It has been demonstrated by Miyamoto et al. that dihydrotestosterone (DHT) treatment 
increased the growth of TCC-SUP cells by 55 and UMUC3 cells by 45%.  95% CI = 
18% to 73%) and the antiandrogen, hydroxyflutamide (HF) partially antagonized (up 
to  75%  reduction)  
in  both  cell  
lines.  Of  note,  no  significant  activity  was  seen  with 
DHT and HF on cell growth in AR negative bladder cancer cell lines, thus indicating 
that  androgen  
treatment  
increases  proliferation  of  AR-positive  bladder  cancer  cells.
7 
These  
findings  were  confirmed  
in  xenograft  mouse  models  as  well,  using  androgen 
deprivation therapy via  castration and/or  antiandrogen like flutamide,  
treatment with 
an anti-AR compound ASC-J9, and treatment with AR-siRNA.
7 TCC-SUP tumors in 
mice  treated  with  castration  and/or  antiandrogen  were  statistically  significantly 
smaller than those in the control mice at 16 weeks. When the tumors in the treatment 
groups  were  harvested,  their  weights  were  found  to  be  reduced  by  57%  to  63%. 
Significant reduction in tumors was also seen in UMUC3 xenograft tumors, and only 
minimal effects of  androgen deprivation therapy  were seen in the AR-negative 5637 
xenograft  
tumors.  Androgen  deprivation  also  decreased  proliferation  by  up  
to  73%, 
induced  apoptosis and  reduced levels  of  angiogenic  factors  and  metastasis-related 
factors in TCC-SUP tumors.  
 


 
 
 
6 
The  effect  of  a  novel  AR  antagonist,  ASC-J9,  a  curcumin  analog  which  directly 
targets  the  AR  by  dissociating  AR  coregulators  from  the  AR,  leading  to  selective 
degradation  of  the AR  proteins  were  also  studied  in  vitro  and  in  vivo. 8,9 ASC-J9 
inhibited DHT-simulated growth of TCCSUP and UMUC3 cells and inhibited tumor 
growth  by  58  %.  Moreover,  it  decreased  the  proliferation  index,  increased  the 
apoptotic  index,  and  reduced  levels  of  angiogenic  factors  and  metastasis-related 
factors. ASC-J9 also reduced AR expression by 39% suggesting that directly targeting 
the  AR  can  inhibit  androgen-sensitive  bladder  cancer  progression. It  has  been 
demonstrated  that  AR  knockdown  in  AR-expressing  bladder  cancer  cell  lines  by 
siRNA  also  decreased  cell  proliferation,  even  
in  androgen-depleted  conditions,  and 
castration and flutamide treatment had little effect on the development of AR-siRNA–
expressing  
tumors,  
it  
is  possible  
that  AR  signals  (via  androgen-mediated  and  non–
androgen-mediated pathways) might contribute to the bladder cancer progression.6 
These  preclinical  findings  demonstrate  that  androgens  increase  the  growth  of  AR-
positive bladder cancer cells and androgen deprivation and or/ anti-androgen therapy, 
including novel AR antagonist suppressed cancer progression. This study supports the 
concept  that  androgens  may  be  implicated  in  the  growth  of  bladder  cancer  and 
effective  blockade  of  androgen  receptors  offers  a  potentially  new  approach  to 
treatment.  
 
 
2.3   Enzalutamide 
 
Enzalutamide  (formerly  MDV3100)  is  an  androgen-receptor–signaling  inhibitor 
chosen for clinical development on the basis of activity in prostate-cancer models with 
over expression of the androgen receptor. Enzalutamide is distinct from the currently 
available antiandrogen agents in that it inhibits nuclear translocation of the androgen 
receptor, DNA binding, and co activator recruitment. It also has a greater affinity for 
the  receptor,  induces  tumor  shrinkage  in  xenograft  models  (in  which  conventional 
agents  only  retard  growth),  and  has  no  known  agonistic  effects.
14,15 Enzalutamide, 
unlike conventional anti-androgens bicalutamide and flutamide, lacks agonist activity. 
In the landmark phase 3, double-blind, placebo-controlled trial (AFFIRM), 1199 men 
with  castration-resistant  prostate  cancer  after  chemotherapy  were  randomized  to 
receive oral enzalutamide at a dose of 160 mg per day (800 patients) or placebo (399 
patients). The primary end point was overall survival. The study was stopped after a 
planned interim analysis at the time of 520  deaths. The median overall survival was 
18.4  months  in  the  enzalutamide  group  versus  13.6  months  in the  placebo  group 
(hazard  ratio  for  death  in  the  enzalutamide  group,  0.63;  95%  CI,  0.53  to  0.75; 
P<0.001). The superiority of enzalutamide over placebo was shown with respect to all 
secondary  end  points:  the  proportion  of  patients  with  a  reduction  in  the  prostate-
specific antigen (PSA) level by 50% or more (54% vs. 2%, P<0.001), the soft-tissue 
response rate (29% vs. 4%, P<0.001), the quality-of-life response rate (43% vs. 18%, 
P<0.001),  the  time  to  PSA  progression  (8.3  vs.  3.0  months;  hazard  ratio,  0.25; 
P<0.001),  radiographic  progression-free  survival  (8.3  vs.  2.9  months;  hazard ratio, 
0.40; P<0.001), and the time to the first skeletal-related event (16.7 vs. 13.3 months; 
hazard ratio, 0.69; P<0.001). Rates of fatigue, diarrhea, and hot flashes were higher in 


 
 
 
7 
the  enzalutamide  group  and  seizures  were  
reported  
in  
five  patients  
(0.6%)  
receiving 
enzalutamide
16 Enzalutamide was approved by the FDA in 2012, and by the EMA in 
2013, for patients with mCRPC progressing on docetaxel chemotherapy.  
 Enzalutamide has also  been studied in men with  chemotherapy-naive  asymptomatic 
or  mildly  symptomatic  mCRPC  in  the  PREVAIL  study  (randomized,  double  blind 
placebo  controlled  multinational  phase  3  trial).17 A  total  of  1717  patients  were 
randomized  
to  enzalutamide  160mg  orally  daily  or  placebo.  The  
interim  analysis  at 
540 deaths showed a statistically significant benefit of enzalutamide over placebo with 
a  29%  
reduction  
in  
risk  of  death  
(OS:  HR  0.71;  95%  CI:  0.6-0.84,  p<0.001  and  an 
81% reduction in risk of radiographic progression or death (rPFS: HR 0.19; 95% CI: 
0.15-0.23;  P<  0.001).  Estimated  median  OS  was  32.4  months  with  enzalutamide  
compared  to  30.2  months  with  placebo.  An  updated  survival  analysis  presented  at 
ASCO  2014  with  additional  follow-up  
time  and  events  demonstrated a  median  OS 
that  was  not  reached  with  enzalutamide  vs.  31  months  for  placebo  (HR  0.73, 
p<0.001).  Median  
rPFS  was  not  
reached  
in  
the  enzalutamide  arm  vs  3.9  mo  
  
in  
the 
placebo  arm.  The  Independent  Data  Monitoring  Committee  considered  the  benefit-
risk  
ratio to  
favor  enzalutamide  
  and  
recommended  stopping  
the  study  and  crossing 
placebo  patients  to  enzalutamide.  Thus  treatment  with  enzalutamide  significantly 
improves OS and rPFS in men with chemotherapy-naive mCRPC and is anticipated to 
receive FDA approval for this setting soon. 
 
Based on the preclinical rationale for utilizing androgen blockade in bladder  cancer, 
we  will  attempt  to  study  whether  it  can  be  safely  combined  with  cisplatin  and 
gemcitabine in bladder cancer.  
Enzalutamide  has  been  safely  combined with  chemotherapy  agents  
like  docetaxel  at 
doses of 160 mg and there was no incidence of increased toxicity.18  
 
 
3. PATIENT SELECTION 
 
3.1   Inclusion Criteria  
 
3.1.1Cytologically or histologically confirmed evidence of transitional cell carcinoma 
of   bladder, renal pelvis, ureter or urethra.  
 
3.1.2  Patients  with  Stage  IV  (locally  advanced  or  metastatic)  disease.  The  AJCC 
cancer  staging  manual,  7
th edition  will  be  used  
for  staging  (as  below).  RECIST  1.1 
criteria will be used for measurable disease.   
 
T4b 
N0 
M0 
Any T 
N1–3 
M0 
Any T 
Any N 
M1 
 
    3.1.3   Age ≥ 18 years. 


 
 
 
8 
 
    3.1.4 Minimum of four weeks since any major surgery, completion of radiation. 
 
3.1.5  Prior  
treatment  with  cytotoxic  chemotherapy  
is  not  a  requirement,  but allowed  
only if used in neoadjuvant, adjuvant or for bladder preserving protocols, as long as was 
administered  > 6 months prior to starting study.  
 
    3.1.6 ECOG performance status ≤ 2. 
 
    3.1.7 Life expectancy 12 weeks or more. 
 
           3.1.8 Patients must have normal organ and marrow function as defined below: 
 
-  leukocytes 
>3,000/µL 
-  absolute neutrophil count    >1,500/µL 
- platelets 
>100,000/µL 
-    hemoglobin                             > 9 g/dL 
- total bilirubin 
<2 X institutional upper limit of normal 
- AST(SGOT)/ALT(SGPT)   <3 X institutional upper limit of normal (<5 
if liver metastases present) 
- creatinine 
<1.5 mg/dl 
- INR  
<1.3 (or < 3 if on warfarin or other 
anticoagulants) 
 
Blood transfusion will be allowed for patients with hemoglobin less than 9 g/dl 
and G-CSF is allowed for neutropenic patients at time of enrollment. 
Chemotherapy treatment can only be administered 48 hours post G-CSF therapy. 
 
 
3.1.9 Women  of  childbearing  potential  must  have  a  negative  serum  or  urine 
pregnancy test within 14  days of the  administration of the first study treatment.  
Women must not be lactating.  
 
3.1.10  Sexually  active  women  of  childbearing  age  and  men  should  be  willing  
to 
use two acceptable methods of birth control (one of which must include a condom 
as a barrier method of contraception) starting at screening and continuing through 
3  months  after  the  final  study  drugs  administration.  Men  must  agree  to  avoid 
sperm  donation  while  on  study  and  3  months  after  the  final  study  drugs 
administration.  
 
 
3.1.11 Signed informed consent to participate in the study, including participation 
in the  expansion cohort after safety of enzalutamide and gemcitabine and cisplatin 
have been   established, must be obtained from patients after they have been fully 
informed of the nature and potential risks by the investigator (or his/her designee) 
with the aid of written information. 


 
 
 
9 
 
3.1.12 Patients should be able to swallow enzalutamide and comply with study 
requirements.  
 
 
 
3.2    Exclusion Criteria 
 
            3.2.1Prior treatment with any cytotoxic chemotherapy in metastatic setting. Prior 
treatment with cytotoxic chemotherapy is allowed  only if used in neoadjuvant, 
adjuvant or for bladder preserving protocols, as long as was administered  > 6 
months prior to starting study.  
 
3.2.2 Patients who have undergone major surgery within 4 weeks prior to study    
enrollment 
 
3.2.3 Chronic treatment with steroids or any other immunosuppressant drugs. 
 
3.2.4 Patients should not receive immunization with attenuated live vaccines     
during study period or within 1 week of study entry. 
 
            3.2.5 Patients with a history of seizures, predisposing factors for seizures,          
            including underlying brain injury with loss of consciousness within previous     
12 months, transient ischemic attack within previous 12 months, cerebral               
vascular accident or brain arteriovenous malformation. 
             
3.2.6 Untreated brain or leptomeningeal metastases, including patients who    
continue to require glucocorticoids for brain or leptomeningeal metastases. 
 
3.2.7 Patients who have congestive heart failure (NYHA Class III or IV), unstable 
angina, sustained ventricular tachycardia, ventricular fibrillation, clinically 
significant bradycardia, advanced heart block or a history of acute myocardial 
infarction within the six months preceding enrollment. 
 
3.2.8 Patients with known history of HIV.  
 
3.2.9 Patients who have any severe and/or uncontrolled medical conditions or 
other conditions that could affect their participation in the study such as any  
active (acute or chronic) or uncontrolled infection/ disorders or nonmalignant 
medical illnesses that are uncontrolled or whose control may be jeopardized by the 
treatment with the study therapy 
 
3.2.10 Women who are pregnant or breast feeding, or women/men able to 
conceive and unwilling to practice an effective method of birth control (one of 
which must include a condom as a barrier method of contraception) starting at 


 
 
 
10 
screening and continuing through 3 months after the final study drugs 
administration   
 
3.2.11 Concurrent medications which strongly inhibit or induce CYP enzymes 
(gemfibrozil, Rifampin, carbamazepine, phenobarbital, phenytoin, rifabutin, 
rifampin, rifapentine, bosentan, efavirenz, etravirine, modafinil, nafcillin, St. 
John’s Wort) 
 
3.2.12 History of stage III or greater cancer, except basal or squamous cell skin 
cancers adequately treated or any other stage I or II cancer adequately treated and 
disease-free for ≥ 2 years.  Incidental findings of stage I or II prostate cancer that 
is considered to be cured with radical cystoprostatectomy is allowed. 
 
3.2.13 Prior use of enzalutamide.  
 
3.2.14 Radiation therapy via external beam or brachytherapy within 28 days of 
registration.  
 
3.2.15 Patients who are ineligible to receive cisplatin: 
Creatinine clearance of less than 60 mL/minute, hearing loss of 25 dB at two 
contiguous frequencies, grade 2 or higher peripheral neuropathy, or New York 
Heart Association Class III or higher heart failure.  
 
Hearing test will not be routinely done, it will only be done if patients report 
hearing loss at baseline or during treatment. 
 
3.2.16 Allergy/sensitivity to any study drug (gemcitabine, cisplatin, enzalutamide), 
or drugs chemically related to study drug, or excipients . 
 
3.2.17 Patients with brain metastases (including treated or stable brain 
metastases).  
 
Although, positive AR expression is not a  requirement for the dose escalation 
phase, it will be tested in archival tissue from formalin-fixed, paraffin-embedded, 
tumor specimen from either radical cystectomy or TURBT. If patients have 
received neoadjuvant chemotherapy, then pre-chemotherapy TURBT archival 
tissue specimen will be used and if there was no neoadjuvant chemotherapy 
administered, then either TURBT specimen or radical cystectomy specimen can be 
used.  A fresh biopsy specimen would be obtained if archival tissue not available. 
Dose expansion Cohort: The inclusion and exclusion criteria for the expansion 
cohort are the same as above, except for the expansion cohort also required to 
express AR (score 1+ or more) by IHC in archival bladder cancer samples or fresh 
biopsy specimens (if archival tissue not available).  
 
 
 


 
 
 
11 
4. TREATMENT PLAN 
 
4.1    Drug Administration 
 
Treatment  will  be  administered  on  an  outpatient  basis.  
  Reported  AEs  and  potential 
risks  are  described  
in  Section  6.  
  Appropriate  dose  modifications  for enzalutamide, 
cisplatin,  and gemcitabine are  described  in  Section  5.  No  investigational  or 
commercial agents or therapies other than those described below may be administered 
with the intent to treat the patient
's cancer.  
For the phase 1 dose escalation phase, the starting dose of enzalutamide will be 80 mg 
orally once a day (Level 1). The dosing regimen of cisplatin and gemcitabine will be 
at standard doses of Gemcitabine at 1000 mg/m2 IV on days 1, 8 and cisplatin at 70 
mg/m2 IV on day 1, repeated every 21 days for total of 6 cycles.  
Three  patients  will  be  
treated  dose  
level  1 (enzalutamide  80  mg  daily). If  0  patients 
experience  dose  
limiting  
toxicity  (DLT),  dose  escalation  will  be  done  
to  
level  2  of 
enzalutamide 160  mg  daily.  If  1  patient  experiences  DLT,  3  more  patients  will  be 
treated  at  
the  same  dose  
level;  
if  1  of  6  experiences  DLT,  escalate  
the  dose  
to  next 
level, and if 2 or more of 6 experiences DLT, the dose level 1 (80 mg enzalutamide) 
will be the recommended dose for dose expansion cohort.   
Three patients  have  been  
treated  with  dose  
level  1  and  one  patients  has  completed 
dosel level 2 and completed the DLT period.  
 
The cohort expansion will then be done by enrolling 12 patients with stage IV bladder 
cancer, who express AR staining of 1+ and above by IHC, to determine the safety and 
tolerability  of  cisplatin  and  gemcitabine  with  the  recommended  dose  level  of 
enzalutamide  (80  mg  or  160  mg,  depending  upon  the  safety  results  from  dose 
escalation part) in this expanded cohort of patients with AR+ bladder cancer.  
Enzalutamide  would  be  continued  after  completion  of  6  cycles  of  gemcitabine-
cisplatin  for  patients  exhibiting  a  response  or  stable  disease,  until  they  experience 
disease progression.  
 
 
 
 
 
 
 
 
     Regimen Description:  
     Days 1-21: Enzalutamide 80 mg or 160 mg PO daily 
     Day 1: Premeditations: 
Aloxi 0.25mg IV Push, Fosaprepitant 150mg in 250mL 0.9% NaCl IVPB over 30 
minutes Dexamethasone 12mg PO  
     Treatment Drugs: 
           Gemcitabine: IV infusion in 250 ml 0.9% NaCl over 30 minutes  
0.9% NaCl over 1 hour pre-Cisplatin 
Dose Escalation Schedule 
Dose Level 
Dose 
Enzalutamide 
Gemcitabine   
Cisplatin 
Level 1   
80 mg PO daily 
1000  mg/m
2 IV  day 
1,and 8 every 21 days 
70 mg/m2 every 21 
days  
Level  2   
160 mg PO daily  
1000  mg/m
2 IV  day 
1,and 8 every 21 days 
70 mg/m2 every 21 
days 


 
 
 
12 
Mannitol 12.5 gm IVPB in 50ml 0.9% NaCl over 15 minutes pre-Cisplatin  
Cisplatin: IV solution in 500mL NaCl 0.9% over 60-120 minutes  
1000mL 0.9% NaCl + 8mEq MgSO4 + 20 mEq KCL over 2 hours post-Cisplatin  
     Day 8: Premedications: 
            Prochlorperazine 10mg po Pre-Chemo  
           Treatment Drug: 
            Gemcitabine: IV infusion in 250 ml 0.95 NaCl over 30-60 minutes  
 
4.2    Definition of Dose-Limiting Toxicity 
 
Dose-Limiting Toxicity (DLT) is defined as any of the following occurring in the first 
21 days (cycle 1) of study participation that are considered at least possibly related to 
enzalutamide  administration.  Toxicities  
that  are  
in  
the  opinion  of  
the  
investigator(s) 
attributable exclusively to gemcitabine or cisplatin will not be considered DLT.  
• More  
than  7  consecutive  missed  doses  (out  of  21  doses)  of  enzalutamide  
in  21 
days due to enzalutamide related toxicity. 
• Missed day 8 dose of gemcitabine in cycle 1 will not be considered DLT.  
• Delay  of  greater  than  3  weeks from scheduled  date  
in  
initiating  cycle  2  due  
to 
enzalutamide, gemcitabine or cisplatin  related toxicity. 
Discontinuation  of  a  patient  due  to  enzalutamide related toxicity before 
completing cycle 1. Hematologic toxicity 
• Hematologic toxicity is generally not expected from enzalutamide, the frequency 
of  grade  3-4  neutropenia  reported  with  enzalutamide  is  1%  and  grade  3-4 
thrombocytopenia  is  0.5%.  However,  it  is  frequently  seen  with  cytotoxic 
chemotherapeutic  agents,  like  cisplatin  and  gemcitabine, mainly  due  to 
gemcitabine. For  the  purposes  of  this  study,  any  grade  3/4  hematologic  event 
resulting in neutropenic fever or neutropenia lasting more than 7 days in spite of 
optimal  supportive  medications  or  spontaneous  bleeding  will  be likely  from 
chemotherapy and not considered a DLT.  
 
 
Non-Hematologic toxicity 
• Grade ≥ 3 nausea, vomiting or diarrhea lasting more than 72 hours in the setting of 
optimal supportive care and medications.  
• Any  other  Grade  3  non-hematological  toxicity  (except  for  electrolytes 
abnormalities that are reversible or hair loss which is not dose-limiting) that results 
in greater than 7 days  interruption of therapy. 
• Intra-patient  dose  de-escalation  will  be  allowed, i.e.  if  patients  have Grade  3-4 
AEs on 160 mg enzalutamide, they will be allowed to try 80 mg enzalutamide. If 
they  cannot tolerate 80  mg enzalutamide,  enzalutamide will  be stopped  and they 
can receive only gemcitabine-cisplatin off protocol. 
• Occurrence  of  seizure,  which  can  rarely  occur  with  enzalutamide,  will  be 
considered a DLT.  
• Any  other  grade 3  or 4  non-hematologic toxicity that is definitely attributable to 
enzalutamide and not gemcitabine or cisplatin.  


 
 
 
13 
• Hepatic  toxicity:  Hepatic  enzyme  and  bilirubin  increase  which  meet  Hy’s  law 
criteria (ALT/AST > 3 X upper limits of normal, total bilirubin > 2 X upper limits 
of normal and alkaline phosphatase < 2 X upper limits of normal. 
 
 
The DLT evaluation set is defined as all patients who receive at least one dose of the 
enzalutamide, gemcitabine and cisplatin  and complete Cycle 1 or discontinue due to 
toxicity related  to  enzalutamide.  DLT  will  be  derived  from  the  toxicities  observed 
during the first cycle (21 days) for each dose level.  
 
Any  patient  who  does  not  complete  
the  evaluation  period  for  DLTs  
in  cycle  1  for 
reasons other than study drug-related toxicity will be replaced.  
 
Adverse  events  will  be  graded  using  the  National  Cancer  Institute  Common 
Terminology Criteria for Adverse Events (NCI CTCAE) Version 4.0.  
 
At dose level 1, if 0 patients experience dose limiting toxicity (DLT), dose escalation 
will be done to level 2 of 160 mg daily.  
 
For dose level 1 (80 mg enzalutamide), if 1 patient experiences DLT, 3 more patients 
will be treated at the same dose level; if 1 of 6 patients experiences DLT, escalate to 
dose to next level (160 mg enzalutamide), and if 2 or more of 6 experiences DLT on 
160  mg enzalutamide, the  recommended  dose of enzalutamide  will  be  80  mg. If  at 
dose level 1 (80 mg), 2 or more patients experience DLT, the study would be stopped.  
 
The cohort expansion will then be done by enrolling 12 patients with stage IV bladder 
cancer, who express AR staining of 1+ and above by IHC, to determine the safety and 
tolerability of the recommended dose of enzalutamide  with gemcitabine and cisplatin 
in this expanded cohort of patients with AR+ bladder cancer. 
 
 
4.3    Supportive Care Guidelines 
 
Anti-emetics  are  permitted  for  prevention  and  treatment  of  nausea  and  vomiting. 
Patients will be given the standard anti-emetics used for gemcitabine and cisplatin as 
outlined above. For patients who are allergic, have unacceptable side effects or have 
limited benefit from the above anti-emetics, other agents including ondansetron can be 
used for both prophylaxis and treatment. Prophylactic dexamethasone at doses of 4 mg 
Po  BID  can  be  used  day  after  cisplatin  chemotherapy. Anti-diarrheal  agents  can  be 
used for the treatment of diarrhea.   
 
G-CSF is allowed for treatment and prevention of neutropenia. The dose and schedule 
are at  the  discretion  of  the  investigators. Chemotherapy  treatment can  only  be 
administered 48 hours post G-CSF therapy. 
Packed  red  cell transfusion  and  platelet  transfusion  will  be  allowed  as  clinically 
indicated.  


 
 
 
14 
 
4.4    Duration of Therapy 
 
In the absence of treatment delays due to AEs, treatment may continue until one of the 
following criteria applies: 
 
• Disease progression 
 
• Intercurrent illness that prevents further administration of treatment 
 
• Unacceptable AEs 
 
• Patient decides to withdraw from the study 
 
• Any changes in the patient
's condition render the patient unacceptable for further 
treatment in the judgment of the investigator. 
 
For  cycle 2 and beyond, if  there is a treatment cycle delay of more than 3 weeks, 
patients will be removed from the study. 
 
   4.5    Duration of Follow Up 
 
Patients will be followed for 30 days for AEs after removal from study or until death, 
whichever occurs first. Patients with significant or unacceptable AEs at the time of 
removal from the study therapy will be followed until the toxicities resolve or are 
deemed irreversible. Patients will be followed for survival every 2-3 months by 
telephone call for up to 1 year. 
 
 
   4.6   Patient Replacement 
 
Any patient who does not complete the evaluation period for DLTs in cycle 1 for 
reasons other than study drug (enzalutamide)-related toxicity will be replaced.  
 
      4.7       Discontinuation Criteria 
 
  Patients would be discontinued form the study for any of the following:  
• Any AE that is intolerable to the subject and that cannot be ameliorated by the use 
of adequate medical intervention, or that in the opinion of the investigator would 
lead to undue risk to the subject if dosing continued 
• Any treatment emergent seizure or any condition that significantly predisposes the 
patient to have seizures, like brain metastases or clinically evident stroke will be a 
criteria for discontinuation from the study.  
• Symptomatic or radiographic disease progression 
• Any current illness that prevents further administration of treatment 


 
 
 
15 
•  Subject who is, in the opinion of the investigator, grossly non-compliant with the 
protocol’s requirements 
 
 
 
5.        DOSE DELAYS/DOSE MODIFICATIONS 
 
The treatment can be interrupted if the treatment criteria are not met as mentioned in 
section  5.1 and  5.2 If  a  patient  
requires  
treatment  cycle interruption  of  more  
than 3 
weeks, the patient will be taken off study. Patient can continue to receive gemcitabine 
and cisplatin off protocol at the discretion of treating physician.  
Dose modifications for certain events may be limited to just one of the drugs based on 
what  the  event  is  and  which  drug  may  be  most  likely  causing  it.  For  example, 
nausea/vomiting, ototoxicity or neuropathy with cisplatin, diarrhea with gemcitabine, 
hot flashes with enzalutamide etc. However, if improvement does not occur following 
reduction or cessation of dosing of the suspected investigational agent, other drug(s) 
should  be  considered  as  a  contributing  factor. Once  the  dose  has  been  reduced, 
patients  cannot  be  dose  escalated  to  previous  level.  The  treatment  can  be  held  at 
investigator  discretion,  
if  
in  
the  opinion  of  
the  
investigator  
it  
is  not  safe  
to  proceed 
with  the  treatment. For  cycle  2  and  beyond,  dose  delay  for  day  8  Gemcitabine  is 
allowed for 1 week and  
if patients are unable to get  gemcitabine  on day  15 as well, 
they will not receive it as part of that cycle.  
 
5.1             Dose Modification Guidelines for Hematologic Toxicity 
The dose modification guidelines for gemcitabine and cisplatin for hematologic   
toxicity on day 1 of cycle 2 and subsequent cycles is mentioned below. 
 
The dose modification guidelines for gemcitabine for hematologic toxicity on day 8 of 
each cycle of the treatment are mentioned below: 
 
 
 
ANC 
 
Platelet count   
Gemcitabine  Cisplatin 
≥1,500/mm
3 
and 
≥ 
100,000/mm
3 
Give full dose 
<1500/mm3 or/and 
< 
100,000/mm
3 
Delay treatment by 1 week.  
ANC 
 
Platelet 
count 
Gemcitabine 
≥1,000/mm3 
and   
≥ 
75,000/mm
3 
Give full dose 
≥1,000/mm3 
and   
50,000-
74,999 
Give 75% dose  
<1,000/mm
3 
or/and   
< 
50,000/mm
3 
Skip treatment. Reduce 
dose by 25% for next 
treatment. 


 
 
 
16 
It  
is  
recommended  
that  G-CSF  
is  administered  
if  patients  develop  neutropenia. Primary 
prophylaxis with G-CSF should be considered with subsequent cycles if patients develop 
neutropenic  complications  in  the  immediate  previous  cycle.  If  febrile  neutropenia 
requiring  antibiotic  
therapy  or  grade  4  
thrombocytopenia  occurs,  
the  gemcitabine  dose 
will  be  reduced  
to  75%  for  subsequent  
treatment  cycles.  The  dose  of  cisplatin  may  be 
reduced  
to  75%  for  subsequent  
treatment  cycles  at  
the  discretion  of  
treating  physician.  
The dose of enzalutamide will not be modified for hematologic toxicity as the incidence 
of cytopenias with enzalutamide is less than or equal to 1%.  
 
 
   5.2   Dose Modification Guidelines for Non-Hematologic Toxicity  
 
The dose modification guidelines for cisplatin and gemcitabine for non-hematologic 
toxicities on day 1 and day 8 of each cycle (as applicable)  is mentioned below: 
 
Non-Hematologic 
Toxicity*  
Gemcitabine and Cisplatin 
Grade 1 or 2 
Give full dose.  
Grade 3 or 4 
Give 50% dose or hold dose (per treating physician 
discretion). Delay treatment until resolves to ≤ Grade 
2. Reduce dose by 25% for next treatment.  
Non Hematologic 
Toxicity*  
Enzalutamide 
Grade 1 or 2 
Treat as scheduled 
Grade 3 or 4 
Delay treatment until resolves to ≤ Grade 2.  
For  dose  escalation  portion:  At dose  level  1  (80  mg 
enzalutamide),  if  1  patient  experiences  DLT,  3  more 
patients will be treated at the same dose level, if 2 or more 
patients  experience  DLT,  the  enzalutamide  would  be 
stopped.  
If  1/6 patients  experiences  DLT,  the  enzalutamide  dose 
will  be  escalated  to 160  mg.  If 2  or  more  of  6 patients 
experience  DLT  on  160   mg  enzalutamide,  the 
recommended  dose  of  enzalutamide  will  be  80  mg  for 
dose expansion portion.  
 
For  dose  expansion  portion:  Intra-patient  dose  de-
escalation  will  be  allowed,  
i.e.  
if  patients  has  Grade  3-4 
AEs on 160 mg enzalutamide, they will be allowed to try 
80  mg  enzalutamide.  If  they  cannot  tolerate  80  mg 
enzalutamide, enzalutamide will be stopped and they can 
receive only  gemcitabine-cisplatin  off  protocol. If  the 
recommended  dose  expansion  phase  dose  
is  80  mg,  and 
patients cannot tolerate it, they will be allowed to hold it 
for 7-10 days, and if symptoms do not improve, and they 
cannot resume this dose, enzalutamide will be stopped and 
they can receive only gemcitabine-cisplatin off protocol.   
 


 
 
 
17 
 
*Except for alopecia, clinically insignificant laboratory abnormalities, and 
inadequately treated nausea, vomiting and diarrhea.  
 
Serum creatinine will be evaluated on the first treatment day of each cycle. The 
treatment will be delayed by 1 week if the serum creatinine was >1.5 mg/dl; cisplatin 
will be reduced by 25% or held for subsequent cycles if the repeat serum creatinine 
level a week later is 1.6–2 or >2 mg/dl, respectively. The dose of cisplatin will also be 
decreased by 25% in the event of severe neurotoxicity 
 
 
6. PHARMACEUTICAL INFORMATION 
 
   6.1   Enzalutamide 
 
Enzalutamide (MDV3100) is an AR signaling inhibitor that targets several steps in the 
AR  signaling  pathway. It  
is  approved  
for  
the  
treatment  of  castrate  
resistant  prostate 
cancer. Refer to the package insert for full information about enzalutamide. 
 
Chemical Name 
 
4-{3-[4-Cyano-3-(trifluoromethyl)phenyl]-5,5-dimethyl-4-oxo-2-
sulfanylideneimidazolidin-1-yl}-2-fluoro-N-methylbenzamide 
 
Structural Formula 
 
The  molecular  formula  is  C21H16F4N4O2S.  The  structure  of  enzalutamide  is 
represented in the figure below. 
 
 
 
 
 
Packaging and Storage 
Enzalutamide  is  supplied  as  soft  gelatin  capsules.  Each  capsule  contains  40  mg  of 
enzalutamide  as  a  solution  in  caprylocaproyl  polyoxylglycerides.  The  inactive 
ingredients  are  caprylocaproyl  polyoxylglycerides,  butylated  hydroxyanisole, 
butylated hydroxytoluene, gelatin, sorbitol sorbitan solution, glycerin, purified water, 
titanium  dioxide,  and  black  iron  oxide. The  drug  is  stored  at  room  temperature 
 


 
 
 
18 
(≤25○C). 
 
Reported Adverse Events and Potential Risks 
 
The safety profile of enzalutamide is derived from multiple clinical studies. More than 
1400  patients  have  been  treated  with  enzalutamide,  predominantly  patients  with 
prostate  and  breast  cancer.  Overall  enzalutamide  has  been  well  
tolerated  by  patients 
with prostate cancer with less than 10% of patients discontinuing the treatment due to 
treatment-emergent AEs. The following treatment related AEs are believed to be 
associated with enzalutamide treatment and are considered adverse drug reactions: 
seizure (<1%),  fatigue (34%),  diarrhea  (21%),  hot  flash (20%),  headache (20%), 
hypertension,  anxiety,  hallucinations,  cognitive/memory impairment,  falls,  non-
pathologic  fractures,  pruritis and  dry  skin.  The  most  clinically important treatment-
emergent AE,  seizure,  occurred  in  less  than  1%  (7/800)  of  enzalutamide-treated 
patients in a phase 3 study involving castrate resistant prostate cancer. In the phase 3 
AFFIRM  
trial,  ≥grade  3  AEs  were  reported  
in  45%  of  
the  patients  as  compared  
to 
53% in the placebo group.[16 Most common ≥grade 3 AEs in the enzalutamide group 
included  fatigue  (6%),  diarrhea  (1%),  musculoskeletal  pain  (1%),  headache  (<1%), 
cardiac disorder (1%), seizure (<1%), and liver function abnormalities (<1%). 
 
Availability 
 
Enzalutamide is provided by Medivation/Astellas 
 
Agent Accountability 
 
The  Investigator,  pharmacist  or  qualified  designee  is  responsible  for  making  an 
inventory of study drug(s) upon their receipt. All used and unused study drug supplies 
should  be  retained  until  
final  reconciliation  or  as  
indicated  by  
the  
investigator.  The 
study drug is to be prescribed by the principal investigator or appropriately qualified 
site personnel named on the delegation of authority log. Under no circumstances will 
the investigator allow the study drug to be used other than as directed by this protocol. 
Although  appropriate  personnel  may  be  designated  
to  administer/dispense  drug  and 
maintain  drug  accountability  records,  the  Principal  Investigator  is  ultimately 
responsible for all drug accountability.  
The  Investigator  or  designee  must  maintain  accurate  records  of  the  receipt  and 
disposition of study drug supplies. 
  
After  
study  drug  
is  
reconciled, drug may be  destroyed as per  
Institutional  Policy, or 
returned  to Astellas. The  Investigator,  or  a  responsible  party  designated  by  the 
Investigator,  must  maintain  a  careful  record  of  
the  
inventory  and  disposition of  all 
agents. 
 
   6.2   Gemcitabine  
 


 
 
 
19 
Gemcitabine  is  a  nucleoside  inhibitor  that  
is  indicated  for  the  treatment  of various 
cancers, including bladder cancer. Gemcitabine is commercially available and will be 
supplied by the site
's pharmacy. Refer to the package insert for full information about 
gemcitabine. 
 
 
   6.3   Cisplatin  
 
Cisplatin  
  
is  a  platinum  agent  
indicated  for  
treatment  of  various  cancers,  
including 
bladder cancer. Cisplatin is administered intravenously in normal saline for treatment 
of solid malignancies. Cisplatin is commercially available and will be supplied by the 
site
's  pharmacy. It  is  infused  intravenously.  Refer  to  the  package  insert  for  full 
information about cisplatin. 
 
 
 
7. CORRELATIVE/SPECIAL STUDIES 
 
    7.1       AR Expression    
 
The  AR  expression  
in  bladder  cancer  
is  not  validated  and  
this  study  would  aim  
to 
evaluate  AR  expression  and  outcomes  
in  bladder  cancer.  All  
the  patients  would  be 
included for AR analysis. While AR + by IHC is not an inclusion criteria for the dose 
finding phase and is an inclusion criteria only for the expansion cohort, for evaluation 
of outcomes, even AR- patients from the dose finding study will be included. 
Archival tissue from formalin-fixed, paraffin-embedded, tumor specimen from either 
radical cystectomy or TURBT used to establish the diagnosis of urothelial carcinoma 
would be used for AR evaluation by IHC.  
 
If patients have received neoadjuvant chemotherapy, then pre-chemotherapy TURBT 
archival tissue specimen will be used and if there was no neoadjuvant chemotherapy 
administered,  
then either  TURBT  specimen  or  radical  cystectomy  specimen  can  be 
used. If  
these  archival  
tissues  are  unavailable  or  
insufficient,  a  
fresh  core needle  or 
incisional  biopsy  from  a  metastatic  lesion  would  be  used  for  AR  evaluation.  AR 
expression  will  be  detected  in  tissue  sections  of  formalin-fixed  urothelial  cancer 
specimens from bladder biopsy or cystectomy using standard IHC procedure.  
We  have  validated  AR  (SP107)  rabbit  monoclonal  antibody (Cell  Marque) in 
Moffitt’s CLIA certified pathology lab and will use this for the purposes of this study. 
The slides would be reviewed by a genitourinary pathologist for absence or presence 
of AR expression, based upon number of tumor cells exhibiting AR and the intensity 
of staining. Positive AR staining would be in 1% or more tumor cells.  
For  patients  with positive  AR  expression,  we  will  use Automated  Quantitative 
Analysis (AQUA) for precise quantitative scoring. Automated image acquisition will 
be  performed using the APERIO ScanScope FL and digital images will be  analyzed 
using   AQUAnalysis®   software   version   2.3.4.1.  Briefly,   high-resolution 
monochromatic  8-bit  digital  images  will  be  obtained  for  each  WTS slide  using 


 
 
 
20 
separate  
filters  
to  define  
the  nuclear  
(DAPI),  
tumor  
(Cy3),  and  AR  biomarker  
target 
(Cy5) compartments. An analysis algorithm will be constructed to identify tumor cell 
nuclei and calculate the nuclear AQUA score, defined as the average concentration of 
Cy5 (AR) pixel intensity within the tumor nuclear area for each WTS. 
AQUA  can  be  better  calibrated  using  internal  controls  to  overcome  preanalytical 
variations that could lead to false results. 
 
    7.2        PTEN  loss   
The PI3K-AKT-mTOR signaling pathway is one of the most frequently 
dysregulated pathways in cancer and is thought to play a major role in many cancers, 
including bladder cancer. 
19-21 PTEN is a potent inhibitor of the PI3K/Akt/mTOR 
pathway and PTEN alterations have been described in several cancers, including 
baldder cancer, leading to tumorogensis and poor prognosis. We will evaluate for loss 
of PTEN (which would imply the activation of the PI3k-AKT-mTOR pathway) in the 
bladder cancer tissues to better understand biological behavior of tumors, including 
responders and non-responders. The PTEN analysis will be done with a rabbit 
monoclonal antibody, clone Y184using AQUA , as described in section 7.1. Loss of 
PTEN will be described as <10% of PTEN expression. We  will also study the 
correlation between AR and loss of PTEN in bladder cancer.  
 
Tumor biopsy for clinically responding and stable subjects at treatment 
discontinuation is highly encouraged to evaluate for any changes in AR signaling and 
apoptosis. Tumor biopsies that are inaccessible or contraindicated due to subject 
safety concerns are exempt from this requirement. 
 
   
    7.3         Circulating Tumor Cells  
 
Several studies in patients with circulating tumor cells (CTCs) in metastatic prostate, 
breast  and  colon  cancer  have  established  their prognostic  and treatment-predictive 
value.22-26 The molecular features of CTCs in  advanced  cancers have the potential to 
study pharmacodynamic  effects, treatment  selection,  and  possible  mechanisms  of 
resistance  
to treatment.  Currently,  
there  are  no  biologic  markers  for  bladder  cancer 
that may serve as a prognostic or predictive marker. Some studies have looked at the 
utility  of  CTCs  in  both  high grade non-invasive  and  metastatic  bladder  cancer.
27-29 
Gallagher et al. evaluated CTCs in 33 patients with metastatic bladder cancer, 44% of 
them had a positive assay with significantly higher number of CTCs correlated  with 
disease  burden;  moreover  one-third  of  patients  had  5  or  more CTCs making  it  a 
potential marker to monitor response to chemotherapy.
28 
 
We propose to measure CTCs at baseline, and on day 1 of cycle 3 in all patients, if 
budget allows. Baseline counts and changes in counts at the time of day 1 of cycle 3 
will be evaluated for association with disease burden, RECIST response and/or 
changes in bone scan if applicable. CTC counts will be measured with CellSearch 
(Veridex, LLC, Huntingdon Valley, PA, USA), an analytically valid assay approved 
by the US FDA and report as number of CTCs per 7·5 mL of blood, as previously 


 
 
 
21 
described.26  We will also test the CTCs for AR expression,to look at presence or 
absence of AR and in cases of positive AR in CTCs at baseline, we will monitor the 
AR expression while on treatment. Correlation will be done between presence or 
absence of AR in CTCs and response. We will use the AR (D6F11) XP  rabbit mAB 
for detection of AR in CTCs. From available data from 2 patients enrolled in the dose 
escalation portion of the study, 1 patient expressed 3 CTCs of which 1 CTC expressed 
AR.  
 
 
8. STUDY CALENDAR/PROCEDURES 
8.1    Study Calendar 
 
 
 
 
 
Cycle1   Cycles 2-6   Cycle 7 
and 
beyond 
   
   
 
 
Screening  
within 14 
days  of 
C1d1 
Day1 
 
Day 
8 
Day1 
 
Day
8 
Day1   End of 
treatment  
visit ± 14 
days 
End of 
study 
visit 
30 ± 7 
days 
Followup 
for 1year 
Gemcitabine 
 
x   x   x   x      
   
   
 
Cisplatin 
 
x      
x   
   
   
   
   
 
Enzalutamide1 
   
x-------------------------------------------------x     
   
 
Pre-Screening 
Consent 
x    
 
   
   
   
 
Consent 
x    
 
   
   
   
 
Demographics 
x    
 
   
   
   
 
Medical history 
x   
x      
x      
x   
x   
x    
Concurrent 
meds 
x   x----------------------------------------------------------------------------- x    
Physical exam 
x   
x   
   
x   
   
x   
x   
x    
Vital signs 
x   
x   x   x   x   
x   
x   
x    
Weight 
x   
x   x   x   x   
x   
x   
x    
ECOG PS  
x   
x   
   
x   
   
x   
x   
x    
CBC w/diff 
x   
x   x   x   x   
x   
x   
x    
CMP, 
Magnesium 
x   
x   x   x   x   
x   
x   
x    
Urine β-HCG2 
x    
 
   
   
   
 
Adverse event 
evaluation 
   
x---------------------------------------------------------------------------------x   
Radiologic 
evaluation
3 
x    
x   
   
   
   
 
Archival tissue 
x    
 
   
   
   
 


 
 
 
22 
for AR
4 
Tumor Biopsy5 
   
 
 
 
x   
   
 
CTCs 
x    
x 
Cycle 
3,day 1 
   
   
   
 
 
Telephone call 
for survival 
   
 
 
   
   
 
x 
 
All scheduled procedures/visits can be performed +/- 3 days unless specifically mentioned. 
 
1Enzalutamide must be administered at the time of completing gemcitabine and cisplatin infusion 
on cycle 1 day 1 of treatment. 
 
2Serum pregnancy test will be performed within 14 days of starting treatment only in women of 
childbearing potential. 
 
3CT scan of thorax, abdomen, pelvis should be  performed  within 4 weeks of starting treatment 
and every 2 cycles (anytime after day 15 dosing of the preceding cycle and prior to starting next 
cycle).  
 
4 While AR expression in tumor tissue will be tested for all patients in dose escalation and dose 
expansion  phases,  positive  AR  expression  is  only  a  requirement  for  enrollment  in  the  dose 
expansion phase. Pre-screening consent for AR testing from archival tissue will be obtained for 
all patients in the dose expansion phase.  
 
5 Tumor biopsy for clinically responding and stable subjects at treatment discontinuation is highly 
encouraged to evaluate for any changes in AR signaling and apoptosis. 
 
9. MEASUREMENT OF EFFECT 
 
Patients  will  be  evaluated  
for response at  
the  end  of every 2  cycles. Each  cycle  
lasts for 3 
weeks. 
9.1 Antitumor Effect  
 
Response and progression will be evaluated in this study using the new international 
criteria  proposed  by  the  revised  Response  Evaluation  Criteria  in  Solid  Tumors 
(RECIST)  guideline  (version  1.1).  Changes  
in  
the  
largest  diameter  (unidimensional 
measurement) of the tumor lesions and the shortest diameter in the case of malignant 
lymph nodes are used in the RECIST criteria. 
All the  patients  would  be  included  for  analysis.  While  AR  +  by  IHC  is not an 
inclusion  criteria  
for  
the  dose  
finding  phase  and  
is  an  
inclusion  criteria only for  
the 
expansion cohort, for evaluation of outcomes, even AR- patients from the dose finding 
study will be included. 
 
9.1.1  Definitions 
 
Evaluable for toxicity.   All patients will be evaluable for toxicity from the time of their 


 
 
 
23 
first treatment with enzalutamide. 
 
Evaluable  for  objective  response.    Only  those  patients  who  have  measurable  disease 
present at baseline, have received at least one cycle of therapy, and have had their disease 
re-evaluated  will  be  considered  evaluable  for  response.  
  These  patients  will  have  their 
response classified according to the definitions stated below.  (Note:  Patients who exhibit 
objective  disease  progression  prior  to  the  end  of  cycle  1  will  also  be  considered 
evaluable.) 
 
9.1.2  Disease Parameters 
 
Measurable  disease.    Measurable  lesions  are  defined  as  those  that  can  be  accurately 
measured in at least one dimension (longest diameter to be recorded) as ≥10 mm with CT 
scan,  MRI  or  calipers  by  clinical  exam.  
  All  
tumor  measurements  must  be  recorded  
in 
millimeters (or decimal fractions of centimeters).  
 
Note:  Tumor lesions that are situated in a previously irradiated area might be considered 
measurable if the lesion has increased in size since the radiation. 
 
Malignant  lymph  nodes.    To  be  considered  pathologically  enlarged  and  measurable,  a 
lymph  node  must  be  ≥15  mm  
in  short  axis  when  assessed  by  CT  scan  (CT  scan  slice 
thickness recommended to be no greater than 5 mm).  At baseline and in follow-up, only 
the short axis will be measured and followed. 
 
Non-measurable  disease.  
  All  other  
lesions  
(or  sites  of  disease),  
including  small  
lesions 
(longest diameter <10 mm or pathological lymph nodes with ≥10 to <15 mm short axis), 
are  considered  non-measurable  disease.  
  Bone  lesions,  leptomeningeal  disease,  ascites, 
pleural/pericardial  effusions,  lymphangitis  cutis/pulmonitis,  and  abdominal  masses  (not 
followed by CT or MRI), are considered as non-measurable. 
 
Target  
lesions.  
  All  measurable  
lesions  up  
to  a  maximum  of  2  
lesions  per  organ  and  5 
lesions  in  total,  representative  of  all  involved  organs,  should  be  identified  as target 
lesions and recorded and measured at baseline.  Target lesions should be selected on the 
basis  of  
their  size  (lesions  with  
the  
longest  diameter),  be  representative  of  all  
involved 
organs,  but  in  addition  should  be  those  that  lend  themselves  to  reproducible  repeated 
measurements.  It may be the case that, on occasion, the largest lesion does not lend itself 
to reproducible measurement in which circumstance the next largest lesion which can be 
measured reproducibly should be selected.  A sum of the diameters (longest for non-nodal 
lesions, short axis for nodal lesions) for all target lesions will be calculated and reported 
as the baseline sum diameters.  If lymph nodes are to be included in the sum, then only the 
short axis is added into the sum.  The baseline sum diameters will be used as reference to 
further  characterize  any  objective  
tumor  regression  
in  
the  measurable  dimension  of  
the 
disease. 
 
Non-target  lesions.    All  other  lesions  (or  sites  of  disease)  including  any  measurable 
lesions over and above the 5 target lesions should be identified as non-target lesions and 


 
 
 
24 
should also be recorded at baseline.  Measurements of these lesions are not required, but 
the presence, absence, or in rare cases unequivocal  progression of each should be noted 
throughout follow-up.  
 
9.1.3 Methods for Evaluation of Measurable Disease 
 
All  measurements  should  be  taken  and  recorded  in  metric  notation  using  a  ruler  or 
calipers.    All  baseline  evaluations  should  be  performed  as  closely  as  possible  to  the 
beginning  of  treatment  and  never  more  than  4  weeks  before  the  beginning  of  the 
treatment. 
 
The  same  method  of  assessment  and  
the  same  
technique  should  be  used  
to  characterize 
each  identified  and  reported  lesion  at  baseline  and  during  follow-up.  Imaging-based 
evaluation  is  preferred to  evaluation  by  clinical  examination  unless  
the  
lesion(s)  being 
followed cannot be imaged but are assessable by clinical exam. 
 
Conventional  CT  Scans This  guideline  has  defined  measurability  of  
lesions  on  CT  scan 
based on the assumption that CT slice thickness is 5 mm or less.  If CT scans have slice 
thickness greater than 5 mm, the minimum size for a measurable lesion should be twice 
the slice thickness.  MRI is also acceptable in certain situations (e.g. for body scans).   
 
9.1.4 Response Criteria 
 
9.1.4.1  Evaluation of Target Lesions 
 
Complete  Response  (CR):    Disappearance  of  all  target  lesions.    Any  pathological 
lymph nodes (whether target or non-target) must have reduction in short axis to <10 
mm. 
 
Partial Response (PR):  At least a 30% decrease in the sum of the diameters of target 
lesions, taking as reference the baseline sum diameters. 
 
Progressive  Disease  (PD):  
  At  
least  a  20%  
increase  
in  
the  sum  of  
the  diameters  of 
target lesions, taking as reference the smallest sum on study (this includes the baseline 
sum if that is the smallest on study).  In addition to the relative increase of 20%, the 
sum  must  also  demonstrate  an  absolute  increase  of  at  least  5  mm.    (Note:    the 
appearance of one or more new lesions is also considered progressions). 
 
Stable  Disease  (SD):    Neither  sufficient  shrinkage  to  qualify  for  PR  nor  sufficient 
increase  
to  qualify  
for  PD,  
taking  as  
reference  
the  smallest  sum  diameters  while  on 
study. 
 
9.1.4.2  Evaluation of Non-Target Lesions 
 
Complete Response (CR):  Disappearance of all non-target lesions and normalization 
of tumor marker level.  All lymph nodes  must be non-pathological  
in  
size  
(<10  mm 


 
 
 
25 
short axis). 
 
Non-CR/Non-PD:  Persistence of one or more non-target lesion(s). 
 
Progressive  Disease  (PD):    Appearance  of  one  or  more new  lesions  and/or 
unequivocal  progression of  existing  non-target  lesions.   Unequivocal  progression 
should  not  normally  
trump  
target  
lesion  status.  
  
It  must  be  
representative  of  overall 
disease status change, not a single lesion increase.     
 
Although a clear progression of “non-target” lesions only is exceptional, the opinion 
of  
the  
treating  physician  should  prevail  
in  such  circumstances,  and  
the  progression 
status should be confirmed at a later time by the Principal Investigator. 
 
9.1.4.3 Evaluation of Best Overall Response 
 
The best overall response is the best response recorded from the start of the treatment 
until disease progression/recurrence (taking as reference for progressive disease the 
smallest measurements recorded since the treatment started).  The patient
's best 
response assignment will depend on the achievement of both measurement and 
confirmation criteria. 
 
 
For Patients with Measurable Disease (i.e., Target Disease) 
 
Target 
Lesions 
Non-Target Lesions   
New Lesions   
Overall Response 
CR 
CR 
No 
CR 
CR   
Non-CR/Non-PD 
No 
PR 
CR   
Not evaluated 
No 
PR 
PR   
Non-CR/Non-PD/not 
evaluated 
No 
PR 
SD   
Non-CR/Non-PD/not 
evaluated 
No 
SD 
PD 
Any 
Yes or No 
PD 
Any 
PD* 
Yes or No 
PD 
Any 
Any 
Yes 
PD 
*      In exceptional circumstances, unequivocal progression in non-target lesions may be 
        accepted as disease progression. 
 
9.1.5 Duration of Response 
 
Duration of overall response:  The duration of overall response is measured from the time 
measurement criteria are met for CR or PR (whichever is first recorded) until the first date 
that recurrent or progressive disease is objectively documented (taking as reference for 
progressive disease the smallest measurements recorded since the treatment started). 
 


 
 
 
26 
The duration of overall CR is measured from the time measurement criteria are first met 
for CR until the first date that progressive disease is objectively documented.    
 
Duration of stable disease:  Stable disease is measured from the start of the treatment until 
the criteria for progression are met, taking as reference the smallest measurements 
recorded since the treatment started, including the baseline measurements.  
 
9.1.6 Progression-Free Survival 
 
PFS is defined as the duration of time from start of treatment to time of progression or 
death, whichever occurs first. 
10. REGULATORY CONSIDERATIONS 
 
 
  10.1  Adverse Event 
An  AE  
is  any untoward  medical  occurrence  or  worsening  of  a  pre-existing  medical 
condition in a subject. AE will be graded using the National Cancer Institute CTCAE 
version 4.0. A laboratory test abnormality considered clinically relevant, e.g., causing 
the  subject  to  withdraw  from  the  study,  requiring  treatment  or causing  apparent 
clinical manifestations, or judged relevant by the investigator, should be reported as an 
AE.  
 
      Serious Adverse Event 
AEs are classified as serious or non-serious.  A serious adverse event (SAE) is any AE 
that is:  
1) fatal 
2) life-threatening 
3) requires or prolongs hospital stay 
4) results in persistent or significant disability or incapacity 
5) a congenital anomaly or birth defect 
 
6) an important medical event. Important medical events are those that may not be 
immediately  
life  
threatening,  but  are  clearly  of  major  clinical  significance.  They 
may  
jeopardize  
the  subject,  and  may  require  
intervention  
to  prevent  one  of  
the 
other  serious  outcomes  noted  above.    For  example,  drug  overdose  or  abuse,  a 
seizure  that  did  not  result  in  in-patient  hospitalization  or  intensive  treatment  of 
bronchospasm in an emergency department would typically be considered serious.  
 
   10.2   Reporting Adverse Events 
All SAEs should be reported to H. Lee Moffitt Cancer Center & Research Institute 
through  Oncore  for  review  by  our  Protocol  Review  &  Monitoring  Committee. All 
SAEs related to enzalutamide should be reported to Astellas. SAEs are reported to the 
reviewing IRB as well per the institution policy. All SAEs regardless of relationship to 
investigational  product  will  be  collected  from  the  time  a  subject  signs  the  inform 
consent to participate until the end of the follow-up period (30 days after last dose).  
 


 
 
 
27 
All AEs will be recorded on the appropriate CRF and in the subject’s medical records. 
The  
Investigator  will  also  
identify  
the  date  of  onset,  date  of resolution,  seriousness, 
outcome,  and  
the  relationship  
to  study  drug (enzalutamide). Every  effort  should  be 
made  to  determine  the  cause  of  each  AE and whether  or  not  it  is  related  to 
enzalutamide. The relationship of the AE to enzalutamide must be rated and recorded 
following the guidelines outlined in the CTCAE v4.0. The 5 categories for AE grading 
are: 
1- Not related 
2- Not Likely 
3- Possible 
4- Probable 
5- Definite 
 
Safety events of interest that may require expedited reporting and/or safety evaluation 
include, but are not limited to overdose of enzalutamide, suspected abuse/misuse of 
enzalutamide, medication error with or without subject/patient exposure to 
enzalutamide, e.g. name confusion) 
 
10. 3  Investigator Responsibilities 
Investigator responsibilities are set out in the ICH guideline for Good Clinical Practice 
and  in  the  US  Code  of  Federal  Regulations. Investigators,  or  designee,  must  enter 
study  data  onto  a  data  collection  system. The  Investigator  will  permit  study-related 
monitoring visits and audits IRB/EC review, and regulatory inspection(s) (e.g., FDA, 
EMEA, and TPP), providing direct access to the facilities where the study took place, 
to source documents, to the data collection system, and to all other study documents. 
The Investigator, or a designated member of the Investigator’s staff, must be available 
at some time during monitoring visits to review data and resolve any queries  and  
to 
allow  direct  access  to  the  subject’s  records  (e.g.,  medical  records, office  charts, 
hospital  charts,  and  study  related  charts)  for  source  data  verification. The  data 
collection must be completed prior to any visits. 
 
      
   10.4    Institutional Review Board Approval 
The protocol for this study has been designed in accordance with the general ethical 
principles outlined in the Declaration of Helsinki. The review of this protocol by the 
IRB and the performance of all aspects of the study, including the methods used for 
obtaining informed consent, must also be in accordance with principles enunciated in 
the  declaration,  as  well  as ICH  Guidelines,  Title  21  of  the Code  of  Federal 
Regulations  (CFR),  Part  50  Protection  of  Human  Subjects  and Part  56  Institutional 
Review  Boards. The  Investigator  will  be  responsible  for  preparing  documents  for 
submission  to the  relevant  IRB  and  obtaining  written  approval  for  this  study.  The 
approval will be obtained prior to the initiation of the study. The Investigator is also 
responsible  for  notifying  the  IRB  of  any  serious deviations  from  the  protocol,  or 
anything  else  
that  may  
involve  added  risk  
to subjects. Any  advertisements  used  
to 
recruit subjects for the study must be reviewed and approved by the IRB prior to use. 
 


 
 
 
28 
 
   10.5   Informed consent 
The Investigator must obtain informed consent of a subject or his/her designee prior to 
any study related procedures as per Good Clinical Practices (GCP) as set forth in the 
CFR and ICH guidelines. Documentation that informed consent occurred prior to the 
subject’s entry into the study and the informed consent process should be recorded in 
the subject’s source documents. The original 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. 
 
 
   10.6   Study Records Requirements 
The Investigator must ensure that the records and documents pertaining to the conduct 
of  
the  study  and  
the  distribution  of  
the  study  drug (enzalutamide),  
that  
is  copies  of 
data collection  and  source  documents  (original  documents,  data,  and  records  [e.g., 
hospital  records;  clinical  and  office  charts;  laboratory  notes;  memoranda; subject’s 
diaries  or  evaluation  checklists;  pharmacy  dispensing  records;  recorded data  from 
automated  instruments;  copies  or  transcriptions  certified  after verification  as  being 
accurate  copies;  subject  
files;  and  
records  kept  at  
the pharmacy,  at  
the  
laboratories, 
and  at  medico-technical  departments  involved  in the  clinical  study;  documents 
regarding  subject  
treatment  and  study  drug accountability;  original  signed  
informed 
consents, etc.]) be retained by the investigator for as long as needed to comply with 
national  and  
international regulations  (generally  2  years  after  discontinuing  clinical 
development or after the last marketing approval). At any time the  
Investigator may 
be subject to a field audit by regulatory authorities (e.g., FDA, TPP, EMEA) in order 
to  validate  the participation  of  subjects  in  the  study.  Therefore,  careful  attention 
should be paid to seeing that all study documents/records are complete, accurate, and 
filed and retained by the Investigator. 
 
 
   10.7      Patient Registration 
All subjects  must  be  registered  with  
the  MCRN  Coordinating  Center  
to  be  able  
to 
participate  in  a  trial.  The  participating  site  must  fax  or  email  the  completed  study 
specific eligibility checklist and registration forms, supporting documents and signed 
informed consent to the Coordinating Center. Unsigned or  
incomplete forms will be 
returned to the site. Once documents are received, the MCRN Research Coordinator 
will  review  them  to  confirm  eligibility  and  to  complete  the  registration  process.  If 
eligibility  cannot  be  confirmed,  the  research  coordinator  will  query  the  site  for 
clarification  or  additional  documents  as  needed.  Subjects  failing  to  meet  all  study 
eligibility requirements will not be registered and will be unable to participate in the 
trial. 
 
Upon  completion  of  
registration,  
the  MCRN  Research  Coordinator  will  provide  
the 
participating site with the study  sequence number and  
randomization information, if 
indicated. Within 24-48 hours after registration, it is the site’s responsibility to: 
•  Enter the demographic and on-study patient information into the Oncore database 




 
 
 
30 
Before  the  study  can  be  initiated  at  any  site,  the  site  will  be  required  to  provide 
regulatory  documentation  to  the  Moffitt  Clinical  Research  Network  (MCRN)  at  
Moffitt Cancer Center. 
Sites must provide a copy of their informed consent to the MCRN coordinating center 
for review and approval prior to submission of any documents to the site’s IRB. Any 
changes requested by the site’s IRB must be provided to the MCRN staff for review 
and approval prior to resubmission to the IRB. 
 
The MCRN Coordinating Center must receive the following trial specific documents 
either by hardcopy, fax, or email before a site can be activated for any trial: 
 
1. IRB Approval Letter that includes the protocol version and date 
2.  FDA Related Forms 1572/1571/310 as appropriate 
3. Signed Protocol Title Page 
4.  IRB Approved Consent Form 
5. Site Delegation of Authority Log 
6.  Signed Financial Interest Disclosure Forms (principal and sub investigators) 
7. Updated  Investigator/Personnel  documents  (CVs,  licenses,  Conflict  of  Interest 
statements, etc.) as needed 
8. Updated Laboratory Documents (certifications, normal ranges, etc.) as needed  
9.  Signed protocol specific Task Order 
A  study  
initiation  
teleconference  will  be  held  prior  
to  
the  start  of  any  study  
related 
activity at the site. Attendance is required for:  
•  The site PI and appropriate research staff 
•   Moffitt PI and MCRN research coordinator 
The requirements of the protocol and all associated procedures and processes will be 
reviewed and agreed upon prior to the activation of the study. The MCRN utilizes the 
EDC  system,  Oncore.  Oncore  training  will  be  scheduled,  if  indicated,  with  the 
appropriate staff from the site.  
A conference call/study meeting will be held weekly for the phase I and monthly for 
the  phase  II  
to  review  patient  enrollment  and  accrual,  safety  and  
toxicity  data,  and 
treatment results, as available.  
 
10.9.3 Monitoring  
Data  will  be  captured  in  Oncore,  Moffitt’s Clinical  Trials  Database.  Regulatory 
documents  and  case  report  forms  will  be  monitored  
internally  according  
to  Moffitt 
Cancer Center Monitoring Policies. Monitoring will be performed regularly to verify 
data is accurate, complete, and verifiable from source documents; and the conduct of 
the  trial  is  in  compliance  with  currently  approved  protocol  /  amendments,  good 
clinical practice (GCP) and applicable regulatory requirements. Monitoring at external 
sites will be per Moffitt policy. 
 
 
11. STATISTICAL CONSIDERATIONS 
 
11.1  Study Design/Endpoints 


 
 
 
31 
 
The primary goal of this study is to determine the safety and tolerability of 
enzalutamide used in combination with standard doses of cisplatin and gemcitabine.  
Secondary goals are to assess objective tumor response, time to progression, overall 
survival.  
Exploratory objectives include 1) correlation of AR expression with outcomes 
(quantitative and qualitative AR expression using AQUA), and co-expression of 
pAKT; 2) Correlation of CTCs at baseline and on day 1 of cycle 3 with disease 
burden, and treatment response. AR expression in CTCs will also be evaluated and 
correlated with response.   
   
Standard “3+3” design will be used for the dose defining portion of the study.   
The maximum number of patients in the dose finding phase 1 portion will be 12, and 
in addition, there will be cohort expansion to 12 more patients with Stage IV bladder 
cancer once safety of the combination is established. The assessment of objective 
response, time to progression, and overall survival will be done; objective response 
will be summarized as frequency counts and percentages; and time to progression and 
overall survival will be summarized using the method of Kaplan and Meier.  
 
11.2  Sample Size 
       
The maximum number of patients in phase 1 portion of the study will be 12. Cohort 
expansion will be done to 12 more patients with stage IV bladder cancer who are 
planned to be treated and eligible to receive gemcitabine and cisplatin; to assess 
response rate, safety profile, progression free survival and overall survival in patients 
with bladder cancer who expresses AR.  
The estimated total number of patients in the study (Phase 1 and 1b included) will be 
24.  
 
11.3  Analysis of Secondary Endpoints 
 
The  secondary  objective  is  to  evaluate  the  efficacy  of  the  combination  regimen 
consisting  of  enzalutamide,  gemcitabine  and cisplatin. The  secondary  endpoints  for 
efficacy  evaluation  will  be  response  rate, progression  free  survival,  and  overall 
survival. The intention to treat population will include all patients who have received 
at least one dose of the drug. Efficacy outcomes will be reported for all patients, and 
subset  analysis for  patients  in  the  dose  expansion  cohort  (all  of  whom  have  AR 
positive tumor). The Kaplan-Meier method and the Cox proportional will be used for 
time-to-event  variable.  The  
response  
rate  and  best  overall  
response  along  with  95% 
confidence  
interval  will  be  reported.  The  
logistic  regression  model  will  be  used  
to 
explore the association of response with other potential predictors. A two-side p-value 
of <0.05 will be considered statistically significant. 
 
For toxicity assessment, incidence of AEs will be described along with drug 
attribution. If the AE is at least possibly related to the study drug, the AE will be 
attributed to the drug.  


 
 
 
32 
 
11.4  Analysis of Exploratory Endpoints 
             
Quantitative assessments and analysis of AR expression will be done using AQUA, 
and correlated with treatment response, and evaluation of correlation between CTCs 
with  disease  burden,  and  
treatment  response.  AR  expression in  CTCs  will  also  be 
evaluated and correlated with response.   
 
 
   12.0  Publications 
 
         The study of these patients and results of all laboratory studies are considered private  
         and confidential.  The progress and results of this study will not be presented without  
         approval by the principal investigator.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
 
 
33 
REFERENCES 
1. Siegel R, Naishadham D, Jemal A. Cancer statistics, 2013. CA Cancer J Clin 2013;63(1): 11-30. 
2.  von  der  Maase H,  Hansen  SW,  Roberts  JT,  et  al.  Gemcitabine  and  cisplatin  versus  methotrexate,  vinblastine, 
doxorubicin,  and  cisplatin  
in  advanced  or  metastatic  bladder  cancer:  
results  of  a  
large,  
randomized,  multinational, 
multicenter, phase III study. J Clin Oncol 2000;18(17): 3068-77. 
3.  Noronha  RF,  Rao  BR.  Sex  hormone  
receptors  
in  
localized  and  advanced  
transitional  cell  carcinoma  of  urinary 
tract in humans. Urology 1986;28(5): 401-3. 
4.  Zhuang  YH,  Blauer  M,  Tammela  T,  Tuohimaa  P.  Immunodetection  of  androgen  receptor in  human  urinary 
bladder cancer. Histopathology 1997;30(6): 556-62. 
5. Laor E, Schiffman ZJ, Braunstein JD, et al. Androgen receptors in bladder tumors. Urology 1985;25(2): 161-3. 
6.  Boorjian  S,  Ugras  S,  Mongan  NP,  et  al.  Androgen  receptor  expression  
is  
inversely  correlated  with  pathologic 
tumor stage in bladder cancer. Urology 2004;64(2): 383-8. 
7.  Miyamoto  H,  Yang  Z,  Chen  YT,  et  al.  Promotion  of  bladder  cancer  development  and  progression  by  androgen 
receptor signals. J Natl Cancer Inst 2007;99(7): 558-68. 
8.  Ohtsu  H,  Xiao  Z,  Ishida  J,  et  al.  Antitumor  agents.  217.  Curcumin  analogues  as  novel  androgen  receptor 
antagonists with potential as anti-prostate cancer agents. J Med Chem 2002;45(23): 5037-42. 
9.  Yang  Z,  Chang  YJ,  Yu  IC,  et  al.  ASC-J9  ameliorates  spinal  and  bulbar  muscular  atrophy  phenotype  via 
degradation of androgen receptor. Nat Med 2007;13(3): 348-53. 
10. Gelmann EP: Molecular biology of the androgen receptor. J Clin Oncol. 2002;20:3001-3015. 
11. Mangelsdorf  DJ,  Thummel  C,  Beato  M,  Herrlich  P,  Schutz  G,  Umesono  K et  al:  The  nuclear  receptor 
superfamily: the second decade. Cell. 1995;83:835-839. 
12. Chen  CD,  Welsbie  DS,  Tran  C,  Baek  SH,  Chen  R,  Vessella  R et  al:  Molecular  determinants  of  
resistance  
to 
antiandrogen therapy. Nat Med. 2004;10:33-39. 
13. Balbas  MD,  Evans  MJ,  Hosfield  DJ,  Wongvipat  J,  Arora  VK,  Watson  PA et  al:  Overcoming  mutation-based 
resistance to antiandrogens with rational drug design. Elife. 2013;2:e00499. 
14. Jung ME, Ouk S, Yoo D, et al. Structure-activity relationship for thiohydantoin androgen receptor antagonists for 
castration-resistant prostate cancer (CRPC). J Med Chem 2010;53(7): 2779-96. 
15.  Tran  C,  Ouk  S,  Clegg  NJ,  et  al.  Development  of  a  second-generation  antiandrogen  
for  
treatment  of  advanced 
prostate cancer. Science 2009;324(5928): 787-90. 
16. Scher HI, Fizazi K, Saad F, et al. Increased survival with enzalutamide in prostate cancer after chemotherapy. N 
Engl J Med 2012;367(13): 1187-97. 
17. Beer TM, Armstrong AJ, Rathkopf DE, et al. Enzalutamide in Metastatic Prostate Cancer before Chemotherapy. 
N Engl J Med 2014. 
18. Enzalutamide in combination with docetaxel in men  with prostate cancer (PC): Preliminary results from a phase 
I study. J Clin Oncol 31, 2013 (suppl 6; abstr 63) 
19.  Knowles  MA,  Platt  FM,  Ross  RL,  et  al.  Phosphatidylinositol  3-kinase  (PI3K)  pathway  activation  in  bladder 
cancer. Cancer Metastasis Rev 2009;28:305–16. 
20. Wu X, Obata T, Khan Q, et al. The phosphatidylinositol-3 kinase pathway regulates bladder cancer cell invasion. 
BJU Int 2004;93:143–50. 
21. Puzio-Kuter  AM,  Castillo-Martin  M,  Kinkade  CW, et  al.  Inactivation  of  p53  and  PTEN  promotes  invasive 
bladder cancer. Genes Dev 2009;23:675–680. 
22.  Cristofanilli  M,  Hayes  DF,  Budd  GT  ,et  al.  Circulating  tumor cells:  a  novel  prognostic  factor  for  newly 
diagnosed metastatic breast cancer. J Clin Oncol 2005;23:1420-30. 
23. Moreno JG, Miller MC, Gross S, et al. Circulating tumor cells predict survival in patients with metastatic prostate 
cancer. Urology 2005;65:713-8. 
24. Budd GT, Cristofanilli M, Ellis MJ, et al. Circulating tumor cells  versus imaging-predicting overall survival in 
metastatic breast cancer. Clin Cancer Res 2006;12:6403-9. 
25. Garcia JA, Rosenberg JE,WeinbergV, et al. Evaluation and significance of circulating epithelial cells in patients 
with hormone-refractory prostate cancer. BJUInt 2007;99:519-24. 
26. Cristofanilli M, Budd GT, Ellis MJ, et al. Circulating tumor cells, disease progression, and survival in metastatic 
breast cancer. N Engl J Med 2004;351:781-91. 
27. Gazzaniga  P,  Gradilone  A,  de  Berardinis  E,  et  al.  Prognostic  value  of  circulating  
tumor  cells  
in non-muscle 
invasive bladder cancer: a CellSearch analysis. Ann Oncol 2012;23:2352–6. 
28.  Flaig  TW,  Wilson  S,  van  Bokhoven  A,  et  al.  
 Detection  of  circulating  
tumor  cells  
in  metastatic and  clinically 
localized urothelial carcinoma Urology 2011;78:863–7. 
29. Gallagher DJ, Milowsky MI, Ishill N, et al. Detection of circulating tumor cells in patients with urothelial cancer 


 
 
 
34 
Ann Oncol 2009;20:305–8.