Conditions: Castration-resistant Prostate Cancer Metastatic Prostate Cancer Prostate Cancer
Keywords: Bipolar Androgen Therapy Testosterone Nivolumab
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 45
Healthy volunteers: no

Brief summary:
Single arm, multicenter, open-label Phase II study of the effects of parenteral testosterone in combination with nivolumab in men with metastatic castration-resistant prostate cancer who previously progressed on at least one novel androgen-receptor targeted therapy (i.e. Abiraterone acetate, Enzalutamide). Up to one taxane agent is permitted.

Detailed description:
The trial will enroll up to 44 participants (45 were enrolled because the last two patients consented at two sites simultaneously). Eligible participants will continue on androgen ablative therapy with a GnRH analogue (i.e. Zoladex, Trelstar, Eligard, or Lupron) if they have not undergone orchiectomy. Following enrollment, participants will receive an intramuscular injection of testosterone cypionate 400mg every 4 weeks for a lead-in period of 12 weeks. After the lead-in period, all participants will be treated with nivolumab 480mg IV every 4 weeks and maintained on testosterone cypionate 400mg IM every 4 weeks. Assessments for response to testosterone + nivolumab will be performed approximately every 3 months. Treatment \[with a minimum drug exposure of 12 weeks\] will be continued until PSA progression (Prostate Cancer Working Group 3 \[PCWG3\] criteria) or clinical/radiographic progression (whichever comes first), or until unmanageable toxicity requiring drug cessation.

Arms:
arm 1: All participants must have a rising PSA and/or radiographic progression and prior treatment with at least one novel androgen receptor (AR) targeted therapy (i.e. abiraterone acetate, enzalutamide). Up to one taxane agent for metastatic castration-resistant prostate cancer is permitted. Patients will be treated with testosterone cypionate 400mg IM every 4 weeks for a lead-in period of 12 weeks. After the lead-in period, all patients will be treated with nivolumab 480mg IV every 4 weeks and maintained on testosterone cypionate 400mg IM every 4 weeks. Treatment \[with a minimum drug exposure of 12 weeks\] will be continued until PSA progression (PCGW3 criteria) or clinical/radiographic progression (whichever comes first), or until unmanageable toxicity requiring drug cessation.

Interventions: intervention 1: Testosterone cypionate intervention 2: Nivolumab
Intervention descriptions: intervention 1: Depot (DEPO)-Testosterone Injection, for intramuscular (IM) injection, contains testosterone cypionate which is the oil-soluble 17 (beta)-cyclopentylpropionate ester of the androgenic hormone testosterone. Testosterone cypionate is a white or creamy white crystalline powder, odorless or nearly so and stable in air. Depot (DEPO)-Testosterone Injection is available in two strengths, 100 mg/mL and 200 mg/mL testosterone cypionate. intervention 2: Nivolumab Injection, 100 mg/10 mL (10 mg/mL) or 40 mg/4 mL (10 mg/mL), is a clear to opalescent, colorless to pale yellow liquid, which may contain light (few) particulates. The drug product is a sterile, non-pyrogenic, single-use, isotonic aqueous solution formulated at 10 mg/mL in sodium citrate, sodium chloride, mannitol, diethylenetriaminepentacetic acid (pentetic acid), and polysorbate 80 (Tween 80), at potential hydrogen (pH) 6.0 and includes an overfill to account for vial, needle, and syringe holdup. It is supplied in 10-cc Type I flint glass vials, stoppered with butyl rubber. The clinical study product is a sterile solution to be administered through parenteral intravenous infusion.

Protocol document:
Prot_SAP_000.pdf: 
COMbination of Bipolar Androgen Therapy and Nivolumab in Patients with Metastatic 
Castration-Resistant Prostate Cancer
Principal Investigator: Mark C. Markowski, M.D., PhD
NCT03554317
Protocol Version 8.9, Date: June 9, 2021


Bipolar Androgen Therapy and Nivolumab in mCRPC 
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COMbination of Bipolar Androgen Therapy and Nivolumab in Patients 
with Metastatic Castration‐Resistant Prostate Cancer  
[COMBAT‐CRPC] 
 
PCCTC LOI #: c18-219 
BMS Protocol #: CA209-8CE 
IND #: IND 138431 
Lead Site and Sponsor: Johns Hopkins University 
 
Principal Investigator 
Mark C. Markowski, M.D., Ph.D. 
Prostate Cancer Program 
The Skip Viragh Outpatient Cancer Building 
Johns Hopkins University 
201 N. Broadway, Room 9160, Mailbox 7  
Baltimore, MD 21287 
Tel 410-614-0567 
Fax 410-367-2668 
Email: mmarko12@jhmi.edu  
 
 
 
Co‐Principal investigator 
Emmanuel S. Antonarakis, M.D. 
Prostate Cancer Program 
The Skip Viragh Outpatient Cancer Building 
Johns Hopkins University 
201 N. Broadway, Room 9129, Mailbox 7                    
Baltimore, MD 21287 
Tel 410-502-7528 
Fax 410-367-2668 
Email: eantona1@jhmi.edu  
 
 
Statistician 
Hao Wang, Ph.D. 
Wei Fu, MS 
Division of Biostatistics & Bioinformatics 
Sidney Kimmel Comprehensive  
Cancer Center at Johns Hopkins  
Johns Hopkins University, School of Medicine 
Baltimore, MD, USA 
Tel 410-614-3426 
Tel 410-955-4884 
Email: hwang76@jhmi.edu; wfu@jhu.edu  
 
 
Lead Study Pathologist 
Angelo De Marzo M.D., Ph.D. 
Department of Pathology 
Johns Hopkins University,  
School of Medicine 
1650 Orleans Street 
CRB2, Room 144 
Baltimore, MD 21231 
Tel 410-614-5686 
Email: ademarz@jhmi.edu   
 
 
Project Manager 
Aliya Lalji 
The Skip Viragh Outpatient Cancer Building 
Johns Hopkins University 
201 N. Broadway, Mailbox 7 
Baltimore, MD 21287 
Tel 410-502-5101 
Fax 410-367-2668 
Email: alalji1@jhmi.edu  


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Protocol Version 8.0  Protocol Date: June 9, 2021 
CONFIDENTIALITY STATEMENT 
The information in this document is provided to you as an investigator, potential investigator, 
consultant, or contractor, for review by you, your staff, and the appropriate Institutional Review 
Board or Ethics Committee. By accepting this document, you agree that the information 
contained herein will not be disclosed to others without written authorization from the lead 
site/sponsor, except to the extent necessary to initiate the study or conduct study-related 
activities. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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INVESTIGATOR APPROVAL OF PROTOCOL 
 
COMbination of Bipolar Androgen Therapy and Nivolumab in Patients with 
Metastatic Castration‐Resistant Prostate Cancer  
[COMBAT‐CRPC] 
 
 
Protocol Version: 
 
 
 
V. 8.0 
Version Date:   
 
 
 
6/9/2021 
 
 
 
Principal Investigator Signature:  
_______________________________________________________ 
Principal Investigator Name:  
_______________________________________________________ 
Date of Signature:  
 
 
_______________________________________________________ 
 
 
 
 
 
 
 
 


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SYNOPSIS 
Title 
COMbination of Bipolar Androgen Therapy and Nivolumab in Men with Metastatic 
Castration-Resistant Prostate Cancer [COMBAT-CRPC] 
Lead site 
Johns Hopkins University 
Sponsor 
IND holder 
Bristol-Myers Squibb 
Mark C. Markowski, MD, Ph.D 
Investigational 
agent 
Testosterone Cypionate 400mg IM every 28 days; Nivolumab 480mg IV every 4 weeks 
Phase 
2 
Target 
population 
 
Adult male > 18 years of age 
 
Histologic or cytologic diagnosis of adenocarcinoma of the prostate. 
 
Known castration-resistant disease, defined according to PCWG3 
 
Metastatic disease as defined for ≥ 1 bone metastases confirmed by bone 
scintigraphy or radiographic soft tissue metastasis. Pelvic lymph nodes will be 
considered as metastatic disease if they measure > 15 mm in short-axis diameter. 
 
Soft tissue lesion available for biopsy collection. 
 
PSA and/or radiographic progression on at least ONE prior second generation AR-
targeted therapies (i.e. abiraterone acetate, enzalutamide); and up to ONE prior 
chemotherapy agent for mCRPC is permitted. 
 
Serum PSA at screening > 2.0 ng/mL 
 
Serum testosterone level < 50 ng/dL at time of screening 
 
Life expectancy ≥ 6 months 
 
ECOG performance status  < 2 
 
Adequate bone marrow, renal and liver function (ANC > 1.0K, Plt > 100K, Hgb ≥ 9 
g/dL; CrCl ≥ 40 mL/min; AST/ALT WNL; Total Bilirubin WNL). 
 
Study centers 
 
Two participating sites in the United States, parts of the PCCTC network. 
Start 
date/Duration 
First patients are expected to be enrolled in Q3/Q4 2018. Accrual is estimated to last 
18 months with up to 24 months of follow-up after the last patient has been entered. 
Expected 
enrollment 
44 patients 
Rationale 
Rationale for Combination of High-Dose Testosterone with Nivolumab in Metastatic 
Castration Resistant Prostate Cancer (mCRPC) Patients 
 
Bipolar Androgen Therapy (BAT) alone: BAT is a paradoxical approach for the 
treatment of mCRPC whereby testosterone levels are rapidly cycled between 
supraphysiologic and near-castrate concentrations. Based on prior studies, the 
incidence of germline mutations in DNA-repair genes in mCRPC patients is ~12% with 
somatic DNA-repair mutations approaching 20-25%.  Interestingly, we have identified 
a correlation between long-term (“exceptional”) responders to BAT and the presence 


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of mutations in homologous-recombination DNA repair genes.  In Teply et al. (Eur Urol, 
2017), we report the case of a patient with mCRPC who achieved a durable (>24 mo) 
complete radiographic and serologic response following treatment with BAT.  DNA 
sequencing found inactivating mutations in both BRCA2 and ATM, which were 
confirmed on germline DNA testing.  We are currently sequencing tumor/germline 
DNA from other “exceptional” responders to BAT, and remarkably, we have found DNA 
repair mutations in 5/6 extreme responders.  These unpublished findings suggest a 
relationship between responses to BAT and the presence of mutations in DNA-repair 
genes.   
    
Checkpoint Blockade alone: Two randomized phase III trials involving single-agent 
checkpoint (CTLA-4) inhibitors in mCRPC patients did not meet their primary 
endpoints.  However, a small subset (~20%) of mCRPC patients did derive clinical 
benefit.  In pilot studies conducted at Johns Hopkins, we have observed dramatic 
responses to checkpoint inhibition in those patients with DNA-repair defects.  For 
instance, two patients (#1: MSH6-mutated; #2: BRCA2-mutated) achieved a PSA50 
response following combined PD-1/CTLA-4 checkpoint inhibition.  A third mCRPC 
patient (#3: ATM-mutated) achieved a partial radiographic RECIST response.  A fourth 
patient (#4: POLH-mutated) also had a RECIST response.  Similar to the efficacy of 
checkpoint inhibitors in patients with MSI-High colon cancer, we speculate that a 
benefit of immunotherapy may be observed in those mCRPC patients with germline 
and/or somatic mutations in DNA-repair genes.  
 
BAT/Immunotherapy Combination: Even more notably, we have observed two mCRPC 
patients with intact DNA repair processes (i.e. no repair gene mutations) that were 
treated initially with BAT and subsequently achieved dramatic PSA/RECIST responses 
to PD-1 checkpoint inhibition.  Patient #1 achieved a PSA50 response to BAT which 
lasted 11 months before developing subsequent PSA progression.  Upon starting 
nivolumab in combination with an anti-CD73 inhibitor, his PSA level dropped from 692 
ng/mL to 3 ng/mL in the first 12 weeks with an associated clinical benefit.  Patient #2 
also achieved a PSA50 response to BAT lasting 6 months.  Following subsequent 
treatment with checkpoint inhibition, his PSA dropped from 56 ng/mL to 4 ng/mL with 
a partial radiographic response after only 3 months of therapy. As mentioned, neither 
patients had a DNA-repair mutation although both benefited dramatically from PD-1 
inhibition. Further study of BAT with nivolumab is warranted. 
Objectives 
Primary: 
To estimate the PSA50 response rate, defined as a > 50% decline in PSA from baseline, 
confirmed with a second measurement at least 4 weeks apart (PCWG3). 
Secondary: 
 
To estimate the median PSA progression-free survival (PSA-PFS)(PCWG3). 
 
To estimate the median progression-free survival (PFS)(PCWG3). 
 
To estimate the durable progression-free survival (PFS > 6 months) 
 
To estimate the objective response rate (ORR) 
 
To estimate median overall survival (OS) 
 
To determine the safety and tolerability of BAT/Nivolumab in the mCRPC 
population. 
 


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Correlatives/Tertiary: 
 
To estimate the percentage of patients with somatic (tumor) or germline 
(inherited) mutations in homologous repair (HR) and/or mismatch repair 
genes. 
 
To measure IHC-based changes in gamma-H2AX, RAD51, 53BP1 (DNA damage 
markers) following treatment with BAT and at progression on BAT/nivolumab. 
 
To measure changes in CD4, CD8, FOXP3, Ki-67, PD-1, PD-L1 tumor levels with 
BAT alone and at progression following BAT/Nivolumab. 
 
To investigate any association between PD-1 and PD-L1 expression in tumor 
specimens and PSA50 response rates. 
 
To explore the relationship between mutation-associated neoantigen (MANA) 
and tumor-associated neoantigen (TAA) assays and clinical outcomes. 
 
To characterize the effect of BAT on production of inflammatory chemokines 
and cytokines. 
 
Study design 
The study is an open-label, single arm, Phase II trial. Eligible patients are men with 
mCRPC.  All patients must have a rising PSA and/or radiographic progression and prior 
treatment with at least one novel AR targeted therapy (i.e. abiraterone acetate, 
enzalutamide), and up to one prior chemotherapy agent for mCRPC is permitted. A 
mandatory tumor biopsy will be performed prior to the start of therapy in all patients. 
A second, mandatory tumor biopsy will take place after three months of therapy with 
BAT alone.  A third, OPTIONAL biopsy will be performed following PSA and/or 
radiographic progression on BAT/Nivolumab. 
After enrollment, patients will be treated with testosterone cypionate 400mg IM every 
4 weeks for a lead-in period of 12 weeks.  Patients will be followed monthly with clinic 
visits, safety labs (including CBC w/ Diff, CMP), PSA, and toxicity assessments.  After 
the lead-in period, all patients will be treated with nivolumab 480mg IV every 4 weeks 
and maintained on testosterone cypionate 400mg IM every 4 weeks.  Treatment [with 
a minimum drug exposure of 12 weeks] will be continued until PSA progression 
(PCGW3 criteria) or clinical/radiographic progression (whichever comes first), or until 
unmanageable toxicity requiring drug cessation.  Patients will continue a GnRH 
analogue during the study or have undergone orchiectomy. 
 
 
 
 
 
 
 
 


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The trial schema:  
 
 
Criteria for 
evaluation 
Primary Endpoint 
 
PSA50 response rate, defined as a ≥ 50% decline in PSA from baseline, confirmed 
with a second measurement at least 4 weeks later (PCWG3).  
Secondary Endpoints 
 
Safety/Tolerability, defined as incidence of CTCAE Grade ≥ 3 toxicities 
experienced by patients on the trial. 
 
PSA progression-free survival (PSA-PFS), defined as the time from initiation on 
testosterone therapy until PSA increase of 25%, confirmed with another 
measurement at least 4 weeks later (PCWG3). 
 
Progression–free survival (PFS)(PCWG3), defined as the time to radiographic or 
clinical progression or death, whichever comes first. Based on RECIST version 
1.1 and PCWG3 definitions including: Progression of soft tissue lesions according 
to RECIST 1.1; Progression of bone lesions detected with bone scan according to 
PCWG3 criteria; Radiologically-confirmed spinal cord compression or 
pathological fracture due to malignant progression, or other clinical event 
deemed to be cancer-related. 
 
Objective response rate (ORR), defined as the proportion of patients achieving a 
complete/partial response in target lesions (RECIST 1.1). 
 
Durable Progression-free survival (Durable PFS), defined as a lack of 
clinical/radiographic progression for > 6 months. 
 
Median Overall Survival (OS), defined as the time from study enrollment to 
death from any cause up to 2 years after the last dose of study treatment 
received. 
 
Testosterone Lead‐in 
Testosterone + Nivolumab 
Testosterone 400mg IM q4wks 
Nivolumab 480mg IV q4wks 
T 
T 
T 
Nivo 
PSA 
CT C/A/P 
Bone Scan 
 
PSA  
CT C/A/P 
Bone Scan 
 
PSA 
 
Con nue  
un l  
Progression 
or 
Toxicity 
(Biopsy at progression) 
biopsy 
biopsy 
PSA 
 
12 weeks 
12 weeks 
T 
PSA 
 
T 
Nivo 
PSA 
 
T 
Nivo 
T 
Nivo 
PSA  
CT C/A/P 
Bone Scan 
 
C1D1 
C2D1 
C3D1 
C4D1 
C5D1 
C6D1 
C7D1 
Cycle Length: 28 days 


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Exploratory Endpoints 
 
PSA50 response, in patients with and without a somatic or germline HR or MMR  
gene mutation. 
 
To associate PSA response to BAT/Nivolumab with changes in gamma-H2AX, 
RAD51, 53BP1 formation in tumor tissue compared to baseline. 
 
To associate PSA50 response to BAT/Nivolumab with changes in CD4, CD8, 
FOXP3, PD-1, PD-L1 levels in tumor tissue compared to baseline. 
 
To associate clinical responses to BAT +/- Nivolumab with the generation of 
mutation-associated neoantigens. (MANAs) or tumor-associated neoantigens 
(TAAs). 
 
To characterize the effect of BAT on production of inflammatory chemokines 
and cytokines. 
 
Exploratory Analyses 
 
Estimate the Percentage of Patients with a Pathogenic Somatic or Germline Mutation in a 
HR or MMR Gene Mutations: 
The somatic DNA mutations present in the tumor will be identified through Foundation 
Medicine sequencing.  Germline DNA mutation testing per standard of care practice will 
be done using clinical-grade testing in a CLIA-certified laboratory prior to the start of 
treatment for consenting subjects only. Patients with a germline and/or somatic 
deleterious alteration in the pre-specified gene list (BRCA1, BRCA2, ATM, CHEK2, NBN, 
RAD50, RAD51C, RAD51D, PALB2, MRE11, FANCA, FANCB, FANCC, FANCD2, FANCE, 
FANCF, FANCG, FANCI, FANCL, FANCM, MLH1, MLH3, MSH2, MSH3, MSH6, PMS1 and 
PMS2) will be considered biomarker positive. For biomarker positive and biomarker 
negative subjects, we will calculate PSA50 response rates with confidence intervals for 
hypothesis generation.   
  
PD‐1, PD‐L1, FOXP3, CD4, CD8, γH2AX, RAD51, 53BP1 Protein Levels:  
Subjects will have pretreatment, on-treatment (and at progression) tumor biopsy 
specimens analyzed.  IHC staining for PD-1 and PD-L1 will be performed on the 
pretreatment samples and scored as <1%, 1-5%, 5-10%, >10% and the results will be 
associated with responses for both proteins, separately, using descriptive statistics and 
Fisher’s Exact Tests.   Immunofluorescence will be used to quantify the median intensity 
of each gamma-H2AX, RAD51 and 53BP1 foci per cell as well as determine the median 
number of foci per cell on the pretreatment biopsies.  Using analytical microscopy, Drs. 
Meeker and Heaphy have developed imaging software, which can isolate single nuclei 
and quantify both the intensity and number of immunofluorescent foci per nucleus (i.e. 
per cell). Using FFPE tissue obtained at biopsy, we will examine the change in DNA 
damage foci number and intensity (reported as median percent change) induced by 
BAT/Nivolumab in PSA50 responders versus non-responders using a T-test.  Using 
imaging software, we will count the number of CD4+ and CD8+ lymphocytes in pre-
treatment and on-treatment biopsies. We will correlate PSA50 responses with CD4+ and 
CD8+ lymphocyte tumor infiltration. 
 
 
 


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Interrogate for Mutation‐associated Neoantigens (MANAs) and Tumor‐associated 
Neoantigens (TAAs): 
Whole-exome sequencing will be performed on pre-treatment samples, after 12 weeks 
of BAT lead-in therapy, and post-progression tumor and matched normal samples. 
Exome data will be applied in a neoantigen prediction pipeline that evaluates antigen 
processing, MHC binding, and gene expression to generate neoantigens specific to the 
patient’s HLA haplotype. Truncal neoantigens will be identified by correcting for tumor 
purity and ploidy. Putative-neoantigens will then be used to generate peptides and 
stimulate autologous T cells, followed by TCR next-generation sequencing. 
 
To Characterize the Effect of BAT on Production of Inflammatory Chemokines and 
Cytokines:   
Milliplex human cytokine/chemokine Immunology Multiplex Assay (Millipore-Sigma) 
will be used to assay acute effects of BAT on production of cytokines and chemokines.  
Plasma samples are obtained at screening, 3 hours after the first testosterone injection, 
3 days after the first testosterone injection, Cycle 2 Day 1, and Cycle 7 Day 1. Analysis 
will be performed by the Immune Processing Core Lab at Johns Hopkins. 
 
Statistical 
method 
Primary Analysis 
The primary endpoint of this study is PSA50 response, defined as a decrease in the PSA to 
≥ 50% less than the baseline PSA upon enrollment in the trial. The decrease must be 
confirmed by a second measurement at least 4 weeks apart. For purposes of meeting the 
primary endpoint, patients will be considered to have done so if they have a PSA50 
response either while on therapy with BAT alone (during lead-in) or BAT in 
combination with Nivolumab (combination phase).  PSA values will be measured 
monthly during the trial.  All patients who take at least one dose of BAT (during lead-in) 
will be considered evaluable for the primary endpoint. If patients do not have at least 
one follow-up PSA after initiation of BAT due to stopping therapy for toxicity or 
withdrawing consent, then they will be replaced. PSA50 response rate will be estimated 
along with 95% confidence interval. 
 
Secondary Analysis 
Safety: 
Patients will be assessed for toxicities at each clinical evaluation. Toxicities will graded 
according to current CTCAE standardized grading scales.  The incidence of grade 3-5 
toxicities will be reported to the lead site and to BMS. Patients will be assessed for 
toxicity as long as they are taking BAT alone or BAT in combination with Nivolumab, 
and patients will continue to be followed if treatment is discontinued for toxicity until 
the toxicities improve to grade 1 or resolve. Toxicities will be reported as a tabulated 
table by type and grade. 
 
PSA Progression‐free Survival (PSA‐PFS): 
A standard definition of PSA progression per PCWG3 will be used. PSA-PFS will be 
defined as an increase in 25% over a nadir value, confirmed by a follow-up PSA at least 4 
weeks later. If patients are removed from the study prior to PSA progression, then they 
will be censored at that time.  We will use the Kaplan-Meier method to summarize the 
median PSA-PFS. 
 
Progression‐free Survival (PFS): 


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Progression-free survival will be measured from the time of the first dose to objective 
clinical or radiographic tumor progression as defined by PCWG3 for progressive disease 
or death, and summarized using a Kaplan-Meier curve. Progression will be assigned to 
the earliest observed time. Patients whose disease has not progressed at follow-up will 
be censored at the date when the last tumor assessment determined a lack of 
progression.  We will use the Kaplan-Meier method to summarize the median PFS. 
 
Objective Response Rate (ORR): 
The objective response rate is defined as the percentage of patients who achieve an 
objective response by RECIST 1.1 criteria (i.e. Complete response or Partial Response) 
to BAT alone or BAT in combination with Nivolumab. We will estimate the objective 
response rate, along with the exact 95% confidence interval, for the population of 
patients with RECIST-evaluable disease.   
Durable Progression‐free Survival (durable‐PFS): 
Durable PFS will be defined as the proportion of patients without clinical or 
radiographic progression, as defined by PCWG3, or death for at least 24 weeks from the 
start of treatment. 
Overall Survival (OS): 
Overall survival will be defined as the time from study enrollment to death from any 
cause up to 2 years after the last dose of study treatment.  This will be summarized 
using a Kaplan-Meier curve. 
 
Sample Size/Power Calculation: 
The sample size is calculated to detect an improved PSA50 response rate from 25% (null 
hypothesis) to 45% (alternative). A minimax Simon two stage design is planned. A total 
of 23 patients will be entered in the first stage. A planned analysis will be performed 12 
weeks after the last patient in the first stage receives the first dose of nivolumab.  If ≤ 5 
subjects have a PSA50 response, the study will be terminated and we will conclude the 
regimen is ineffective (i.e. not more effective than BAT alone). If ≥ 6 subjects respond in 
the first stage, then an additional 16 patients will be enrolled, for a total of 39 patients.  
If a total of ≤ 13 subjects respond in stage one and two combined, we consider this 
regimen ineffective. If a total of ≥ 14 respond, we will conclude that the regimen is 
promising and warrants further study. A total of 44 patients will be enrolled to account 
for a 10% possible dropout rate and unevaluable patients.  
 
This design provides 90% power to detect an absolute 20% increase in PSA response 
rate with a one-sided type I error of 0.1. The chance of early stopping for futility is 0.49 
if PSA50 response rate is 25%. 
 
Safety analysis Standard safety summaries will be provided for treatment exposure, patient disposition, 
adverse events leading to discontinuation, serious adverse events, and all events 
resulting in death, including those up to 100 days after treatment discontinuation. The 
incidence of adverse events will be tabulated and reviewed for potential significance 
and clinical importance. 


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TABLE OF CONTENTS 
1. INTRODUCTION .............................................................................................................................................................. 13 
1.1 
Disease Background .......................................................................................................................................................... 13 
1.2 
Treatment Background .................................................................................................................................................... 14 
1.3 
Rationale ................................................................................................................................................................................. 24 
2.1 
Primary Objective ............................................................................................................................................................... 28 
2.2 
Secondary Objectives ........................................................................................................................................................ 28 
2.3 
Correlative/Exploratory/Tertiary Objectives ....................................................................................................... 28 
3. 
PATIENT SELECTION ............................................................................................................................................. 29 
3.1 
Target Population ............................................................................................................................................................... 29 
3.2 
Expected Enrollment ......................................................................................................................................................... 29 
3.3 
Inclusion Criteria ................................................................................................................................................................ 29 
3.4 
Exclusion Criteria ............................................................................................................................................................... 30 
4. 
PATIENT REGISTRATION AND ENROLLMENT PLAN .................................................................................... 33 
4.1 
Registration Procedure .................................................................................................................................................... 33 
5. 
TREATMENT/INTERVENTION PLAN ................................................................................................................. 33 
5.1 
Screening Assessment ...................................................................................................................................................... 36 
5.2 
Testosterone Lead-in Period ......................................................................................................................................... 38 
5.3 
Testosterone/Nivolumab Combination Period ..................................................................................................... 39 
5.4 
End of Treatment/Treatment Discontinuation Visit .......................................................................................... 40 
5.5 
Follow-up……………………………………………………………………………………………………………………………..40 
5.6 
Correlative/Special Studies ............................................................................................................................................ 41 
6.        STUDY DRUGS……………………………………………………………………………………………………………………................41 
6.1 
Description of Treatments .............................................................................................................................................. 41 
6.2 
Administration, Supply, and Storage ......................................................................................................................... 41 
7. 
DOSE ADJUSTMENT AND DELAY, TREATMENT DISCONTINUATION,  WITHDRAWAL, AND 
TERMINATION CRITERIA ..................................................................................................................................... 42 
7.1 
Dosing and Dose Modifications .................................................................................................................................... 42 
7.2      Dose Delay and Treatment Discontinuation ........................................................................................................... 43 
7.3 
Dose Delay Criteria ............................................................................................................................................................ 43 
7.4  
Criteria to Resume Treatment ...................................................................................................................................... 43 
7.5      Discontinuation Criteria .................................................................................................................................................. 44 
7.6 
Treatment of Nivolumab-Related Infusion Reactions ........................................................................................ 45 
7.7    Treatment Beyond Disease Progression .................................................................................................................. 46 
7.8 
Immunotherapy Adverse Event Management…………………………………………………………………………47 
7.9 
Removal of Subjects from the Study, Therapy Assessment ............................................................................. 47 
7.10    Treatment Compliance..................................................................................................................................................... 48 
7.11    Destruction of Study Drug .............................................................................................................................................. 48 
7.12   Return of Study Drug ........................................................................................................................................................ 48 
8. 
ADVERSE EVENTS ................................................................................................................................................... 49 
8.1 
Definitions .............................................................................................................................................................................. 49 
8.2 
Expectedness ........................................................................................................................................................................ 52 
8.3 
Recording and Grading ..................................................................................................................................................... 52 
8.4 
Reporting Adverse Events .............................................................................................................................................. 53 
9. 
CRITERIA FOR OUTCOME ASSESSMENT/THERAPEUTIC RESPONSE ...................................................... 56 
9.1 
Outcome Assessment ........................................................................................................................................................ 56 
9.2 
Therapeutic Response ...................................................................................................................................................... 57 
9.3 
Response Criteria for Primary and Secondary Endpoints ................................................................................ 59 
9.4 
Criteria for Progressive Disease. .................................................................................................................................. 61 
10. 
DATA REPORTING AND REGULATORY REQUIREMENTS ............................................................................ 61 
10.1  Data Entry .............................................................................................................................................................................. 62 
10.2  Data Management ............................................................................................................................................................... 63 
10.3  Study Monitoring and Quality Assurance ................................................................................................................ 63 


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10.4  Clinical Trial Agreement .................................................................................................................................................. 64 
11. 
STATISTICAL CONSIDERATIONS ........................................................................................................................ 64 
11.1  Study Endpoints .................................................................................................................................................................. 65 
11.2  Analysis Populations ......................................................................................................................................................... 67 
11.3  Safety Analysis ..................................................................................................................................................................... 68 
12. 
PROTECTION OF HUMAN SUBJECTS ................................................................................................................. 68 
12.1  Ethical Considerations ....................................................................................................................................................... 68 
12.2  Protocol Amendments ........................................................................................................................................................ 68 
12.3  Written Informed Consent ................................................................................................................................................ 68 
12.4  Protection of Privacy .......................................................................................................................................................... 69 
12.5  Terminating or Modifying the Study ............................................................................................................................ 69 
13. 
REFERENCES ............................................................................................................................................................. 71 
 
APPENDIX A: MANAGEMENT ALGORITHM FOR IMMUNO‐ONCOLOGY AGENTS…………………………………...75 
APPENDIX B: PERFORMANCE STATUS CRITERIA……………………………………………………..……………………...….83 
APPENDIX C: LABORATORY MANUAL .......................................................................................................................... 84 
APPENDIX D: GLOSSARY OF ABBREVIATIONS AND ACRONYMS ......................................................................... 87 
APPENDIX E: ACCEPTABLE BIRTH CONTROL METHODS ....................................................................................... 93 
APPENDIX F:  HY’S LAW………………………………………………………………………………………………………………………94 
APPENDIX G:  TUMOR SAMPLE INFORMATION FORM…………………………………………………………………………97 
 
List of Tables: 
 
Table 1         Somatic Gene Analysis of 7 mCRPC Patients Treated with Bipolar Androgen Therapy 
           25 
Table 2         Study Calendar 
   
 
 
 
 
                       
 
           34 
Table 3         Relationship of Adverse Event to Study Drug  
 
 
 
 
           53 
Table 4         RECIST 1.1 Response Criteria for Target Lesions 
 
 
 
                           59 
Table 5          RECIST 1.1 Response Criteria for Nontarget Lesions 
 
 
 
 
           60 
Table 6          Categories for Response to Treatment 
 
 
 
 
 
           67 
 
 
 
List of Figures: 
 
Trial Schema 
 
 
 
 
 
 
 
 
 
 
             7 
Figure 1       Clinical States of Prostate Cancer 
 
 
 
 
 
 
           13 
Figure 2       Androgen Induced Double Strand DNA Breaks in Prostate Cancer Cell Lines Stimulated with  
       High Levels of Androgen. 
 
 
 
 
 
 
                           15 
Figure 3       Castrated NOG Mice Inoculated with LNCaP/A-cells Were Either Exposed to BAT Therapy or  
       Left in a Permanently Castrate State.  
 
 
 
 
 
           16 
Figure 4       Clinical Trial of BAT Plus Etoposide.  
 
 
 
 
 
 
           19 
Figure 5       Results from the Pilot BAT Study in Men with CRPC. 
 
 
 
 
           20 
Figure 6       PSA Values of Extreme Responder Patients Treated with Bipolar Androgen Therapy                      24 
Figure 7       Waterfall Plot of Maximal PSA Change in mCRPC Patients Treated with Combination  
       Checkpoint Inhibitor Therapy  
 
 
 
 
 
           
           26 
Figure 8       CT Imaging of Post BAT mCRPC Patients Before and During Treatment with Checkpoint  
       Inhibition 
 
 
 
 
 
 
 
 
 
           27 
 


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1. INTRODUCTION 
 
1.1 
Disease Background 
 
Prostate cancer is the most commonly diagnosed non-cutaneous malignancy in men, with 
an estimated 180,000 cases annually in the United States (1).  It is the second most common 
cause of cancer mortality in the United States as well, with over 26,000 deaths in 2016 (1).  
The discrepancy between the incidence and mortality numbers demonstrate its potential 
curability if treated while disease is local, as well as the non-lethal nature of some cancers, 
even if not treated definitively.  While many men are cured of their disease, many others 
will unfortunately progress to incurable and lethal metastatic disease. 
 
1.1.1 Clinical States of Prostate Cancer 
 
The course of prostate cancer from diagnosis to death is best categorized as a series of 
clinical states (Fig. 1). These states are defined by the extent of disease and status of 
responsiveness to hormonal therapy. Therapies have been developed for specific states, as 
each state presents unique risks to the patient and different responsiveness of the disease 
to therapy. 
 
 
Figure 1. Clinical states of prostate cancer (2) 
 
1.1.2  Metastatic Castration‐Resistant Disease State 
 
Androgen deprivation therapy (ADT) is the backbone of treatment for metastatic prostate 
 
cancer,  and while ADT is initially highly effective, prostate cancers invariably adapt to a 
 
low-testosterone environment, leading to castration resistance. Studies have demonstrated 
 
that castration-resistant prostate cancer (CRPC) remains dependent on AR signaling. Based 
 
on this understanding, several drugs have been developed and Food and Drug 
 
Administration (FDA)-approved for the treatment of mCRPC, including abiraterone acetate 
 
and enzalutamide. However, we have observed in multiple clinical studies a paradoxical 
 
effect of high dose testosterone resulting in both PSA and radiographic responses in 
 
patients with mCRPC. 


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1.2 
Treatment Background 
1.2.1 
Description and Mechanism of Action 
 
Testosterone cypionate is the oil-soluble form of the androgenic hormone, testosterone. A 
paradoxical inhibition of cell growth has been observed in both androgen-sensitive and 
CRPC cell lines following the addition of high-dose testosterone.(3,4) Several mechanisms 
underlying this paradoxical response to androgens have been identified. First, our group 
and others have showed that AR may be involved in DNA relicensing during cell cycle 
progression.(5-7) Under normal conditions, AR is degraded during the cell cycle. Our group 
found that the AR protein is stabilized in the presence of supraphysiologic levels of 
androgen and remains bound to origins of replication.(5-7) This binding inhibits 
progression through the cell cycle, leading to cell death. Second, androgen-starved prostate 
cancer cells up-regulate both full-length AR and AR splice variants as a survival mechanism. 
The addition of high-dose androgen to the growth media results in the down-regulation of 
these AR splice variants (including AR-V7), potentially re-sensitizing these cells to 
ADT.(8,9) Third, we have shown that following androgen starvation, exposure of CRPC cells 
to high-dose androgen induces double-strand (ds) DNA breaks, resulting in cell growth 
inhibition and decreased clonogenic survival.(10)  Mechanistically, high-dose androgen has 
also been shown to induce structural genomic rearrangements/translocations in CRPC cells, 
including the TMPRSS2-ERG fusion.(11) 
 
 
Nivolumab (also referred to as BMS-936558, MDX1106, or ONO-4538) is a human 
 
monoclonal antibody (HuMAb; immunoglobulin G4 [IgG4]-S228P) that targets the 
 
programmed death-1 (PD-1) cluster of differentiation 279 (CD279) cell surface membrane 
 
receptor. PD-1 is a negative regulatory molecule expressed by activated T and B 
 
lymphocytes. Binding of PD-1 to its ligands, programmed death–ligands 1 (PD-L1) and 2 
 
(PD-L2), results in the down-regulation of lymphocyte activation. Inhibition of the 
 
interaction between PD-1 and its ligands promotes immune responses and antigen-specific 
 
T-cell responses to both foreign antigens as well as self-antigens. Nivolumab is expressed in 
 
Chinese hamster ovary (CHO) cells and is produced using standard mammalian cell 
 
cultivation and chromatographic purification technologies. The clinical study product is a 
 
sterile solution for parenteral administration.  
 
 
OPDIVO (nivolumab) is approved for the treatment of several types of cancer in multiple 
 
regions including the United States (US, Dec-2014), the European Union (EU, Jun-2015), and 
 
Japan (Jul-2014). Nivolumab is also being investigated in various other types of cancer as 
 
monotherapy or in combination with other therapies, and as single-dose monotherapy for 
 
the treatment of sepsis.  
 
1.2.3     Preclinical Studies  
 
High-dose testosterone, also referred to as Bipolar Androgen Therapy (BAT): 
The mechanisms underlying the growth-suppressive effects of high levels of androgens in 
prostate cancer cells in vitro and in vivo is likely highly complex. Recent evidence from our 
group suggests that one mechanism may involve the formation of androgen-induced 
Topoisomerase II beta (TOP2B)-mediated double strand breaks at AR target genes (Figure 
2).(10) Studies have shown that estrogen signaling in breast cancer cells involves the co-
recruitment of Estrogen receptor and TOP2B to estrogen receptor target sites, where 


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TOP2B introduces transient double strand breaks. We hypothesized that such a mechanism 
may be involved in androgen signaling in prostate cancer cells and that at high doses of 
androgens, such breaks may persist and ultimately lead to growth suppression. In support 
of this, we observed that stimulation of androgen-deprived LNCaP cells with 
dihydrotestosterone (DHT) led to recruitment and catalytic activity of TOP2B at AR target 
sites in the TMPRSS2 enhancer as well as at other known AR target sites. At high doses of 
DHT, this TOP2B recruitment and catalytic activity was associated with significant 
formation of AR and TOP2-dependent persistent double strand breaks at the TMPRSS2 
gene, as observed by fluorescence in situ hybridization (FISH) assay which is capable of 
detecting genomic breaks on an individual cell basis.(10) Such breaks likely occurred 
throughout the genome at AR target sites since we observed numerous γH2A.x foci, a 
marker for double strand break formation, throughout the nucleus in response to 
stimulation of LNCaP cells with high-dose DHT (Figure 2). In further confirmation of this, 
we also observed recruitment of ATM, a double strand break repair signaling protein, to AR 
target sites in PSA and TMPRSS2, genes present on different chromosomes in the cell. These 
findings suggest that exposure of prostate cancer cells from patients with CRPC to high 
doses of testosterone may induce growth suppression due to the accumulation of androgen- 
mediated, TOP2-induced double strand DNA breaks.(10) 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
Figure 2.  Androgen-induced double strand DNA breaks in prostate cancer cell lines 
stimulated with high levels of androgen. Stimulation of androgen-deprived LAPC4 cells 
(control) to high levels of DHT (DHT) leads to numerous double strand breaks throughout 
the nucleus as evidenced by the accumulation of numerous γH2A.x foci, a marker for 
formation of double strand breaks.  
 
 
 
 


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Recently, the Denmeade laboratory has explored a mechanism for growth inhibition by 
testosterone (T) in CRPC cells. These studies document that the increase in AR expression 
observed in these cells in the low T environment creates a unique therapeutic vulnerability 
to selectively kill CRPC cells. This is based upon the fact that AR is involved in DNA 
relicensing and DNA replication and AR must be degraded in each cell cycle for proper 
relicensing to occur. Overstabilization of the increased levels of AR observed in CRPC with 
supraphysiologic testosterone prevents complete degradation of AR via the proteasome 
during mitosis. This was demonstrated by in vivo treatment of resistant human LNCaP 
prostate cancer xenografts with T implants to achieve supraphysiologic serum T- levels.(5) 
This treatment resulted in significant growth inhibition (Figure 3a). These growth-inhibited 
cells had similar amount of cells with nuclear AR in the nucleus and Ki-67 positivity (Figure 
3a). However, in xenografts treated with supraphysiologic T, the Cell Death Index was ~ 3- 
fold higher.(5) More strikingly, the percent of cells staining positive for AR in mitosis was 
approximately 10-fold higher in cells exposed to supraphysiologic T versus castrate-only 
animals (Figure 3b). This data suggests that CRPC cells that have not properly relicensed 
DNA, can die when they attempt to proceed through a subsequent cell cycle. Thus, based on 
this proposed mechanism, prostate cancer cells that maintain high AR levels will be 
vulnerable to cell death when exposed to supraphysiologic T conditions due to their 
inability to rapidly auto-regulate AR to lower levels. Due to the bipolar cycling between high 
and low serum T achieved with BAT, those cells that do manage to survive the high T 
environment through adaptive down-regulation of AR will become vulnerable to cell death 
when suddenly exposed to low T conditions that occur over the cycle of BAT.  
 
  
 
Figure 3. Castrated NOG mice inoculated with LNCaP/A-cells were either exposed to BAT 
therapy (via an implanted testosterone filled capsule that was placed and removed at two 
week intervals) or left in a permanently castrate state (diamond versus box). (A) Evaluation 
of indicated parameters in LNCaP/A- cells growing in castrate mice vs. castrate mice 
supplemented with subcutaneous testosterone-filled silastic implants. (B) 
Immunohistochemical staining for AR in harvested LNCaP/A- xenografts growing in 
castrate vs. castrate + T-pelleted mice. Blue arrows indicate mitotic figures. 
 
Nivolumab: 
Tumors can express tumor-specific antigens as a result of mutational burden, and ongoing 
immune surveillance is believed to control the development of many tumors. Tumor 
progression may depend on the acquisition of mechanisms that permit them to evade an 
effective immune response. One such mechanism of evasion may be the expression of 
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expression has been found on a number of tumors and may be a mechanism by which 
tumors can directly engage PD-1 to evade an effective anti-tumor immune response.(12-14) 
Expression of IFN-γ by activated T cells is known to induce PD-L1 expression in tumors.(15) 
PD-L1 expression has been associated with poor prognoses in renal,(16-18) 
esophageal,(19) gastric,(20) ovarian,(14) pancreatic,(21) and lung cancers.(22)  PD-1 
engagement on T cells by PD-L1-positive APC or PD-L1-positive tumor cells in the tumor 
microenvironment may limit effective immune responses. Conversely, PD-L1 expression 
may be a positive prognostic factor as it may indicate infiltration of tumor-specific T cells 
that secrete IFN-γ, which up-regulates PD-L1 expression. Consistent with this hypothesis is 
the co-localization of lymphoid cell infiltrates and PD-L1 staining observed in human 
melanoma lesions.(23) 
 
Studies in multiple tumor models using a chimeric murine anti-mouse PD-1 antibody 
showed that PD-1 blockade has anti-tumor activity.(24) Blocking PD-1 in PD-L1-positive 
tumors may reverse the inactivation of tumor-specific effector T cells at the tumor site, as 
well as activate anti-tumor responses that are limited by PD-L1 expression on “host” DC or 
APC. The anti-tumor effects of anti-PD-1 observed in several murine models suggest that 
both PD-L1-positive and PD- L1-negative tumors may be targeted using this approach. In 
addition, in several tumor models in which anti-PD-1 has proved ineffective, PD-1 blockade 
can be combined with vaccines or other immunomodulatory antibodies for improved 
therapeutic efficacy.(25-27) PD-1 blockade by Nivolumab is a promising avenue to pursue 
as an anti-tumor therapy for recurrent or treatment-refractory malignancies.  
 
1.2.4    Clinical Studies 
BAT: 
Up until recently, there had been very limited clinical experience in the PSA-era treating 
CRPC patients with testosterone. Brendler et al. (1949) at the Brady Urological Institute 
reported in the Archives of Surgery on the use of parenteral testosterone in several men 
with advanced CRPC.(28) They observed considerable improvement in several men that 
included decreased pain, decreased prostate size, and decreases in acid and alkaline 
phosphatase. In a second study, Prout and Brewer (1967) reported in Cancer on the 
treatment of men who had been either untreated or recently castrated or long term 
castrates with parenteral testosterone.(29) Five relapsed patients in the long term castrate 
group received testosterone for at least one month and 4 of 5 had subjective improvement. 
Five remaining patients in the long term castrate group received testosterone for 1-19 days, 
with each progressing and subsequently coming off therapy. Acid phosphatase declined in 
2/5 men receiving a longer course of testosterone. Remarkably, one man in this group 
admitted to hospital with severe back pain, weakness, and anorexia had a 10 month 
response with complete cessation of pain, excellent appetite, and weight gain with a 
decrease in acid phosphatase from 50 to 5 units.  
In contrast, a number of studies during the 1960-70s evaluated the use of T-priming in 
combination with 32P-sodium phosphate to treat men with CRPC and severe pain due to 
widespread bony metastases.(30,31) In these studies, initial T-priming using a variety of 
parenteral dosing regimens was associated with transient increase in bone pain during the 
first week followed by excellent pain palliation following administration of 32P. Similar 
results were observed in studies led by Manni who evaluated T- priming with 
chemotherapy in the 1980’s.(32) These studies were also conducted in men with CRPC and 


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pain due to widely metastatic disease. In these studies, increased bone pain was also 
observed in men upon initial treatment with oral androgens. The increased pain in these 
studies typically occurred within days of T administration. Thus, given this time frame, it is 
likely the increased pain was due to T-stimulation of inflammation/cytokine release within 
sites of bone metastases rather than a direct effect on tumor growth. Such rapid change is 
also seen in men with bone pain upon initially starting ADT. Marked improvement in pain 
after ADT often occurs within hours of treatment, an effect not due to tumor death but 
rather a rapid change in expression of pain-promoting gene products.  
Two contemporary Phase I studies were reported describing the results of the use of 
transdermal T as therapy for men with CRPC who had minimal to moderate disease burden 
and no pain due to prostate cancer. In the first study, Szmulewitz et al. (2009) evaluated the 
effect of increasing doses of transdermal T in 15 men with early CRPC (rising PSA and 
minimal bone disease).(33) Five men each were treated with 2.5, 5.0 or 7.5 mg/day of 
transdermal T which brought the median concentration of T from castrate to 305, 308, and 
297 ng/dL respectively. In this study, no grade 3 or 4 toxicities were observed with the 
exception of one man who was taken off study at week 53 for grade 4 cardiac toxicity. Only 
one patient had symptomatic progression and three patients (20%) had a decrease in PSA 
(largest was 43%). Patients treated at the highest T dose had a prolonged time to 
progression that did not reach statistical significance, most likely due to the small cohort 
size. In the second study, Morris et al. (2016) evaluated the effect of transdermal T at a dose 
of 7.5 mg/day administered for 1 week (n=3), 1 month (n=3) or until disease progression 
(n=6) in 12 patients with CRPC.(34) They observed no grade 3 or 4 toxicities and no pain 
flares. Eugonadal serum T levels were reported for this study. No objective responses were 
observed. Four patients had at least 20% declines and one achieved a > 50% PSA decline.  
Neither of these Phase I studies achieved the supraphysiologic levels of serum T that can be 
reached with FDA-approved doses of T administered as an intramuscular depot.(35) 
However, the levels of serum T achieved were in the high-end of the eugonadal range. 
Remarkably, although the studies were considered “negative” from the standpoint of 
disease response, in both studies the administration of parenteral T to men with CRPC was 
very well-tolerated and did not result in significant worsening of disease or symptoms, 
including pain flares. While only one patient out of 27 from the combined studies had a 
reported > 50% decline in PSA, smaller PSA declines were observed in a few of the patients 
on these two studies with a trend toward a dose-responsive effect, suggesting a potential for 
therapeutic benefit in some patients.(33,34)  
 


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Figure 4. Clinical trial of BAT plus etoposide. (A) Schematic of study design. (B) Baseline 
characteristics of patients on study. (C) Mean serum testosterone levels at indicated time 
points for patients on study.  
 
Based on the preclinical results and potential mechanisms for growth inhibition that include 
androgen-induced double strand breaks and the stabilization of AR preventing relicensing, 
we have conducted a pilot study evaluating the efficacy and safety of pharmacologic doses 
of testosterone to produce supraphysiologic T levels in conjunction with oral etoposide (E) 
in chronically castrated men with rising PSA and CRPC (Figure 4a).(36) Patients who had 
been continuously castrate for more than one year with minimal metastatic disease burden 
(≤ 5 total bone metastases and ≤ 10 total sites of metastases), and/or rising PSA were 
eligible (Figure 4b). To achieve rapid cycling between supraphysiologic and near-castrate 
serum T, patients received an intramuscular injection of 400 mg testosterone cypionate (i.e. 
BAT) every 28 days. For the first 3 cycles of therapy, patients received BAT plus oral 
etoposide 100 mg PO/day, days 1-14 of a 28 day cycle. After 3 cycles, PSA and objective 
responses were assessed. Those patients with a PSA that was declining from peak levels and 
no objective evidence of disease progression or worsening pain were continued on therapy. 
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trial,(37) patients who were responding after 3 cycles of testosterone plus etoposide were 
continued on testosterone alone based on protocol amendment.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Figure 5. Results from the pilot BAT study in men with CRPC. (A) Waterfall plot of best PSA 
response with 7/14 men and 4/14 men achieving PSA declines > 30% and > 50%, 
respectively; (B) Representative patterns of PSA response in pilot study; PSA and serum T 
level in non-responder; (C) PSA response in patient receiving 3 cycles of T + E and then 13 
additional cycles of T alone. Patient demonstrated renewed sensitivity to ADT after 
progressing on BAT; (D) Objective lymph node complete and partial response after 3 cycles 
of BAT + E.  
 
Seven of fourteen patients had a decline in PSA from baseline value (Figure 5a). An eighth 
patient progressing after testosterone treatment for 6 months, had a decline in PSA upon 
reaching castrate-level testosterone. Non-responders came off trial after 3 cycles due to PSA 
progression. Overall, three patterns of PSA response were observed (Figure 5b). For the 
seven patients that had a PSA decline, the median time to PSA progression was 221 days 
(range, 95 to 454 days).  
  
The dose of 400 mg testosterone cypionate produces supraphysiologic levels > 1500 ng/dL 
within 2 days post injection (Figure 4c). At baseline, ten subjects had RECIST-evaluable soft 
tissue metastases (Figure 4b). Of these patients, two (20%) had progressive disease (PD), 
three (30%) had stable disease (SD) after a median follow-up of 91 days (range, 87 to 92 
days), four (40%) had partial responses (PRs), and one (10%) had a complete response 


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(CR) (Figure 5d). None of the 14 patients completing 3 months of therapy developed new 
bone metastases. One patient with > 50% decrease in PSA had intensification of an isolated 
tibial metastases on bone scan and was removed from study despite decline in PSA levels. 
No other patient developed worsening pain on study.  
 
Two clinical trials involving high-dose T are ongoing at Johns Hopkins: 1. RESTORE Trial 
(J1416) - A Phase II Study to Determine Sequential Response to Bipolar Androgen Therapy 
(BAT) followed by Enzalutamide or Abiraterone Post-BAT in Men with Prostate Cancer 
Progressing on Combined Androgen Ablative Therapies; 2. TRANSFORMER trial (J14146) - 
A Randomized Phase II Study Comparing Bipolar Androgen Therapy vs. Enzalutamide in 
Asymptomatic Men with Castration-Resistant Metastatic Prostate Cancer.   
Nivolumab 
This updated Investigators Brochure (IB) references the most recent USPI and EU SmPC as 
the basis for the current state of knowledge on Nivolumab for use in humans with cancer. 
The approved USPI and SmPC are provided in Appendix 1 and Appendix 2 of the IB, 
respectively. The USPI and SmPC summarize Nivolumab monotherapy clinical data for 
melanoma (based on CA209037 and CA209066), SQ NSCLC (based on CA209063 and 
CA209017), NSQ NSCLC (based on CA209057), RCC (based on CA209025), Classical 
Hodgkin Lymphoma (cHL; based on CA209205 and CA209039), and urothelial carcinoma 
(UC; based on CA209275 and CA209032), as well as clinical data for Nivolumab in 
combination with Ipilimumab for melanoma (based on CA209004, CA209069, and 
CA209067). In addition, the USPI describes Nivolumab monotherapy clinical data for 
SCCHN (based on CA209141). Data from clinical studies that are relevant to ongoing clinical 
investigations in oncology that are not in the approved USPI and SmPC or to subjects with 
sepsis are included in this updated IB.  
The PK, clinical activity, and safety of Nivolumab have been assessed in approximately 75 
clinical studies sponsored by BMS or ONO. The description and status of studies with 
reference safety information are provided in Appendix 4 of the IB. Across those studies, 
approximately 16,900 subjects have received Nivolumab monotherapy in single- or 
multiple-dose Phase 1/2/3 studies or studies with Nivolumab in combination with other 
therapeutics (Ipilimumab, cytotoxic chemotherapy, anti-angiogenics, and targeted 
therapies). Results from the ongoing studies are preliminary and are subject to change.  
Nivolumab has demonstrated clinical activity in NSCLC, melanoma, RCC, cHL, SCCHN, UC 
(approved indications) and other tumor types (Section 5.4 of the IB) as monotherapy or in 
combination with Ipilimumab or other therapeutics. The majority of responses were 
durable and exceeded 6 months. In randomized-controlled studies, Nivolumab 
monotherapy demonstrated statistically significant improvement in OS over standard-of-
care in subjects with advanced or metastatic melanoma, subjects with advanced or 
metastatic NSCLC, subjects with advanced RCC, and subjects with recurrent or metastatic 
SCCHN.  In randomized-controlled studies, Nivolumab in combination with Ipilimumab 
demonstrated statistically significant improvement in PFS and ORR over Ipilimumab 
monotherapy in subjects with advanced or metastatic melanoma.  
All available data suggest that Nivolumab monotherapy has a consistent AE profile across 
tumor types. The safety profile is generally consistent across completed and ongoing clinical 
trials, with no maximum tolerated dose (MTD) reached at any monotherapy dose tested up 
to 10 mg/kg. There was no pattern in the incidence, severity, or causality of AEs to 


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Nivolumab dose level. The safety profile of Nivolumab in combination with Ipilimumab was 
consistent with the mechanisms of action of Nivolumab and Ipilimumab. The nature of the 
AEs was similar to that observed with either agent used as monotherapy; however, both 
frequency and severity of most AEs were increased with the combination. A dose of 3 
mg/kg Nivolumab/3 mg/kg Ipilimumab exceeded the MTD, and both 1 mg/kg 
Nivolumab/3-mg/kg Ipilimumab and 3 mg/kg Nivolumab/1 mg/kg Ipilimumab were 
identified as the MTD. Across all studies conducted to date, drug-related AEs have included 
pulmonary toxicity, renal toxicity (including acute renal failure), endocrine abnormalities, 
GI toxicity, dermatologic toxicity (including rash), and hepatotoxicity. For Nivolumab 
monotherapy and combination therapy, the majority of these AEs have been managed 
successfully with supportive care and, in more severe cases, a combination of dose delay, 
permanent discontinuation, and/or use of corticosteroids or hormone replacement therapy 
(endocrinopathies) as instructed in the management guidelines provided in Appendix 3 of 
the IB.  
In addition to BMS-sponsored ongoing studies, 22 studies sponsored by ONO 
Pharmaceuticals, Ltd. and conducted in Japan, Korea, and/or Taiwan are included in the 
reference safety information in Section 5.6 of the IB. Brief descriptions of these studies are 
provided in Appendix 4 of the IB. The studies are not under any US investigational new drug 
application (IND). Efficacy and safety information from ONO studies (ONO-4538-01, ONO-
4538-04, ONO-4538-07, ONO-4538-12, ONO-4538-13, and ONO-4538-14) are provided in 
Section 5.4 and Section 5.5 of the IB.  
All studies were conducted in accordance with Good Clinical Practice, as defined by the 
International Conference on Harmonisation and in accordance with the ethical principles 
underlying European Union Directive 2001/20/EC and the US Food and Drug 
Administration Code of Federal Regulations (CFR), Title 21, Part 50 (21CFR50).  
 
1.2.5     Clinical Safety Summary 
 
 
BAT: 
The majority of adverse events (AEs) occurred during the initial phase of treatment and 
were largely consistent with known side effects of etoposide. Initial-phase side effects were 
mostly low grade (i.e. ≤ Grade 2) and included: nausea (N=10), fatigue (N=9), alopecia 
(N=9), edema (N=8), and neutropenia (N=3), as listed in the table below. Two patients had a 
grade 3 asymptomatic, subsegmental pulmonary embolism. Two subjects did not complete 
the initial treatment phase, one individual was taken off study after developing grade 2 
priapism, and a second individual expired due to pneumonia/neutropenic sepsis. AEs 
occurring during the BAT monotherapy phase of the trial were rare and low grade. Only 
four subjects experienced an AE during this phase, and all but three AEs were grade 1. 
Grade 2 events included alopecia and an elevated creatinine in one subject and grade 2 
nausea in a separate subject.  
 
None of the 14 patients developed new pain, skeletal events or urinary obstruction due to 
prostate cancer. Although quality of life was not formally evaluated in the study, most 
subjects reported enhanced well-being and increased functional activity. Patients with 
intact sexual function prior to ADT had return of sexual function and libido on BAT.  
 


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Nivolumab: 
 
The overall safety experience with Nivolumab as a monotherapy, is based on experience in 
 
approximately 11,000 subjects treated to date.  For monotherapy, the safety profile is 
 
similar across tumor types. The only exception is pulmonary inflammation adverse events 
 
(AEs), which may be numerically greater in subjects with NSCLC, because in some cases, 
 
it can be difficult to distinguish between Nivolumab-related and unrelated causes of 
 
pulmonary symptoms and radiographic changes. There is no pattern in the incidence, 
 
severity, or causality of AEs to Nivolumab dose level.  A detailed list of AEs for patients 
 
treated with Nivolumab as monotherapy on clinical trials can be found in Table 5.6.1-1 in 
 
the IB. 
 
 
In several ongoing clinical trials, the safety of Nivolumab in combination with other 
 
therapeutics such as Ipilimumab, cytotoxic chemotherapy, anti-angiogenics, and targeted 
 
therapies is being explored. Most studies are ongoing and, as such, the safety profile of 
 
Nivolumab combinations continues to evolve.    
 
 


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1.3 
Rationale 
 
1.3.1 
Rationale for Conducting the Study 
 
BAT and DNA Repair:  
We have discovered a provocative association between germline and/or somatic DNA-
repair mutations and response to BAT. Based on prior studies, the incidence of germline 
mutations in DNA-repair genes in mCRPC patients is 8-12%, with somatic DNA-repair 
mutations approaching 20-25%. As mentioned, we have recently identified a correlation 
between long term (“exceptional”) responders to BAT and the presence of mutations in 
homologous recombination DNA repair genes. Our index case was an enzalutamide-
pretreated patient with mCRPC who achieved a durable (> 24 mo) complete radiographic 
and serologic response following treatment with BAT (Figure 6).(38) Tumor DNA 
 
sequencing found inactivating mutations in both BRCA2 (with LOH) and ATM (mono-
 
allelic), which were then confirmed on germline DNA testing (i.e. these were both inherited
 
mutations). We have since systematically sequenced tumor/germline DNA from patients 
 
receiving BAT and, remarkably, have detected DNA repair mutations in the majority of 
 
responders (Table 1). Overall, our preliminary unpublished findings suggest an 80% 
 
response rate to BAT (4/5) in men with DNA repair mutations, implying a provocative 
 
association between DNA repair-deficient prostate cancer and BAT responsiveness. This is a 
 
rational inference based on the fact that BAT may induce dsDNA breaks that may go 
 
unrepaired in the setting of homologous recombination defects. 
 
 
Nilutamide 
150 mg qd 
Ketoconazole 
200 mg d 
Ketoconazole 
400 mg d 
Enzalutamide 
160 mg qod 
Testosterone Cypionate  
400 mg IM q 28 days 
PSA Level (ng/ml) 
Months 
Figure 6. PSA values of Extreme Responder Pa ent to Bipolar Androgen Therapy 


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Immune Checkpoint Blockade and DNA Repair:  
Two randomized phase III trials involving single-agent checkpoint (CTLA-4) inhibitors in 
mCRPC patients did not meet their primary endpoints.(39,40) However, a small subset 
(~20%) of mCRPC patients did derive clinical benefit, although the molecular 
characteristics of these patients are unknown. In pilot studies conducted at Johns Hopkins, 
we have observed significant responses to checkpoint inhibition in several heavily 
pretreated mCRPC patients with DNA repair defects (Figure 7). For instance, two patients 
(#1: MSH6-mutated; #2: BRCA2-mutated) achieved a PSA50 response following combined 
PD-1/CTLA-4 checkpoint inhibition using Ipilimumab plus Nivolumab. Patient #1 also had a 
partial radiographic RECIST response and remains progression-free for > 6 months.  Patient 
#2 had over 20 sites of symptomatic bone metastases at that start of therapy. Following 
combination checkpoint inhibition, his pain disappeared (pain score: 6/10  0/10) and his 
clinical response is ongoing after 9 months. A third mCRPC patient (#3: ATM-mutated) 
achieved a partial radiographic RECIST response without a PSA response. A fourth patient 
(#4: POLH-mutated) also had a RECIST response without a PSA response. Moreover, those 
patients with a DNA repair mutation had significantly improved radiographic-PFS (HR 0.28, 
p=0.027) and PSA-PFS (HR 0.14,P=0.001) compared to DNA repair-proficient patients. 
Similar to the efficacy of checkpoint inhibitors in patients with MSI-High (mismatch repair-
deficient) colon cancer, we speculate that a benefit of immunotherapy may be observed in 
mCRPC patients with germline and/or somatic mutations in DNA repair genes, including 
homologous recombination genes (i.e. not just MMR genes), thus potentially expanding the 
pool of mCRPC patients that may be susceptible to immune checkpoint blockade. 
 
Pa ent 
Max PSA Change (%) 
DDR Muta ons 
Sequencing results 
1 
100 
None 
Not done 
2 
37 
None 
POSITIVE for TMPRSS2‐ERG Fusion, TP53 muta on and 
addi onal altera ons.   
3 
-11
 1 copy loss of BRCA2 
PTEN homozygous dele on, TP53 p.R175H point 
muta on and copy neutral LOH, TMPRSS2‐ERG 
fusion, 1 copy loss of RB1, 1 copy loss of BRCA2 
4 
-55
CDK12 p.G923V  muta on and 
copy neutral LOH, BRCA2 
p.Y1762* muta on and 1 copy 
loss 
FOXA1 p.H247Q muta on, TP53 p.Y163C  muta on 
and copy neutral LOH, CDK12 p.G923V  muta on 
and copy neutral LOH, BRCA2 p.Y1762* muta on 
and 1 copy loss, RB1 Dele on exon 4 and 1 copy 
loss, HOXB13 p.G84E germline variant and LOH 
5 
-74
CHD1 copy loss, chr13 copy 
loss (BRCA2 region) 
AR amplifica on, TP53 muta on, ERBB4 muta on, FOXA1
muta on, CHD1 copy loss, and chr13 copy loss in the 
region of BRCA2 and RB1 
6 
-85
ATRX‐ATAD2B gene fusion 
(loss of ATRX func on) 
PTEN homozygous dele on, TP53 p.R175H point 
muta on (hot spot), AR p.W742C (bicalutamide 
resistance), TMPRSS2‐ERG, ATRX‐ATAD2B gene 
fusion (out‐of‐frame, loss of ATRX func on) 
7 
-94
None 
PTEN copy loss, TP53 muta on 
Table 1. Soma c Gene Analysis of 7 mCRPC pa ents treated with Bipolar Androgen Therapy 
DDR = DNA Damage Response Genes 


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BAT/Immunotherapy Combination:  
Even more notably, we have observed intriguing tumor responses in two mCRPC 
patients with intact DNA repair processes (i.e. no repair gene mutations) that were treated 
sequentially (on two different trials) with BAT followed by PD-1 inhibition, who achieved 
dramatic PSA/RECIST responses to PD-1 blockade (Figure 8). Patient #1 initially achieved a 
PSA50 response to BAT, which lasted 11 months, before developing subsequent progression. 
Upon starting checkpoint inhibition following BAT, his PSA level dropped from 56 ng/mL to 
4 ng/mL in the first 12 weeks, accompanied by a dramatic soft tissue response (Figure 8A). 
Patient #2 also initially achieved a PSA50 response to BAT lasting 6 months, but eventually 
progressed. Following subsequent treatment with Pembrolizumab, his PSA dropped from 
692 ng/mL to 3 ng/mL, with a partial radiographic response after only 3 months of anti-PD-
1 therapy (Figure 8B). Importantly, neither patient had a DNA repair mutation although 
both benefited dramatically from PD-1 inhibition following BAT. Based on these 
preliminary data, we believe that further study of BAT with a checkpoint inhibitor is 
warranted. 
 
 
 
‐100.00% 
‐75.00% 
‐50.00% 
‐25.00% 
0.00% 
25.00% 
50.00% 
75.00% 
100.00% 
Percent Change 
PSA responses 
DRD ‐ 
DRD + 
Figure 7. Waterfall Plot of Maximum PSA Change (%) in mCRPC Pa ents Following Treatment  
       With Combina on Checkpoint Inhibitor Therapy   
 
    Red Bars– DNA Repair Deficient; Blue Bars – Intact DNA Repair  
 


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In this trial, we will adopt a timed-sequential approach, whereby patients will first receive 
BAT and followed 12 weeks later by the addition of Nivolumab. We hypothesize that (1) 
BAT-induced dsDNA breaks/rearrangements will result in neoantigen formation and 
increased sensitivity to Nivolumab (primary hypothesis); that (2) mCRPC patients with 
germline/somatic mutations in DNA repair genes will derive the greatest clinical benefit 
from both BAT and Nivolumab; and (3) that the combination of BAT with Nivolumab will be 
safe and well-tolerated in mCRPC patients resulting in minimal grade 3/4 toxicities. 
 
1.3.2 
Rationale for Dosage Selection 
Nivolumab will be administered at a flat dose of 480mg IV given every 4 weeks until 
progression. Nivolumab has been extensively studied in humans at doses ranging from 1-
10mg/kg every 2 weeks to 0.3-10mg/kg every 3 weeks.  Using these doses, the clinical 
pharmacology of Nivolumab is well-established.  Based on the exposure-response 
relationships for efficacy and safety, the benefit-risk profile of Nivolumab 480mg given 
every 4 weeks is predicted to be similar to the 3mg/kg dosing across multiple tumor types 
(Zhao X et al. A Model‐Based Exposure–Response (E–R) Assessment of a Nivolumab (NIVO)  4‐
Weekly (Q4W) Dosing Schedule Across Multiple Tumor Types. AACR 2017: CT101.)  
Testosterone cypionate will by administered at a dose of 400mg IM every 28 days (4 
weeks). This dose of testosterone has been shown to be both safe and efficacious in mCRPC 
patients. 
 
 
Pa ent #1 
PSA Decline: 92% 
Pre‐Treatment 
On‐Treatment 
Pa ent #2 
PSA Decline: 99.6% 
Figure 8. CT Imaging of Post‐BAT mCRPC Pa ents Before and During Treatment  
       With Checkpoint Inhibi on.  Red arrows indicate target lesion.  
A. 
B. 


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2.  
OBJECTIVES 
2.1 
Primary Objective 
The primary objective is to estimate the PSA response rate (PSA50) in patients with 
metastatic castration-resistant prostate cancer (mCRPC). This will serve as an initial 
exploration of this drug-drug combination’s activity in this disease state. 
2.2 
Secondary Objectives 
 
Safety/Tolerability, defined as incidence of CTCAE grade ≥ 3 toxicities experienced by 
patients on the trial. 
 
PSA progression-free survival, defined as the time from initiation on BAT until PSA increase 
of 25%, confirmed with another measurement at least 4 weeks later (PCWG3). 
 
Progression-free survival, defined as the time to radiographic or clinical progression or 
death, whichever comes first.  Based on RECIST version 1.1 and PCWG3 definitions 
including: 1. Progression of soft tissue lesions according to RECIST 1.1; 2. Progression of 
bony lesions detected by bone scan according to PCWG3 criteria; 3. Radiographically-
confirmed spinal cord compression or pathological fracture due to malignant progression, 
or other clinical event deemed to be cancer-related. 
 
Objective response rate, defined as the proportion of patients achieving a complete/partial 
response in target lesions (RECIST 1.1). 
 
Durable progression-free survival (Durable-PFS), defined as the proportion of patients 
without clinical or radiographic progression (as defined by PCWG3) or death at 24 weeks 
from the start of treatment. 
 
Overall survival will be defined as the time from study enrollment to death or up to 2 years 
after the last dose of study treatment.   
2.3 
Correlative/Exploratory/Tertiary Objectives 
 
To estimate the percentage of patients with somatic (tumor) or germline mutations in 
homologous repair (HR) and mismatch DNA repair mutations. 
 
To measure changes in gamma-H2AX, RAD51, 53BP1 (DNA damage markers) following 
treatment with BAT and at progression on BAT/Nivolumab. 
 
To measure changes in CD4, CD8, FOXA3, Ki-67, PD-1, PD-L1 tumor levels with BAT alone 
and at progression following BAT/Nivolumab. 
 
To investigate any association between PD-1 and PD-L1 expression in tumor specimens and 
PSA50 response rates. 
 
To explore the relationship between mutation-associated neoantigens (MANAs) and tumor-
associated neoantigens (TAAs) and clinical outcomes. 
 
To characterize the effect of BAT on production of inflammatory chemokines and cytokines. 
 
 
 


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3. 
PATIENT SELECTION 
3.1 
Target Population 
The target population is men with metastatic castration-resistant prostate cancer with prior 
treatment of at least ONE novel AR-targeted therapy such as abiraterone acetate or 
enzalutamide. One prior chemotherapy agent for mCRPC will be allowed but is not required. 
3.2 
Expected Enrollment 
A total of 44 patients will be included in this study. The first patients are expected to be 
enrolled in Q3/Q4 2018. Accrual is expected to be completed in 18 months once the 
protocol has been approved by the IRB at each participating institution. 
3.3 
Inclusion Criteria 
To be included in this study, patients should meet all of the following criteria: 
 
Willing and able to provide signed informed consent. 
 
Males aged 18 years of age and above. 
 
Histological or cytologic proof of adenocarcinoma of the prostate. 
 
Known castration-resistant disease, defined according to PCWG3 criteria as: 
 
Castrate serum testosterone level ≤ 50 ng/dL (≤ 1.7 nmol/L). 
 
Subjects who have failed initial hormonal therapy, either by orchiectomy or 
by using a GnRH agonist in combination with an anti-androgen, must first 
progress through anti-androgen withdrawal prior to being eligible. The 
minimum timeframe to document failure of anti-androgen withdrawal will 
be 4 weeks. 
 
Serum PSA progression defined as 2 consecutive increases in PSA over a 
previous reference value within 6 months of the first study treatment, each 
measurement at least 1 week apart. 
 
Or 
 
Documented bone lesions by the appearance of ≥ 2 new lesions by bone 
scintigraphy or dimensionally-measureable soft tissue metastatic lesion 
assessed by CT or MRI. 
 
Absolute PSA ≥ 2.0 ng/mL at screening.   
 
Must have PSA and/or radiographic progression on AT LEAST ONE novel AR-
targeted therapy (abiraterone acetate, enzalutamide). One prior chemotherapy 
agent for mCRPC will be allowed. 
 
Prior treatment with abiraterone, enzalutamide, bicalutamide, and/or ketoconazole 
is allowed. There is no limit on the maximum number or types of prior hormonal 
therapies received. 
 
Must be maintained on a GnRH analogue or have undergone orchiectomy. 
 
Radiographic evidence of metastatic disease by CT scan and/or bone scan, 
performed within the prior 4 weeks of the screening visit. 


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 
Must have a soft tissue lesion available for biopsy collection to perform tumor tissue 
analysis. 
 
Karnofsky Performance Status (KPS): ≥ 70% within 28 days before start of study 
treatment (ECOG ≤ 2) (See Appendix B). 
 
Participants must have normal organ and bone marrow function measured within 
28 days prior to administration of study treatment as defined below: 
 
Hemoglobin ≥ 9.0 g/dL with no blood transfusion in the past 28 days   
 
Absolute neutrophil count (ANC) ≥ 1.0 x 109/L 
 
Platelet count ≥ 100 x 109/L 
 
Total bilirubin within institutional upper limit of normal (ULN) (In patients 
with Gilbert’s syndrome, total bilirubin < 1.5x institutional ULN will be 
acceptable) 
 
Aspartate aminotransferase (AST) (Serum Glutamic Oxaloacetic 
Transaminase (SGOT)) / Alanine aminotransferase (ALT) (Serum Glutamic 
Pyruvate Transaminase (SGPT)) within institutional upper limit of normal  
 
Participants must have Creatinine Clearance estimated using the Modified 
Cockcroft-Gault equation of ≥ 40 mL/min: 
Estimated Creatinine Clearance    = 
(140-age [years]) x weight (kg) 
 
 
 
 
 
 
 serum creatinine (mg/dL) x 72 
 
Participants must have a life expectancy ≥ 6 months. 
 
Male participants and their partners, who are sexually active and of childbearing 
potential, must agree to the use of two highly effective forms of contraception in 
combination [see appendix E for acceptable methods], throughout the period of 
taking study treatment and for 7 months after the last dose of Nivolumab to prevent 
pregnancy in a partner. 
 
No evidence (within 5 years) of prior malignancies (except successfully treated 
basal cell or squamous cell carcinoma of the skin). 
3.4 
Exclusion Criteria 
Patients that meet any of the criteria listed below will not be eligible for study entry: 
 
Has received external-beam radiotherapy within the last 2 weeks prior to start of 
study treatment. 
 
Prior oral anti-androgen (e.g. bicalutamide, nilutamide, enzalutamide, apalutamide), 
or androgen synthesis inhibitor (e.g. abiraterone, orteronel) within the past 2 weeks 
is not permitted. 5-alpha reductase inhibitor therapy (e.g. finasteride, dutasteride) is 
allowed, as long as subject has been stable on medication for past 6 months. 
 
Prior treatment with chemotherapy for the treatment of metastatic hormone-
sensitive prostate cancer is allowed if the last dose of chemotherapy was ≥ 6 months 
prior to enrollment.  In addition, one prior chemotherapy agent for mCRPC will be 
allowed after a minimum wash-out period of 4 weeks prior to enrollment. 


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 
Patients who have received prior treatment with bipolar androgen therapy (e.g. 
high-dose testosterone, BAT) for castrate-resistant prostate cancer (CRPC); 
permitted if used for hormone-sensitive prostate cancer (HSPC). 
 
Pain due to metastatic prostate cancer requiring opioid therapy. 
 
Patients with an intact prostate AND urinary obstructive symptoms are excluded 
(which includes patients with urinary symptoms from benign prostatic hyperplasia 
(BPH), except where the urinary tract obstruction has been medically or surgically 
resolved. 
 
Patients receiving anticoagulation therapy with Coumadin are not eligible for study. 
[Patients on non-coumadin anticoagulants (Lovenox, Xarelto, etc.) are eligible for 
study. Patients on Coumadin who can be transitioned to Lovenox or Xarelto prior to 
starting study treatments will be eligible] . 
 
Patients with prior history of an arteriovenous thromboembolic event that occurred 
within the last 12 months are excluded.  
 
Patients allergic to sesame seed oil or cottonseed oil are excluded.  
 
Involvement in the planning and/or conduct of the study (applies to both BMS staff 
and/or staff at the study site). 
 
Participation in another clinical study with an investigational product during the 
last 4 weeks/28 days. 
 
Patients should be excluded if they have had prior systemic treatment with an anti-
PD-1, anti-PD-L1, anti-PD-L2, anti-CTLA-4 antibody, or any other antibody or drug 
specifically targeting T cell co-stimulation or immune checkpoint pathways (e.g. 
immune checkpoint antagonists). 
 
Evidence of disease in sites or extent that, in the opinion of the investigator, would 
put the patient at risk from therapy with testosterone (e.g. femoral metastases with 
concern over fracture risk, severe and extensive spinal metastases with concern 
over spinal cord compression, extensive liver metastases).  
 
Concurrent use of other anticancer agents or treatments, with the following 
exceptions:  
 
 
Ongoing treatment with LHRH agonists or antagonists, denosumab (Prolia) 
or bisphosphonate (e.g. zoledronic acid) is allowed. Ongoing treatment 
should be kept at a stable schedule; however, if medically required, a change 
of dose, compound, or both is allowed. 
 
Any treatment modalities involving major surgery within 4 weeks prior to the start 
of study treatment. 
 
Symptomatic nodal disease, i.e. scrotal, penile or leg edema (CTCAE ≥ Grade 3). 
 
Patients are excluded if they have active, known brain metastases or leptomeningeal 
metastases. Subjects with brain metastases are eligible if metastases have been 
treated and there is no magnetic resonance imaging (MRI) evidence of progression 
for ≥ 4 weeks after treatment is complete and within 28 days prior to the first dose 
of testosterone administration. There must also be no requirement for 


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immunosuppressive doses of systemic corticosteroids (> 10 mg/day prednisone 
equivalents) for ≥ 2 weeks prior to study drug administration. 
 
Patients should be excluded if they have an active, known or suspected autoimmune 
disease (e.g. inflammatory bowel disease, rheumatoid arthritis, autoimmune 
hepatitis, lupus, celiac disease). Subjects are permitted to enroll if they have vitiligo, 
type I diabetes mellitus, residual hypothyroidism due to autoimmune condition only 
requiring hormone replacement, psoriasis not requiring systemic treatment, or 
conditions not expected to recur in the absence of an external trigger. 
 
Patients should be excluded if they have a condition requiring systemic treatment 
with either corticosteroids (> 10 mg/day prednisone equivalents) or other 
immunosuppressive medications within 14 days of study drug administration. 
Inhaled or topical steroids and adrenal replacement doses > 10 mg/day prednisone 
equivalents are permitted in the absence of active autoimmune disease. 
 
Permitted therapies include topical, ocular, intra-articular, intranasal, and 
inhalational corticosteroids (with minimal systemic absorption). Physiologic 
replacement doses of systemic corticosteroids are permitted, even if > 10 mg/day 
prednisone equivalents. A brief course of corticosteroids for prophylaxis (e.g. 
contrast dye allergy) or for treatment of non-autoimmune conditions (e.g. delayed-
type hypersensitivity reaction caused by contact allergen) is permitted. 
 
As there is potential for hepatic toxicity with Nivolumab, drugs with a 
predisposition to hepatotoxicity should be used with caution in patients treated 
with Nivolumab-containing regimen. 
 
Patients should be excluded if they have a positive test for hepatitis B virus surface 
antigen (HBV sAg) or hepatitis C virus ribonucleic acid (HCV antibody) indicating 
acute or chronic infection. 
 
Patients should be excluded if they have known history of testing positive for human 
immunodeficiency virus (HIV) or known acquired immunodeficiency syndrome 
(AIDS). 
 
History of allergy to study drug components. 
 
History of severe hypersensitivity reaction to any monoclonal antibody. 
 
Other primary tumor (other than CRPC) including hematological malignancy 
present within the last 5 years (except non-melanoma skin cancer or low-grade 
superficial bladder cancer). 
 
Has imminent or established spinal cord compression based on clinical findings 
and/or MRI. 
 
Any other serious illness or medical condition that would, in the opinion of the 
investigator, make this protocol unreasonably hazardous, including, but not limited 
to: 
 
Any uncontrolled major infection. 
 
Cardiac failure NYHA (New York Heart Association) III or IV. 
 
Crohn’s disease or ulcerative colitis. 
 
Bone marrow dysplasia. 
 
Known allergy to any of the compounds under investigation. 


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 
Unmanageable fecal incontinence. 
 
Persistent toxicities (CTCAE > Grade 2) caused by previous cancer therapy, 
excluding alopecia. 
 
Poor medical risk due to a serious, uncontrolled medical disorder, non-malignant 
systemic disease, or active, uncontrolled infection. Examples include, but are not 
limited to, uncontrolled ventricular arrhythmia, recent (within 6 months) 
myocardial infarction, uncontrolled major seizure disorder, extensive interstitial 
bilateral lung disease, or any psychiatric disorder that prohibits obtaining informed 
consent. 
4. 
PATIENT REGISTRATION AND ENROLLMENT PLAN 
4.1 
Registration Procedure 
After eligibility screening and confirmation that a patient is eligible, patients who are 
selected to participate will be registered with the Lead Center, Johns Hopkins University, 
with their local study site/institution, and if applicable, in the online centralized PCCTC 
database. A record of patients who fail to meet entry criteria (i.e. screen failures) will be 
maintained. Patient registration must be complete before beginning any treatment or study 
activities. A complete, signed study consent is required for registration. 
4.1.1 
Registration at Johns Hopkins University 
Confirm eligibility as defined in Section 3. 
Patient Selection.  
Obtain informed consent, by following procedures in Section 12.3 
 
Written Informed Consent. 
Patient will be entered into the CRMS system and enrolled in the trial.  
4.1.2 
Multicenter/Participating Site Registration 
Central registration for this study will take place at Johns Hopkins University. 
Patient registration at each study site/institution will be conducted according to the 
institution’s established policies. Before registration, patients will be asked to sign 
and date an Institutional Review Board (IRB)-approved consent form. Patients must 
be registered with their local site/institution and also with the Lead Site before 
beginning any treatment or study activities. 
 
 
5. 
TREATMENT/INTERVENTION PLAN 
 
The following assessments and procedures will occur during the study. A schedule of 
assessments is provided in Table 2. 


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Table 2. Study Calendar 
  
Screening 
                                                      Study Period 
On Treatment Assessments                     
(Every 28 days) 
BAT Alone 
On Treatment Assessments    
(Every 28 days) 
Nivolumab + BAT  
End of 
Treatment 
Visit 
Off study 
follow‐up 
 
Survival 
follow‐up 
 
Day           
-28 to -1 
C1D1    
(±5 d) 
JHU only 
 
C1D4 
(±5 d) 
 
 
C2D1      
(±5 d) 
C3D1       
(±5 d) 
C4D1          
(±5 d)c 
CnD1           
(±5 d) 
28 days 
after last 
dose 
 
 
 
(±5 d)c 
Every 28 
days e / 
100 days 
after last 
dose 
 
(±5 d) 
Up to 1 year 
after last 
dose or AE 
resolution 
datee 
 
(Q6mo.) 
Informed Consent 
Xa 
  
 
  
  
  
  
  
 
Demographics 
X 
  
 
  
  
  
  
  
 
Complete Medical History 
X 
  
 
  
  
  
  
  
 
EKG 
Xk 
  
 
  
  
  
  
 
Testosterone cypionate 
  
X 
 
X 
X 
X 
X 
  
 
Nivolumab 
  
  
 
  
  
X 
X 
  
 
Focused Medical History 
  
X 
 
X 
X 
X 
X 
X 
 
Physical Exam 
Xl 
Xl 
 
Xl 
Xl 
Xl 
Xl 
Xl 
 
Vital Signs (P, BP, RR, T) 
Xl 
Xl 
 
Xl 
Xl 
Xl 
Xl 
Xl 
 
Height 
Xl 
  
 
  
  
  
  
  
 
Weight 
Xl 
Xl 
 
Xl 
Xl 
Xl 
Xl 
Xl 
 
ECOG Performance Status 
(ECOG) 
X 
  
 
X 
X 
X 
X 
X 
 
Toxicity Assessment 
X 
  
 
X 
X 
X 
X 
X 
 
Concomitant Medications 
X 
X 
 
X 
X 
X 
X 
X 
 
 
CBC w/ Diff 
X 
Xg 
 
X 
X 
X 
X 
X 
 
 
CMP 
X 
Xg 
 
X 
X 
X 
X 
X 
 
 
PSA 
X 
Xg 
 
X 
X 
X 
X 
X 
 
 
 


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Serum Testosterone 
X 
Xg 
X 
X 
X 
X 
X 
X 
 
 
Serum Amylase/Lipase/ 
CK; TSH w/ Reflex T3, T4 
X 
  
  
  
 
X 
X 
X 
 
 
Hepatitis B/C; PTT, 
PT/INR; Urinalysis 
X 
  
  
  
 
  
  
  
 
 
Radiologic Tests 
Xb 
  
  
  
 
Xbc 
Xb 
Xbc 
 
 
Core Tumor Biopsy 
Xf 
  
  
  
 
Xf 
  
Xf 
 
 
Rectal Swab  
 
  Xi  
  
  
 
 Xi 
 Xi 
  
 
 
Germline DNA Testing 
 
 Xh 
  
  
 
 
 
  
 
 
Plasma for MANAs/TAAs 
 
Xd 
  
  
 
Xd 
 
Xd 
 
 
Plasma for Chemokines 
 
Xj 
Xj 
Xj 
 
 
Xj 
 
 
 
Adverse Events 
  
  
 
X 
X  
X 
X 
X 
Xe 
 
Survival Contact 
 
 
 
 
 
 
 
 
Xe 
Abbreviations: CBC, complete blood count; CT, computerized tomography; MRI, magnetic resonance imaging; PSA, prostate-specific antigen; CK, creatine kinase; TSH, thyroid 
stimulating hormone 
 
a 
Informed consent should be obtained within 4 weeks (28 days) of study start date (C1D1).  
b 
Radiographic evaluations (CT C/A/P) and NM Bone Scan every 3 months while enrolled in the study) are needed within 4 weeks of the screening visit; if previously performed within the last 4 
weeks they do not need to be repeated. CT C/A/P and NM Bone Scan are to be performed at the End of Treatment (EOT) visit if they have not been performed within the prior month.  
c 
For visits C4D1 and EOT only, the window for radiographic evaluations will be extended to 2 weeks before the visit occurs to account for biopsy scheduling availability. 
d 
Plasma for MANAs/TAAs assay will be drawn at C1D1, C4D1, and at progression (EOT) for JHU patients ONLY. 
e 
Subjects will be followed after withdrawal of BAT +/- Nivolumab therapy due to toxicity, monthly until toxicities resolve to grade ≤ 1. Otherwise, subjects will be followed at 100 days after last 
dose for AE reassessment. Survival follow-up will continue for up to 1 year through telephone contact every 6 months, to begin after the 100-day follow-up contact or from the AE resolution date 
if it exceeds the 100 day follow-up timepoint. 
f 
MANDATORY core tumor biopsy performed during the Screening period (prior to C1D1) (Day -28 to -1) and on C4D1 (+/- 7 days). An OPTIONAL tumor biopsy will be performed at the End of 
Treatment visit (+/- 7 days).  
g  
Labs do not need to be repeated if done within 7 days of screening. 
h  
Germline DNA testing per standard of care practice is optional. To be submitted after obtaining informed consent and prior to C2D1. 
i        Rectal Swabs to be performed before treatment with testosterone (C1D1), prior to starting Nivolumab (C4D1), and after 3 cycles of Nivolumab (C7D1) for JHU patients ONLY. 
j        Plasma sample for Chemokines analysis (optional) will be obtained at C1D1 prior to the first injection of BAT, 3 hours after the first injection of BAT, C1D4, C2D1, and C7D1 for JHU patients ONLY. 
k       EKG’s must be collected within 14 days of receiving the first study treatment. 
l       Physical exam (including vital signs/height/weight) may be missed if not clinically indicated or in the event of a telemedicine visit. In order to minimize the need for research-only in-person visits, 
telemedicine visits may be substituted for in-person clinical trial visits or portions of clinical trial visits where determined to be appropriate and where determined by the investigator not to 
increase the participants risks. Prior to initiating telemedicine for study visits the study team will explain to the participant, what a telemedicine visit entails and confirm that the study participant 
is in agreement and able to proceed with this method. Telemedicine acknowledgement will be obtained in accordance with the Guidance for Use of Telemedicine in Research. In the event 
telemedicine is not deemed feasible, the study visit will proceed as an in-person visit. Telemedicine visits will be conducted using HIPAA compliant method approved by the Health System and 
within licensing restrictions. 
 
 


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5.1 
Screening Assessment (Day ‐28 to Day ‐1) 
Before initiating any screening activities, the scope of the study should be explained to each 
patient. Patients should be advised of any known risks inherent in the planned procedures, 
any alternative treatment options, their right to withdraw from the study at any time for 
any reason, and their right to privacy. After this explanation, patients should be asked to 
sign and date an IRB-approved informed consent that meets the requirements of the Code 
of Federal Regulations (Federal Register Vol. 46, No. 17, January 27, 1981, part 50).
The screening visit will determine patient eligibility according to the inclusion and 
exclusion criteria (Sections 3.3 Inclusion Criteria & 3.4 Exclusion Criteria). The following 
assessments will be performed at this visit:  
 
Obtain informed consent and research authorization. 
 
Record demographics (including age) and medical history (including 
prior treatment for prostate carcinoma). 
 
Conduct physical exam (including vital signs, height/weight).  The 
physical exam may be missed if screening visit is taking place over 
telemedicine. 
 
Obtain histologic and radiologic confirmation of disease. If radiographic 
studies have not been performed in prior 4 weeks of the screening visit, 
they must be obtained as part of screening. 
 
Obtain history regarding prior treatment history for prostate cancer 
(including history of ADT, history of radiation therapy, or other local 
therapy). 
 
Perform laboratory tests (Complete blood count w/ Diff, PSA, 
Comprehensive metabolic panel, urinalysis, PT/INR, PTT, serum 
testosterone, TSH with reflexive T3, T4 testing, serum Creatine kinase 
(CK), serum amylase/lipase, and Hepatitis B/C panel). 
 
Assess performance status (ECOG). (Appendix B). 
 
Perform 12-lead EKG. ECGs are required within 14 days prior to 
starting study treatment and when clinically indicated. 
 
Twelve-lead ECGs will be obtained after the patient has been 
rested in a supine position for at least 5 minutes in each case.  
The Investigator or designated physician will review the paper 
copies of each of the timed 12-lead ECGs on each of the study 
days when they are collected. 
 
ECGs will be recorded at 25 mm/sec.  All ECGs should be 
assessed by the Investigator as to whether they are clinically 
significantly abnormal or not clinically significantly abnormal.  
If there is a clinically significant abnormal finding, the 
Investigator will record it as an AE on the eCRF.  The original 
ECG traces must be stored in the patient medical record as 
source data. 
 
Determine suitability for Testosterone + Nivolumab. 


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 
Obtain image-guided biopsy of a site of disease (i.e. soft tissue, lymph 
node) – further described in section 5.1.1. 
 
Discuss concurrent medications.  
 
Provide instructions for obtaining a CLIA-certified laboratory (i.e. 
COLOR genomics) kit for germline DNA testing per standard of care 
practice (Optional). 
 
Relevant information should be documented. The institutional registration should be 
finalized, and appropriate documents (i.e. signed informed consent and supporting source 
documentation for eligibility questions) emailed to the Lead site. 
 
Information for patients who do not meet the eligibility criteria to participate in this study 
(i.e. screening failures) should be captured in the CRMS database at the screening 
assessment. 
 
5.1.1 
Surgical Procedures 
A core needle biopsy of a site of disease (soft tissue, lymph node) will be performed 
during the Screening period (prior to C1D1). Patients will be referred to their 
respective biopsy service for an image-guided core biopsy. At least 4 standard core 
biopsies should be attempted to be obtained from the site (soft tissue, lymph node). 
Fine needle aspiration is unlikely to yield adequate tumor tissue for molecular 
analysis, and should only be attempted when core biopsy is not feasible.  The unique 
subject number given by the Lead site during registration should be used to identify 
the biopsy samples to protect the subject’s identity.  
For each biopsy timepoint, ≥ 4 fresh cores will be collected from the same site of 
disease chosen during the Screening period (prior to C1D1); ≥ 2 fresh cores will be 
collected for immediate flash-freezing in liquid nitrogen and ≥ 2 cores will be 
formalin-fixed and paraffin-embedded. For soft-tissue biopsies, 18-gauge core 
biopsy needles are recommended. 
To minimize tissue autolysis, a dedicated tissue technician should be appointed and 
called/paged to the biopsy room to initiate processing steps including FFPE 
preparation, which should be done within 30 minutes of biopsy collection, and the 
flash-freezing of the other designated cores with liquid nitrogen. FFPE specimens 
should be processed according to standard institutional FFPE procedures. All 
samples will be sent to the De Marzo Laboratory for analysis. 
Note. If site(s) do not have the capability to perform flash-freezing of tumor tissue 
cores with liquid nitrogen, all available tumor tissue core specimens should be 
prepared and processed according to standard institutional FFPE procedures. 
 
5.1.1.1 Potential Biopsy Complications 
Potential complications of a research biopsy include: infection, bleeding, and 
pain at the biopsy site. 
 
 


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5.2 
Testosterone Lead‐in Period (Day 1 of each 28 day cycle +/‐ 5 days, (C1D1, C2D1, 
 
C3D1)) 
Patients will be seen on Day 1 of each cycle of testosterone (consisting of 28 days, +/- 5 
days).  The following assessments will be performed at each visit:  
 
Conduct physical exam (including vital signs, weight).  The physical 
exam may be missed if visit is taking place over telemedicine. 
 
Obtain any medical history changes from prior assessment. 
 
Assess performance status (ECOG). (Appendix B). 
 
Review concurrent medications.   
 
Confirm germline DNA sample submitted per standard of care practice, 
if applicable (To be submitted prior to C2D1). 
 
Obtain Rectal swab for microbiome analysis for JHU patients ONLY. 
5.2.1 
Clinical and Laboratory Assessments 
On Day 1 of each cycle, patients will have a non-fasting blood draw for the following 
values: (Repeat labs are not needed on C1D1 if within 7 days of screening values.) 
 
CBC w/ Diff 
 
Comprehensive metabolic panel 
 
PSA 
 
Serum Testosterone 
 
MANAs/TAAs assay blood draw (100mL; C1D1 only) for JHU patients 
ONLY 
 
Chemokines plasma blood draw (10mL; C1D1 predose, 3 hours after 
first testosterone injection, C1D4, C2D1) for JHU patients ONLY 
(Optional). 
Laboratory Safety Assessments: 
Full hematology assessments for safety (hemoglobin, red blood cells [RBC], 
platelets, mean cell volume [MCV], mean cell hemoglobin concentration [MCHC], 
mean cell hemoglobin [MCH], white blood cells [WBC], absolute differential white 
cell count (neutrophils, lymphocytes, monocytes, eosinophils and basophils) and 
absolute neutrophil count or segmented neutrophil count and Band forms should be 
performed at each visit and when clinically indicated.  If absolute differentials not 
available, will check % differentials. Coagulation [activated partial thromboplastin 
time (APTT) and international normalized ratio (INR)] will be performed at baseline 
and if clinically indicated. 
Biochemistry assessments for safety (sodium, potassium, calcium, glucose, 
creatinine, total bilirubin, alkaline phosphatase [ALP], aspartate transaminase 
[AST], alanine transaminase [ALT], urea or blood urea nitrogen [BUN], total protein, 
albumin. 
Urinalysis should be performed at baseline and then only if clinically indicated. 
Microscopic analysis should be performed by the hospital’s local laboratory if 
required. 


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These tests will be performed by the hospital’s local laboratory.  Additional analyses 
may be performed if clinically indicated. 
Any clinically significant abnormal laboratory values should be repeated as clinically 
indicated and recorded on the eCRF. 
In case a subject shows an AST or ALT ≥ 3xULN or total bilirubin ≥ 2xULN, please 
refer to Appendix F “Actions required in cases of combined increase of 
Aminotransferase and Total Bilirubin – Hy’s Law”, for further instructions. 
5.2.3 
Safety Assessments 
Adverse events (AEs) will be monitored at each scheduled visit and throughout the 
study. Toxicity will be assessed using the most recent National Cancer Institute 
(NCI) guidance: the most recent version of Common Terminology Criteria for 
Adverse Events (CTCAE).  
5.3 
Testosterone/Nivolumab Combination Period (Day 1 of each 28 day cycle +/‐ 5 days, 
 
(C4D1, C5D1, CnD1,  continuous)) 
Patients will be seen on D1 of each cycle of Testosterone/Nivolumab (consisting of 28 days, 
+/- 5 days).  The following assessments will be performed at each visit:  
 
Conduct physical exam (including vital signs, weight).  The physical 
exam may be missed if visit is taking place over telemedicine. 
 
Obtain any medical history changes from prior assessment. 
 
Assess performance status (ECOG). (Appendix B). 
 
Review concurrent medications.  
5.3.1 
Clinical and Laboratory Assessments 
On Day 1 of each cycle (beginning C4D1), patients will have a non-fasting blood 
draw for the following values:   
 
CBC w/ Diff 
 
Comprehensive metabolic panel 
 
PSA  
 
Serum Testosterone 
 
TSH w/ reflexive T3, T4 
 
Serum Amylase/Lipase 
 
Serum Creatine kinase (CK) 
 
MANAs/TAAs assay blood draw (C4D1, End of Treatment) for JHU patients 
ONLY 
 
Rectal swab will be obtained prior to C4D1 and C7D1 for JHU patients ONLY 
 
Chemokines plasma blood draw (10mL; C7D1) for JHU patients ONLY 
(Optional) 
Every 3 cycles, patients will have radiographic studies beginning C4D1: 
 
CT Chest, Abdomen, and Pelvis with contrast. 
 
NM Bone scan. 


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Note: For visits C4D1 and EOT only, the window for obtaining radiographic 
evaluations will be extended to 2 weeks before the visit occurs to account for biopsy 
scheduling availability. 
5.3.2 
Surgical Procedures 
A core needle biopsy will be performed on C4D1 (+/- 7 days) at the same site of     
disease previously biopsied during the Screening period. This biopsy is considered 
mandatory. However, patients can remain on study if biopsy is refused. Further 
description of this biopsy can be found in section 5.1.1. 
5.4 End of Treatment/Treatment Discontinuation Visit (28 days after last dose +/‐ 5 days) 
 
Conduct physical exam (including vital signs, weight).  The physical exam may be missed if 
visit is taking place over telemedicine. 
 
Assess performance status (ECOG). (Appendix B). 
 
Review concurrent medications. 
 
Assess AEs. 
 
If patient is discontinuing participation in study, perform radiographic tests: CT C/A/P and 
NM Bone Scan (if not performed within the prior month). 
 
The following non-fasting blood draw will include: 
 
CBC w/ Diff 
 
Comprehensive metabolic panel 
 
PSA  
 
Serum Testosterone 
 
TSH w/ reflexive T3, T4 
 
Serum Amylase/Lipase 
 
Serum Creatine kinase (CK) 
 
MANAs/TAAs assay blood draw (if not done within the prior 90 days) 
for JHU patients ONLY 
5.4.1 
Surgical Procedures 
A core needle biopsy will be performed at progression (EOT) (+/- 7 days) at the 
same site of disease previously biopsied during the Screening period. This biopsy is 
considered optional. Further description of this biopsy can be found in section 5.1.1. 
 
5.5 
Follow‐up (Every 28 days while active AEs/100 days after last dose & Survival status 
+/‐ 5 days) 
Patients that received Nivolumab and discontinue due to progression, will be followed and 
contacted at 100 days after last dose.  
 
Patients that have discontinued the study due to AEs will be followed every 28 days 
(monthly) beyond the end of treatment (EOT) visit. They will be followed until the AE has 
either resolved or stabilized (Grade ≤ 1). If the event resolves or stabilizes before they reach 
100 days after last dose, they will be contacted at the 100 day timepoint. Reasons for 
premature withdrawal should be determined and noted.  
 
To be performed at each contact will be: 
 


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 
Reassess AEs. 
 
Following completion of the 100 day follow-up OR the resolution/stabilization of the AE(s) 
responsible for premature withdrawal (if beyond 100 days after last dose), patients will be 
followed for overall survival every 6 months for 1 year.  
 
To be performed at each contact will be: 
 
 
Reassess for survival. 
 
5.6 
Correlative/Special Studies 
5.6.1. DNA Sequencing 
FFPE biopsy tissue (collected during the Screening period) will be sent to Foundation 
Medicine for next generation sequencing, based upon their commercially available platform.   
 
5.6.2. PD‐1, PD‐L1, FOXP3, CD4, CD8, γH2AX, RAD51, 53BP1 Protein Levels 
A sample of biopsy (from each biopsy done on study) will be sent to the De Marzo 
Laboratory for analysis. 
 
5.6.3. Whole Exome Sequencing  
Flash frozen biopsy tissue collected from the Screening period/C4D1/ progression (EOT) 
biopsies will be sent to the De Marzo Laboratory for whole exome sequencing in 
collaboration with the Next Generation Sequencing Core Lab to be performed in concert 
with the MANAs/TAAs assays. 
 
5.6.4. MANAs/TAAs Assay 
Plasma will be obtained at C1D1, C4D1, and at progression (EOT). The MANAs/TAAs assay 
will be performed by the Immune Processing Core Lab (Appendix C). 
 
5.6.6.  Chemokines Analysis 
Plasma will be obtained prior to the first BAT injection on C1D1, 3 hours and 3 days (C1D4) 
after the first testosterone injection, C2D1, and C7D1. Samples will be processed and stored 
in the Denmeade Laboratory at Johns Hopkins. Analysis will be performed by the Immune 
Processing Core Lab. 
 
 
6. 
Study Drugs 
6.1 
Description of Treatments 
The drugs to be tested in this clinical protocol are Testosterone cypionate and Nivolumab.    
Nivolumab will be supplied by Bristol-Myers Squibb, Co. 
6.2 
Administration, Supply, and Storage 
Nivolumab will be dosed at 480mg IV over a 30 minute period every 4 weeks (+/- 5 days) 
beginning on C4D1. Testosterone cypionate will be dosed at 400mg IM every 4 weeks (+/- 5 
days) beginning on C1D1. Treatment will be administered on an outpatient basis.  
 


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Nivolumab: 
 
PRODUCT INFORMATION TABLE: Please also see Nivolumab Investigator Brochure. 
Table 
Product Description 
Product 
Description and 
Dosage Form 
Potency 
Primary 
Packaging
(Volume) 
Secondary 
Packaging 
(Qty)/ 
Label Type 
Appearance 
Storage 
Conditions 
(per label) 
Nivolumab BMS-
936558-01 
Solution for 
Injection 
100 mg  
(10 mg/mL) 
10 mL vial
5 vials per 
carton/Open-
label 
Clear to opalescent 
colorless to pale 
yellow liquid. May 
contain particles. 
2 to 8°C. Protect 
form light and 
freezing. 
*Nivolumab may be labeled as BMS-936558-01 Solution for Injection 
 
If stored in a glass front refrigerator, vials should be stored in the carton. Recommended 
safety measures for preparation and handling of Nivolumab include laboratory coats and 
gloves. 
For additional details on prepared drug storage and use time of Nivolumab under room 
temperature/light and refrigeration, please refer to the BMS-936558 (Nivolumab) 
Investigator Brochure section for “Recommended Storage and Use Conditions”.  
 
Testosterone cypionate 
Testosterone cypionate injection is for intramuscular use only. It should not be given intravenously. 
Intramuscular injections should be given deep in the gluteal muscle.  
Testosterone will be used in the commercially available formulation, it will be purchased by the 
participant’s site pharmacy; the cost will be covered by the study and will be provided to the 
patient at no charge.  
Vials should be stored at controlled room temperature 20°C to 25°C (68°F to 77°F) [see USP]. 
Protect from light. Use carton to protect contents from light until used. Warming and rotating the 
vial between the palms of the hands will redissolve any crystals that may have formed during 
storage at low temperatures.  
7 
DOSE ADJUSTMENT AND DELAY, TREATMENT DISCONTINUATION, 
 
WITHDRAWAL, AND TERMINATION CRITERIA 
 
7.1 
Dosing and Dose Modifications 
 
7.1.1 Dosing 
Testosterone cypionate will be given at a dose of 400mg IM every 28 days (4 weeks) 
approximately (+/- 5 days) beginning on C1D1 until progression or end of study. 
Nivolumab 480mg will administered intravenously over a 30 minute period every 4 weeks 
(+/- 5 days) beginning on C4D1 until progression or end of study.   
 


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7.1.2 Dose Modifications 
There will be no dose modifications permitted. Dose reductions or dose escalations are not 
permitted. 
7.2        Dose Delay and Treatment Discontinuation 
Dose delay criteria apply for all drug-related adverse events (regardless of whether or not 
the event is attributed to Nivolumab, Testosterone, or both). All study drugs must be 
delayed until treatment can resume. 
7.3 
Dose Delay Criteria  
Nivolumab and Testosterone administration should be delayed for the following: 
 
Any Grade ≥ 2 non-skin, drug-related adverse event, with the following exceptions: 
 
Grade 2 drug-related fatigue or laboratory abnormalities do not require a treatment 
delay. 
 
Any Grade 3 skin, drug-related adverse event. 
 
Any Grade 3 drug-related laboratory abnormality, with the following exceptions for AST, 
ALT, or total bilirubin: 
 
Delay dosing for drug-related AST, ALT, or total bilirubin grade ൒ 2 toxicity. 
 
Grade 3 amylase or lipase abnormalities that are not associated with symptoms or clinical 
manifestations of pancreatitis do not require a dose delay.  
 
Grade 3 lymphopenia does not require a dose delay. 
 
Any adverse event, laboratory abnormality, or intercurrent illness, which, in the judgment 
of the investigator, warrants delaying the dose of study medication. 
Because of the potential for clinically meaningful Nivolumab-related AEs requiring early 
recognition and prompt intervention, management algorithms have been developed for 
suspected pulmonary toxicity, GI, hepatotoxicity, endocrinopathy, skin toxicity, neurological 
toxicity and renal toxicity. The recommendations are to follow the Nivolumab IB adverse 
event algorithm (Appendix A). 
7.4  
Criteria to Resume Treatment 
Missed doses of Nivolumab and/or Testosterone should be administered when subject 
meets criteria to resume treatment. If a Testosterone and Nivolumab dose has been 
missed, the subject should wait until the next scheduled dosing date following the 
originally planned dosing schedule that is consistent with the study calendar. 
 
Subjects  may  resume  treatment  with  study  drug  when  the  drug-related AE(s)  
resolve to Grade ≤ 1 or baseline value, with the following exceptions: 
 
Subjects may resume treatment in the presence of Grade 2 fatigue. 
 
Subjects who have not experienced a Grade 3 drug-related skin AE may resume 
treatment in the presence of Grade 2 skin toxicity. 
 
For subjects with Grade 2 AST, ALT, or total bilirubin elevations, dosing may resume 
when laboratory values return to baseline and management with corticosteroids, if 
needed, is complete. 
 
Subjects with combined Grade 2 AST/ALT AND total bilirubin values meeting 
discontinuation parameters should have treatment permanently discontinued. 
 
Drug-related diarrhea, or colitis, must have resolved to baseline before treatment is 
resumed.  
 
Subjects with persistent Grade 1 pneumonitis after completion of a steroid taper over at 


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least 1 month may be eligible for retreatment if discussed with and approved by the 
investigator. 
 
Drug-related endocrinopathies adequately controlled with only physiologic hormone 
replacement may resume treatment. 
 
If treatment is delayed > 10 weeks, the subject must be permanently discontinued from 
study therapy. 
 
If the subject is unable to resume both Nivolumab and Testosterone, permanent 
discontinuation is required. 
 
7.5         Discontinuation Criteria 
Treatment with Nivolumab and Testosterone should be permanently discontinued for any 
of the following: 
     Any Grade 2 drug-related uveitis or eye pain or blurred vision that does not respond 
to topical therapy and does not improve to Grade 1 severity within the re-treatment period 
OR requires systemic treatment. 
     Any Grade 3 non-skin, drug-related adverse event lasting > 7 days, with the following 
exceptions for drug-related laboratory abnormalities, uveitis, pneumonitis, bronchospasm, 
diarrhea, colitis, neurologic toxicity, hypersensitivity reactions, and infusion reactions: 
 
Grade 3 drug-related uveitis, pneumonitis, bronchospasm, diarrhea, colitis, 
neurologic toxicity, hypersensitivity reaction, or infusion reaction of any duration 
requires discontinuation. 
 
Grade 3 drug-related endocrinopathies adequately controlled with only physiologic 
hormone replacement do not require discontinuation, except for Grade 3 adrenal 
insufficiency which requires permanent discontinuation. 
 
Grade 3 drug-related laboratory abnormalities do not require treatment 
discontinuation except: 
 
Grade 3 drug-related thrombocytopenia > 7 days or associated with 
bleeding requires discontinuation. 
 
Any drug-related liver  function  test  (LFT)  abnormality that  meets  the  
following criteria require discontinuation: 
 
Grade > 3 drug-related AST, ALT, or total bilirubin requires 
discontinuation. 
 
Concurrent AST or ALT > 3xULN and total bilirubin > 2xULN. 
     Any Grade 4 drug-related adverse event or laboratory abnormality, except for the 
following events which do not require discontinuation: 
 
Grade 4 amylase or lipase abnormalities that are not associated with symptoms or 
clinical manifestations of pancreatitis.  
 
Isolated Grade 4 electrolyte imbalances/abnormalities that are not associated with 
clinical sequelae and are corrected with supplementation/appropriate management   
within 72 hours of their onset. 
 
Grade 4 neutropenia < 7 days. 
 
Grade 4 lymphopenia or leukopenia. 
 
Grade 4 drug-related endocrinopathy AEs, such as, hyper- or hypothyroidism, or 
glucose intolerance, that resolve or are adequately controlled with physiologic 
hormone replacement (corticosteroids, thyroid hormones) or glucose-controlling 
agents, respectively, may not require discontinuation after discussion with and 


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approval from the investigator. Grade 4 drug-related adrenal insufficiency or 
hypophysitis requires discontinuation regardless of control with hormone 
replacement. 
    Any dosing interruption lasting > 10 weeks unless the investigator is consulted and agrees 
with the rationale for resuming therapy after a delay > 10 weeks. Note that tumor 
assessments should continue as per protocol even if dosing is interrupted. 
   Any adverse event, laboratory abnormality, or intercurrent illness which, in the judgment 
of the Investigator, presents a substantial clinical risk to the subject with continued 
Nivolumab dosing. 
7.6 
Treatment of Nivolumab‐Related Infusion Reactions 
Since Nivolumab contains only human immunoglobulin protein sequences, each is 
unlikely to be immunogenic and induce infusion or hypersensitivity reactions. However, 
if such a reaction were to occur, it might manifest with fever, chills, rigors, headache, rash, 
pruritus, arthralgias, hypo- or hypertension, bronchospasm, or other symptoms. Infusion 
reactions should be graded according to the most current NCI CTCAE guidelines. 
Treatment recommendations are provided below and may be modified based on local 
treatment standards and guidelines as appropriate: 
For Grade 1 symptoms: (Mild reaction; infusion interruption not indicated; intervention 
not indicated) 
Remain at bedside and monitor subject until recovery from symptoms. The following 
prophylactic premedications are recommended for future infusions: diphenhydramine 50 
mg (or equivalent) and/or paracetamol 325 to 1000 mg (acetaminophen) at least 30 
minutes before additional nivolumab administrations. 
For Grade 2 symptoms: (Moderate reaction requires therapy or infusion interruption but 
responds promptly to symptomatic treatment [e.g. antihistamines, non-steroidal anti-
inflammatory drugs, narcotics, corticosteroids, bronchodilators, IV fluids]; prophylactic 
medications indicated for up to 24 hours). 
Stop the Nivolumab infusion, begin an IV infusion of normal saline, and treat the subject 
with diphenhydramine 50 mg IV (or equivalent) and/or paracetamol 325 to 1000 mg 
(acetaminophen); remain at bedside and monitor subject until resolution of symptoms. 
Corticosteroid or bronchodilator therapy may also be administered as appropriate. If the 
infusion is interrupted, then restart the infusion at 50% of the original infusion rate when 
symptoms resolve; if no further complications ensue after 30 minutes, the rate may be 
increased to 100% of the original infusion rate. Monitor subject closely. If symptoms recur 
then no further Nivolumab will be administered at that visit. Administer diphenhydramine 
50 mg IV, and remain at bedside and monitor the subject until resolution of symptoms. 
The amount of study drug infused must be recorded on the electronic case report form 
(eCRF). The following prophylactic premedications are recommended for future infusions: 
diphenhydramine 50 mg (or equivalent) and/or paracetamol 325 to 1000 mg 
(acetaminophen) should be administered at least 30 minutes before additional Nivolumab 
or administrations. If necessary, corticosteroids (recommended dose: up to 25 mg of IV 
hydrocortisone or equivalent) may be used. 
For Grade 3 or Grade 4 symptoms: (Severe reaction, Grade 3: prolonged [i.e. not rapidly 
responsive to symptomatic medication and/or brief interruption of infusion]; recurrence of 
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sequelae [e.g. renal impairment, pulmonary infiltrates]). Grade 4: (life-threatening; pressor 
or ventilatory support indicated). 
Immediately discontinue infusion of Nivolumab. Begin an IV infusion of normal saline, and 
treat the subject as follows. Recommend bronchodilators, epinephrine 0.2 to 1 mg of a 
1:1,000 solution for subcutaneous administration or 0.1 to 0.25 mg of a 1:10,000 solution 
injected  slowly  for  IV  administration,  and/or  diphenhydramine  50  mg  IV  with 
methylprednisolone 100 mg IV (or equivalent), as needed. Subject should be monitored 
until the investigator is comfortable that the symptoms will not recur. Nivolumab will be 
permanently discontinued. Investigators should follow their institutional guidelines for the 
treatment of anaphylaxis. Remain at bedside and monitor subject until recovery from 
symptoms. In the case of late-occurring hypersensitivity symptoms (e.g. appearance of a 
localized or generalized pruritis within 1 week after treatment), symptomatic treatment 
may be given (e.g. oral antihistamine, or corticosteroids). 
7.7   
Treatment Beyond Disease Progression 
Accumulating evidence indicates a minority of subjects treated with immunotherapy may 
derive clinical benefit despite initial evidence of PD, as described by irRECIST criteria 
(Nishino et al, Clin Cancer Res; 19(14) July 15, 2013). Subjects will be permitted to continue 
treatment beyond initial investigator-assessed progression without reconsent as long as 
they meet the following criteria: 
 
  Investigator-assessed clinical benefit and subject is tolerating study drug. 
  The assessment of clinical benefit should take into account whether the subject is clinically  
deteriorating and unlikely to receive further benefit from continued treatment. 
  Subjects should discontinue study therapy upon evidence of further progression, defined as 
an additional 10% or greater increase in tumor burden volume from time of initial 
progression (including all target lesions and new measurable lesions). 
  Per irRECIST criteria, new lesions are considered measurable at the time of initial 
progression if the longest diameter is at least 10 mm by CT scan (except for pathological 
lymph nodes, which must have a short axis of at least 15 mm). Any new lesion considered 
non-measurable at the time of initial progression may become measurable and therefore 
included in the tumor burden measurement if the longest diameter increases to at least 10 
mm by CT scan (except for pathological lymph nodes, which must have an increase in short 
axis to at least 15 mm). In situations where the relative increase in total tumor burden by 
10% is solely due to inclusion of new lesions which become measurable, these new lesions 
must demonstrate an absolute increase of at least 5 mm.  Further bone disease progression is 
defined as additional two or more new bone lesions noted on bone scans compared to the 
time of PCWG3-defined progression of bone disease. 
 
 
Testosterone Only Phase: 
During the Testostone-only lead-in phase (12 weeks), patients may experience PSA 
progression in the presence or absence of radiographic progression. Patients will be allowed 
to remain on study in the following circumstances: 
 
PSA Progression Only: 
In the setting of a rising PSA (including patients with PSA progression [PCWG3 criteria]) in the 
absence of radiographic progression (RECIST 1.1 Criteria), patients without clinical symptoms 


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of disease progression will be allowed to remain on study.  If the patient is not deriving clinical 
benefit, patients may be removed from the study at the discretion of the treating physician. 
 
Radiographic Progression: 
Patients with radiographic progression (per RECIST 1.1 Criteria) determined on post-
testosterone, restaging imaging may remain on study except in ANY of the following 
circumstances: 
 
Patient is not deriving clinical benefit as determined by the treating physician 
 
Development of symptoms of clinical progression (any of the below): 
 
New bony pain. 
 
Risk of impending fracture. 
 
Pending spinal cord compression. 
 
Obstructive urinary symptoms. 
 
Decline in performance status from baseline assessment. 
 
Development of new liver or brain metastases. 
For patients that continue on study after radiographic progression (as documented on initial 
imaging), restaging must occur between 6-7 weeks +/- 5 days from prior imaging. Subjects 
should discontinue study therapy upon evidence of further progression, defined as an 
additional 10% or greater increase in tumor burden volume from time of initial progression 
(i.e. post testosterone only imaging).  Subsequent imaging will continue as per protocol and 
irRECIST criteria should be used to assess further progression of the Testosterone + 
Nivolumab combination. 
 
7.8       Immunotherapy Adverse Event Management 
Because  of  the  potential  for  clinically  meaningful  Nivolumab-related AEs requiring early 
recognition and prompt intervention, management algorithms have been developed for 
suspected pulmonary toxicity, GI toxicity, hepatotoxicity, endocrinopathy, skin toxicity, 
neurological toxicity, and renal toxicity (Nivolumab IB). 
These adverse event management algorithms are included in Appendix A. 
7.9 
Removal of Subjects from the Study, Therapy Assessment 
7.9.1 
Subject Withdrawal 
Single subject termination is by definition when the patient is withdrawn or when 
the patient has died.  The study termination page in the eCRF must be completed. 
The Investigator also has the right to withdraw subjects from the study in the event 
of: 
 
Occurrence of an exclusion criterion, which is clinically relevant and affects the 
subject’s safety, and discontinuation is considered necessary by the Investigator 
and/or the Sponsor. 
 
Therapeutic failure requiring urgent additional medication (if applicable) 
 
Occurrence of AEs, if discontinuation of study medication is considered 
necessary by the Investigator and/or Subject (if applicable). 
 
Intake of non-permitted concomitant medication as defined in Appendix A 
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 
Progression of disease (subjects will only come off study after meeting PCWG3 
criteria for radiographic progression and not for PSA) except as described in 
Section 7.7. 
 
Lack of subject compliance. 
 
Protocol violation. 
 
7.10     Treatment Compliance 
Trained medical personnel will administer Nivolumab and dispense other study 
medications. Treatment compliance will be monitored by drug accountability, as well as by 
recording administration of all medications in the CRF. The date and the exact dosage 
amount given at each infusion will be recorded. Any missed doses will be recorded. In case 
the treatment has to be interrupted during an infusion and the dosing is not resumed, the 
medical personnel should evaluate the percentage of dose received by the patient and 
document it in the patient record. Any reason for non-compliance should also be 
documented. 
 
7.11      Destruction of Study Drug 
Investigator drug destruction is allowed provided the following minimal standards are met: 
• On-site disposal practices must not expose humans to risks from the drug. 
• On-site disposal practices and procedures are in agreement with applicable laws and 
regulations, including any special requirements for controlled or hazardous substances. 
• Written procedures for on-site disposal are available and followed. The procedures must be 
filed with the Sponsor SOPs and a copy provided to BMS upon request. 
• Records are maintained that allow for traceability of each container, including the date 
disposed of, quantity disposed, and identification of the person disposing the containers. 
The method of disposal, ie, incinerator, licensed sanitary landfill, or licensed waste disposal 
vendor must be documented. 
• Accountability and disposal records are complete, up-to-date, and available for BMS to 
review throughout the clinical trial period as per the study agreement. A copy of the drug 
destruction certificate should be maintained for provision to BMS at the end of the study. 
If conditions for destruction cannot be met, please contact BMS.  
It is the Investigator’s responsibility to arrange for disposal of all empty containers, 
provided that procedures for proper disposal have been established according to applicable 
federal, state, local, and institutional guidelines and procedures, and provided that 
appropriate records of disposal are kept. 
7.12   Return of Study Drug 
It is the Investigator’s responsibility to arrange for destruction of drug upon completion or 
termination of the study and disposal of all empty containers, provided that procedures for 
proper disposal have been established according to applicable federal, state, local, and 
institutional guidelines and procedures, and provided that appropriate records of disposal 
are kept. 
 
 


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8. 
ADVERSE EVENTS 
 
8.1 
Definitions 
8.1.1 
Adverse Event (AE) 
 
 
An AE is defined as any untoward medical occurrence in a patient administered a 
medicinal product that does not necessarily have a causal relationship with this 
treatment. An AE can, therefore, be any unfavorable and unintended sign (including 
an abnormal laboratory finding), symptom, or disease temporally associated with 
the use of an investigational product, whether or not related to the investigational 
medicinal product. This includes an exacerbation of pre-existing conditions or 
events, intercurrent illnesses, drug interaction, or the significant worsening of the 
indication under investigation that is not recorded elsewhere on the eCRF under 
specific efficacy assessments. Anticipated fluctuations of pre-existing conditions, 
including the disease under study, that do not represent a clinically significant 
exacerbation or worsening are not considered AEs. 
 
It is the responsibility of the Investigator to document all AEs that occur during the 
study. AEs should be elicited by asking the patient a non-leading question (e.g. 
“Have you experienced any new or changed symptoms since we last asked/since 
your last visit?”). The existence of an AE may be concluded from a spontaneous 
report of the patient; from the physical examination; or from special tests such as 
the ECG, laboratory assessments, or other study-specified procedure (source of AE). 
Symptoms reported spontaneously by the patient during the physical examination 
would also qualify as an AE (and hence documented on the AE eCRF, not on the 
physical examination eCRF, which is reserved for physical signs or findings). 
 
8.1.2 
Serious Adverse Event (SAE) 
An SAE is any untoward medical occurrence that occurs at any dose (or, occurs after 
informed consent is given and prior to dosing if the SAE is related to a study 
procedure) that: 
 
Results in death. Any event resulting in death during the reporting period (from 
date of first dose of study drug through 100 days after last dose) must be treated as 
an SAE and reported as such. An event related to a study procedure that occurs after 
informed consent, but prior to dosing that results in death must also be reported as 
an SAE. 
 
Is life-threatening (patient is at immediate risk of death from the event as it 
occurred). 
 
Requires in-patient hospitalization (formal admission to a hospital for medical 
reasons) or prolongation of existing hospitalization. 
 
Results in persistent or significant disability/incapacity. 
 
Results in a congenital anomaly or birth defect. 
 
Important medical events that may not result in death, are not life-threatening, or do 
not require hospitalization may be considered SAEs when, based on appropriate 
medical judgment, they may jeopardize the patient and may require medical or surgical 
intervention to prevent one of the outcomes listed in this definition. Examples of such 


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events include allergic bronchospasm requiring intensive treatment in an emergency 
room or at home or the development of drug dependency or drug abuse. 
 
8.1.2.1 Events or Outcomes Not Qualifying as Serious Adverse Events 
 
The following are not considered SAEs and therefore do not need to be reported as 
 
such: 
 
Pre-planned or elective hospitalization including social and/or convenience 
situations (e.g. respite care). 
 
Hospital visits of less than 24 hours duration (e.g. patient presents to the emergency 
room, but is not admitted to a ward). 
 
Overdose of either BMS study drug or concomitant medication unless the event 
meets SAE criteria (e.g. hospitalization). However, the event should still be captured 
as a nonserious AE on the appropriate eCRF page. 
 
Events of progression of the patient’s underlying cancer as well as events clearly 
related to progression of the patient’s cancer (signs and symptoms of progression) 
should not be reported as a serious adverse event unless the outcome is fatal within 
the safety reporting period. If the event has a fatal outcome within the safety 
reporting period, then the event of Progression of Disease must be recorded as an 
AE and as a SAE with CTCAE Grade 5 (fatal outcome) indicated. 
8.1.3 
Progression of Malignancy 
Progression of a patient’s malignancy should not be considered an AE or SAE, unless 
in the Investigator’s opinion, study treatment resulted in an exacerbation of the 
patient’s condition. If disease progression results in death or hospitalization while 
on study or within 100 days of the last dose, progressive disease will be considered 
an SAE. 
8.1.4 
Life‐threatening Events 
A life-threatening event is any AE that places the patient at immediate risk of death 
from the reaction as it occurs. It is not a reaction that had it occurred in a more 
severe form, might have caused death. 
8.1.5 
Hospitalization or Prolongation of Hospitalization 
Hospitalization encompasses any inpatient admission (even for less than 24 hours) 
resulting from a precipitating, treatment-emergent adverse event. For chronic or 
long-term patients, inpatient admission also includes transfer within the hospital to 
an acute or intensive care inpatient unit. Hospitalizations for administrative reasons 
or a non-worsening preexisting condition should not be considered AEs (e.g. 
admission for workup of a persistent pretreatment laboratory abnormality, yearly 
physical exam, protocol-specified admission, elective surgery). Pre-planned 
treatments or surgical procedures should be noted in the baseline documentation. 
Hospitalization because of an unplanned event will be deemed an SAE. 
Prolongation of hospitalization is any extension of an inpatient hospitalization 
beyond the stay anticipated or required for the original reason for admission. 
8.1.6 
Significant Disability 
Disability is a substantial disruption of the patient’s ability to conduct normal life 
functions. 


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8.1.7 
Pregnancy 
Male participants should refrain from fathering a child or donating sperm during the 
study and for 7 months following the last dose of nivolumab. 
Pregnancy of the patient’s partners is not considered to be an adverse event. 
However, the outcome of all pregnancies (spontaneous miscarriage, elective 
termination, ectopic pregnancy, normal birth or congenital abnormality) should, if 
possible, be followed up and documented.  
The outcome of any conception occurring from the date of the first dose until 7 
months after the last dose should be followed up and documented. 
All outcomes of pregnancy should be reported to BMS. 
8.1.8 
Medical Significance 
An event that is not fatal or life-threatening and that does not necessitate 
hospitalization may be considered serious if, in the opinion of the Investigator, it 
jeopardizes the patient’s status and might lead to medical or surgical intervention to 
prevent any of the outcomes described in section 7.1.2. Such medically significant 
events could include allergic bronchospasm requiring intensive treatment in the 
emergency room or at home, blood dyscrasias that do not result in inpatient 
hospitalization, or the development of drug dependency or abuse. 
 
8.1.9 
Deaths 
All deaths that occur during the study, or within the protocol-defined 100-day 
post-study follow-up period after the administration of the last dose of study 
treatment, must be reported as follows: 
 
Death that is clearly the result of disease progression should be reported to 
the study monitor at the next monitoring visit, be documented, and reported 
as an SAE. 
 
Where death is not due (or not clearly due) to progression of the disease 
under study, the AE causing the death must be reported to the study monitor 
as a SAE within 24 hours. The report should contain a comment regarding 
the co-involvement of progression of disease, if appropriate, and should 
assign main and contributory causes of death.   
 
Deaths with an unknown cause should be reported as a SAE., but followup 
should be done to determine the cause of death.  If a cause of death is 
determined, the event term of “death” must be updated at that time.    A post 
mortem maybe helpful in the assessment of the cause of death, and if 
performed a copy of the post-mortem results should be forwarded to BMS 
within the usual timeframes. 
 
The most recent version of the NCI CTCAE handbook will be used for adverse event 
descriptions and grading. 
 
All AEs (including SAEs and AESIs) occurring during the study are to be followed up in 
accordance with good medical practice until resolved; judged no longer clinically 
significant; or, if a chronic condition, until fully characterized through 100 days after the last 
dose of study drug. Any SAEs, AESIs, and treatment-related Grade 3/4 AEs must be followed 


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until resolution or stabilization, or until lost to follow-up. After the 100-day window, 
treatment-related SAEs and all AESIs, irrespective of causality, do not need to be reported.  
 
8.2 
Expectedness 
 
Adverse events can be considered, “expected,” or, “unexpected.” 
 
8.2.1  
Expected Adverse Events 
Expected adverse events are those that have been previously identified as resulting 
from administration of the agent. An adverse event can be considered expected 
when it appears in the same nature severity and specificity as what is in the current 
adverse event list of the Investigator’s Brochure. 
 
 
8.2.2 
Unexpected Adverse Events 
An adverse event can be considered unexpected when the nature, intensity or 
frequency of which is not consistent with the current adverse event list of the 
Investigator’s Brochure, contact the lead site, principal investigator or sponsor to 
confirm unexpected adverse events when necessary.   
8.3 
Recording and Grading 
8.3.1 
Recording 
All observed or volunteered adverse events, regardless of treatment group, severity, 
suspected causal relationship, expectedness, or seriousness will be documented. 
A clinically significant change in a physical examination finding or an abnormal test 
result (i.e., laboratory, X-ray, EKG) should be recorded as an AE, if it: 
 
Is associated with accompanying symptoms. 
 
Is suggestive of organ toxicity. 
 
Requires additional diagnostic testing or medical or surgical 
intervention. 
 
Leads to a change in study dosing or discontinuation from the study. 
 
Is considered clinically significant by the Investigator. 
 
An abnormal test result that is subsequently determined to be in error does not 
require recording as an adverse event, even if it originally met one or more of the 
above criteria. 
8.3.2 
Grading Severity 
All adverse events will be graded for intensity on a scale of 0 to 5. Severity grades 
will be recorded and based on the most recent version of the NCI CTCAE handbook. 
8.3.3 
Attributing Causality 
 
 
Medical judgment should be used to determine the cause of the AE considering  
 
 
all relevant factors such as, but not limited to, the underlying study indication,  
 
 
coexisting disease, concomitant medication, relevant history, pattern of the AE,  
 
 
temporal relationship to the study medication, dechallenge or rechallenge with  
 
 
the study drug (Table 3).  


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Not Related 
To Study 
Drug 
• 
An AE that is clearly due to extraneous causes (e.g. concurrent disease, 
concomitant medications, disease under study, etc.) 
• 
It does not follow a reasonable temporal sequence from administration of 
the study drug. 
• 
It does not follow a known pattern of response to study drug 
• 
It does not reappear or worsen when study drug is restarted. 
• 
An alternative explanation is likely, but not clearly identifiable. 
Related to 
Study Drug 
• 
An AE that is difficult to assign to alternative causes. 
• 
It follows a strong or reasonable temporal sequence from administration of 
study drug. 
• 
It could not be reasonably explained by the patient’s clinical state, 
concurrent disease, or other concomitant therapy administered to the 
patient.  
• 
It follows a known response pattern to study drug. 
• 
It is confirmed with a positive rechallenge or supporting laboratory data. 
Table 3. Relationship of Adverse Event to Study Drug 
8.4 
Reporting Adverse Events 
 
8.4.1 
Reporting Serious Adverse Events 
 
Following the subject’s written consent to participate in the study, all SAEs, whether 
 
related or not related to study drug, must be collected, including those thought to be 
 
associated with protocol-specified procedures. All SAEs must be collected that occur 
 
within 100 days of discontinuation of dosing.  
 
All SAEs must be collected that occur during the screening period. If applicable, 
SAEs must be collected that relate to any protocol-specified procedure (e.g. a follow-
up skin biopsy). The Investigator should report any SAE that occurs after these time 
periods that is believed to be related to study drug or protocol-specified procedure 
up to and including 100 days after the last dose received.  
 
 
All SAEs that occur following the subject’s written consent to participate in the 
 
study through 100 days of discontinuation of dosing must be reported to BMS 
 
Worldwide Safety, (Email: worldwide.safety@BMS.com; Fax: 1(609) 818-3804) 
 
whether related or not related to study drug. If applicable, SAEs must be 
 
collected that relate to any later protocol-specified procedure (e.g. a follow-up skin 
 
biopsy). 
 
 
An appropriate SAE form (e.g. ex-US = CIOMS form or USA = Medwatch form) 
 
should be used to report SAEs to BMS. The BMS protocol ID number must be 
 
included on whatever form is submitted by the Sponsor/Investigator.  
 


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 
The CIOMS form is available at: http://www.cioms.ch/index.php/cioms-form-i  
 
The MedWatch form is available at: 
https://www.fda.gov/downloads/AboutFDA/ReportsManualsForms/Forms/UCM0
48334.pdf  
 
 
 
SAEs, whether related or not related to study drug, and pregnancies must be 
 
reported to BMS within 24 hours. SAEs must be recorded on either CIOMS or 
 
MedWatch form & pregnancies must be reported on a Pregnancy Surveillance Form 
 
or can be submitted on the aforementioned SAE form to BMS. 
The Sponsor will reconcile the clinical database SAE cases (case level only) 
transmitted to BMS Global Pharmacovigilance (Worldwide.Safety@bms.com).  
Frequency of reconciliation should be every 3 months and prior to the database lock 
or final data summary. BMS Global Pharmacovigilance will email, upon request from 
the Investigator, the Global Pharmacovigilance reconciliation report. 
Requests for reconciliation should be sent to aepbusinessprocess@bms.com. The 
data elements listed on the Global Pharmacovigilance reconciliation report will be 
used for case identification purposes. If the Investigator determines a case was not 
transmitted to BMS Global Pharmacovigilance, the case should be sent immediately 
to BMS. 
 
 
IND application sponsors are required to notify FDA in a written safety report of: 
 
Any adverse experience associated with the use of the drug that is both serious 
and unexpected or, 
 
Any findings from tests in laboratory animals that suggest a significant risk for 
human subjects including reports of mutagenicity, teratogenicity, and 
carcinogenicity.  
  
 
Adverse event means any untoward medical occurrence associated with the use of a 
 
drug in humans, whether or not considered drug related. 
 
 
Suspected adverse reaction means any adverse event for which there is a reasonable 
 
possibility that the drug caused the adverse event. For the purposes of IND safety 
 
reporting, “reasonable possibility” means there is evidence to suggest a causal 
 
relationship between the drug and the adverse event. A suspected adverse reaction 
 
implies a lesser degree of certainty about causality than an adverse reaction. 
 
Adverse reaction means any adverse event caused by a drug. Adverse reactions are 
 
a subset of all suspected adverse reactions where there is reason to conclude that 
 
the drug caused the event.   
 
Unexpected adverse event or suspected adverse reaction refers to an event or 
 
reaction that is not listed in the Investigator’s Brochure or is not listed at the 
 
specificity or severity that has been observed; or, if an Investigator’s Brochure is not 


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required or available, is not consistent with the risk information described in the 
 
general investigational plan or elsewhere in the current IND application. 
 
Serious adverse event or suspected adverse reaction refers to an event or reaction 
 
that, in the view of either the Investigator or Sponsor, results in any of the following 
 
outcomes: 
 
Death. 
 
A life-threatening adverse event. 
 
In-patient hospitalization or prolongation of existing hospitalization. 
 
A persistent or significant incapacity or substantial disruption of the    
ability to conduct normal life functions. 
 
A congenital anomaly or birth defect.  
 
A life-threatening adverse event or suspected adverse reaction is considered “life-
 
threatening” if, in the view of the investigator or sponsor, its occurrence places the 
 
patient or subject at immediate risk of death. It does not include an adverse event or 
 
suspected adverse reaction that, had it occurred in a more severe form, might have 
 
caused death. 
 
Important medical events that may not result in death, be life-threatening, or 
 
require hospitalization may be considered serious when, based upon appropriate 
 
medical judgment, they may jeopardize the patient or research subject and may 
 
require medical or surgical intervention to prevent one of the outcomes listed as 
 
serious.  
 
Mandatory Safety Reporting  
• Initial reporting: IND application sponsor must report any suspected adverse 
reaction or adverse reaction to study treatment that is both serious and unexpected.  
Unexpected serious suspected adverse reactions suggesting significant risk to 
human subjects must be reported to FDA as soon as possible but no later than 
within 15 calendar days following the sponsor’s initial receipt of the information. 
Unexpected fatal or life-threatening suspected adverse reactions represent 
especially important safety information and must be reported to FDA as soon as 
possible but no later than 7 calendar days following the sponsor’s initial receipt of 
the information. 
 
• Follow-up reporting: Any relevant additional information obtained by the sponsor 
that pertains to a previously submitted IND safety report must be submitted as a 
Follow-up IND Safety Report. Such report should be submitted without delay, as 
soon as the information is available but no later than 15 calendar days after the 
sponsor receives the information. 
 
All IND safety reports must be submitted on Form 3500A and be accompanied by 
Form 1571. The type of report (initial or follow-up) should be checked in the 
respective boxes on Forms 3500A and 1571.  
 
The submission must be identified as: 
•  “IND safety report” for 15-day reports or, 


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•  “7-day IND safety report” for unexpected fatal or life-threatening 
suspected adverse reaction reports or, 
•  “Follow-up IND safety report” for follow-up information. 
 
The report must be submitted to an appropriate Review division that has the 
responsibility to review the IND application under which the safety report is 
submitted. Each submission to this IND must be provided in triplicate (original plus 
two copies). Send all submissions to the following address: 
 
Food and Drug Administration 
Center for Drug Evaluation and Research 
Division of Oncology Products 1 
5901-B Ammendale Road 
Beltsville, MD 20705-1266 
8.4.2 
Reporting SAEs at Multi‐Site/Participating Institutions  
SAEs should be reported to the Lead site and BMS. 
9. 
CRITERIA FOR OUTCOME ASSESSMENT/THERAPEUTIC RESPONSE 
9.1 
Outcome Assessment 
All baseline evaluations will be performed as closely as possible to the beginning of 
treatment (within 7 days). For subsequent evaluations, the method of assessment and 
techniques will be the same as those used at baseline. 
Note: Any bone lesions, however, that are identified on the baseline CT or MRI 
studies and judged as providing meaningful information about nontarget disease 
status on the basis of their size or other features should be considered for inclusion 
in the follow-up assessments of nontarget lesions by the same imaging modality. 
 
Conventional CT, NM Bone Scan. 
CT Chest, Abdomen, Pelvis and NM Bone scans will be used to measure tumor 
response as a secondary endpoint per RECIST 1.1 Criteria. 
 
Tumor markers. 
       PSA measurements will be used to assess the primary endpoint. 
9.1.1 
Primary Endpoint 
The primary endpoint is defined as a PSA50 response, defined as a ≥ 50% decline in 
PSA from baseline, confirmed with a second measurement at least 4 weeks later. 
 
9.1.2 
Secondary Endpoints 
 
9.1.2.1  Safety 
This endpoint is defined as incidence of grade 3-5 toxicities based upon the 
most current CTCAE standard grading scales. 
 
 
 
9.1.2.2  PSA Progression‐Free Survival (PFS)  
PSA progression (PSA progression-free survival; PSA–PFS) will be defined 


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per PCWG3 guidelines. 
 
 
 
 
For those subjects showing an initial decline in PSA from baseline, is   
 
 
 
defined as an increase in PSA that is ≥ 25% and ≥ 2 ng/mL above the nadir,  
 
 
 
and which is confirmed by a second value ≥ 3 weeks later (i.e. a  
 
 
 
 
confirmed rising trend). 
 
 
 
 
For those subjects with no decline in PSA from baseline, is defined as an  
 
 
 
increase in PSA that is ≥ 25% and ≥ 2 ng/mL after 12 weeks. 
 
 
 
9.1.2.3  Progression–free Survival 
Time to radiographic or clinical progression or death, whichever comes first.  
 
Based on RECIST version 1.1 and PCWG3 definitions including:  
 
Progression of soft tissue lesions according to RECIST 1.1 Criteria.  
 
Progression of bone lesions detected with bone scan according to 
PCWG3 criteria.  
 
Radiologically-confirmed spinal cord compression or pathological 
fracture due to malignant progression, or other clinical event 
deemed to be cancer-related. 
 
 
 
9.1.2.4   Objective Response Rate 
Defined as the proportion of patients achieving a complete/partial response 
in target lesions (RECIST 1.1 Criteria). 
 
  
 
9.1.2.5    Durable Progression‐free Survival (durable‐PFS)  
Durable PFS will be defined as the proportion of patients without clinical or 
radiographic progression, as defined by PCWG3 criteria, or death at 24 
weeks from the start of treatment. 
 
  
 
9.1.2.6  Overall Survival (OS) 
Overall survival will be defined as the time from study enrollment to death 
or up to 2 years after last dose. 
This will be summarized using a Kaplan-Meier curve. 
 
9.2 
Therapeutic Response 
Response and progression will be evaluated in this study using a combination of the 
international criteria proposed by the Response Evaluation Criteria in Solid Tumors 
(RECIST) Committee(42) and the guidelines for prostate cancer endpoints developed by the 
Prostate Cancer Clinical Trials Working Group (PCWG3).(43)
Patients will need to be re-evaluated for response every cycle according to the guidelines 
below.
9.2.1 
PSA 
Perform PSA testing at a minimum of 1-week intervals with the threshold PSA level 
at 2.0 ng/mL. To report PSA-based outcomes, PCWG3 recommends that the percent 
of change in PSA from baseline to 12 weeks (or earlier for those who discontinue 


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therapy) and the maximum decline in PSA that occurs at any point after treatment 
be reported for each patient using a waterfall plot. PSA measurements obtained 
during the first 12 weeks should not be used as the sole criterion for clinical 
decision making. 
9.2.2 
Measurable Disease 
According to RECIST 1.1, measurable disease is defined as at least 1 lesion > 10mm 
in its longest diameter as measured with conventional techniques (i.e. CT with slice 
cut of 5 mm, MRI). All tumor measurements will be taken using a ruler or calipers 
and recorded in millimeters (or decimal fractions of centimeters).  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).  
9.2.3 
Nonmeasurable Disease 
Following RECIST 1.1, all other lesions (or sites of disease) will be considered 
nonmeasurable disease. This includes small lesions (longest diameter < 10 mm 
using spiral CT scan), lymph nodes (shortest diameter > 10 mm to < 15 mm) and 
any of the following: 
 
Bone lesions. 
 
Ascites. 
 
Pleural or pericardial effusion. 
 
Lymphangitis cutis or pulmonis. 
 
Abdominal masses that are not confirmed and followed by imaging 
techniques. 
 
Cystic lesions. 
 
Lesions occurring within a previously irradiated area unless they are 
documented as new lesions since the completion of radiation therapy. 
 
Note. If only a single, asymptomatic bone lesion is present at baseline, and 
will be irradiated, the metastatic nature of this lesion must be 
confirmed by X-ray, CT, or MRI. 
9.2.4 
Target (nodal and visceral) Lesions 
Following RECIST 1.1 Criteria, progression in a nodal or visceral site (i.e. liver and 
lung) is sufficient to document disease progression. The presence or absence of 
nodal and visceral disease before and after treatment should be recorded 
separately. 
All measurable lesions (up to a maximum of 2 lesions per organ and 5 lesions in 
total) will be identified as target lesions to be measured and recorded at baseline. 
The target lesions should be representative of all involved organs. Target lesions 
will be selected on the basis of size (i.e. the largest area) and suitability for accurate, 
repeated measurements (either by imaging techniques or clinically). The sum of the 
longest diameter (LD) of all non-nodal and shortest diameter (nodal) target lesions 
will be calculated and reported as the baseline sum LD. The baseline sum LD will be 
used as a reference by which to characterize the objective tumor response. 
Because small lymph nodes are difficult to measure accurately and may not be 
malignant, to be considered pathologically enlarged and measurable, a lymph node 


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must be > 15 mm in short axis when assessed by CT scan (CT scan slice thickness 
recommended to be no greater than 5 mm). 
  
9.2.5 
Bone Lesions 
When the bone scan is the sole indicator of progression, disease progression in bone 
is defined as ≥ 2 new lesions seen on bone scan compared with a prior scan for used 
trial entry. In situations where scan findings suggest a flare reaction or where new 
lesion(s) may represent trauma, confirm these results with other imaging 
modalities (e.g. MRI or fine-cut CT). If many new areas of uptake are observed, 
confirmation is generally not necessary. 
9.2.6 
Nontarget Lesions 
All other lesions (or sites of disease) will be identified as nontarget lesions and 
recorded at baseline. Nontarget lesions will include measurable lesions that exceed 
the maximum number per organ (2) or total of all involved organs (5), as well as 
nonmeasurable lesions. The presence or absence of these lesions will be recorded 
on the CRF and should be evaluated at the same assessment time points as all target 
lesions. 
9.2.7 
New Lesions 
 
The appearance of new malignant lesions denotes disease progression. There are 
 
no specific criteria for the identification of new radiographic lesions; however, the 
 
finding of a new lesion should be unequivocal, i.e. not attributable to differences in 
 
scanning technique, change in imaging modality or findings thought to represent 
 
something other than tumor (for example, some “new” bone lesions may be simply 
 
healing or flare of pre-existing lesions).  
 
9.3 
Response Criteria for Primary and Secondary Endpoints 
9.3.1 
Measurable Soft‐tissue Lesions 
When evaluating soft-tissue lesions, the definitions in Table 4 apply. 
Table 4. RECIST 1.1 Response Criteria for Target Lesions 
Response 
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 diameters of target 
lesions, taking as reference the baseline sum diameters.  
Progressive disease 
(PD)  
At least a 20% increase in the sum of 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 ≥ 5 mm. (Note: the 
appearance of one or more new lesions is also considered 
progression). 


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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.  
 
In some circumstances, it may be difficult to distinguish residual disease from 
normal tissue. When the evaluation of complete response depends on this 
determination, it is recommended that the residual lesion be investigated (e.g. fine 
needle aspirate or biopsy) before confirming the complete response status. 
Changes in nodal and visceral sites should be recorded and reported separately, and 
lymph nodes in the pelvis must measure ≥ 15 mm in shortest diameter to be 
considered target lesions. Complete elimination of disease at a particular site 
should be recorded separately. Any favorable change should be confirmed using a 
second follow-up scan. 
9.3.2 
PSA 
For each patient, use a waterfall plot to report the percent change in PSA from 
baseline to 12 weeks (or earlier for those who discontinue therapy) and the 
maximum decline in PSA that occurs at any point after treatment.  We will also 
report the proportion of patients to achieve a 50% of greater decrease in PSA from 
baseline (i.e. PSA50 response rate). 
9.3.3 
Bone 
Record post-treatment changes as either “no new lesions” or “new lesions.” 
 
In the absence of clearly worsening soft-tissue (nodal and visceral) disease or 
disease-related symptoms, progression at the first scheduled assessment should be 
confirmed on a second scan performed ≥ 6 weeks later. In the rare case where 
visible lesions disappear, this too should be confirmed. 
9.3.4 
Nontarget Lesions 
When assessing nontarget lesions, the definitions in Table 5 will apply. 
 
Table 5. RECIST 1.1 Response Criteria for Nontarget Lesions 
Response 
Evaluation of Nontarget Lesions 
Complete response 
(CR) 
The disappearance of all nontarget lesions and 
normalization of tumor marker levels. All lymph nodes must 
be non-pathological in size (< 10 mm short axis). 
Non-CR/non-PD 
The persistence of one or more nontarget lesions and/or 
maintenance of tumor marker levels above the normal 
limits. 
Progressive disease 
(PD) 
The appearance of one or more new lesions and/or 
unequivocal progression of existing nontarget lesions. 
 


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9.4 
Criteria for Progressive Disease. 
9.4.1 
Measurable Soft‐tissue Lesions 
When evaluating soft-tissue lesions, the definitions in Table 4 apply. 
In some circumstances, it may be difficult to distinguish residual disease from 
normal tissue. When the evaluation of complete response depends on this 
determination, it is recommended that the residual lesion be investigated (e.g. fine 
needle aspirate or biopsy) before confirming the complete response status. 
Progression in a nodal or visceral site should be defined using RECIST 1.1 Criteria 
(Table 4).  
9.4.2 
PSA 
Per the PCWG3, PSA progression is defined as the date that a 25% or greater 
increase and an absolute increase of 2 ng/mL or more from the nadir is documented 
and confirmed by a second value obtained 3 or more weeks later. Where no decline 
from baseline is documented, PSA progression is defined as a 25% increase from the 
baseline value along with an increase in absolute value of 2 ng/mL or more after 12 
weeks of treatment. 
9.4.3 
Bone 
Progressing disease on bone scan is considered when at least 2 new lesions are 
observed. Yet, progression remains unconfirmed unless at least 2 additional new 
lesions appear at a subsequent time point. 
Unless clinically indicated, there is no need to perform a follow-up bone scan before 
12 weeks of treatment. To define disease progression requires a confirmatory scan 
(which shows additional new lesions compared with the first follow-up scan) 
performed ≥ 6 weeks later. When further progression is documented on the 
confirmatory scan, the date of progression recorded for the trial is the date of the 
first scan that shows the change. 
9.4.4 
Nontarget Lesions 
When assessing nontarget lesions, the definitions in Table 5 apply.
 
10. 
DATA REPORTING AND REGULATORY REQUIREMENTS 
 
 
Multicenter Guidelines 
 
The Protocol Chair 
 
The Protocol Chair, Dr. Mark Markowski is responsible for performing the following tasks: 
 
Coordinating, developing, submitting, and obtaining approval for the protocol as 
well as its subsequent amendments. 
 
Assuring that all participating institutions are using the correct version of the 
protocol. 
 
Taking responsibility for the overall conduct of the study at all participating 
institutions and for monitoring the progress of the study. 
 
Reviewing and ensuring reporting of Serious Adverse Events (SAEs). 
 
Reviewing data from all sites. 


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Lead Center 
The Lead Center (Johns Hopkins University) is responsible for performing the following 
tasks: 
 
Ensuring that IRB approval has been obtained at each participating site prior to the 
first patient registration at that site, and maintaining copies of IRB approvals from 
each site. 
 
Managing central patient registration. 
 
Collecting and compiling data from each site. 
 
Establishing procedures for documentation, reporting and submitting of AEs and 
SAEs to the Protocol Chair and all other applicable parties. 
 
Facilitating audits by securing selected source documents and research records 
from participating sites for audit, or by auditing at participating sites. 
 
Participating PCCTC Sites 
Participating sites are responsible for performing the following tasks: 
 
Following the protocol as written, and the guidelines of Good Clinical Practice (GCP). 
 
Submitting data to the Lead Center.  
 
Registering all patients with the Lead Center by submitting patient registration form 
and signed informed consent promptly. 
 
Providing sufficient experienced clinical and administrative staff and adequate 
facilities and equipment to conduct a collaborative trial according to the protocol. 
 
Maintaining regulatory binders on site and providing copies of all required 
documents to the Lead Center. 
 
Collecting and submitting data according to the schedule specified by the protocol. 
 
10.1 
Data Entry 
Data collected during this study will be entered into a secure database. Staff at Johns 
Hopkins University will be responsible for the initial study configuration and setup in the 
CRMS database and for any future changes. 
10.1.1 Case Report Forms Completion 
Electronic Case report forms will be generated by the coordinating center for the 
collection of all study data. Investigators will be responsible for ensuring that the 
CRFs are kept up-to-date. 
The paper Eligibility Checklist CRF must be completed using black ink.  Any errors 
must be crossed out so that the original entry is still visible, the correction clearly 
indicated and then initialed and dated by the individual making the correction. 
eCRFs will be completed within 2 weeks of the patient coming to the clinic and all 
relevant supporting documentation such as scans, progress notes, nursing notes, 
blood work, pathology reports, etc., will be submitted via email to the SKCCC 
Coordinating Center Study Manager.  All patient names or other identifying 
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or non-redacted source documents can be sent via a password-protected/secured 
document transfer based on each institution’s guidelines.  
Authorized representatives of the Coordinating Center (SKCCC) may visit the 
satellite sites to perform audits or inspections, including source data verification. 
The purpose of these audits or inspections is to systematically and independently 
examine all trial-related activities and documents to determine whether these 
activities were conducted and data were recorded, analyzed, and accurately 
reported according to the protocol, Good Clinical Practice (GCP), and any applicable 
regulatory requirements. 
10.1.2 Source Documents 
Study personnel will record clinical data in each patient’s source documents (i.e. the 
patient’s medical record). Source documentation will be made available to support 
the patient research record. Study monitors will review entries on the CRFs at 
regular intervals, comparing the content with source documents. 
10.1.3 Record Retention 
The Investigator will maintain adequate and accurate records to enable the conduct 
of the study to be fully documented and the study data to be subsequently verified. 
After study closure, the Investigator will maintain all source documents, study-
related documents, and the CRFs. Because the length of time required for retaining 
records depends upon a number of regulatory and legal factors, documents should 
be stored until the Investigator is notified that the documents may be destroyed. In 
this study, records are to be retained and securely stored for a minimum of 5 years 
after the completion of all study activities. 
10.2 
Data Management 
10.2.1 Lead Research Program Coordinators 
A Lead research program coordinator at the coordinating center will be assigned to 
the study. A Lead Research Program Coordinator will manage the study activities at 
each of the participating sites. The responsibilities of the Lead Research Program 
Coordinator include project compliance, data collection, data entry, data reporting, 
regulatory monitoring, problem resolution and prioritization, and coordination of 
the activities of the protocol team. 
10.3 
Study Monitoring and Quality Assurance 
Regularly scheduled registration reports will be generated to monitor patient accruals and 
the completeness of registration data. Routine data quality reports will be generated to 
assess missing data and inconsistencies. Accrual rates and the extent and accuracy of 
evaluations and follow-up will be monitored periodically throughout the study period, and 
potential problems will be brought to the attention of the principal investigator for 
discussion and action. 
Random-sample data quality and protocol compliance audits will be conducted by the study 
team at least once a year, more frequently if indicated. Audits by the coordinating center 
may entail (1) shipping source documents and research records for selected patients from 
participating sites to the coordinating center for audit, or (2) on-site auditing of selected 
patient records at participating sites. 


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All clinical work conducted under this protocol is subject to Good Clinical Practice (GCP) 
guidelines. This includes inspection of study-related records by the lead site, sponsor, its 
designee, or health authority representatives at any time. 
 
Data and Safety Monitoring:  
This is a DSMP Medium Risk study under the SKCCC Data and Safety Monitoring Plan 
(6/5/2020). Data Monitoring of this protocol will occur annually. The protocol will be 
monitored internally at SKCCC by the Principal Investigator. The SKCCC Compliance 
Monitoring Program will provide external monitoring for JHU affiliated sites in accordance 
with SKCCC DSMP (Version 6.0, 02/21/2019). The SMC Subcommittee will determine the 
level of patient safety risk and level/frequency of monitoring.  
Additionally, scheduled meetings will take place monthly and will include the protocol 
Principal Investigator, research nurse, data manager, and, when appropriate, the 
collaborators, subinvestigators, and biostatistician involved with the conduct of the 
protocol. 
During these meetings the investigators will discuss matters related to: the safety of 
protocol participants, validity and integrity of the data, enrollment rate relative to 
expectation, characteristics of participants, retention of participants, adherence to protocol 
(potential or real protocol violations), data completeness, and progress of data for 
secondary objectives. 
 
10.4 
Clinical Trial Agreement 
This trial is being conducted under one or more clinical trial agreements that contain, 
among other terms, the publication policy, indemnity agreements, and financial 
arrangements for the study.
11. 
STATISTICAL CONSIDERATIONS 
The primary endpoint will be the proportion of subjects who achieve a PSA response, 
defined as a 50% or greater decline in PSA from baseline, confirmed on a subsequent 
measurement at least 4 weeks apart. The treatment regimen would be considered of 
insufficient activity for further study in this population if the PSA response rate is 25% or 
less. The sample size is calculated to detect an improved PSA response rate from 25% (null 
hypothesis) to 45% (alternative). A minimax Simon two stage design is planned. A total of 
23 patients will be entered in the first stage. A planned analysis will be performed 12 weeks 
after the last patient in the first stage receives the first dose of nivolumab.  If ≤ 5 subjects 
have a PSA response, the study will be terminated and we will conclude the regimen is 
ineffective. If ≥ 6 subjects respond, then an additional 16 patients will be studied, for a total 
of 39 patients. If a total of ≤ 13 subjects respond in stage one and two combined, we 
consider this regimen ineffective. If a total of ≥ 14 respond, we conclude the regimen is 
promising and warrants further study. The maximum sample size will be increased to 44 
patients to account for 10% possible dropouts and unevaluable patients.   
 
This design provides 90% power to detect an absolute 20% increase in PSA response rate 
with a one-sided type I error of 0.1. The probability of early stopping is 0.49 under the null 
hypothesis that the PSA50 response rate is 25%.  
 


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11.1 
Study Endpoints 
 
11.1.1 Analysis of the Primary Endpoint 
The primary endpoint of this study is PSA50 response, defined as a decrease in the 
PSA to 50% less than the baseline PSA upon enrollment in the trial. The decrease 
must be confirmed by a second measurement at least 4 weeks apart. For purposes of 
meeting the primary endpoint, patients will be considered to have done so if they 
have a PSA50 response only while on therapy with Testosterone +/- Nivolumab. PSA 
values will be measured each cycle during the trial.  All patients who are 
administered at least one dose of Testosterone will be considered evaluable for the 
primary endpoint. If patients do not have follow-up PSAs after initiation of 
Testosterone therapy due to withdrawing consent or being lost to follow-up for 
example, then they will be replaced.   
We will estimate the PSA50 response rate, along with the exact 95% confidence 
interval, for the population of patients. 
   
11.1.2 Analysis of Secondary Endpoints 
 
11.1.2.1 Safety 
Patients will be assessed for toxicities at each clinical evaluation. Toxicities 
will graded according to the most current CTCAE standardized grading 
scales.  The incidence of grade 3-5 toxicities will be reported. Patients will be 
assessed for toxicity as long as they are taking Testosterone +/- Nivolumab, 
and patients will continue to be followed if treatment is discontinued for 
toxicity until the toxicities improve to grade 1 or resolve. 
Toxicities will be reported as a tabulated table by type and grade. 
 
 
11.1.2.2 PSA Progression‐free Survival (PSA‐PFS)  
A standard definition of PSA progression per PCWG3 will be used. PSA-PFS 
will be defined as an increase in 25% over a nadir value, confirmed by a 
follow-up PSA at least 4 weeks apart. If patients are removed from study 
prior to PSA progression, then they will be censored at that time. 
 
 
We will use the Kaplan-Meier method to summarize the median PSA PFS. 
 
   
11.1.2.3 Progression‐free Survival (PFS) 
Progression-free survival will be measured from the time of first dose to 
objective tumor progression as defined by RECIST 1.1 for progressive 
disease or death and summarized using a Kaplan-Meier curve. Progression 
will be assigned to the earliest observed time. Patients whose disease has 
not progressed at follow-up will be censored at the date when the last tumor 
assessment determined a lack of progression.  
 
 
We will use the Kaplan-Meier method to summarize the median PFS. 
 
 
11.1.2.4 Objective Response Rate (ORR) 


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The objective response rate is defined as the percentage of patients who 
achieve an objective response by RECIST 1.1 criteria (i.e. Complete response 
or Partial Response) to Testosterone +/- Nivolumab. 
We will estimate the objective response rate, along with the exact 95% 
confidence interval, for the population of patients with RECIST 1.1 evaluable 
disease. 
 
 
 
11.1.2.5 Durable Progression‐free Survival 
 
 
 
Durable PFS will be defined as the proportion of patients without clinical or  
 
 
 
radiographic progression or death at 24 weeks from start of treatment. 
 
 
 
11.1.2.6 Overall Survival (OS) 
Overall survival will be defined as the time from study enrollment to death 
or up to 2 years after the last dose of study treatment.  
This will be analyzed as a Kaplan-Meier plot. 
 
11.1.3 Analysis of Exploratory Endpoints 
 
 
11.1.3.1 Estimate the Percentage of Patients with a Pathogenic Somatic or Germline  
 
 
 Mutation in a HR or MMR Gene Mutation 
The somatic DNA mutations present in the tumor will be identified through 
Foundation Medicine sequencing. Germline DNA mutation testing per 
standard of care practice will be done using clinical-grade testing in a CLIA-
certified laboratory (i.e. COLOR genomics) for consenting subjects only. 
Patients with a germline or somatic deleterious mutation or deletion in the 
pre-specified gene list (BRCA1, BRCA2, ATM, CHEK2, NBN, RAD50, RAD51C, 
RAD51D, PALB2, MRE11, FANCA, FANCB, FANCC, FANCD2, FANCE, FANCF, 
FANCG, FANCI, FANCL, FANCM, MLH1, MLH3, MSH2, MSH3, MSH6, PMS1 
and PMS2) will be considered biomarker positive. For biomarker positive 
and biomarker negative subjects, we will calculate PSA50 response rates with 
confidence intervals for hypothesis generation.  
   
 
11.1.3.2 PD‐1, PD‐L1, CD4, CD8, FOXP3, γH2AX, RAD51, 53BP1 Protein Levels:  
Subjects will have pre-treatment, on-treatment (and at progression) tumor 
biopsy specimens analyzed.  IHC staining for PD-1 and PD-L1 will be 
performed on the pre-treatment samples and scored as <1%, 1-5%, 5-10%, 
>10% and the results will be associated with responses for both proteins, 
separately, using descriptive statistics and Fisher’s Exact Tests. 
Immunofluorescence will be used to quantify the median intensity of each 
gamma-H2AX, RAD51m and 53BP1 foci per cell as well determine the 
median number of foci per cell on the pretreatment biopsies. Using   
 analytical microscopy, Drs. Meeker and Heaphy have developed imaging 
software which can isolate single nuclei and quantify both the intensity and 
number of immunofluorescent foci per nucleus (i.e. per cell). Using FFPE 
tissue obtained at biopsy, we will examine the change in DNA damage foci 
number and intensity (reported as median percent change) induced by BAT 
+/- Nivolumab in PSA50 responders versus non-responders using a T-test. 


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Using imaging software, we will count the number of CD4+ and CD8+ 
lymphocytes in pre-treatment and on-treatment biopsies. We will correlate 
PSA50 responses with CD4+ and CD8+ lymphocyte tumor infiltration. 
 
 
11.1.3.3 MANAs/TAAs Assay  
Whole-exome sequencing will be performed on pre-treatment samples, after 
12 weeks of BAT lead-in therapy, and post-progression tumor and matched 
normal samples. Exome data will be applied in a neoantigen prediction 
pipeline that evaluates antigen processing, MHC binding, and gene 
expression to generate neoantigens specific to the patient’s HLA haplotype. 
Truncal neoantigens will be identified by correcting for tumor purity and 
ploidy. Putative neoantigens will then be used to generate peptides and 
stimulate autologous T cells, followed by TCR next-generation sequencing. 
 
 
11.1.3.4  Cytokines and Chemokines Analysis 
Milliplex human cytokine/chemokine Immunology Multiplex Assay 
(Millipore-Sigma) will be used to assay acute effects of BAT on production of 
cytokines and chemokines. Plasma samples are obtained at prior to the first 
BAT injection on C1D1, 3 hours after the first BAT injection (C1D1), 3 days 
after the first BAT injection (C1D4), prior to C2D1, and prior to C7D1.  
Samples will be processed and stored in the Denmeade Laboratory and 
analyzed by the Immune Processing Core Lab at Johns Hopkins. 
11.2 
Analysis Populations 
11.2.1 Intent‐to‐treat/Response‐to‐treatment/Evaluable Population 
All patients who meet eligibility criteria and receive at least 1 dose of testosterone 
will be included in the main analysis of the response rate, even if there are major 
protocol deviations (e.g. incorrect treatment schedule or drug administration). Each 
patient will be assigned to one of the following categories: 
 
Table 6. Categories for Response to Treatment 
Category 
Response 
1 
Complete response 
2 
Partial response 
3 
Stable disease 
4 
Progressive disease 
5 
Early death from malignant disease 
6 
Early death from toxicity 
7 
Early death from other causes 
8 
Unknown (not assessable/insufficient data) 
NOTE:  By arbitrary convention, category 8 designates unknown status in a 
clinical database. Patients in response categories 4 to 6 will be 
considered to have treatment failure (disease progression) Patients in 
response categories 7 and 8 will be censored (i.e. stable disease) or 
considered disease progression at the discretion of the PI. 


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Conclusions are to be based on the population of all eligible patients. Subanalyses 
may be performed on various subsets of patients, such as those with no major 
protocol deviations or those who continued in the study for the entire treatment 
period (i.e. did not withdraw prematurely). Subanalysis will not serve as the basis 
for drawing conclusions concerning treatment efficacy. 
11.2.2 Safety Population 
All patients enrolled in the study will be included in the safety analysis population 
and considered evaluable for toxicity and safety from the time of their first dose. 
Demographic and baseline characteristics for the safety population will be 
summarized by number and percent for categorical data (e.g. sex, race/ethnicity) 
and by descriptive statistics for continuous data (e.g. weight, vital signs, EKG 
readings, disease status). 
11.3 
Safety Analysis 
11.3.1 Evaluation of Adverse Events 
Treatment-emergent adverse events will be translated from investigator terms to 
MedDRA v.20.1 terminology and summarized (number and percentage of patients) 
for all patients who receive at least 1 dose. Adverse event summaries will be 
organized by body system, frequency of occurrence, intensity (i.e. severity grade), 
and causality or attribution. Patients who experience an adverse event more than 
once will be counted only once. The occurrence with the maximum severity will be 
used to calculate intensity. 
11.3.2 Evaluation of Serious Adverse Events and Premature Withdrawals 
Adverse events deemed serious and those resulting in treatment withdrawal or 
death will be summarized separately. Narrative paragraphs will be generated to 
describe the circumstances surrounding each SAE and death. 
11.3.3 Evaluation of Laboratory Parameters and Assays 
Selected clinical laboratory parameters will be summarized and clinically significant 
changes from baseline will be discussed. 
11.3.4 Extent of Exposure 
Treatment exposure will be summarized for all patients, including dose 
administration, number of cycles, dose modifications or delays, and duration of 
therapy. 
12. 
PROTECTION OF HUMAN SUBJECTS 
12.1 
 
Ethical Considerations 
This study will be conducted in compliance with the protocol, GCP guidelines 
established by the International Conference on Harmonization, and the ethical 
standards set forth in the Declaration of Helsinki 2004 (available at: 
www.laakariliitto.fi/e/ethics/helsinki.html). 


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12.2 
 
Protocol Amendments 
Before starting the study, the protocol must be approved by each institution’s IRB or 
Independent Ethics Committee (IEC). Amendments to the protocol may be made 
only with consent of the lead site/sponsor and principal investigator and are subject 
to IRB approval before instituting. 
12.3 
 
Written Informed Consent 
Before obtaining consent, members of the study team will review the rationale for 
the treatment program with the patient. The discussion will review the alternatives 
available (including hormonal therapy, chemotherapy, or supportive care as 
appropriate), the potential benefits of this program, the risks and the probability of 
their occurrence, and the procedures to minimize these risks. Should an adverse 
event occur, the provisions available to ensure medical intervention will also be 
reviewed. Why the risks are reasonable in relation to the anticipated benefits, 
incentives, or costs that will or may be incurred as a result of participating in the 
study, as well as the efforts to maintain confidentiality, will also be discussed with 
the patient. 
Patients will be required to sign and date (in duplicate) a statement of informed 
consent that meets the requirements of the Code of Federal Regulations (Federal 
Register Vol. 46, No. 17, January 27, 1981, part 50) and the IRB. The medical record 
will include a statement that written informed consent was obtained (and document 
the date that it was obtained) before the patient is enrolled in the study. The original 
signed document will become part of the patient’s medical record, a copy will be 
forwarded to the lead site/sponsor pursuant to sponsor registration, and a copy will 
be sent home with each patient. 
The consent form will include the following: 
 
The nature and objectives, potential toxicities, and benefits of the intended 
study. 
 
The length of therapy and likely follow-up required. 
 
Alternatives to the proposed therapy (including available standard and 
investigational therapies). 
 
The name of the investigator(s) responsible for the protocol. 
 
The right of the patient to accept or refuse treatment and to withdraw from 
participation in this study. 
 
Text regarding the coordinating center should be added to all institutional 
informed consent documents. 
12.4 
 
Protection of Privacy 
Patients will be informed of the extent to which their confidential health 
information generated from this study may be used for research purposes. After this 
discussion, they will be asked to sign a Notice of Privacy Practice research 
authorization/HIPAA form. The original signed documents will become part of the 
patient’s medical records, and each patient will receive a copy of the signed 
documents. The use and disclosure of protected health information will be limited to 
the individuals described in the research authorization form. The research 
authorization form must be completed by the principal investigator and approved 
by the IRB. 


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12.5 
 
Terminating or Modifying the Study 
Adverse event and laboratory data from this trial will be assessed by the medical 
monitor (Dr. Mark Markowski) on an ongoing basis. At least quarterly, data from the 
clinical database will be reviewed. The results of this review will be shared with all 
investigators either in writing or as part of a teleconference. SAEs will be reviewed 
as they are reported to the lead site/sponsor, and the medical monitor will make an 
assessment regarding the safety of continuing or modifying the study. This 
assessment will be shared with the investigators either in writing or as part of a 
teleconference as well as with BMS. Should the assessment of either the lead 
site/sponsor or the principal investigator be that the study should be terminated, 
the study will be closed to further accrual. Patients who are receiving Testosterone 
+/- Nivolumab will be assessed individually by the investigator to see if it is in the 
patients’ best interest to continue, which might be the case for a patient that is 
responding to the intervention. Follow-up safety assessments will be performed for 
all patients who are terminated from the study prematurely. Any planned data 
disclosures will also be discussed with BMS.


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Sengupta S, Chen L, Zincke H, Blute ML, Strome SE, Leibovich BC, Kwon ED. Costimulatory 
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therapeutic target. Proceedings of the National Academy of Sciences of the United States of 
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17. 
Thompson RH, Gillett MD, Cheville JC, Lohse CM, Dong H, Webster WS, Chen L, Zincke H, 
Blute ML, Leibovich BC, Kwon ED. Costimulatory molecule B7-H1 in primary and metastatic 
clear cell renal cell carcinoma. Cancer 2005;104(10):2084-2091. 
18. 
Thompson RH, Kuntz SM, Leibovich BC, Dong H, Lohse CM, Webster WS, Sengupta S, Frank I, 
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with poor prognosis in renal cell carcinoma patients with long-term follow-up. Cancer 
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programmed death-1 ligand-1 and programmed death-1 ligand-2 expression in human 
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Wu C, Zhu Y, Jiang J, Zhao J, Zhang XG, Xu N. Immunohistochemical localization of 
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41. 
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Morris MJ, Scher HI, Stadler WM, Higano C, Basch E, Fizazi K, Antonarakis ES, Beer TM, 
Carducci MA, Chi KN, Corn PG, de Bono JS, Dreicer R, George DJ, Heath EI, Hussain M, Kelly 
WK, Liu G, Logothetis C, Nanus D, Stein MN, Rathkopf DE, Slovin SF, Ryan CJ, Sartor O, Small 
EJ, Smith MR, Sternberg CN, Taplin ME, Wilding G, Nelson PS, Schwartz LH, Halabi S, Kantoff 
PW, Armstrong AJ, Prostate Cancer Clinical Trials Working G. Trial Design and Objectives for 
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APPENDIX A: MANAGEMENT ALGORITHM FOR IMMUNO‐ONCOLOGY AGENTS 
 
 
These general guidelines constitute guidance to the Investigator. The guidance applies to all 
immuno-oncology agents and regimens. 
 
A general principle is that differential diagnoses should be diligently evaluated according to 
standard medical practice. Non-inflammatory etiologies should be considered and 
appropriately treated.  
 
Corticosteroids are a primary therapy for immuno-oncology drug-related adverse events. 
The oral equivalent of the recommended IV doses may be considered for ambulatory 
patients with low-grade toxicity. The lower bioavailability of oral corticosteroids should be 
taken into account when switching to the equivalent dose of oral corticosteroids. 
 
For subjects expected who require more than 4 weeks of corticosteroids or other 
immunosuppressants to manage an adverse event, consider the following 
recommendations: 
  
 
Antimicrobial/antifungal prophylaxis per institutional guidelines to prevent 
opportunistic infections such as Pneumocystis jiroveci (PJP) and fungal infections. 
 
 
Early consultation with an infectious disease specialist should be considered. 
Depending on the presentation, consultation with a pulmonologist for bronchoscopy 
or a gastroenterologist for endoscopy may also be appropriate. 
 
 
In patients who develop recurrent adverse events in the setting of ongoing or prior 
immunosuppressant use, an opportunistic infection should be considered in the 
differential diagnosis. 
 
 
Consultation with a medical or surgical specialist, especially prior to an invasive 
diagnostic or therapeutic procedure, is recommended. 
 
The frequency and severity of the related adverse events covered by these algorithms will 
depend on the immuno-oncology agent or regimen being used.


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APPENDIX B: PERFORMANCE STATUS CRITERIA  
 
ECOG Performance Status Scale 
Karnofsky Performance Scale 
Grade 
Description 
% 
Description 
0 
Normal activity. Fully active, able to 
continue all predisease performance 
without restriction. 
100 
Normal, no complaints, no evidence 
of disease. 
90 
Able to carry on normal activity, 
minor signs or symptoms of disease. 
1 
Symptoms, but ambulatory. 
Restricted in physically strenuous 
activity but ambulatory and able to 
carry out work of a light or sedentary 
nature (e.g. light housework, office 
work). 
80 
Normal activity with effort, some 
signs or symptoms of disease. 
70 
Cares for self, unable to carry on 
normal activity or to do active work. 
2 
In bed < 50% of the time. Ambulatory 
and capable of all self-care but unable 
to carry out any work activities. Up 
and about more than 50% of waking 
hours. 
60 
Requires occasional assistance but is 
able to care for most needs. 
50 
Requires considerable assistance and 
frequent medical care. 
3 
In bed > 50% of the time. Capable of 
only limited self-care, confined to bed 
or chair > 50% of waking hours. 
40 
Disabled, requires special care and 
assistance. 
30 
Severely disabled, hospitalization 
indicated. Death not imminent. 
4 
100% bedridden. Completely 
disabled, cannot carry on any self-
care, totally confined to bed or chair. 
20 
Very sick, hospitalization indicated. 
Death not imminent. 
10 
Moribund, fatal processes 
progressing rapidly. 
5 
Dead. 
0 
Dead. 


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APPENDIX C: LABORATORY MANUAL 
 
Pathology will be reviewed and processed centrally at Johns Hopkins. Biopsy specimens 
will be handled and sampled in a uniform fashion. The lead pathologist at Johns Hopkins 
University, Dr. Angelo De Marzo, will perform the central review and prepare tissue for 
correlative analysis.   
 
For Outside Sites ONLY: Tumor tissue cores for FFPE will each be prepared into 
separate blocks (≥ 2 cores) and the cores for flash freezing will be combined into 1 
block (≥ 2 cores). Specimens will be sent for prior review to the De Marzo Laboratory 
on dry ice to the following address: 
 
De Marzo Laboratory 
Koch Cancer Research Building II 
1550 Orleans Street, Room 138 
Baltimore, Maryland 21231 
 
Please email a copy of the Tissue Sample Information Form (Appendix G) and the 
shipment tracking number to the Lead Site coordinator on the day of shipment. Be sure 
to include a copy inside of the shipping container. 
 
Tumor Tissue Specimens: 
 5 unstained slides and 1 H&E slide representative of tumor collected during the 
Screening period only, will be prepared and sent to Foundation Medicine for 
FoundationOne testing.  Tumor will be placed in the FoundationOne specimen kit 
and shipped to the following address by the De Marzo Laboratory: 
 
Foundation Medicine, Inc. 
7010 Kit Creek Road 
Morrisville, NC 27560 
Phone: 888.988.3639 
 
 20 unstained slides representative of tumor will be prepared from all collected 
biopsies and sent to the De Marzo Laboratory for PD-1, PD-L1, CD4, CD8, Ki-67, 
gamma-H2AX, 53BP1, and RAD51 analysis. 
 
 5 unstained slides representative of tumor will be prepared from all collected 
biopsies and banked in the De Marzo Laboratory for optional tissue banking to be 
utilized for future research. 
 
 
JHU Only: Page Tracy Jones (3-3186) for pick-up, processing, and transport of all tumor 
tissue to the De Marzo Laboratory. 
 
 
 


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MANAs/TAAs assay blood collection for JHU patients ONLY: 
1. Blood will be drawn into ten 10mL purple top (EDTA) tubes for a total volume of 
100mL for the MANAs/TAAs assay at C1D1, C4D1, and at progression (EOT). 
2. Tubes will be sent to the Johns Hopkins Immune Processing Core Lab for PBMC 
processing & plasma isolation for immune studies.  
3. Call the Immune Processing Core Lab (410-283-0693) for pick-up, processing, and 
transport. 
4. Once processing is complete, the Immune Processing Core Lab will contact Eugene 
Shenderov, MD and/or Mark Markowski, MD within 24-48 hours for transfer to 
long-term storage. 
 
Processing Instructions of MANAs/TAAs assay blood collection: 
1. Uncap purple tops and pour blood into 50mL conicals. 
2. Spin conicals at 2500rpm for 15min, 4°C, decel on 1. 
3. Collect plasma layer and immediately freeze in 2mL cryovials at -80°C; 1.5mL per 
vial. 
4. Dilute remaining blood 1 in 2 with PBS, gently mix up and down with a 10mL 
pipette. 
5. Allow blood to sit at room temperature on a rocker for ~30min to bring up 
temperature. 
6. Split diluted blood so there is ~35mL in each 50mL conical. 
7. Continue processing according to Leucosep protocol. 
8. Spin at 2200rpm for 20 minutes with accel and decel on “1” or off, depending on the 
centrifuge. 
9. Collect the buffy coat layer into 50mL conicals, ensuring no more than 20mL of buffy 
coat layer goes into each conical. 
10. Fill up remaining volume in the tubes with PBS. 
11. Spin at 1400rpm for 10min. 
12. Decant supernatant, break up pellet, and add 10mL PBS to each tube. 
13. Spin at 1000rpm for 10min. 
14. Assess the pellet. If there are a lot of RBCs, remove a few microliters and add 4mL 
ACK lysis buffer. 
15. Fill 50mL conical with PBS and spin for 5min at 1400rpm. 
16. Continue to decant off supernatant, break up pellet, and resuspend in 10mL PBS 
(30mL PBS for large blood draws or relevant volume depending on volume of blood 
received). 
17. Count cells, spin at 1400rpm for 5min, continue to decant off supernatant. 
18. Resuspend PBMC in pre-chilled AIM V media at a concentration of 10x106 cells/mL. 
19. Transfer 0.5mL aliquots (5x106 cells) to pre-labeled cryovials. Labels should contain 
patient lab ID, study number, time point, total number of cells, and date. 
20. Quickly add 0.5mL 10% AIM V to each vial and cap. Gently rotate upside down 
twice. 
21. Place in a slow freeze container at -80°C. Leave undisturbed overnight or for a 
minimum of 12 hours and a maximum of 24 hours. 
22. Transfer into liquid nitrogen for long-term storage. 


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Chemokines Assay blood collection for JHU patients ONLY: 
1. Blood will be drawn into one 10mL EDTA purple top tube at C1D1 predose, 3 hours 
post BAT injection on C1D1, 3 days after the first BAT injection (C1D4), C2D1 predose, 
and C7D1 predose. 
2. Tubes should be sent to the Denmeade Laboratory for PBMC processing & plasma 
isolation for chemokine studies.  
3. Call Marc Rosen (410-502-3825/443-275-8982/410-502-8810) or Mark Markowski, 
MD for pickup when collection is complete. 
4. The Denmeade Laboratory will process the specimens and transport them to the 
Immune Processing Core Lab for analysis. 
 
Processing instructions of Chemokines assay: 
1. Uncap purple top tubes and transfer blood into 15mL conicals. 
2. Spin conicals at 2500rpm for 15min, 4°C, decel on “1”. 
3. Collect plasma layer and immediately freeze in 2mL cryovials at -80°C; 1mL per vial. 
 
Rectal swab collection for JHU patients ONLY: 
1. Rectal swabs will be collected via culture swab predose at C1D1, C4D1, and at C7D1. 
2. Culture swabs will be sent to the Sfanos Laboratory for processing. 
3. Call Sarah Ernst (443-386-8057) for pickup when collection is complete. 
 
Collection instructions of Rectal swab cultures: 
1. Write the subject ID, cycle visit, and the date and time of collection on the culture tubes 
for identification purposes. 
2. Gently insert each swab about 1.2 inches (3cm) into anus and swirl the swab in a 
circular motion for 15-30 seconds. 
3. Slowly remove each swab from anus without touching the skin and insert back into the 
tube. 
 
 
 
 
 
 
 
 
 
 


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APPENDIX D: GLOSSARY OF ABBREVIATIONS AND ACRONYMS 
 
17-AAG 
17-allylamino-17-demethoxygeldanamycin 
17-DMAG 
17-dimethylaminoethylamino-17-demethoxygeldanamycin 
2-MPPA 
2-(3-mercaptopropyl) Pentanedioic acid  
AdEERS 
Adverse Event Expedited Reporting System  
ADR 
Adverse drug reaction 
ADT 
Androgen-deprivation therapy 
AE 
Adverse event 
AGA 
Androgenetic alopecia 
AI 
Accumulation index 
ALT 
Alanine aminotransferase 
AML 
Acute myeloid leukemia 
ANC 
Absolute neutrophil count 
ANOVA 
Analysis of variance 
APTT 
Activated partial thromboplastin time 
AR 
Androgen receptor 
ASAEL 
Agent Specific Adverse Event List 
AST 
Aspartate aminotransferase 
AUC 
Area under the plasma concentration-time curve 
AUC(INF) 
Area under the concentration-time curve from time zero extrapolated to infinite 
time 
AUC(0-T) 
Area under the concentration-time curve from time zero to the time of the last 
quantifiable concentration 
AUC(TAU) 
Area under the concentration-time curve in one dosing interval 
AUMC(INF) 
Area under the moment concentration time curve extrapolated to infinity 
A-V 
Atrioventricular 
-HCG 
Beta-human chorionic gonadotrophin 
%BE 
Percent biliary excretion 
bid 
bis in die (twice a day) 
BLQ 
Below limit of quantification 
BMI 
Body mass index 
BP 
Blood pressure 
BSA 
Body Surface Area 
BUN 
Blood urea nitrogen 
C 
Celsius 
Ca++ 
Calcium 
caBIG 
Cancer Biomedical Informatics Grid 
CAEPR 
Comprehensive Adverse Event and Potential Risks 
CALGB 
Cancer and Leukemia Group B 


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CBC 
Complete blood count 
CCC 
Clinical Consortium Committee 
CCD 
Central Consortium Database 
CDE 
Common data element 
CDUS 
Clinical Data Update System  
CFR 
Code of Federal Regulations 
CI 
Confidence interval 
Cl- 
Chloride 
Clcr 
Creatinine clearance 
CLNR 
Nonrenal clearance 
CLR 
Renal clearance 
CLT 
Total body clearance 
CLT/F 
Apparent total body clearance 
Cm 
Centimeter 
Cmax 
Maximum plasma concentration 
Cmin 
Trough observed concentration 
COSTART 
Coding Symbols for Thesaurus of Adverse Reaction Terms 
CNS 
Central nervous system 
CR 
Complete response 
CRC 
Clinical Research Center 
CRDB 
Clinical Research Database 
CRF 
Case report form 
CRMIS 
Clinical Research Management Information System 
CRPC 
Castration resistant prostate cancer 
CT 
Computerized tomography 
CTC 
Circulating tumor cell 
CTCAE 
Common Terminology Criteria for Adverse Events 
CTEP 
Cancer Therapy Evaluation Program 
CTMS 
Clinical Trials Monitoring Service 
CTO 
Clinical Trials Office 
CV 
Coefficient of variation 
CYP 
Cytochrome p-450 
DCTD 
Division of Cancer Treatment and Diagnosis 
DEV 
Deviation from the nominal value 
%DEV 
Percent deviation 
dL 
Deciliter 
DHEA 
Dehydroepiandrosterone 
DHEA-S 
Dehydroepiandrosterone sulfate 
DHT 
Dihydrotestosterone 
DLT 
Dose-limiting toxicity 


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DSM 
Data and safety monitoring 
EA 
Extent of absorption 
ECG 
Electrocardiogram 
ECOG 
Eastern Cooperative Oncology Group 
EDC 
Electronic data capture 
EEG 
Electroencephalogram 
EKG 
Electrocardiogram 
EORTC 
European Organization  for Research and Treatment of Cancer 
ESF 
Eligibility screening form 
ESR 
Expedited safety report 
F 
Bioavailability 
FDA 
Food and Drug Administration 
FDG-PET 
2-[18F]fluoro-2-deoxyglucose positron emitting tomography 
FDHT 
18-fluoro-dehydrotestosterone 
%FE 
percent fecal excretion 
FISH 
Fluorescence in situ hybridization 
FSH 
Follicle stimulating hormone 
GAPDH 
Glyseraldehayde-3-phophate dehydrogenase 
GC 
Gas chromatography 
GCP 
Good clinical practice 
GCPII 
Glutamate carboxypeptidase II enzyme 
GFR 
Glomerular filtration rate 
GGT 
Gamma-glutamyl transferase 
GnRH 
Gonadotropin-releasing hormone  
HAT 
Histone acetyltransferases 
HCO3- 
Bicarbonate 
HDAC 
Histone deacetylase 
HIPAA 
Health Insurance Portability and Accountability Act 
HIV 
Human immunodeficiency virus 
HL7 
American National Standards Institute’s Health Level Seven 
HPF 
High power field 
HPLC 
High-performance liquid chromatography 
HR 
Heart rate 
HRPC 
Hormone-refractory prostate cancer 
HRT 
Hormone replacement therapy 
HSP90 
Heat-shock protein 90 
ICD 
International Classification of Diseases 
ICH 
International Conference on Harmonization 
IEC 
Independent Ethics Committee 
IHC 
Immunochemical 


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IM 
Intramuscular 
IMSL 
International Mathematical Statistical Library 
IND 
Investigational new drug 
INR 
International normalized ratio 
IP 
Intraperitoneal 
IRB 
Institutional Review Board 
ITT 
Intent-to-treat population 
IV 
Intravenous 
K 
Slope of the terminal phase of the log concentration-time curve 
K+ 
Potassium 
K3EDTA 
Potassium ethylenediaminetetraacetic acid 
KLK1 
Kallikrein 1 
LBD 
Ligand-binding domain 
LC 
Liquid chromatography 
LCM 
Laser capture microdissection 
LC-MS 
Liquid chromatography/mass spectrometry 
LD 
Longest diameter 
LDH 
Lactate dehydrogenase 
LLQ 
Lower limit of quantitation 
ln 
Natural logarithm 
LOCF 
Last observation carried forward 
LOI 
Letter of intent 
LPF 
Low power field 
MAD 
Maximum administered dose 
MDS 
Myelodysplasia 
MedDRA 
Medical Dictionary for Regulatory Activities 
MIC 
Minimum inhibitory concentration 
MMP 
Matrix metalloproteinase 
MRI 
Magnetic resonance imaging 
MRT 
Mean residence time 
MRT(INF) 
Mean residence time adjusted for infusion time 
MRT(PO) 
Mean residence time following oral administration 
MRT(SS) 
Mean residence time at steady-state 
MSKCC 
Memorial Sloan-Kettering Cancer Center 
MS 
Mass spectrometry 
MTD 
Maximum tolerated dose 
N 
Number of subjects or observations 
NA 
Not applicable 
N/A 
Not available 
NBN 
National Biospecimen Network 


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NCI 
National Cancer Institute 
NIH 
National Institutes of Health 
NOAEL 
No observed adverse effect level 
NOS 
Not otherwise specified 
NSAID 
Nonsteroidal anti-inflammatory drug 
NTX 
N-telopeptide cross-link 
NVB 
Neurovascular bundle 
OCR 
Office of Clinical Research at MSKCC 
PCCTC 
Prostate Cancer Clinical Trials Consortium 
PCRP 
Department of Defense Prostate Cancer Research Program 
PD 
Progressive disease 
PET 
Positron emission tomography 
PFS 
Progression-free survival 
PI 
Principal investigator 
PIN 
Prostatic intraepithelial neoplasia 
PK 
Pharmacokinetics 
PMB 
Pharmaceutical Management Branch 
PO 
per os (by mouth) 
PR 
Partial response 
PSA 
Prostate-specific antigen 
PSA-DT 
Prostate-specific antigen doubling time 
PSMA 
Prostate specific membrane antigen 
PT 
Prothrombin time 
PTT 
Partial thromboplastin time 
QC 
Quality control 
qd 
quaque die (every day) 
qRT-PCR 
Quantitative reverse transcription-polymerase chain reaction 
QOL 
Quality of life 
RBC 
Red blood cell 
RC 
Research Council 
RDBMS 
Relational Database Management System 
RDRC 
Radioactive Drug Research Committee 
RECIST 
Response Evaluation Criteria in Solid Tumors 
RP 
Radical prostatectomy  
RPC 
eResearch Program Coordinator 
RSA 
Research Study Assistant 
RSD 
Relative standard deviation 
%RSD 
Percent relative standard deviation 
SAE 
Serious adverse event 
SAHA 
Suberoylanilide hydroxamic acid 


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SC 
Subcutaneous 
SD 
Standard deviation 
SD 
Stable disease 
Seq 
Sequence 
SHBG 
Sex hormone binding globulin 
SKI 
Sloan-Kettering Institute for Cancer Research 
SMD 
Stable metabolic disease 
SOP 
Standard Operating Procedures 
SPORE 
Specialized Programs of Research Excellence 
STAR 
Symptom Tracking and Reporting 
SUV 
Standardized uptake value 
t 
Temperature 
t1/2 
Terminal half-life  
T 
Time 
TAUC(TAU) 
Trapezoidal area under the concentration-time curve in one dosing interval 
TAUC(0-T) 
Trapezoidal area under the concentration-time curve from time zero to the time of 
the last quantifiable concentration 
TDP 
Time to disease progression 
TGP 
Prostate-specific transglutaminase  
tid 
ter in die (3 times a day) 
TMA 
Tissue microarray  
Tmax 
Time of maximum observed concentration 
TMPRSS2 
Transmembrane protease, serine 2 
TNM 
Tissue, lymph node, metastases 
TX 
Treatment 
ULN 
Upper limit of normal 
ULQ 
Upper limit of quantitation 
UR 
Urinary recovery 
VEGF 
Vascular endothelial growth factor 
Vss 
Volume of distribution at steady-state 
WBC 
White blood cell 
WHO 
World Health Organization
 
 
 
 
 
 
 
 
 


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APPENDIX E: ACCEPTABLE BIRTH CONTROL METHODS 
 
Subjects with partners of childbearing potential, who are sexually active, must agree to the use of 
TWO highly effective forms of contraception (defined as a method that can achieve a failure rate of 
< 1% per year when used consistently and correctly) in combination [as listed below], throughout 
the period of taking study treatment and for at least 7 months after last dose of study drug(s), or 
they must totally/truly abstain from any form of sexual intercourse [see below].   
 
Highly Effective Non-hormonal birth control methods include: 
 
Total sexual abstinence. Abstinence must continue for the total duration of study treatment 
and for at least 1 month after the last dose. Periodic abstinence (e.g. calendar ovulation, 
symptothermal post ovulation methods) and withdrawal are not acceptable methods of 
contraception. 
 
Vasectomised sexual partner PLUS male condom. With participant assurance that partner 
received post-vasectomy confirmation of azospermia. 
 
Tubal occlusion PLUS male condom. 
 
IUD PLUS male condom. Provided coils are copper-banded. 
 
Highly Effective hormonal methods: 
 
Normal and low dose combined oral pills PLUS male condom. 
 
Cerazette (desogestrel) PLUS male condom. Cerazette is currently the only highly 
efficacious progesterone based pill. 
 
Hormonal shot or injection (e.g. Depo-Provera) PLUS male condom. 
 
Etonogestrel implants (e.g. Implanon, Norplant) PLUS male condom. 
 
Norelgestromin / EE transdermal system PLUS male condom. 
 
Intrauterine system [IUS] device (e.g. levonorgestrel releasing IUS - Mirena®) PLUS male 
condom. 
 
Intravaginal device (e.g. EE and etonogestrel) PLUS male condom. 


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APPENDIX F: ACTIONS REQUIRED IN CASES OF COMBINED INCREASE OF 
AMINOTRANSFERASE AND TOTAL BILIRUBIN – HY’S LAW 
 
1. 
INTRODUCTION 
 
During the course of the study the Investigator will remain vigilant for increases in liver 
biochemistry. The investigator is responsible for determining whether a patient meets potential 
Hy’s Law (PHL) criteria at any point during the study. The Investigator participates, together with 
BMS clinical project representatives, in review and assessment of cases meeting PHL criteria to 
agree whether Hy’s Law (HL) criteria are met. HL criteria are met if there is no alternative 
explanation for the elevations in liver biochemistry other than Drug Induced Liver Injury (DILI) 
caused by the Investigational Medicinal Product (IMP). The Investigator is responsible for 
recording data pertaining to PHL/HL cases and for reporting Adverse Events (AE) and Serious 
Adverse Events (SAE) according to the outcome of the review and assessment in line with standard 
safety reporting processes. 
 
2. 
DEFINITIONS 
 
Potential Hy’s Law (PHL): 
 
Aspartate Aminotransferase (AST) or Alanine Aminotransferase (ALT) ≥ 3x Upper Limit of 
Normal (ULN) and Total Bilirubin (TBL) ≥ 2xULN at any point during the study irrespective 
of an increase in Alkaline Phosphatase (ALP).  
 
Hy’s Law (HL): 
 
AST or ALT ≥ 3xULN and TBL ≥ 2xULN, where no other reason, other than the IMP, can be 
found to explain the combination of increases, e.g. elevated ALP indicating cholestasis, viral 
hepatitis, another drug.  
 
3. 
IDENTIFICATION OF POTENTIAL HY’S LAW CASES 
 
In order to identify cases of PHL it is important to perform a comprehensive review of laboratory 
data for any patient who meets any of the following identification criteria in isolation or in 
combination: 
• ALT ≥ 3xULN 
• AST ≥ 3xULN 
• TBL ≥ 2xULN 
 
The Investigator will without delay review each new laboratory report and if the identification 
criteria are met will: 
• 
Determine whether the patient meets PHL criteria (see Section 2 of this Appendix for 
definition) by reviewing laboratory reports from all previous visits. 
• 
Promptly enter the laboratory data into the laboratory CRF. 
 
 
 
 
 
 


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4. 
FOLLOW‐UP 
 
Potential Hy’s Law Criteria not met 
If the patient does not meet PHL criteria the Investigator will: 
• 
Perform follow-up on subsequent laboratory results according to the guidance provided in 
the Clinical Study Protocol. 
 
Potential Hy’s Law Criteria met 
If the patient does meet PHL criteria the Investigator will: 
• 
Notify the BMS representative who will then inform the central Study Team. 
• 
The Study Physician contacts the Investigator, to provide guidance, discuss and agree an 
approach for the study patients’ follow-up and the continuous review of data. Subsequent to 
this contact the Investigator will: 
 
Monitor the patient until liver biochemistry parameters and appropriate clinical 
symptoms and signs return to normal or baseline levels, or as long as medically 
indicated. 
 
Investigate the etiology of the event and perform diagnostic investigations as 
discussed with the Study Physician. 
 
Complete the three Liver CRF Modules as information becomes available. 
 
If at any time (in consultation with the Study Physician) the PHL case meets serious 
criteria, report it as an SAE using standard reporting procedures. 
 
 
5. 
REVIEW AND ASSESSMENT OF POTENTIAL HY’S LAW CASES 
 
The instructions in this Section should be followed for all cases where PHL criteria are met.  No 
later than 3 weeks after the biochemistry abnormality was initially detected, the Study 
Physician contacts the Investigator in order to review available data and agree on whether 
there is an alternative explanation for meeting PHL criteria other than DILI caused by the 
IMP. BMS and the Principal Investigator will also be involved in this review together with other 
subject matter experts as appropriate. According to the outcome of the review and assessment, the 
Investigator will follow the instructions below: 
 
If there is an agreed alternative explanation for the ALT or AST and TBL elevations, a 
determination of whether the alternative explanation is an AE will be made and subsequently 
whether the AE meets the criteria for a SAE: 
• 
If the alternative explanation is not an AE, record the alternative explanation on the 
appropriate CRF. 
• 
If the alternative explanation is an AE/SAE, record the AE/SAE in the CRF accordingly and 
follow BMS standard processes. 
 
If it is agreed that there is no explanation that would explain the ALT or AST and total bilirubin level 
elevations other than the IMP: 
• 
Report an SAE (report term ‘Hy’s Law’) according to BMS standard processes. 
 
The ‘Medically Important’ serious criterion should be used if no other serious 
criteria apply. 
 
As there is no alternative explanation for the HL case, a causality assessment of 
“related” should be assigned. 
 


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If, there is an unavoidable delay of over 3 weeks in obtaining the information necessary to assess 
whether or not the case meets the criteria for HL, then it is assumed that there is no alternative 
explanation until such time as an informed decision can be made: 
• 
Report an SAE (report term “Potential Hy’s Law”) applying serious criteria and causality 
assessment as per above. 
• 
Continue follow-up and review according to agreed plan. Once the necessary supplementary 
information is obtained, repeat the review and assessment to determine whether HL 
criteria are met. Update the SAE report according to the outcome of the review. 
 
 
6. 
ACTIONS REQUIRED FOR REPEAT EPISODES OF POTENTIAL HY’S LAW 
 
This section is applicable when a patient meets PHL criteria on study treatment and has 
already met PHL criteria at a previous on study treatment visit.   
 
The requirement to conduct follow-up, review and assessment of a repeat occurrence(s) of 
PHL is based on the nature of the alternative cause identified for the previous occurrence. 
The investigator should determine the cause for the previous occurrence of PHL criteria being 
met and answer the following question: 
 
• 
Was the alternative cause for the previous occurrence of PHL criteria being met chronic or 
progressing malignant disease? 
 
 
If No: follow the process described in Section 4 of this Appendix. 
 
If Yes: Determine if there has been a significant change in the patient’s condition# 
compared with when PHL criteria were previously met. 
 
If there is no significant change no action is required. 
 
If there is a significant change follow the process described in Section 4 of 
this Appendix. 
 
A “significant” change in the patient’s condition refers to a clinically relevant change in any of the 
individual liver biochemistry parameters (ALT, AST or total bilirubin) in isolation or in 
combination, or a clinically relevant change in associated symptoms. The determination of whether 
there has been a significant change will be at the discretion of the Investigator, this may be in 
consultation with the Study Physician if there is any uncertainty. 
 
 
7. 
REFERENCES 
 
FDA Guidance for Industry (issued July 2009) ‘Drug-induced liver injury: Premarketing clinical 
evaluation’: 
http://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/U
CM174090.pdf 
 
 
 


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J1812 – COMbination of Bipolar Androgen Therapy and Nivolumab in Men with 
Metastatic Castration-Resistant Prostate Cancer [COMBAT-CRPC] 
Johns Hopkins University Multi-center Phase II Clinical Trial 
PI:  Mark Markowski, MD, Ph.D 
 
Appendix G: Tumor Sample Information Form 
 
Subject No.: ___________________________ 
     Site No.: ______________________ 
 
Study Visit:          Screening Period           Cycle 4 Day 1          Progression/EOT 
 
Date of Collection: ____________________ 
FFPE Tissue: 
 
No. of cores: _____________________ 
Consent obtained to allow storage of biospecimens for Future 
Research?             Yes                 No 
 
Flash Frozen Tissue:  
 
No. of cores: ______________________ 
 
 
Not applicable for site 
 
Label all cores and/or containers with the Fixative used (i.e. FFPE, Flash Frozen), 
Subject ID #, Cycle visit, & Date of collection. 
Shipping Address: 
De Marzo Laboratory 
Koch Cancer Research Building II 
1550 Orleans Street, Room 138 
Baltimore, MD 21231 
 
Please email a copy of this form and the shipment tracking number to the Lead Site 
coordinator on the day of shipment. Include a copy inside the shipping container.  
All tumor specimens should be shipped on dry ice. 

ICF_001.pdf: 
COMbination of Bipolar Androgen Therapy and Nivolumab in Patients with Metastatic
Castration-Resistant Prostate Cancer
Principal Investigator: Mark C. Markowski, M.D., PhD
NCT03554317
Consent form approval date: October 6, 2020


Do not use this form for consenting research
participants unless the Johns Hopkins Medicine
Logo appears here.
Date: October 6, 2020
Principal Investigator: Mark Markowski M.D. Ph.D.
Application No.: IRB00164973
Page 1 of 19
Combined Informed Consent/Authorization June 2015 Version 15
        COMBAT-CRPC ICF v.5.0 dated 28-Aug-2020
RESEARCH PARTICIPANT INFORMED CONSENT AND PRIVACY 
AUTHORIZATION FORM
Protocol Title: 
COMbination of Bipolar Androgen Therapy and Nivolumab in 
Patients with Metastatic Castration-Resistant Prostate Cancer 
[COMBAT-CRPC]
Application No.:     
IRB00164973
Sponsor:
Johns Hopkins University
United States Army Medical Research and Materiel Command
Principal Investigator:   Mark C. Markowski M.D., Ph.D.
Johns Hopkins Sidney Kimmel Comprehensive Cancer Center
201 North Broadway
Baltimore, MD 21287
Phone: 410 955-0567
Fax: 410 367-2668            
 
1.
What you should know about this study:

You are being asked to join a research study. This consent form explains the research study and your 
part in it. Please read it carefully and take as much time as you need. Ask your study doctor or the 
study team to explain any words or information that you do not understand.

You are a volunteer. If you join the study, you can change your mind later. There will be no penalty 
or loss of benefits if you decide to quit the study.  

During the study, we will tell you if we learn any new information that might affect whether you 
wish to continue to participate.

If we think your participation in this study may affect your clinical care, information about your 
study participation will be included in your medical record, which is used throughout Johns Hopkins.   
Doctors outside of Johns Hopkins may not have access to this information. You can ask the research 
team to send this information to any of your doctors.

When Johns Hopkins is used in this consent form, it includes The Johns Hopkins University, The 
Johns Hopkins Hospital, Johns Hopkins Bayview Medical Center, Howard County General Hospital, 
Johns Hopkins Community Physicians, Suburban Hospital, Sibley Memorial Hospital and All 
Children’s Hospital. 

Biospecimens will be collected in this study. Biospecimens may include any of the following: blood, 
tissue, saliva, urine, bone marrow, cells, etc. Most biospecimens contain DNA, which is the genetic 
code for each person.
If you are using Epic for this study, fax a copy 
of the signed consent form to 410-367-7382.
Patient I.D. plate
Approved October 6, 2020
J1812
Web Posting 10/13/2020


Do not use this form for consenting research
participants unless the Johns Hopkins Medicine
Logo appears here.
Date: October 6, 2020
Principal Investigator: Mark Markowski M.D. Ph.D.
Application No.: IRB00164973
Page 2 of 19
Combined Informed Consent/Authorization June 2015 Version 15
        COMBAT-CRPC ICF v.5.0 dated 28-Aug-2020

A description of this clinical trial will be available on http://www.ClinicalTrials.gov, as required by 
U.S. Law. This Web site will not include information that can identify you. At most, the Web site 
will include a summary of the results. You can search this Web site at any time. 

If you would like to review the information for this study, or a summary of the results, ask the study 
team doctor for the ClinicalTrials.gov study registration number.
2.
Why is this research being done?
This aim of this research is to find out if rapid cyclical treatment with testosterone in combination with 
nivolumab leads to lowering of PSA levels in men with metastatic prostate cancer that is resistant to 
androgen deprivation therapy (also referred to as metastatic castration resistant prostate cancer). We also 
want to determine if treating first with testosterone may cause nivolumab to work more effectively 
against your cancer. 
This study is based on our prior and current studies using high dose testosterone in men with metastatic 
castration resistant prostate cancer, in which we observed decreases in PSA levels in a subset of patients.  
Further laboratory and animal studies found that high dose testosterone can damage the DNA (i.e. 
genes) of cancer cells resulting in cell death.  This increase in DNA damage may result in changes in the 
tumor DNA making it recognizable to the immune system with the addition of nivolumab.
Nivolumab (BMS-936558) is a human monoclonal antibody made in a laboratory. Antibodies exist 
normally in your body. An antibody is a type of protein normally made by immune cells that helps 
protect the body against foreign matter, such as bacteria and viruses. These antibodies attach, or bind to, 
foreign matter in a very specific way, and this binding helps the body clear the infection. Nivolumab 
works by attaching to and blocking a protein called PD-1. PD-1 is present on different types of cells in 
the immune system and can shut down the immune cells so that they do not effectively fight disease. 
Antibodies that block the PD-1 protein on these immune cells can potentially stop PD-1 from shutting 
down the immune cells, thus allowing the cells to recognize and help the body destroy the cancer cells. 
Nivolumab is approved by the Food and Drug Administration (FDA) for the treatment of patients with 
advanced skin, kidney and lung cancers. Nivolumab is not approved by the FDA for the treatment of 
metastatic prostate cancer and its use in this study is considered investigational. Nivolumab is currently 
being studied in prostate cancer, but no clinical benefit has been shown at the time of study initiation.
The testosterone used in this study will be administered as an intramuscular (IM) injection. Testosterone 
is approved by the FDA for the treatment of hypogonadism (low testosterone in the blood). It is not 
approved for use in prostate cancer and therefore its use in this study is investigational. The testosterone 
is given at the standard dose that is used to treat men with low testosterone levels in their blood. 
However, the purpose is to increase your testosterone levels above normal briefly, before they return to 
low levels. 
  
Men with prostate cancer who have been on continuous castrating therapy and who have received prior 
treatment with Zytiga or Xtandi and have signs of worsening prostate cancer that include either new 
tumor growth on bone or CT scan or increasing PSA levels in the blood may join. Prior treatment with 
other kinds of hormonal therapy or one chemotherapy is allowed. 
How many people will be in this study?
Up to 44 participants are expected to enroll in this study. About 34 of these participants are expected to 
be enrolled at Johns Hopkins. 
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3.
What will happen if you join this study?
If you agree to be in this study, we will ask you to do the following things:
Screening Period: 
There will be a screening period to see if you can participate in the study. During the screening period 
the following procedures will be performed:

The study team will ask you questions about your medical history and current health and review 
your medical record.

A physical examination and vital signs (body temperature, blood pressure, pulse, respiratory rate, 
weight).

Eastern Cooperative Oncology Group (ECOG) performance status score. This is a scale used to 
assess how your cancer is progressing and how your cancer affects your daily living abilities.

Review of other medications you are currently taking.

Collection of a blood sample (about 3 tablespoons of blood) for laboratory tests which measure 
your blood chemistry, including kidney, pancreas, and liver function, count your red and white 
blood cells and platelets, measure your thyroid function, and measure how long it takes your 
blood to clot. 

Blood test to monitor levels of Prostate Specific Antigen (PSA).

Blood test to determine your level of testosterone.

Blood samples will be obtained for Hepatitis B and C testing. The law requires us to report 
positive tests to the health department. This reporting will include information that identifies you 
(for example, name, date of birth, home address, phone number, etc.) as required by Maryland 
law. The health department may use this information to contact you for further follow up and/or 
to help conduct health surveillance activities aimed at preventing or controlling diseases.

Collection of a urine sample for routine analysis.

Electrocardiogram (ECG): This is a test that gives a picture of the electrical action of your heart.

CT or MRI scan and bone scan (if these have not been performed in the past 4 weeks).  
Computed tomography (CT) scan or magnetic resonance imaging (MRI) of the known areas of 
disease will be done. These pictures will allow your doctor to monitor your disease before, 
during, and after you receive the study drugs. In addition, bone scans will be completed to 
measure your disease.

If you are eligible for the study and choose to participate, you will be scheduled for an image-
guided biopsy of your tumor tissue, which is required prior to the start of the testosterone and the 
nivolumab regimen.
If, based on the results of the screening visit tests and procedures, you qualify to continue to participate 
in the study, you will be scheduled for a clinic visit after which you will start on the testosterone 
regimen. Testosterone is given for 3 months prior to the addition of nivolumab.  
All participants who enroll in the study will have the same procedures and receive the same study drug 
(testosterone alone for the first 12 weeks (3 months) then nivolumab will be added at week 16).
Study Drug Administration Period:
If you are found to be eligible to continue to participate in the study, you will return to the clinic to begin 
the study drugs. Testosterone is given as an injection into the muscle of the buttock. Nivolumab is given 
as an intravenous (IV) infusion.
You will visit the study doctor as instructed. Each study drug cycle is about 4 weeks. The study doctor 
or staff will discuss with you when and on which days to report to the clinic.
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During Cycles 1-3 (Every 4 weeks, total of 12 weeks): TESTOSTERONE ONLY PERIOD
You will return to the clinic every 4 weeks. At each visit, the following tests and procedures will be 
performed:

Review of any changes in your health and medications since your last visit.

You will be asked about the symptoms you are having from your disease and any side effects 
you may be experiencing.

Measurement of your weight and vital signs.

An evaluation of your ability to carry out daily activities will be performed.

A physical examination.

Collection of a blood sample (about 2 tablespoons of blood) for laboratory tests which measure 
your blood chemistry, including kidney and liver function, count your red and white blood cells 
and platelets.

Blood test to monitor levels of Prostate Specific Antigen (PSA).

Blood test to determine your level of testosterone.

Rectal swab: A cotton swab is placed into the rectum. The swab is rotated gently, and removed. 
You will have a rectal swab before you start receiving testosterone, at the end of the testosterone 
only period, and after 3 cycles of starting the testosterone and nivolumab period. Rectal swabs 
will be done for research purposes. 

Administration of testosterone into the muscle of the buttock.
During Cycles 4 and beyond (every 4 weeks): TESTOSTERONE AND NIVOLUMAB PERIOD
You will return to the clinic every 4 weeks. At each visit, the following tests and procedures will be 
performed:

Review of any changes in your health and medications since your last visit.

You will be asked about the symptoms you are having from your disease and any side effects 
you may be experiencing.

Measurement of your weight and vital signs.

An evaluation of your ability to carry out daily activities will be performed.

A physical examination.

Collection of a blood sample (about 2 tablespoons of blood) for laboratory tests which measure 
your blood chemistry, including kidney, pancreas, and liver function, count your red and white 
blood cells and platelets, measure your thyroid function, and monitor for autoimmune conditions.

Blood test to monitor levels of Prostate Specific Antigen (PSA).

Blood test to determine your level of testosterone.

Administration of testosterone into the muscle of the buttock.

Nivolumab will be given intravenously (IV) through a vein in the arm.
Every 3 months: 
You will have a CT scan and bone scan every 3 months while you are enrolled in the study, as well as a 
CT and bone scan at the end of the study (if it has been at least 1 month since your last CT and bone 
scan).  
The following tests will be done for research: 

Collection of a blood sample (about 8 tablespoons) for research at the time of your first 
treatment, 12 weeks after your first treatment, and at the time of disease worsening (progression). 

In addition to the biopsy performed during the screening period, a SECOND image-guided tumor 
biopsy will be performed after 12 weeks of testosterone. This procedure is considered mandatory 
and part of this study.
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Optional Tumor Biopsies:
We would like your permission to perform a third optional image-guided tumor biopsy at the time of 
disease worsening (progression) while receiving both testosterone and nivolumab. This procedure is 
considered optional. If you refuse to have this biopsy, it will not affect your participation on this study 
nor will it affect your future care.
Will you give permission to take part in this optional tumor biopsy at the time of disease worsening or 
progression while receiving both testosterone and nivolumab?
YES     ________________________ 
Signature of Participant
NO      __________________
Signature of Participant
End of Study Drug Regimen Visit / 28-Day Follow-up Visit: 
If you complete all of the study drug regimen/intervention cycles or if you are withdrawn from the study 
at any time, you will come in for an end of study drug regimen visit 28 days after your last dose of study 
drug to have the following procedures done: 

Review of any changes in your health and medications since your last visit.

Measurement of your weight and vital signs.

An evaluation of your ability to carry out daily activities will be performed.

A physical examination.

Collection of a blood sample (about 2 tablespoons of blood) for laboratory tests which 
measure your blood chemistry, including kidney and liver function, count your red and white 
blood cells and platelets, and monitor for autoimmune conditions.

Imaging tests: CT or MRI of the abdomen and pelvis, CT or MRI of the chest (or chest X-
ray), and bone scan, as determined by the study doctor.

Collection of blood (8 tablespoons) for research purposes.

Optional tumor biopsy as discussed above
Off Study Follow-up (100-Day Follow-up / Every 28-Days Follow-up):
If you complete all of the study drug regimen/intervention cycles, you will be contacted 100 days after 
your last dose of study drug for assessment of any adverse side effects.
If you are withdrawn from the study at any time due to adverse side effects, you will be contacted 
monthly following your end of study drug regimen visit/28-day follow-up visit to reassess any active 
adverse events until the event has resolved or stabilized.
Following completion of the 100-day follow-up/Adverse event resolution or stabilization date, you will 
be contacted every 6 months for up to 1 year following your last dose of study drug.
The procedures and visits in this clinical trial are different from the standard treatments. If you choose to 
join the study, there are more frequent clinic visits (every month instead of every 3 months), more 
frequent blood tests (monthly instead of every 3-6 months), and receiving testosterone +/- nivolumab 
instead of standard treatments. You will not be receiving an FDA approved medication that has been 
shown in clinical studies to make patients with your type of cancer live longer.
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The results from all study tests (blood tests, CT, and bone scans) will be available to you and your 
physicians.  
It is important that you tell the study staff about any other medicines, vitamins, nutritional or herbal 
supplements you are taking before and during the study.  It is possible that your study drug could affect 
your other medication and there are certain medications that you will not be allowed to take with the 
study drug during the study, including other anti-cancer therapies and certain vaccines. Your study 
doctor will provide you with a list of medications that you must avoid while you are taking your study 
drug, so it is important to consult your study doctor before taking anything new.
Color Genomics Saliva Test:
You will be asked to provide an optional saliva sample to be analyzed (via Color Genomics) for the 
most relevant genes for mutations associated with prostate cancer per standard of care practice. You 
and/or your insurer will be financially responsible for the cost of this test. If you do not wish to provide 
an optional saliva sample to be analyzed, it will not affect your ability to participate in this trial.
In the hereditary cancer genetic test, Color Genomics uses a sequencing platform to analyze the risk of 
developing hereditary cancer due to inheritance of a pathogenic mutation in 30 cancer predisposition 
genes. Thus, inherited prostate cancer genomic data provided by Color Genomics can further allow us to 
personalize screening and target specified effective therapies for each patient disease. 
You will be asked to provide an optional saliva sample (tube collection) at home, via a Color Genomics 
kit. This optional collection will be performed prior to the second study treatment visit to consenting 
participants. Color Genomics will analyze the genes from the patient salvia sample. You will have 
access to the results and will be allowed to make an appointment with one of the Color Genomics’ 
genetic counselors at no cost. Further, Color Genomics will also keep the patient updated if any 
information related to their results changes. 
Color Saliva Test Procedure: 

A study team member will create a Color Genomics Account, and submit an order. Information 
provided in the order form will include your first and last name, sex, date of birth, mailing address, 
mobile or home number, and your email. 

You will then receive an email to sign the Color Genomics consent; this can be done during one of 
the time point visits or from your personal computer. 

Once you have agreed and signed the Color Genomics consent, your kit will be activated and 
shipped to your home.

In order to not delay results or ruin sample, you must wait 30 minutes if you have: had any food or 
drink, brushed your teeth, used mouthwash, smoked, or chewed gum. 

You will be required to spit into the provided funnel until the amount of saliva reaches the “fill to” 
line. This might take a few minutes (thinking of candy or rubbing your cheeks can speed up the 
process). Remembering that saliva bubbles do not count.

Once your kit is complete, ship the sample back to Color Genomics in the postage-paid package 
provided. 
Once the results are available, you will receive an email from Color Genomics providing you with 
access to the results, tools to the website to share the information with family and primary care 
physicians, as well as the contact information to communicate with Color Genomics genetic counselors 
(free of charge). 
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Application No.: IRB00164973
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Will you give permission to take part in this optional gene sequencing analysis via Color Genomics? If 
you refuse to participate in this analysis, this will not affect your participation on this study nor will it 
affect your future care.
YES     ________________________ 
Signature of Participant
NO      __________________
Signature of Participant
Optional additional blood sample collection 
We would like to collect an additional blood sample to characterize the effect of testosterone on the 
production of inflammatory chemokines and cytokines. Chemokines are a family of small cytokines, or 
signaling proteins secreted by cells. Inflammatory chemokines function mainly as chemo-attractants for 
leukocytes, recruiting monocytes, neutrophils, and other effector cells from the blood to sites of 
infection or tissue damage. Certain inflammatory chemokines activate cells to initiate an immune 
response or promote wound healing. The results of the testing will only be used for research and not to 
guide your medical care. The results will not be added to your medical record and you will not know the 
results. You will not be billed for this additional blood sample collection. 
Do you agree to have 10mL of additional blood collected before you start study drug administration 
(“Cycle 1 Day 1”), 3 hours after the first testosterone injection, 3 days after the first testosterone 
injection, Cycle 2 Day 1, and Cycle 7 Day 1?  If you refuse to participate in this analysis, it will not 
affect your participation on this study nor will it affect your future care.
YES     ________________________ 
Signature of Participant
NO      __________________
Signature of Participant
The Genetic Information Nondiscrimination Act (GINA) may help protect you from health insurance or 
health-related employment discrimination based on genetic information.  
The law provides that health insurance companies and group health plans: 

may not ask for genetic information from this research and, 

may not use genetic information when making decision about eligibility or premiums.
The law will not stop health insurance companies from using genetic information to decide whether to 
pay claims. The law does not apply to other types of insurance (such as life, disability or long-term 
care). 
Despite the GINA protections and the best efforts of the research team to protect your information, you 
may still be at risk if information about you were to become known to people outside of this study.
Request to collect and store biospecimens for future research 
As part of this research study, we would like to ask you to let us store your biospecimens and health 
information for future research. This research could involve other diseases and involve research tools 
such as gene sequencing or creation of cell lines. These samples may also be distributed to other 
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researchers, but they will not contain any information that could be used to identify you. You may limit 
the future use of any banked samples by contacting the study doctor.
The research may involve research tools such as gene sequencing or the creation of cell lines.

Gene sequencing of your DNA provides researchers with the code to your genetic material.  

Cell lines are living tissue samples that can be grown in a laboratory. A cell line can provide an 
unlimited supply of cells in the future without requiring more samples from you. Each cell contains 
your complete DNA.
The study doctor can provide you with additional information if you have questions. Also, further 
information about our use of your biospecimens can be found in this consent document under the 
heading What happens to Data and Biospecimens that are collected in the study?
Will you allow us to store the biospecimens we collect for this study for use in future research?
YES     ________________________ 
Signature of Participant
NO      __________________
Signature of Participant
Incidental Findings
The CT scans you are having as part of this research study will be reviewed by a qualified person just as 
it would be if you were having the CT scans as part of your routine medical care.
There is a possibility that while reviewing your CT scans we may see an abnormality that we did not 
expect to see in this study. This is what is called an “incidental finding.”
We will let you know if we see such an incidental finding. Depending on the type of incidental finding, 
we may contact you by mail or by phone. In the case of a potential serious emergency, someone may go 
to your home.
A qualified person (usually a member of the research team) will talk to you if there is an incidental 
finding. You do not have an option to decline information about an incidental finding.
If you want, we will give information about this incidental finding to your primary doctor or we will 
refer you to an appropriate doctor for further evaluation.

An incidental finding may cause you to feel anxious.  

Since an incidental finding will be part of your medical record, it may affect your current or 
future life or health insurance coverage. This risk will vary depending on the type of insurance 
plan involved. 
The costs for any care that will be needed to diagnose or treat an incidental finding would not be paid for 
by this research study. These costs would be your responsibility.
How long will you be in the study?
We anticipate that most participants will be on the study for about 18 months. Some participants may be 
a part of the study for a shorter time period and some may be for a longer time period.
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4.
What are the risks or discomforts of the study?
Side effects can be mild, moderate or severe (these are explained below). 

Mild: You are aware of the side effect but it doesn’t really bother you.

Moderate: You need to take some sort of action (like painkillers for a headache).

Severe: The side effect stops you from doing what you normally would be doing.
Treatment with testosterone or nivolumab has been associated with the following laboratory findings 
and/or clinical symptoms, generally of mild or moderate severity and generally not requiring treatment 
to be stopped. 
You may experience none, some or all of the side effects listed below.
Risks of Testosterone Injection
Very common side effects (occur in 10% or more of patients):

Inflammation and pain at the site of intramuscular injection

Fluid retention

Increased or decreased libido
Common side effects (occur in 1 to less than 10% of patients):

Enlargement of breast tissue (gynecomastia) 

Excessive frequency of erection 

Prolonged erection (priapism) 

Worsening urinary symptoms due to benign prostatic hyperplasia (BPH) 

Acne 

Nausea 

Headache 

Anxiety, Depression 

Increased cholesterol level 

Decreased blood glucose 

Increased risk of a blood clot in your legs or lungs 

Increased red blood cell count 
Uncommon side effects (occur in up to 1% of patients):

Alterations in liver function tests

Jaundice

Cardiac events such as heart attack or stroke
Rare but serious side effects:

Allergic reaction to testosterone 
The Study Doctor may decide to interrupt and/or reduce your testosterone dose if you experience certain 
side effects.  
In this study, you will be given testosterone, a hormone that can cause your prostate cancer to acutely 
worsen. During this study, you will be allowed to continue on treatment with testosterone with a PSA 
value that is rising. This may lead to delay in changing treatment, disease progression, and/or the 
development of new symptoms (i.e. pain). It is important that you share with your doctor, any new or 
concerning symptoms that you may experience on this trial.
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There may be risks involved in taking this drug that have not yet been discovered. There is always a risk 
involved in taking an experimental drug but every precaution will be taken. If you suffer any side effects 
or injuries, or your condition gets worse, tell your study doctor immediately so you can receive 
appropriate care.    
Risks of Nivolumab
Very common side effects (occur in 10% or more of patients):

Diarrhea

Fatigue

Itching

Rash
Common side effects (occur in 1 to less than 10% of patients):

Abdominal pain

Alkaline phosphatase increased (lab test result associated with liver or bone abnormalities)

ALT increased (lab test result associated with abnormal liver function)

Amylase increased (lab test result associated with pancreas inflammation)

AST increased (lab test result associated with abnormal liver function)

Chills

Constipation

Cough

Creatinine increased (lab test result associated with decreased kidney function)

Decreased appetite

Dizziness

Dry mouth

Dry skin

Fever

Headache

Increased blood sugar

Inflammation of the colon

Inflammation of the mouth

Infusion-related reaction

Lipase increased (lab test result associated with pancreas inflammation)

Joint pain or stiffness

Loss of color (pigment) from areas of skin

Lung inflammation (pneumonitis - see details below)

Musculoskeletal pain

Nausea

Redness

Shortness of breath

Sodium levels in the blood low

Swelling, including face, arms, and legs

Thyroid gland function decreased

Thyroid gland function increased

Thyroid stimulating hormone increased (lab test result associated with abnormal thyroid 
function) 
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
Tingling, burning, numbness or weakness, possibly in arms, legs, hands, and feet

Vomiting 
Uncommon side effects (occur in up to 1% of patients):

Adrenal gland function decreased

Allergic reaction/hypersensitivity

Bilirubin (liver function blood test) increased 

Bronchitis

Cranial nerve disorder

Diabetes

Dry eye

Hair loss

Heart rate increased

Heart rhythm abnormal 

High blood pressure 

Hives 

Inflammation of the eye

Inflammation of the heart

Inflammation of the kidney

Inflammation of the pancreas

Inflammation of the pituitary gland

Inflammation of the stomach

Inflammation of the thyroid gland

Liver inflammation 

Low blood pressure 

Pituitary gland function decreased 

Psoriasis: characterized by patches of abnormal, scaly skin 

Renal (kidney) failure or kidney injury 

Respiratory failure 

Sodium levels in blood low 

Upper respiratory tract infection 

Vertigo (feeling off balance which can lead to dizziness) 

Vision blurred 
Rare but serious side effects:

Anaphylactic reaction (severe allergic reaction)

Damage to the protective covering of the nerves in the brain and spinal cord

Diabetes complications resulting in excess blood acids and diabetic coma

Erythema multiforme, a skin inflammatory reaction

Guillain-Barre syndrome, an autoimmune disorder associated with progressive muscle weakness 
or paralysis

Inflammation of blood vessels

Inflammation of the brain, potentially life-threatening or fatal

Inflammation of the heart

Muscle inflammation

Myasthenic syndrome (neurologic syndrome characterized by muscle weakness) including 
myasthenia gravis, a nerve disease that may cause weakness of eye, face, breathing, and 
swallowing muscles
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
Polymyalgia rheumatica, an inflammatory disorder causing muscle pain and stiffness

Rhabdomyolysis, muscle fiber released into the blood stream which could damage your kidneys

Rosacea, acne-like skin condition resulting in redness of face

Sarcoidosis, a disease involving abnormal collections of inflammatory cells (granulomas) in 
organs such as lungs, skin, and lymph nodes

Stevens-Johnson syndrome, inflammatory disorder of skin and mucous membranes, resulting in 
blistering and shedding of skin

Toxic epidermal necrolysis, a potentially fatal disease characterized by blistering and peeling of 
the top layer of skin resembling a severe burn

Histiocytic necrotizing lymphadenitis or Kikuchi lymphadenitis, disorder of the lymph nodes 
which causes the lymph nodes to become enlarged, inflamed and painful, commonly affecting 
lymph nodes of the neck and possibly associated with fever or muscle and joint pains 

Vogt-Koyanagi-Harada syndrome, a disease that affects the pigmented tissue; this may affect the 
eye leading to swelling, pain and/or blurred vision; the ear leading to hearing loss, ringing in the 
ears and/or the skin leading to loss of skin color 
Lung Inflammation (pneumonitis): 
It is possible that nivolumab may cause inflammation of the tissues of the lung. This adverse effect has 
been reported infrequently in patients treated with nivolumab. While many patients with X-ray or CT 
abnormalities have not developed any symptoms, some patients have developed mild to severe 
symptoms and in rare cases, death has occurred as a result of their lung inflammation. Signs and 
symptoms of lung inflammation may include difficulty breathing, pain or discomfort while breathing, 
chest pain, cough, shortness of breath, increased rate of breathing, fever, low blood oxygen levels or 
fatigue. 
Your study doctor and nurse will watch you closely for changes in your ability to breathe and for other 
signs or symptoms that might show you are developing this type of lung inflammation and will perform 
regular tests including physical exams, measurement of oxygen levels through non-invasive testing (i.e. 
pulse oximeter), blood tests, chest x-rays and/or CT scans. 
Please inform your study doctor or nurse AT ONCE if you experience any of the following: 

Any new or increased shortness of breath.

Any new or increased chest pain.

Any new or increased pain/difficulty while breathing.

Any new or increased cough or any significant change in your type of cough; for example, any new 
or increased mucous or blood in your cough.

Any change in the amount of oxygen you require.

Any fever, fatigue or other symptoms that occur at the same time as any changes to your breathing 
or other lung symptoms. 
If you start to develop symptoms, your study doctor will ask you to return to the clinic for additional 
tests, which could include a physical exam, measurement of oxygen levels, blood tests, chest X-rays, 
and/or CT scans. You will be monitored very closely for changes in your overall lung symptoms, 
monitoring may require hospitalization. You may require specific treatment in order to control 
pneumonitis. You may also be seen by a special doctor called a pulmonologist, who has special training 
to be an expert in how your lungs work. 
Prolonged treatment with medicines that suppress inflammation, sometimes needed to manage the side 
effects of nivolumab treatment, may lower your body’s ability to fight off certain infections (i.e. 
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opportunistic infections). These infections may require treatment with antibiotic or antifungal 
medications and may be fatal. 
Risks of Blood Draw: 
You may feel some discomfort when the needle is placed in your vein to draw blood for testing. 
Sometimes a bruise may develop where the blood was drawn or the needle was placed, and occasionally 
infection or bleeding may develop at the puncture site. Light-headedness and/or fainting may occur 
during blood collection. 
Risks Related to Imaging
This research study includes exposure to radiation from x-rays or gamma-rays if you have CT-guided 
biopsies. This radiation exposure is for research purposes only and is not part of your medical care. X-
rays and gamma rays can damage the genetic material (DNA) in cells. At low doses, cells usually can 
repair this damage. There is some possibility that an incorrect repair may increase the risk of cancer in 
your lifetime. The normal lifetime risk of cancer is 25%. A radiation dose of 15 rems (a rem is a unit of 
radiation dose) would increase your lifetime risk to 25.6%.  
The radiation exposure that you may get in this research study is 5.0 rems (The radiation exposure that 
you will get from the three CT guided biopsies is 2.4 rem. You will also receive 0.8 rems for one extra 
bone scan and 1.8 rems for one extra CT scan if you have the scans repeated at the time of disease 
worsening) (a rem is a unit of absorbed radiation). To put that in context, the average person in the 
United States gets a radiation exposure of 0.3 rems per year from natural sources, like the sun, outer 
space, air, food, and soil. People who work with radiation (for example, X-ray technologists) are 
allowed a maximum exposure of 5.0 rems each year.  Although these levels of radiation are thought to 
cause an increased risk of cancer, studies in people who work with radiation have rarely shown a 
measurable increase in cancer risk. 
The radiation exposure described here is what you will get from this research study only. It does not 
include any exposure you may have received or will receive from other tests outside of this study that 
are a part of your medical care. Radiation risk builds up with each exposure. You should think about 
your own history of radiation exposure from tests (like X-rays or CT scans) in deciding about the 
radiation in this study. If you have questions about the total amount of radiation you will be receiving, 
you should ask your doctor.
Other Risks in the Study:
Your cancer may continue to grow if you elect to participate in this study. You may develop symptoms 
from cancer or the cancer may spread during this clinical trial.
Genetic information is unique to you and your family, even without your name or other identifiers.   
Johns Hopkins follows procedures to prevent people who work with your DNA information from being 
able to discover it belongs to you. However, new techniques are constantly being developed that may in 
the future make it easier to re-identify genetic data, so we cannot promise that your genetic information 
will never be linked to you.
There may be side effects and discomforts that are not yet known.  
5.
Are there risks related to pregnancy?
You must agree not to cause pregnancy during the study and for a period of 7 months after you receive 
the last dose of study drug. Pregnancy could possibly result in birth defects or death to the embryo or 
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fetus that is conceived while you are receiving the study drug or after you receive the last dose of study 
drug. It is, therefore, very important that you do not cause a pregnancy. 
If you are a man who is still able to get a woman pregnant (in other words, not surgically sterilized), you 
must agree for you or your partner to use 2 acceptable methods of contraception (for example, a barrier 
method such as a diaphragm, condom with spermicide, cervical cap, or sponge) for up to 7 months after 
the last dose of study drug. 
If you do cause a pregnancy while in this research study, you must agree to inform your study doctor 
immediately. The study doctor will ask to follow the outcome of your partner’s pregnancy. 
In case of a pregnancy, your partner’s pregnancy and its outcome will be reported to Bristol-Myers 
Squibb, the manufacturer of the study drug. Your pregnant partner will be asked to read and sign a 
separate consent form to allow this information to be sent to Bristol-Myers Squibb. 
This research may hurt an embryo or fetus in ways we do not currently know. 
6.
Are there benefits to being in the study?
You may or may not directly benefit from being in this study. If you take part in this study, you may 
help others in the future.
7.
What are your options if you do not want to be in the study?
If you decide not to join this study, other options are available. You do not have to join this study to get 
treatment. Other treatments include additional androgen deprivation therapy or chemotherapy along with 
blood work, CT scans, and bone scans.
You do not have to join this study. If you do not join, your care at Johns Hopkins will not be affected.
8.
Will it cost you anything to be in this study? 
You will receive a separate Insurance and Research Participant Financial Responsibility Information 
Sheet (Sheet). 
This Sheet will give you the following information:

The procedures, tests, drugs or devices that are part of this research and that will be paid for by 
the study (no cost to you).  

The procedures, tests, drugs or devices that will be billed to you and/or your health insurer. If 
you have health insurance, you will be responsible for any co-pays or deductibles not covered by 
your insurance. 
9.
Will you be paid if you join this study?
You will not be paid to join this study.
10.
Can you leave the study early?

You can agree to be in the study now and change your mind later.

If you wish to stop, please tell us right away.

Leaving this study early will not stop you from getting regular medical care. 
If you leave the study early, Johns Hopkins may use or give out your health information that it has 
already collected if the information is needed for this study or any follow-up activities. 
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Date: October 6, 2020
Principal Investigator: Mark Markowski M.D. Ph.D.
Application No.: IRB00164973
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11.
Why might we take you out of the study early? 
You may be taken out of the study if:

Staying in the study would be harmful.

You need treatment not allowed in the study.

You fail to follow instructions.

The study is cancelled.

There may be other reasons to take you out of the study that we do not know at this time. 
If you are taken out of the study or stop taking the study drug, we will ask you to come in for a final visit 
about 1 month after your last dose of study drug. You will have a physical exam, blood tests, review of 
your medications, CT scan, and bone scan. We will also contact you by telephone and/or email 100 days 
after your last dose of study drug to review and assess any adverse side effects you may experience and 
once every 6 months for up to 1 year following. We will also contact you monthly for reassessment if 
you discontinue the study because of adverse side effects, continuing until the event(s) resolve or 
stabilize.
12.
How will your privacy be protected? 
We have rules to protect information about you. Federal and state laws and the federal medical Privacy 
Rule also protect your privacy. By signing this form, you provide your permission, called your 
“authorization” for the use and disclosure of information protected by the Privacy Rule.
The research team working on the study will collect information about you. This includes things learned 
from the procedures described in this consent form. They may also collect other information including 
your name, address, date of birth, and information from your medical records (which may include 
information about HIV status, drug, alcohol or STD treatment, genetic test results or mental health 
treatment).
The research team will know your identity and that you are in the research study. Other people at Johns 
Hopkins, particularly your doctors, may also see or give out your information. We make this information 
available to your doctors for your safety.   
People outside of Johns Hopkins may need to see or receive your information for this study. Examples 
include government agencies (such as the Food and Drug Administration), safety monitors, other sites in 
the study, and companies that sponsor the study. 
The Department of Defense (DoD) and the U.S. Army Medical Research and Materiel Command
(USAMRMC) will have access to study records for audit purposes.
If you are in a cancer study that receives federal funding, the National Cancer Institute (NCI) now 
requires that we report identifiable information (such as, zip code) about your participation. You may 
contact the NCI if you have questions about how this information is used. 
We cannot do this study without your authorization to use and give out your information. You do not 
have to give us this authorization. If you do not, then you may not join this study.
We will use and disclose your information only as described in this form and in our Notice of Privacy 
Practices; however, people outside Johns Hopkins who receive your information may not be covered by 
this promise or by the federal Privacy Rule. We try to make sure that everyone who needs to see your 
information keeps it confidential – but we cannot guarantee that your information will not be re-
disclosed.
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Date: October 6, 2020
Principal Investigator: Mark Markowski M.D. Ph.D.
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The use and disclosure of your information has no time limit. You may revoke (cancel) your permission 
to use and disclose your information at any time by notifying the Principal Investigator of this study by 
phone or in writing.  If you contact the Principal Investigator by phone, you must follow-up with a 
written request that includes the study number and your contact information. The Principal 
Investigator’s name, address, phone, and fax information are on page one of this consent form. 
If you do cancel your authorization to use and disclose your information, your part in this study will end 
and no further information about you will be collected. Your revocation (cancellation) would not affect 
information already collected in the study, or information we disclosed before you wrote to the Principal 
Investigator to cancel your authorization.
Study Sponsor:
A sponsor of this study is the Department of Defense Prostate Cancer Research Program (DoD PCRP).
Representatives of the DoD may need to review your research records as part of the study and are
authorized to do so.
13.
Will the study require any of your other health care providers to share your health 
information with the researchers of this study?
14.
As a part of this study, the researchers may ask to see your health care records from your other health 
care providers.  What does a conflict of interest mean to you as a participant in this 
study?
A researcher has a financial or other interest in this study.
In some situations, the results of this study may lead to a financial gain for the researcher and/or Johns 
Hopkins.  This financial interest has been reviewed in keeping with Johns Hopkins’ policies.  It has been 
approved with certain conditions, which are intended to guard against bias and to protect participants.
If you have any questions about this financial interest, please talk to Dr. Mark Markowski at 410-955-
0567. This person is a member of the study team, but does not have a financial interest related to the 
study. You may also call the Office of Policy Coordination (410-361-8667) for more information. The 
Office of Policy Coordination reviews financial interests of researchers and/or Johns Hopkins.
15.
What treatment costs will be paid if you are injured in this study? 
Neither Johns Hopkins nor the DoD PCRP, a study sponsor, have a program to pay you if you are hurt 
or have other bad results from being in the study. However, medical care at Johns Hopkins is open to 
you as it is to all sick or injured people.  
The costs for any treatment or hospital care you receive as the result of a study-related injury that are not 
covered by a health insurer will be billed to you.
By signing this form you will not give up any rights you have to seek compensation for injury. 
16.
What other things should you know about this research study?
a. What is the Institutional Review Board (IRB) and how does it protect you? 
The Johns Hopkins Medicine IRB is made up of:

Doctors

Nurses

Ethicists
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Date: October 6, 2020
Principal Investigator: Mark Markowski M.D. Ph.D.
Application No.: IRB00164973
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
Non-scientists

and people from the local community. 
The IRB reviews human research studies. It protects the rights and welfare of the people taking part 
in those studies. You may contact the IRB if you have questions about your rights as a participant or 
if you think you have not been treated fairly. The IRB office number is 410-955-3008. You may also 
call this number for other questions, concerns or complaints about the research.
When the Johns Hopkins School of Medicine Institutional Review Board (IRB) reviews a study at 
another site, that site (institution) is solely responsible for the safe conduct of the study and for 
following the protocol approved by the Johns Hopkins IRB.  
b. What do you do if you have questions about the study?   
Call the principal investigator, Dr. Mark C. Markowski at 410-614-0567. If you wish, you may 
contact the principal investigator by letter or by fax. The address and fax number are on page one of 
this consent form. If you cannot reach the principal investigator or wish to talk to someone else, call 
the IRB office at 410-955-3008.  
c.
What should you do if you are injured or ill as a result of being in this study? 
If you think you are injured or ill because of this study, call Dr. Mark C. Markowski at 410-955-
0567 during regular office hours. 
If you have an urgent medical problem related to your taking part in this study, call the medical 
oncology clinic at 410-955-8893 during regular office hours and at 410-955-4331 after hours and on 
weekends. 
 
d. What happens to Data and Biospecimens that are collected in the study? 
Johns Hopkins, our research partners, and the DoD PCRP, a sponsor of this research, work to 
understand and cure diseases. The biospecimens and/or data you provide are important to this effort.
Both Johns Hopkins and the DoD PCRP, a sponsor of this research, may study your data and the
tissue, blood or other specimens collected from you.
If you join this study, you should understand that you will not own your biospecimens or data, and 
should researchers use them to create a new product or idea, you will not benefit financially. 
With appropriate protections for privacy, Johns Hopkins may share your biospecimens and 
information with our research sponsors and partners.   
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Logo appears here.
Date: October 6, 2020
Principal Investigator: Mark Markowski M.D. Ph.D.
Application No.: IRB00164973
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17.
What does your signature on this consent form mean? 
Your signature on this form means that: You understand the information given to you in this form, you 
accept the provisions in the form, and you agree to join the study. You will not give up any legal rights 
by signing this consent form. 
WE WILL GIVE YOU A COPY OF THIS SIGNED AND DATED CONSENT FORM
________________________________________________________________________________________________________________________
Signature of Participant                                                                           (Print Name)                                                
Date/Time 
________________________________________________________________________________________________________________________
Signature of Person Obtaining Consent                                                  (Print Name)                                              
Date/Time
________________________________________________________________________________________________________________________
Signature of Witness to Consent Procedures                                         (Print Name)
Date/Time
(optional unless IRB or Sponsor required)
I have received the separate Insurance and Research Participant Financial Responsibility Information Sheet.  
___________________________________________________________________________________________________________
Signature of Participant, LAR or Parent/Guardian                    (Print Name)                                                                  Date/Time
NOTE: A COPY OF THE SIGNED, DATED CONSENT FORM MUST BE KEPT BY THE PRINCIPAL INVESTIGATOR; A COPY 
MUST BE GIVEN TO THE PARTICIPANT; IF YOU ARE USING EPIC FOR THIS STUDY A COPY MUST BE FAXED TO 410-367-
7382; IF YOU ARE NOT USING EPIC A COPY MUST BE PLACED IN THE PARTICIPANT’S MEDICAL RECORD (UNLESS NO 
MEDICAL RECORD EXISTS OR WILL BE CREATED). 
ONLY CONSENT FORMS THAT INCLUDE THE JOHNS HOPKINS MEDICINE LOGO CAN BE USED TO OBTAIN THE CONSENT 
OF RESEARCH PARTICIPANTS.
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Do not use this form for consenting research
participants unless the Johns Hopkins Medicine
Logo appears here.
Date: October 6, 2020
Principal Investigator: Mark Markowski M.D. Ph.D.
Application No.: IRB00164973
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DOCUMENTATION OF PHYSICIAN/MID-LEVEL PROVIDER CONSENT
My signature below indicates that I have discussed the risks, benefits, and alternatives, answered any 
questions, and believe the participant is able to make an informed choice to join the study.
________________________________________________________________________________________________________________________
Signature of Physician/Mid-Level Provider                                           (Print Name)                                                          
Date/Time  
________________________________________________________________________________________________________________________
Signature of Participant                                                                          (Print Name)                                                       
Date/Time    
________________________________________________________________________________________________________________________
Signature of Witness to Consent Procedures                                         (Print Name)
Date/Time
(optional unless IRB or Sponsor required)
NOTE: A COPY OF THE SIGNED, DATED CONSENT FORM MUST BE KEPT BY THE PRINCIPAL INVESTIGATOR; A COPY 
MUST BE GIVEN TO THE PARTICIPANT; IF YOU ARE USING EPIC FOR THIS STUDY A COPY MUST BE FAXED TO 410-367-
7382; IF YOU ARE NOT USING EPIC A COPY MUST BE PLACED IN THE PARTICIPANT’S MEDICAL RECORD (UNLESS NO 
MEDICAL RECORD EXISTS OR WILL BE CREATED). 
ONLY CONSENT FORMS THAT INCLUDE THE JOHNS HOPKINS MEDICINE LOGO CAN BE USED TO OBTAIN THE CONSENT 
OF RESEARCH PARTICIPANTS.
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Template Version Date March 28, 2019 
 
 
Insurance and Research Participant Financial Responsibility 
Information Sheet  
 
Clinical Research Study Title: COMbination of Bipolar Androgen Therapy and Nivolumab 
in Patients with Metastatic Castration-Resistant Prostate Cancer [COMBAT-CRPC] 
 
Principal Investigator: Mark Markowski  
eIRB # : IRB00164973 
 
 
 
  
Date: 07/21/2020 – CIR00059512  
 
 
The following procedures, tests, drugs or devices are part of this research and will be supplied 
free of charge by the study:  
 
Testosterone Cypioinate IM 
 
Rectal Swab 
 
Germline DNA Testing 
 
Hepatitis B/C 
 
RECIST Read 
 
Core Tumor Biopsy 
 
Plasma for MANAs/TAAs 
 
Plasma for Chemokines 
 
18F-DCFPyL PET imaging Scan #1 & 
#2 [including radiotracer] 
 
Nivolumab IV 
 
You and/or your health insurer will be responsible for all other procedures, tests, drugs or 
devices that are part of this study such as the following: 
 
EKG 
 
Drug Administration [for both drugs] 
 
Physical Exam 
 
CBC, Diff 
 
CMP 
 
PSA 
 
Serum Testosterone 
 
Serum Amylase, Lipase, CK, TSH [with 
reflex T3,T4] 
 
Coagulation 
 
Urinalysis 
 
Radiologic Tests 
If you have health insurance, you will be responsible for any co-pays or deductibles not 
covered by your insurance.  
 
For questions about your bill, including payment plans, financial assistance or information 
changes, please call: 
 
1-855-662-3017 
 
 
J1812
eIRB uploaded 7/21/2020