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5.4.1 clinical pharmacology program (figg

Upon arrival in the Clinical Pharmacology Program, blood samples will be centrifuged and the plasma transferred into cryovials for storage at -80° C until the time of analysis. Urine samples will be aliquoted into cryovials, diluted with an equal volume of methanol and stored at -80°C until the time of analysis. In addition, samples will be barcoded. All samples sent to the Blood Processing Core (BPC) will be barcoded, with data entered and stored in the Labmatrix utilized by the BPC. This is a secure program, with access to Labmatrix limited to defined Figg lab personnel, who are issued individual user accounts. Installation of Labmatrix is limited to computers specified by Dr. Figg. These computers all have a password restricted login screen. Labmatrix creates a unique barcode ID for every sample and sample box, which cannot be traced back to participants without Labmatrix access. The data recorded for each sample includes the participant ID, name, trial name/protocol number, time drawn, cycle time point, dose, material type, as well as box and freezer location. Participant demographics associated with the clinical center participant number are provided in the system. For each sample, there are notes associated with the processing method (delay in sample processing, storage conditions on the ward, etc.). Barcoded samples are stored in bar-coded boxes in locked freezers at either -20 C or -80 C according to stability requirements. These freezers are located onsite in the CPP and offsite at NCI Frederick Central Repository Services in Frederick, MD. Samples will be stored until requested by a researcher named on the protocol. All requests are monitored and tracked in Labmatrix. All researchers are required to sign a form stating that the samples are only to be used for research purposes associated with this trial (as per IRB approved protocol) and that any unused samples must be returned to the CPP. It is the responsibility of the NCI Principal Investigator to ensure that the samples requested are being used in a manner consistent with IRB approval. Following completion of this study, samples will remain in storage as detailed above. Access to these samples will only be granted following IRB approval of an additional protocol, granting the rights to use the material. If, at any time, a participant withdraws from the study and does not wish for their existing samples to be utilized, the individual must provide a written request. Following receipt of this request, the samples will be destroyed (or returned to the participant, if so requested). The PI will record any loss or unanticipated destruction of samples as a deviation.  
Reporting will be per the requirements of section 7.2.  
Sample barcodes are linked to participant demographics and limited clinical information. This information will only be provided to investigators listed on this protocol, via registered use of the Labmatrix. It is critical that the sample remains linked to participant information such as race, age, dates of diagnosis and death, and histological information about the tumor, in order to correlate genotype with these variables.
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5.4.2 molecular targets core (dr.

Biospecimens will be collected and processed using validated SOPs that will ensure both specimen quality and participant confidentiality pursuant to informed consent provisions. To ensure participant confidentiality, only containers used for the initial specimen collections will be labeled with participant identifiers. Coded, linked labels will be applied to all subsequent specimen containers. When specimens are processed and aliquoted, no participant information will be included on the new containers. Samples are labeled with printed consecutive numbers, frozen on dry ice, and stored in a -80°C freezer located at the NCI Research Facility. The freezer is locked and monitored 24/7 for temperature control. Samples will be tracked using a limited access Excel database. Access to the inventory system and associated documents will be restricted to appropriate personnel only. Requests to use specimens stored in the repository must be approved by the IRB. SOPs ensure that any changes in the informed consent made by a participant and relayed to the PI will be reflected in the inventory system to ensure that specimens are destroyed as appropriate. All laboratory personnel will be trained to adhere to SOPs and will be monitored for high-quality performance. The PI will record any loss or unanticipated destruction of samples as a deviation. Reporting will be per the requirements of section 7.2.
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5.4.3 trepel lab

Tracking and disposition of samples will conform to the NCI CCR Biospecimen Guidelines. All samples will be barcoded and data entered and stored in the Labmatrix system utilized by the NIH Clinical Center. This is a secure system with access limited to defined personnel.  
Labmatrix creates a unique barcode ID for every sample which cannot be traced back to subjects without Labmatrix access. The data recorded for each sample includes the subject ID, name, trial name/protocol number, date/time drawn, as well as box and freezer location. Subject demographics associated with the clinical center participant number are provided in the system. For each sample, there are notes associated with the processing method (delay in sample processing, storage conditions on the ward, etc.). Access to personally identifiable information (PII) is limited to the PI and associate investigators. An additional layer of encryption will be added for samples undergoing genetic analysis in the Trepel lab where a separate clinically annotated unique sample ID will be generated linked with the sample ID in Labmatrix. As additional clinical information is generated and linked to the unique participant ID, it is also electronically linked via Labmatrix to the sample ID. The Trepel lab will proceed with sample analysis and record data under the unique sample ID. Barcoded samples are stored in barcoded boxes in a locked freezer at either -20 or -80°C or in liquid nitrogen according to stability requirements. These freezers are located onsite, and access to stored clinical samples is restricted. Samples will be stored until requested by a researcher named on the protocol. All requests are monitored and tracked in the Labmatrix System. All researchers are required to sign a form stating that the samples are only to be used for research purposes associated with this trial (as per the IRB approved protocol) and that any unused samples must be returned to the NCI. It is the responsibility of the NCI Principal Investigator to ensure that the samples requested are being used in a manner consistent with IRB approval. Samples will be stored in a freezer at either -4°C or -70°C behind a door locked after working hours. Samples will be tracked by a designated member of the laboratory who is responsible for notifying the PI about requests for use of the material, for allocating the material to other members of the laboratory, for recording the disposition of the allocated material. 5.4.4 Future Use/IRB Reporting/Protocol Completion/Sample Destruction Blood and tissue specimens collected in the course of this research project may be banked and used in the future to investigate new scientific questions related to this study, including gene/protein expression and germline analysis. However, this research may only be done if the risks of the new questions were covered in the consent document and the proposed research has undergone prospective IRB review and approval. The PI will record any loss or unanticipated destruction of samples as a deviation. Reporting will be per the requirements of section 7.2. If the subject withdraws consent the participants data will be excluded from future distributions, but data that have already been distributed for approved research use will not be able to be retrieved.
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6 data collection and evaluation

The PI will be responsible for overseeing entry of data into an in-house password protected electronic system, C3D, and ensuring data accuracy, consistency and timeliness. The principal investigator, associate investigators/research nurses and/or contracted data manager will assist with the data management efforts. All data obtained during the conduct of the protocol will be kept in secure network drives or in approved alternative sites that comply with NIH security standards. Primary and final analyzed data will have identifiers so that research data can be attributed to an individual human subject participant. All adverse events, including clinically significant abnormal findings on laboratory evaluations, regardless of severity, will be followed until return to baseline or stabilization of event. Document AEs from the first study intervention, Study Day 1, through 30 days after the last dose of study therapy. Beyond 30 days after the last of study therapy, only adverse events which are serious and related to the study intervention need to be recorded.  
An abnormal laboratory value will be recorded in the database as an AE **only** if the laboratory abnormality is characterized by any of the following:
- Results in discontinuation from the study  
- Is associated with clinical signs or symptoms  
Version Date: *12/18/2020*
- Requires treatment or any other therapeutic intervention  
- Is associated with death or another serious adverse event, including hospitalization.  
.  
- Is judged by the Investigator to be of significant clinical impact - If any abnormal laboratory result is considered clinically significant, the investigator will provide details about the action taken with respect to the test drug and about the participant's outcome.
As the toxicity profile of Enzalutamide and CRLX101 is well defined and published, expected grade 1 clinical adverse events will not be recorded in the database.  
End of study procedures: Data will be stored according to HHS, FDA regulations and NIH
Intramural Records Retention Schedule as applicable.  
Loss or destruction of data: Should we become aware that a major breach in our plan to protect subject confidentiality and trial data has occurred, this will be reported expeditiously per requirements in section **7.2.1**.  
6.2 DATA SHARING PLANS 6.2.1 Human Data Sharing Plan
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what data will be shared?

I will share human data generated in this research for future research as follows: _X__Coded, linked data in an NIH-funded or approved public repository. _X_ Coded, linked data in BTRIS (automatic for activities in the Clinical Center) _X_ Coded, linked or identified data with approved outside collaborators under appropriate agreements.
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how and where will the

Data will be shared through: _X__ An NIH-funded or approved public repository. Insert name or names:: ClinicalTrials.gov. _X_ BTRIS (automatic for activities in the Clinical Center) _X_ Approved outside collaborators under appropriate individual agreements. _X_ Publication and/or public presentations. When will the data be shared?  
_X_ Before publication.  
_X_ At the time of publication or shortly thereafter. 6.2.2 Genomic Data Sharing Plan The present protocol, which ascertains transcriptomic data from 192 genes, does not apply to the GDS policy. The GDS policy states that RNA sequencing data from 100-sample threshold need to be shared. This protocol will not meet the 100 sample threshold. 6.3 RESPONSE CRITERIA Restaging bone scans and/or CT scan of chest, abdomen and pelvis will be obtained at prior to Cycle 3 and every 3 cycles **thereafter.**
Progression will be evaluated in this study using the international criteria proposed by the Prostate Cancer Working Group 3 (PCWG3) guideline(2) and/or the revised Response Evaluation Criteria in Solid Tumors (RECIST) guideline (version 1.1).(62) Changes in the largest diameter (unidimensional measurement) of the tumor lesions and the shortest diameter in the case of malignant lymph nodes are used in the RECIST criteria. Changes in PSA and measurable lesions will be analyzed for efficacy according to PCWG3 recommendations. The recommended PSA progressions criteria will not be applied to the study as the criteria are arbitrarily proposed and do not necessarily reflect overall disease status. PSA values will be captured at each visit and PSA declines and progression will be followed. PSA is not sufficient in the evaluation of disease progression in this participant population. This is consistent with the recent recommendations by the Prostate Cancer Clinical Trials Working Group 2. Progression will be determined by radiographic evidence as discussed below or by clinical symptoms (symptomatic clinical progression). 6.3.1 Disease Parameters Measurable disease: Measurable lesions are defined as those that can be accurately measured in at least one dimension (longest diameter to be recorded) as:
- By chest x-ray: >20 mm;
- By CT scan:
o Scan slice thickness 5 mm or under: as >10 mm o Scan slice thickness >5 mm: double the slice thickness
- With calipers on clinical exam: >10 mm.  
All tumor measurements must be recorded in millimeters (or decimal fractions of centimeters). Malignant lymph nodes. To be considered pathologically enlarged and measurable, a lymph node must be >15 mm in short axis when assessed by CT scan (CT scan slice thickness recommended to be no greater than 5 mm). At baseline and in follow-up, only the short axis will be measured and followed. Non-measurable disease. All other lesions (or sites of disease), including small lesions (longest diameter <10 mm or pathological lymph nodes with ≥10 to <15 mm short axis), are considered non-measurable disease. Bone lesions, leptomeningeal disease, ascites, pleural/pericardial effusions, lymphangitis cutis/pulmonitis, inflammatory breast disease, and abdominal masses (not followed by CT or MRI), are considered as non-measurable. Note: Cystic lesions that meet the criteria for radiographically defined simple cysts should not be considered as malignant lesions (neither measurable nor non-measurable) since they are, by definition, simple cysts. 'Cystic lesions' thought to represent cystic metastases can be considered as measurable lesions, if they meet the definition of measurability described above. However, if non-cystic lesions are present in the same participant, these are preferred for selection as target lesions.  
Target lesions. All measurable lesions up to a maximum of 2 lesions per organ and 5 lesions in total, representative of all involved organs, should be identified as **target lesions** and recorded and measured at baseline. Target lesions should be selected on the basis of their size (lesions with the longest diameter), be representative of all involved organs, but in addition should be those that lend themselves to reproducible repeated measurements. It may be the case that, on occasion, the largest lesion does not lend itself to reproducible measurement in which circumstance the next largest lesion which can be measured reproducibly should be selected. A sum of the diameters (longest for non-nodal lesions, short axis for nodal lesions) for all target lesions will be calculated and reported as the baseline sum diameters. If lymph nodes are to be included in the sum, then only the short axis is added into the sum. The baseline sum diameters will be used as reference to further characterize any objective tumor regression in the measurable dimension of the disease. Non-target lesions. All other lesions (or sites of disease) including any measurable lesions over and above the 5 target lesions should be identified as **non-target lesions** and should also be recorded at baseline. Measurements of these lesions are not required, but the presence, absence, or in rare cases unequivocal progression of each should be noted throughout follow-up. 6.3.2 Methods for Evaluation of Measurable Disease All measurements should be taken and recorded in metric notation using a ruler or calipers. All baseline evaluations should be performed as closely as possible to the beginning of treatment and never more than 4 weeks before the beginning of the treatment. The same method of assessment and the same technique should be used to characterize each identified and reported lesion at baseline and during follow-up. Imaging-based evaluation is preferred to evaluation by clinical examination unless the lesion(s) being followed cannot be imaged but are assessable by clinical exam.  
Clinical lesions: Clinical lesions will only be considered measurable when they are superficial
(e.g., skin nodules and palpable lymph nodes) and ≥10 mm diameter as assessed using calipers
(e.g., skin nodules). In the case of skin lesions, documentation by color photography, including a ruler to estimate the size of the lesion, is recommended.  
Chest x-ray: Lesions on chest x-ray are acceptable as measurable lesions when they are clearly defined and surrounded by aerated lung. However, CT is preferable. Conventional CT and MRI: This guideline has defined measurability of lesions on CT scan based on the assumption that CT slice thickness is 5 mm or less. If CT scans have slice thickness greater than 5 mm, the minimum size for a measurable lesion should be twice the slice thickness. MRI is also acceptable in certain situations (e.g. for body scans). Use of MRI remains a complex issue. MRI has excellent contrast, spatial, and temporal resolution; however, there are many image acquisition variables involved in MRI, which greatly impact image quality, lesion conspicuity, and measurement. Furthermore, the availability of MRI is variable globally. As with CT, if an MRI is performed, the technical specifications of the scanning sequences used should be optimized for the evaluation of the type and site of disease. Furthermore, as with CT, the modality used at follow-up should be the same as was used at baseline and the lesions should be measured/assessed on the same pulse sequence. It is beyond the scope of the RECIST guidelines to prescribe specific MRI pulse sequence parameters for all scanners, body parts, and diseases. Ideally, the same type of scanner should be used and the image acquisition protocol should be followed as closely as possible to prior scans. Body scans should be performed with breath-hold scanning techniques, if possible. PET-CT: At present, the low dose or attenuation correction CT portion of a combined PET-CT is not always of optimal diagnostic CT quality for use with RECIST measurements. However, if the site can document that the CT performed as part of a PET-CT is of identical diagnostic quality to a diagnostic CT (with IV and oral contrast), then the CT portion of the PET-CT can be used for RECIST measurements and can be used interchangeably with conventional CT in accurately measuring cancer lesions over time. Note, however, that the PET portion of the CT introduces additional data which may bias an investigator if it is not routinely or serially performed. Ultrasound: Ultrasound is not useful in assessment of lesion size and should not be used as a method of measurement. Ultrasound examinations cannot be reproduced in their entirety for independent review at a later date and, because they are operator dependent, it cannot be guaranteed that the same technique and measurements will be taken from one assessment to the next. If new lesions are identified by ultrasound in the course of the study, confirmation by CT or MRI is advised. If there is concern about radiation exposure at CT, MRI may be used instead of CT in selected instances. Endoscopy, Laparoscopy: The utilization of these techniques for objective tumor evaluation is not advised. However, such techniques may be useful to confirm complete pathological response when biopsies are obtained or to determine relapse in trials where recurrence following complete response (CR) or surgical resection is an endpoint. Cytology, Histology: These techniques can be used to differentiate between partial responses (PR) and complete responses (CR) in rare cases (e.g., residual lesions in tumor types, such as germ cell tumors, where known residual benign tumors can remain). The cytological confirmation of the neoplastic origin of any effusion that appears or worsens during treatment when the measurable tumor has met criteria for response or stable disease is mandatory to differentiate between response or stable disease (an effusion may be a side effect of the treatment) and progressive disease. FDG-PET: While FDG-PET response assessments need additional study, it is sometimes reasonable to incorporate the use of FDG-PET scanning to complement CT scanning in assessment of progression (particularly possible 'new' disease). New lesions on the basis of FDG-PET imaging can be identified according to the following algorithm:
a. Negative FDG-PET at baseline, with a positive FDG-PET at follow-up is a sign of PD
based on a new lesion.  
b. No FDG-PET at baseline and a positive FDG-PET at follow-up: If the positive FDGPET at follow-up corresponds to a new site of disease confirmed by CT, this is PD. If the positive FDG-PET at follow-up is not confirmed as a new site of disease on CT, additional follow-up CT scans are needed to determine if there is truly progression occurring at that site (if so, the date of PD will be the date of the initial abnormal FDGPET scan). If the positive FDG-PET at follow-up corresponds to a pre-existing site of disease on CT that is not progressing on the basis of the anatomic images, this is not PD.  
c. FDG-PET may be used to upgrade a response to a CR in a manner similar to a biopsy in cases where a residual radiographic abnormality is thought to represent fibrosis or scarring. The use of FDG-PET in this circumstance should be prospectively described in the protocol and supported by disease-specific medical literature for the indication. However, it must be acknowledged that both approaches may lead to false positive CR due to limitations of FDG-PET and biopsy resolution/sensitivity.  
Note: A 'positive' FDG-PET scan lesion means one which is FDG avid with an uptake greater than twice that of the surrounding tissue on the attenuation corrected image. 6.3.3 Response Criteria 6.3.3.1 Evaluation of Target Lesions Complete Response (CR): Disappearance of all target lesions. Any pathological lymph nodes (whether target or non-target) must have reduction in short axis to <10 mm. Partial Response (PR): At least a 30% decrease in the sum of the diameters of target lesions, taking as reference the baseline sum of diameters. Progressive Disease (PD): At least a 20% increase in the sum of the diameters of target lesions, taking as reference the smallest sum on study (this includes the baseline sum if that is the smallest on study). In addition to the relative increase of 20%, the sum must also demonstrate an absolute increase of at least 5 mm. (Note: the appearance of one or more new lesions is also considered progressions). Stable Disease (SD): Neither sufficient shrinkage to qualify for PR nor sufficient increase to qualify for PD, taking as reference the smallest sum of diameters while on study. 6.3.3.2 Evaluation of Non-Target Lesions Complete Response (CR): Disappearance of all non-target lesions and normalization of tumor marker level. All lymph nodes must be non-pathological in size (<10 mm short axis). Note: If tumor markers are initially above the upper normal limit, they must normalize for a participant to be considered in complete clinical response. Non-CR/Non-PD: Persistence of one or more non-target lesion(s) and/or maintenance of tumor marker level above the normal limits. Progressive Disease (PD): Appearance of one or more new lesions and/or *unequivocal* progression of existing non-target lesions. *Unequivocal progression* should not normally trump target lesion status. It must be representative of overall disease status change, not a single lesion increase. Although a clear progression of "non-target" lesions only is exceptional, the opinion of the treating physician should prevail in such circumstances, and the progression status should be confirmed at a later time by the review panel (or Principal Investigator).
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6.3.3.3 metastatic bone lesions

Disease progression is considered if a minimum of two new lesions is observed on bone scan.  
New lesions seen on first re-staging (at 3 months) may represent disease that was not detected on the baseline scan. In these circumstances, the first re-staging scan then will serve as the baseline comparison for future scans. Participant can be removed at first re-staging at the discretion of the investigator if the clinical scenario is most consistent with disease progression and not "flare" on bone scan. This is consistent with Prostate Cancer Working Group 3 recommendations.(63) 6.3.3.4 Clinical Disease Progression  
- The need for chemotherapy or other change in therapy based on increased cancer related symptoms
- Worsening ECOG PS to a PS of 3 or 4 based on cancer (not treatment) related symptoms
- Clinical disease progression can also be determined based on the clinical discretion of the investigator 6.3.3.5 Evaluation of Best Overall Response
The best overall response is the best response recorded from the start of the treatment until disease progression/recurrence (taking as reference for progressive disease the smallest measurements recorded since the treatment started). The participant's best response assignment will depend on the achievement of both measurement and confirmation criteria.  
| For Participants with Measurable Disease (i.e., Target Disease) Target  Non-Target  New  Overall  Best Overall Response when  Lesions Lesions Lesions Response Confirmation is Required* CR CR No CR >4 wks. Confirmation** CR Non-CR/NonPD No PR >4 wks. Confirmation** CR Not evaluated No PR PR Non-CR/NonPD/not  evaluated No PR SD Non-CR/NonPD/not  evaluated No SD Documented at least once >4 wks. from  baseline** PD Any Yes or  PD no prior SD, PR or CRNo   |
|---|  
| Any   | PD***                                                                                                                                                                                                                                                                                                                           | Yes or   | PD   |
|-------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|----------|------|
| No    |                                                                                                                                                                                                                                                                                                                                 |          |      |
| Any   | Any                                                                                                                                                                                                                                                                                                                             | Yes      | PD   |
| *     | See RECIST 1.1 manuscript for further details on what is evidence of a new lesion.                                                                                                                                                                                                                                              |          |      |
| **    | Only for non-randomized trials with response as primary endpoint.                                                                                                                                                                                                                                                               |          |      |
| ***   | In exceptional circumstances, unequivocal progression in non-target lesions may be accepted as disease  progression.                                                                                                                                                                                                            |          |      |
| Note: | Participants with a global deterioration of health status requiring discontinuation of treatment without objective  evidence of disease progression at that time should be reported as "symptomatic deterioration." Every effort  should be made to document the objective progression even after discontinuation of treatment. |          |      |
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for participants with non-measurable disease

| Non-Target Lesions                                                                                                                                                                                                                             | New Lesions   | Overall Response   |
|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------|--------------------|
| CR                                                                                                                                                                                                                                             | No            | CR                 |
| Non-CR/non-PD                                                                                                                                                                                                                                  | No            | Non-CR/non-PD*     |
| Not all evaluated                                                                                                                                                                                                                              | No            | not evaluated      |
| Unequivocal PD                                                                                                                                                                                                                                 | Yes or No     | PD                 |
| Any                                                                                                                                                                                                                                            | Yes           | PD                 |
| * 'Non-CR/non-PD' is preferred over 'stable disease' for non-target disease since SD is increasingly used as an  endpoint for assessment of efficacy in some trials so to assign this category when no lesions can be measured is not  advised |               |                    |  
6.3.4 Duration of Response The duration of response is defined by time of sustained >30% decline in PSA from baseline. 6.3.5 Overall Survival Overall Survival is defined as the duration of time from the start of treatment to the time of death.. 6.3.6 Response Review Tumor measurements will be performed in consultation with the Center for Cancer Research Radiology and Imaging Sciences processing service. 6.4 TOXICITY CRITERIA The following adverse event management guidelines are intended to ensure the safety of each participant while on the study. The descriptions and grading scales found in the revised NCI Common Terminology Criteria for Adverse Events (CTCAE) version 5.0 will be utilized for AE reporting. All appropriate treatment areas should have access to a copy of the CTCAE version 5.0. A copy of the CTCAE version 5.0 can be downloaded from the CTEP web site
(http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm).
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7 nih reporting requirements/ data

7.1 DEFINITIONS Please refer to definitions provided in Policy 801: Reporting Research Events found here. 7.2 OHSRP OFFICE OF COMPLIANCE AND TRAINING/IRB REPORTING
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7.2.1 expedited reporting

Please refer to the reporting requirements in Policy 801: Reporting Research Events and Policy 802 Non-Compliance Human Subjects Research found here. Note: Only IND Safety Reports that meet the definition of an unanticipated problem will need to be reported per these policies. 7.2.2 IRB Requirements for PI Reporting at Continuing Review Please refer to the reporting requirements in Policy 801: Reporting Research Events found here. 7.3 NCI CLINICAL DIRECTOR REPORTING Problems expeditiously reported to the OHSRP in iRIS will also be reported to the NCI Clinical Director. A separate submission is not necessary as reports in iRIS will be available to the Clinical Director. In addition to those reports, all deaths that occur within 30 days after receiving a research intervention should be reported via email to the Clinical Director unless they are due to progressive disease. To report these deaths, please send an email describing the circumstances of the death to Dr. Dahut at NCICCRQA@mail.nih.gov within one business day of learning of the death. 7.4 NIH REQUIRED DATA AND SAFETY MONITORING PLAN
7.4.1 Principal Investigator/Research Team The clinical research team will meet on a weekly regular basis when participants are being actively treated on the trial to discuss each participant. Decisions about dose level enrollment and dose escalation if applicable will be made based on the toxicity data from prior participants. All data will be collected in a timely manner and reviewed by the principal investigator or a lead associate investigator. Events meeting requirements for expedited reporting as described in section **7.2.1** will be submitted within the appropriate timelines.  
The principal investigator will review adverse event and response data on each participant to ensure safety and data accuracy. The principal investigator will personally conduct or supervise the investigation and provide appropriate delegation of responsibilities to other members of the research staff.
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8 sponsor safety reporting 8.1

Any untoward medical occurrence in a patient or clinical investigation subject administered a pharmaceutical product and which does not necessarily have a causal relationship with this treatment. An adverse event (AE) can therefore be any unfavorable and unintended sign (including an abnormal laboratory finding), symptom, or disease temporally associated with the use of a medicinal (investigational) product, whether or not related to the medicinal (investigational) product (ICH E6 (R2)). 8.1.2 Serious Adverse Event (SAE) An adverse event or suspected adverse reaction is considered serious if in the view of the investigator or the sponsor, it results in any of the following:
- A life-threatening adverse event (see **8.1.3**)
- Inpatient hospitalization or prolongation of existing hospitalization o A hospitalization/admission that is pre-planned (i.e., elective or scheduled surgery arranged prior to the start of the study), a planned hospitalization for pre-existing condition, or a procedure required by the protocol, without a serious deterioration in health, is not considered a serious adverse event.  
o Emergency room visits or stays in observation units that do not result in admission to the hospital would not be considered a serious adverse event. The reason for seeking medical care should be evaluated for meeting one of the other serious criteria.  
- Persistent or significant incapacity or substantial disruption of the ability to conduct normal life functions
- Important medical events that may not result in death, be life-threatening, or require hospitalization may be considered a serious adverse drug experience when, based upon appropriate medical judgment, they may jeopardize the patient or subject and may require medical or surgical intervention to prevent one of the outcomes listed in this definition.  
An adverse event or suspected adverse reaction is considered "life-threatening" if, in the view of either 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. (21CFR312.32)
- Death o A hospitalization/admission that is solely driven by non-medical reasons (e.g.,
hospitalization for participant convenience) is not considered a serious adverse event.  
- A congenital anomaly/birth defect.  
8.1.4 Severity The severity of each Adverse Event will be assessed utilizing the CTCAE version 5.0. 8.1.5 Relationship to Study Product All AEs will have their relationship to study product assessed using the terms: related or not related.  
- Related - There is a reasonable possibility that the study product caused the adverse event. Reasonable possibility means that there is evidence to suggest a causal relationship between the study product and the adverse event.  
- Not Related - There is not a reasonable possibility that the administration of the study product caused the event.
8.2 ASSESSMENT OF SAFETY EVENTS AE information collected will include event description, date of onset, assessment of severity and relationship to study product and alternate etiology (if not related to study product), date of resolution of the event, seriousness and outcome. The assessment of severity and relationship to the study product will be done only by those with the training and authority to make a diagnosis and listed on the Form FDA 1572 as the site principal investigator or sub-investigator. AEs occurring during the collection and reporting period will be documented appropriately regardless of relationship. AEs will be followed through resolution.  
For timeframe of recording adverse events, please refer to section 6.1. All serious adverse events recorded from the time of first investigational product administration must be reported to the sponsor. SAEs will be:
- Assessed for severity and relationship to study product and alternate etiology (if not related to study product) by a licensed study physician listed on the Form FDA 1572 as the site principal investigator or sub-investigator.  
- Recorded on the appropriate SAE report form, the medical record and captured in the clinical database.  
- Followed through resolution by a licensed study physician listed on the Form FDA 1572 as the site principal investigator or sub-investigator.
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8.3 reporting of serious adverse

Any AE that meets protocol-defined serious criteria, or meets the definition of Adverse Event of Special Interest that require expedited reporting must be submitted immediately (within 24 hours of awareness) to OSRO Safety using the CCR SAE report form.  
All SAE reporting must include the elements described in 8.2.  
SAE reports will be submitted to the Center for Cancer Research (CCR) at: OSROSafety@mail.nih.gov and to the CCR PI and study coordinator. CCR SAE report form and instructions can be found at: https://ccrod.cancer.gov/confluence/pages/viewpage.action?pageId=157942842 Following the assessment of the SAE by OSRO, other supporting documentation of the event may be requested by the OSRO Safety and should be provided as soon as possible.  
8.4 SAFETY REPORTING CRITERIA TO THE PHARMACEUTICAL COLLABORATORS
All events listed below must be reported in the defined timelines to OSROSafety@mail.nih.gov . 8.4.1 To be sent by OSRO Safety 8.4.1.1 Ellipses Pharma Reporting Requirements - Expedited Reporting To ensure patient safety, every SAE, regardless of suspected causality, occurring after the patient begins taking study drug and until 30 days after the patient has stopped study treatment will be reported by the Sponsor to Ellipses Pharma via their safety vendor, Simbec-Orion, within 1-2 business days of learning of its occurrence. The MedWatch 3500a form or equivalent will be used to report all SAEs. Any SAE experienced after this 30 day period should only be reported to Ellipses Pharma if the investigator suspects a causal relationship to the study drug. Recurrent episodes, complications, or progression of the initial SAE must be reported as follow-up to the original episode within 1-2 business days of the sponsor receiving the follow-up information. An SAE occurring at a different time interval or otherwise considered separately as a new event. The investigator must assess and record the relationship of each SAE to each specific study drug (if there is more than one study drug).  
Ellipses safety vendor, Simbec-Orion: Email address: pharmacovigilance@simbecorion.com Fax no: +1 609 514 1000 Back-up SAE fax: +1 609 452 7888 8.4.1.2 Routine Reporting The Sponsor will also send the FDA annual report to Ellipses Pharma as agreed upon in the collaborative agreement.  
8.4.2 To Be Reported by the Research team 8.4.2.1 Adverse Events of Special Interest (AESI) associated with CRLX101 For all subjects, the following adverse events are categorized as Adverse Events of Special Interest (AESI) associated with CRLX101:
- Infusion-related hypersensitivity reaction(s) of any grade
- Any newly developed cystitis (including Grade 1) in subjects without cystitis at baseline Any occurrence of hypersensitivity/allergic reactions and/or cystitis a patient experiences associated with CRLX101 must be reported to Ellipses Pharma within 1-2 business days of learning of its occurrence using the OSRO Serious Adverse Event Form. AESIs will be sent to Ellipses Pharma via their safety vendor, Simbec-Orion by email to: pharmacovigilance@simbecorion.com Or alternatively by fax to: +1 609 514 1000 or back-up fax: +1 609 452 7888 .  
Version Date: *12/18/2020* 8.5 REPORTING PREGNANCY 8.5.1 Paternal Exposure Male patients should refrain from fathering a child or donating sperm during the study and for 120 days following the last dose of study drug. 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 120 days after the last dose of study drug should be followed up and documented.  
8.6 REGULATORY REPORTING FOR STUDIES CONDUCTED UNDER CCR-SPONSORED IND
Following notification from the investigator, CCR, the IND sponsor, will report any suspected adverse reaction that is both serious and unexpected. CCR will report an AE as a suspected adverse reaction only if there is evidence to suggest a causal relationship between the study product and the adverse event. CCR will notify FDA and all participating investigators (i.e., all investigators to whom the sponsor is providing drug under its INDs or under any investigator's IND) in an IND safety report of potential serious risks from clinical trials or any other source, as soon as possible, in accordance to 21 CFR Part 312.32. All serious events will be reported to the FDA at least annually in a summary format.
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9 clinical monitoring

As a sponsor for clinical trials, FDA regulations require the CCR to maintain a monitoring program. The CCR's program allows for confirmation of: study data, specifically data that could affect the interpretation of primary and secondary study endpoints; adherence to the protocol, regulations, ICH E6, and SOPs; and human subjects protection. This is done through independent verification of study data with source documentation focusing on:
- Informed consent process  
- Eligibility confirmation
- Drug administration and accountability
- Adverse events monitoring
- Response assessment.  
The monitoring program also extends to multi-site research when the CCR is the coordinating center. This trial will be monitored by personnel employed by a CCR contractor. Monitors are qualified by training and experience to monitor the progress of clinical trials. Personnel monitoring this study will not be affiliated in any way with the trial conduct.
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10 statistical considerations

10.1 STATISTICAL HYPOTHESES 10.1.1 Primary efficacy endpoints The primary efficacy endpoint is response to therapy as defined by a composite endpoint. The primary objective is to evaluate the anti-tumor activity of CRLX101 at the recommended phase II dose (RP2D) combined with enzalutamide with respect to treatment response, defined as ≥50% PSA decline or stable disease on imaging following 5 months of treatment in participants with progressive mCRPC following enzalutamide treatment. 10.1.2 Secondary Efficacy endpoints The secondary efficacy endpoints are duration of response, overall survival, and safety.  
The secondary objectives are to evaluate the duration of response as defined by a sustained >30% decline in PSA, overall survival, and changes in measurable disease as determined by Response Evaluation Criteria in Solid Tumors (RECIST) and Prostate Cancer Working Group 3 (PCWG3) for the treatment combination; and to validate the recommended phase 2 dose (RP2D) of CRLX101 in combination with enzalutamide.
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10.2 sample size determination

For the first 3 to 6 participants, there will be a lead-in period of two cycles to ensure the safety and tolerability of CRLX101 in combination with enzalutamide. CRLX101 will be started at a dose of 12 mg/m2, administered via IV infusion on Day 1. Based on limited potential for overlapping toxicity and well-characterized pharmacokinetics for both enzalutamide and CRLX101, it is anticipated 3 participants will participate in the lead-in phase. An accrual ceiling of 6 participants for the lead-in phase will be used to account for possible dose adjustments based on DLTs. Following the 3- to 6-participant lead-in cohort, this study will comprise a single arm cohort of participants with mCRPC eligible for treatment following prior disease progression while on enzalutamide therapy. Based on data derived from a retrospective cohort analysis, the estimated mPFS of participants with mCRPC who failed two prior therapies (all participants received docetaxel first line, followed by either cabazitaxel, enzalutamide, or abiraterone acetate) and were receiving third line of treatment (cabazitaxel, enzalutamide or abiraterone acetate) was 4 months (n = 260 participant; IQR - 3 to 8 months). The ORR (defined as the percentage of participants with a PSA decline of ≥50%) of this participant population was 24%. The reported data for participants receiving a 4th line of treatment (n = 38 participants) showed a mPFS of 5 months (IQR - 3 to 12 months) and an ORR of 16%. The most common therapy sequence of the third line treatment cohort was docetaxel followed by abiraterone acetate or enzalutamide then cabazitaxel (n = 110 participants), which demonstrated an ORR of 28% with a mPFS of 5 months (IQR of 3 to 9 months).(66) The goal is to determine if the addition of CRLX101 with enzalutamide following prior enzalutamide failure could improve current response rates. Response to therapy will be assessed as a composite endpoint (biochemical response defined as 50% decline in PSA or clinical response defined as stable disease on bone scan after 5 months); attaining either of these endpoints will be considered a success. To see at least minimal potential improvement beyond ~35% of participants, the goal is to rule out a 25% cohort specific response (success) rate and target a 50% success rate.  
Following the three- to six-participant lead-in cohort, the trial will be conducted using an optimal two-stage phase II trial design to rule out an unacceptably low success rate of 25% (p0 = 0.25) in favor of an improved success rate of 50% (p1 = 0.50). With an alpha = 0.10 (probability of accepting a poor treatment = 0.10) and beta = 0.20 (probability of rejecting a good treatment = 0.20), this trial will enroll 8 evaluable participants. If 0 to 2 of the 8 participants have success, no further clinical evaluation will be warranted for this combination treatment. If 3 or more of the 8 evaluable participants have success, then accrual will continue until a total of 21 evaluable participants have been treated in the two-stage portion of the trial. If there are 3 to 7 participants with a success, this will be considered inadequate for further investigation while if there are 8 or more participants out of 21 with a success, then this will be considered worthy of further investigation for subsequent trials. Under the null hypothesis (25% success rate), the probability of early termination is 67.9% Participants who receive at least one dose of the study treatment will be evaluable for safety. Participants who receive at least one dose of CRLX101 and have a follow-up imaging study will be evaluable for efficacy in an overall study report but the participants in the two-stage portion of the trial will be the primary cohort for efficacy analysis. The maximum number of evaluable participants enrolled in the lead-in component will be 6 participants (anticipation to enroll 3 participants). With up to 6 participants explored in the lead-in portion, and up to 21 participants in the two-stage portion of the trial, up to 27 evaluable participants would need to be enrolled onto the trial. To allow for a small number of inevaluable participants, the accrual ceiling will be set at 30 participants. 10.3 POPULATIONS FOR ANALYSIS Modified intention to treat: all participants who receive at least one dose of each of the two agents will be included in the statistical analyses performed. 10.4 STATISTICAL ANALYSES 10.4.1 General approach For participants in the primary efficacy cohort, the proportion of evaluable participants who experience a success will be reported along with a confidence interval. Safety will be evaluated by tabulating and describing the DLTs in the first 6 participants of the lead-in arm. 10.4.2 Analysis of the primary endpoints The fraction of evaluable participants who experience a success as defined above will be determined and reported along with 80% and 95% two-sided confidence intervals. 10.4.3 Analysis of the secondary endpoints Duration of response and overall survival will be estimated using a Kaplan-Meier curve based on all evaluable participants included in the two-stage cohort of the trial. The validation of the RP2D of CRLX101 in combination with enzalutamide will be done by evaluating the toxicity and safety data obtained and the RP2D and confirming that the number of DLTs does not 1/6 in participants enrolled during the lead-in phase.
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10.4.4 safety analyses

Safety of the agent will be assessed by determining the grade of adverse events noted in each participant, and reporting the fraction with grade 3 and grade 4 adverse events. Participants who receive at least one dose of the study treatments will be evaluable for safety. Safety data will be presented in a summary. Results from the safety evaluation in the initial 3-6 participant safety cohort will be reported separately from safety data from participants included in the efficacy cohort. The safety data will consist of the reporting of all adverse events, and may also include reporting vital signs, physical examination data, and laboratory safety data. 10.4.5 Baseline Descriptive Statistics Limited demographic and clinical characteristics of all participants will be reported. 10.4.6 Planned interim analyses An evaluation of the safety data based on the initial 3-6 participant lead-in cohort will be performed prior to enrollment of participants in the efficacy cohort. As indicated in the sample size determination section, an interim evaluation of the number of participants who experienced a success in the first stage of the two-stage optimal design will be performed to ensure that enrollment to the second stage is warranted. 10.4.7 Exploratory analyses The following are the intended exploratory objectives:  
- To evaluate the pharmacokinetic profile of CRLX101 (both total drug and released camptothecin) and enzalutamide in plasma;
- To evaluate underlying mechanisms of camptothecin-induced cystitis; - To evaluate the pharmacodynamic activity of CRLX101 and enzalutamide using surrogate biomarkers to measure acquired treatment resistance mediated by angiogenesis and androgen receptor signaling (e.g. VEGF, CTCs, AR-V7);
- To evaluate the activity of CRLX101 and enzalutamide with respect to the prevalence of circulating tumor cells with high genomic instability;
- To explore possible correlations between clinical response and biomarkers of DNA
damage response (e.g. PAR up-regulation, DNA damage response panel).
Any exploratory evaluations which generate quantitative measures will be done using descriptive statistics including confidence intervals when appropriate. Any statistical tests performed for evaluation of exploratory objectives will be done without formal adjustment for multiple comparisons, but in the context of the number of tests performed.
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11.1.1 ellipses pharma

The investigational study agent, CRLX101 is provided by the company, Ellipses Pharma under MTA \# 45025-18 executed 10/10/2018, under CRADA \# 03089.
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12 human subjects protections 12.1

Subjects treated on this study will be individuals with metastatic castration resistant prostate cancer, which has recurred (or persisted) after appropriate treatment. Men of any race or ethnic group will be eligible for this study. Eligibility assessment will be based solely on the participant's medical status. Women will not be eligible as the disease under study is not present in this population. Recruitment of participants onto this study will be through standard CCR mechanisms. No special recruitment efforts will be conducted.
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12.2 participation of children

Individuals under the age of 18 will not be eligible to participate in this study because they are unlikely to have prostate cancer, and because of unknown toxicities of CRLX101 in combination with enzalutamide in the pediatric participant. 12.3 PARTICIPATION OF SUBJECTS UNABLE TO GIVE CONSENT Adults unable to give consent are excluded from enrolling in the protocol. However, re-consent may be necessary and there is a possibility, though unlikely, that subjects could become decisionally impaired. For this reason and because there is a prospect of direct benefit from research participation (section **12.4**), all subjects ≥ age 18 will be offered the opportunity to fill in their wishes for research and care, and assign a substitute decision maker on the "NIH Advance Directive for Health Care and Medical Research Participation" form so that another person can make decisions about their medical care in the event that they become incapacitated or cognitively impaired during the course of the study. Note: The PI or AI will contact the NIH Ability to Consent Assessment Team (ACAT) for evaluation to assess ongoing capacity of the subjects and to identify an LAR, as needed.  
12.4 PLEASE SEE SECTION **12.6.1** FOR CONSENT PROCEDURE. EVALUATION OF BENEFITS AND
RISKS/DISCOMFORTS
The potential benefit to a participant that goes onto study is a reduction in the bulk of their tumor and improvement in their bony lesions, which may or may not have favorable impact on symptoms and/or survival. Potential risks include the possible occurrence of any of a range of side effects which are listed in the Consent Document. The procedure for protecting against or minimizing risks will be to medically evaluate participants on a regular basis.
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12.5 risks/benefits analysis

For participants with castration resistant prostate cancer, median survival is in the range of 12-18 months. Enzalutamide has shown activity against prostate cancer in a clinical setting. CRLX101 has demonstrated clinical activity to down-regulate HIF-1α in ovarian cancer and in vitro assessments examining the down-regulation of HIF-1α in combination with enzalutamide have demonstrated a synergistic effect, decreasing angiogenesis and androgen receptor signaling in LNCaP cell models. Preclinical assessments (*in vitro* and *in vivo*) examining this treatment combination are currently ongoing. Although possible toxicities from the proposed therapy are serious, given the nature of the underlying disease, they are reasonable. Additionally, we do not anticipate toxicities significantly more severe than those observed with other approved agents. For these reasons, the risk/benefit ratio of this protocol is favorable; therefore, this protocol involves greater than minimal risk to all participants on study, but presents the potential for direct benefit to all individual subjects enrolled on study.  
NOTE: This same risks/benefits analysis applies to all study populations included in this clinical study. 12.5.1 Risks related to Imaging CT scans and TC-99 scas often use a contrast agent. There is a small risk of having a reaction to the contrast and most often include nausea, pain in the vein where the contrast is given, headache, metallic and/or bitter taste in the mouth and a warm, flushing feeling. Rarely, some people have more severe allergic reactions to the contrast which may include skin rashes, shortness of breath, wheezing or low blood pressure.
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12.5.2 risks from radiation exposure

The procedures for performing the CT scans (chest/abdomen/pelvis) and Tc-99 whole body scintography scans will follow clinical policies, no special procedures apply to these additional assessments for research purposes. In summary, subjects may receive additional radiation exposure in one year from up to four (4) CT scans of the chest, abdomen, and pelvis, and four (4) Tc-99 whole body scintography scans. Radiation exposure is associated with an increased risk of cancer. 12.6 CONSENT PROCESS AND DOCUMENTATION The informed consent document will be provided to the participant or consent designee(s) as applicable for review prior to consenting. A designated study investigator will carefully explain the procedures and tests involved in this study, and the associated risks, discomforts and benefits. In order to minimize potential coercion, as much time as is needed to review the document will be given, including an opportunity to discuss it with friends, family members and/or other advisors, and to ask questions of any designated study investigator. If a prolonged period of time expires during the decision making process (several weeks, as an example), it may be necessary to reassess the participant for protocol eligibility. A signed informed consent document will be obtained prior to entry onto the study. Re-consent, when required, may take place in person or remotely (e.g., via telephone or other NIH approved remote platforms) per discretion of the designated study investigator and with the agreement of the participant. Whether in person or remote, the privacy of the subject will be maintained. Consenting investigators (and participant, when in person) will be located in a private area (e.g., clinic consult room). When re-consent is conducted remotely, the participant will be informed of the private nature of the discussion and will be encouraged to relocate to a more private setting if needed.  
Version Date: *12/18/2020* 12.6.1 Consent Process for Adults Who Lack Capacity to Consent to Research Participation For participants addressed in section **12.3**, an LAR will be identified consistent with Policy 403 and informed consent obtained from the LAR, as described in Section **12.6**.
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13 regulatory and operational considerations

This study may be temporarily suspended or prematurely terminated if there is sufficient reasonable cause. Written notification, documenting the reason for study suspension or termination, will be provided by the suspending or terminating party to study participants, investigator, funding agency, the Investigational New Drug (IND) sponsor and regulatory authorities. If the study is prematurely terminated or suspended, the Principal Investigator (PI) will promptly inform study participants, the Institutional Review Board (IRB), and sponsor and will provide the reason(s) for the termination or suspension. Study participants will be contacted, as applicable, and be informed of changes to study visit schedule.  
Circumstances that may warrant termination or suspension include, but are not limited to:  
- Determination of unexpected, significant, or unacceptable risk to participants
- Demonstration of efficacy that would warrant stopping
- Insufficient compliance to protocol requirements
- Data that are not sufficiently complete and/or evaluable
- Determination that the primary endpoint has been met - Determination of futility
Study may resume once concerns about safety, protocol compliance, and data quality are addressed, and satisfy the sponsor, IRB and as applicable, Food and Drug Administration (FDA). 13.2 QUALITY ASSURANCE AND QUALITY CONTROL Each clinical site will perform internal quality management of study conduct, data and biological specimen collection, documentation and completion. An individualized quality management plan will be developed to describe a site's quality management. Quality control (QC) procedures will be implemented beginning with the data entry system and data QC checks that will be run on the database will be generated. Any missing data or data anomalies will be communicated to the site(s) for clarification/resolution. Following written Standard Operating Procedures (SOPs), the monitors will verify that the clinical trial is conducted and data are generated and biological specimens are collected, documented (recorded), and reported in compliance with the protocol, International Conference on Harmonisation Good Clinical Practice (ICH GCP), and applicable regulatory requirements (e.g., Good Laboratory Practices (GLP), Good Manufacturing Practices (GMP)). The investigational site will provide direct access to all trial related sites, source data/documents, and reports for the purpose of monitoring and auditing by the sponsor, and inspection by local and regulatory authorities.
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13.3 conflict of interest policy

The independence of this study from any actual or perceived influence, such as by the pharmaceutical industry, is critical. Therefore, any actual conflict of interest of persons who have a role in the design, conduct, analysis, publication, or any aspect of this trial will be disclosed and managed. Furthermore, persons who have a perceived conflict of interest will be required to have such conflicts managed in a way that is appropriate to their participation in the design and conduct of this trial. The study leadership in conjunction with the NCI has established policies and procedures for all study group members to disclose all conflicts of interest and will establish a mechanism for the management of all reported dualities of interest.
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13.4 confidentiality and privacy

Participant confidentiality and privacy is strictly held in trust by the participating investigators, their staff, and the sponsor(s). This confidentiality is extended to cover testing of biological samples and genetic tests in addition to the clinical information relating to participants. Therefore, the study protocol, documentation, data, and all other information generated will be held in strict confidence. No information concerning the study or the data will be released to any unauthorized third party without prior written approval of the sponsor. All research activities will be conducted in as private a setting as possible. The study monitor, other authorized representatives of the sponsor, representatives of the Institutional Review Board (IRB), and/or regulatory agencies may inspect all documents and records required to be maintained by the investigator, including but not limited to, medical records (office, clinic, or hospital) and pharmacy records for the participants in this study. The clinical study site will permit access to such records. The study participant's contact information will be securely stored at each clinical site for internal use during the study. At the end of the study, all records will continue to be kept in a secure location for as long a period as dictated by the reviewing IRB, Institutional policies, or sponsor requirements. Study participant research data, which is for purposes of statistical analysis and scientific reporting, will be transmitted to and stored at the NCI. This will not include the participant's contact or identifying information. Rather, individual participants and their research data will be identified by a unique study identification number. The study data entry and study management systems used by clinical sites and by NCI research staff will be secured and password protected. At the end of the study, all study databases will be de-identified and archived at the NCI. To further protect the privacy of study participants, a Certificate of Confidentiality has been issued by the National Institutes of Health (NIH). This certificate protects identifiable research information from forced disclosure. It allows the investigator and others who have access to research records to refuse to disclose identifying information on research participation in any civil, criminal, administrative, legislative, or other proceeding, whether at the federal, state, or local level. By protecting researchers and institutions from being compelled to disclose information that would identify research participants, Certificates of Confidentiality help achieve the research objectives and promote participation in studies by helping assure confidentiality and privacy to participants.
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14 pharmaceutical information 14.1 crlx101

CRLX101 is a polymer drug conjugate composed of 20 (S)-camptothecin conjugated to a biocompatible polymer. The compound self assembles into soluble nanoparticles composed of several molecules when dissolved in aqueous solution. Camptothecin (CPT) is an antineoplastic that inhibits topoisomerase I resulting in cell death during the S phase of the cell cycle. CRLX101 nanoparticles are believed to be taken up by tumor cells followed by release of the active pharmaceutical ingredient 20(S)-camptothecin.
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14.1.1 source

The CRLX101 is provided by the company, Ellipses Pharma, the manufacturer of drug under a Collaborative Agreement [Cooperative Research and Development Agreement (CRADA)]. 14.1.2 Toxicity Please see Section **1.2.5**.  
14.1.3 Handling and Dispensing CRLX101 is a sterile injectable and must be handled under appropriate controls, conditions, and aseptic techniques to maintain product sterility. CRLX101, a cytotoxic, should be prepared in a class II biological safety cabinet using standard precautions for the safe handling of antineoplastic agents. Latex gloves are recommended. It must be dispensed only from official study sites by authorized personnel according to local regulations, and stored in a secure area according to local regulations. It is the responsibility of the Investigator to ensure that study drug is only dispensed to eligible study participants. 14.1.4 Formulation and preparation CRLX101 will be provided at no cost to the study participant. It is supplied as a lyophilized cake in: a 30 mL single-use vial containing 35 mg of CPT equivalents (approximately 350 mg of polymer drug conjugate).  
Vials of CRLX101 should be removed from the refrigerator and warmed to room temperature for approximately one hour prior to preparation. Concentrated CRLX101 solution is prepared by adding 14 mL of USP Sterile Water for Injection (SWFI) to each 35 mg vial. The required volume of SWFI is to be aseptically withdrawn into a sterile calibrated syringe and the syringe needle inserted through the vial septum. The SWFI should be slowly added along the inside of the vial wall and not directly onto the lyophilized product cake to minimize foaming. The product is dissolved by gentle swirling (do not shake) until a clear homogenous solution is achieved. The majority of the product cake will dissolve quickly, however complete dissolution to a clear, homogeneous solution will take longer and may require up to 30 minutes. The CRLX101 concentrated solution should be inspected visually for particulate matter prior to further preparation. Visually inspect for completion of reconstitution every 2-3 minutes. Reconstitution is complete when (i) foam head has dissipated down to a thin bubble ring along inner wall of vial, (ii) solids in solution and foam head are no longer visible, and (iii) translucent polymer "vapors" are no longer visible in solution and the solution is clear and uniform in appearance. Complete reconstitution of the vial may take up to 30 minutes. Each milliliter of concentrated solution contains 2.5 mg of camptothecin equivalents. Concentrated CRLX101 solution is diluted to the recommended dose with 5% dextrose in water for injection (D5W) to a total volume of 500 mL. After determining the amount of CRLX101 concentrated solution required for dosing, an equivalent volume is aseptically withdrawn from a 500 mL infusion bag or bottle of D5W with a calibrated syringe. The measured volume of concentrated CRLX101 solution is then withdrawn with a calibrated syringe and injected into the prepared 500 mL D5W infusion bag or bottle. The solution is thoroughly mixed by gentle manual rotation. 14.1.5 Stability and Storage CRLX101 vials should be stored at refrigerated conditions (2°-8°C) and should only be accessible to authorized individuals. CRLX101 is stable for at least 3 years when stored at refrigerated conditions (2°-8°C). The reconstituted solution is stable for 24 hours when stored at room temperature. Any unused product solution from the reconstituted vials should be destroyed per the site's standard operating procedures. Formulated CRLX101 (i.e., IV bag) should be used within 6 hours of reconstituting the drug product vials. 14.1.6 Dosage and Administration procedures See Sections 3.2 and 3.3 for the dose levels of CRLX101 to be evaluated in this study. Each dose should be administered by IV infusion over 60-75 minutes on Day 1 and Day 15 of each cycle.  
See Section **13.1.4** for how to prepare each dose for administration. See Section **3.3.2.4** for management of any CLRX101 infusion related/hypersensitivity reactions.  
The second and subsequent dose of CRLX101 may be delayed if related AEs have not resolved to grade 1 or better. If a dose of CRLX101 is delayed, then the subsequent dose should be administered 2 weeks later to avoid significant carry-over of unconjugated plasma CPT from one dose to the next (See Section 3.3). However the maximum delay for AEs to resolve is 28 days beyond which the participant will be taken off treatment. 14.1.7 Incompatibilities No known incompatibilities at this time. 14.1.8 Premedication and Hydration The premedication prior to CRLX101 treatment and pre and post hydration and additional prevention measurements to prevent hypersensitivity/infusion reaction have been described in Section **3.3.2.4**.  
14.1.9 Return and Retention of CRLX101 Any used study drug vials, or partially used vials, remaining after trial is complete will be destroyed per institution drug destruction policy. Unused study drug vials may be destroyed in the same manner or returned if requested to Ellipses Pharma. 14.2 ENZALUTAMIDE Enzalutamide (XTANDI ©) is an androgen receptor inhibitor. The chemical name is 4-(3-[4cyano-3-(trifluoromethyl)phenyl]-5,5-dimethyl-4-oxo-2-sulfanylideneimidazolidin-1-yl)-2fluoro-N-methylbenzamide.  
Please see FDA-approved package insert for Enzalutamide for complete agent information. 14.2.1 Source Enzalutamide will be obtained from commercial sources and dispensed by the institutional pharmacy. 14.2.2 Toxicity
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seizures

In the randomized clinical trial, 7 of 800 (0.9%) participants treated with enzalutamide 160 mg once daily experienced a seizure. No seizures occurred in participants treated with placebo. Seizures occurred from 31 to 603 days after initiation of enzalutamide. Participants experiencing seizure were permanently discontinued from therapy and all seizures resolved. There is no clinical trial experience re-administering enzalutamide to participants who experienced seizures. The safety of enzalutamide in participants with predisposing factors for seizure is not known because these participants were excluded from the trial. These exclusion criteria included a history of seizure, underlying brain injury with loss of consciousness, transient ischemic attack within the past 12 months, cerebral vascular accident, brain metastases, brain arteriovenous malformation or the use of concomitant medications that may lower the seizure threshold. Because of the risk of seizure associated with enzalutamide use, participants should be advised of the risk of engaging in any activity where sudden loss of consciousness could cause serious harm to themselves or others.
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other adverse events

The most common adverse drug reactions (≥5%) reported in participants receiving enzalutamide in the randomized clinical trial were asthenia/fatigue, back pain, diarrhea, arthralgia, hot flush, peripheral edema, musculoskeletal pain, headache, upper respiratory infection, muscular weakness, dizziness, insomnia, lower respiratory infection, spinal cord compression, and cauda equina syndrome, hematuria, paresthesia, anxiety, and hypertension. Grade 3 and higher adverse reactions were reported among 47% of enzalutamide-treated participants and 53% of placebotreated participants. Discontinuations due to adverse events were reported for 16% of enzalutamide-treated participants and 18% of placebo-treated participants. The most common adverse reaction leading to treatment discontinuation was seizure, which occurred in 0.9% of the enzalutamide-treated participants compared to none (0%) of the placebo-treated participants.
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laboratory abnormalities

In the randomized clinical trial, Grade 1-4 neutropenia occurred in 15% of participants on enzalutamide (1% Grade 3-4) and in 6% of participants on placebo (no Grade 3-4). The incidence of Grade 1-4 thrombocytopenia was similar in both arms; 0.5% of participants on enzalutamide and 1% on placebo experienced Grade 3-4 thrombocytopenia. Grade 1-4 elevations in ALT occurred in 10% of participants on enzalutamide (0.3% Grade 3-4) and 18% of participants on placebo (0.5% Grade 3-4). Grade 1-4 elevations in bilirubin occurred in 3% of participants on enzalutamide and 2% of participants on placebo.
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infections

In the randomized clinical trial, 1.0% of participants treated with enzalutamide compared to 0.3% of participants on placebo died from infections or sepsis. Infection-related serious adverse events were reported in approximately 6% of the participants on both treatment arms. Falls and Fall-reported Injuries In the randomized clinical trial, 1.6% of participants treated with enzalutamide were reported to have Grade 1 or 2 hallucinations compared to 0.3% of participants on placebo. Of the participants with hallucinations, the majority were on opioid-containing medications at the time of the event. Hallucinations were visual, tactile, or undefined.
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14.2.3 formulation and preparation

Enzalutamide is a white crystalline non-hygroscopic solid. It is practically insoluble in water. XTANDI is provided as liquid-filled soft gelatin capsules for oral administration. Each capsule contains 40 mg of enzalutamide as a solution in caprylocaproyl polyoxylglycerides. The inactive ingredients are caprylocaproyl polyoxylglycerides, butylated hydroxyanisole, butylated hydroxytoluene, gelatin, sorbitol sorbitan solution, glycerin, purified water, titanium dioxide, and black iron oxide. 14.2.4 Storage and Stability Store enzalutamide capsules at 20°C to 25°C (68°F to 77°F) in a dry place and keep the container tightly closed. Excursions permitted from 15°C to 30°C (59°F to 86°F). The company providing the IND drug will also provide the expiration date for each lot allocated to this study. 14.2.5 Dosage and Administration Procedures Enzalutamide 160 mg (four 40 mg capsules) administered orally once daily. Swallow capsules whole. Enzalutamide can be taken with or without food. 14.2.6 Incompatibilities and Drug-Drug Interactions Drugs that Inhibit or Induce CYP2C8 Co-administration of a strong CYP2C8 inhibitor (gemfibrozil) increased the composite area under the plasma concentration-time curve (AUC) of enzalutamide plus N-desmethyl enzalutamide in healthy volunteers. Co-administration of enzalutamide with strong CYP2C8 inhibitors should be avoided if possible. If co-administration of enzalutamide with a strong CYP2C8 inhibitor cannot be avoided, reduce the dose of enzalutamide. The effects of CYP2C8 inducers on the pharmacokinetics of enzalutamide have not been evaluated *in vivo*.  
Co-administration of enzalutamide with strong or moderate CYP2C8 inducers (e.g., rifampin) may alter the plasma exposure of enzalutamide and should be avoided if possible. Selection of a concomitant medication with no or minimal CYP2C8 induction potential is recommended. Drugs that Inhibit or Induce CYP3A4 Co-administration of a strong CYP3A4 inhibitor (itraconazole) increased the composite AUC of enzalutamide plus N-desmethyl enzalutamide by 1.3 fold in healthy volunteers. The effects of CYP3A4 inducers on the pharmacokinetics of enzalutamide have not been evaluated *in vivo*.  
Co-administration of enzalutamide with strong CYP3A4 inducers (e.g., carbamazepine, phenobarbital, phenytoin, rifabutin, rifampin, rifapentine) may decrease the plasma exposure of enzalutamide and should be avoided if possible. Selection of a concomitant medication with no or minimal CYP3A4 induction potential is recommended. Moderate CYP3A4 inducers (e.g., bosentan, efavirenz, etravirine, modafinil, nafcillin) and St. John's Wort may also reduce the plasma exposure of enzalutamide and should be avoided if possible. Effect of Enzalutamide on Drug Metabolizing Enzymes Enzalutamide is a strong CYP3A4 inducer and a moderate CYP2C9 and CYP2C19 inducer in humans. At steady state, enzalutamide reduced the plasma exposure to midazolam (CYP3A4 substrate), warfarin (CYP2C9 substrate), omeprazole (CYP2C19 substrate). Concomitant use of enzalutamide with narrow therapeutic index drugs that are metabolized by CYP3A4 (e.g., alfentanil, cyclosporine, dihydroergotamine, ergotamine, fentanyl, pimozide, quinidine, sirolimus, and tacrolimus), CYP2C9 (e.g., phenytoin, warfarin) and CYP2C19 (e.g., proton pump inhibitors and clopidogrel) should be avoided as enzalutamide may decrease their exposure. If co-administration with warfarin cannot be avoided, conduct additional INR monitoring.
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| 16   | APPENDIX A-PERFORMANCE STATUS CRITERIA ECOG Performance Status Scale Karnofsky Performance Scale Grade Descriptions Percent Description 100 Normal, no complaints, no  evidence of disease. Normal activity. Fully active,  0 able to carry on all pre-disease  performance without restriction. Able to carry on normal activity;  90 minor signs or symptoms of  disease. Normal activity with effort;  80 some signs or symptoms of  disease. 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). 1 Cares for self, unable to carry on  70 normal activity or to do active  work. 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. Requires occasional assistance,  60 but is able to care for most of  his/her needs. 2 50 Requires considerable assistance  and frequent medical care. 40 Disabled, requires special care  and assistance. In bed >50% of the time.  Capable of only limited self-care,  confined to bed or chair more  than 50% of waking hours. 3 Severely disabled,  30 hospitalization indicated. Death  not imminent. 20 Very sick, hospitalization  indicated. Death not imminent. 100% bedridden. Completely  disabled. Cannot carry on any  self-care. Totally confined to bed  or chair. 4 10 Moribund, fatal processes  progressing rapidly. 5 Dead. 0 Dead.   |
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