............................................................40 6.1.2 Data will be secured in NCI C3D database. Data will be collected using protocol-specific case report forms, and verified for accuracy Version Date: 12/5/17 Abbreviated Title : Enzalutamide in non-met CSPC 8and completeness. Hard copies of data will be stored in locked secured areas and data will be entered onto a secured electronic data base. The following protocol-specific study forms will be complete and stored: eligibility checklist (developed by Central Registration Office, CRO). A copy of all serious AE forms will be kept in the rese arch re cord. ........................................................................40 6.1.3 Treatment is given according to protocol (dated notes about doses given, complications, and clinical outcomes)............................................40 6.1.4 Toxicity is assessed according to pr otocol (laboratory report slips, etc.).............................................................................................................40 6.1.5 Response is assessed according to protocol (X-ray, scan, lab reports, and date noted on clini cal assessment, as appropriate).................40 6.1.6 Drug Accountability Records are kept for each patient.............................40 6.1.7 We will not report Grade 1 adverse events................................................40 6.2 Response Criteria...................................................................................................41 6.2.1 Disease Progression ...................................................................................41 6.3 Toxicity Criteria.....................................................................................................42 7 SAFETY REPORTING REQUIREMENTS/DATA AND SAFETY MONITORING PLAN ......................................................................................................42 7.1 Definitions..............................................................................................................42 7.1.1 Adverse Event............................................................................................42 7.1.2 Suspected adve rse reaction ........................................................................42 7.1.3 Unexpected adve rse reaction .....................................................................42 7.1.4 Serious........................................................................................................43 7.1.5 Serious Adverse Event...............................................................................43 7.1.6 Disability....................................................................................................43 7.1.7 Life-threatening adve rse drug ex perience..................................................43 7.1.8 Protocol Deviation (NIH Definition).........................................................43 7.1.9 Non-compliance (NIH Definition).............................................................43 7.1.10 Unanticipated Problem...............................................................................43 7.2 NCI-IRB and Clinical Director Reporting.............................................................44 7.2.1 NCI-IRB and NCI CD Expedite d Reporting of Unanticipated Problems and Deaths..................................................................................44 7.2.2 NCI-IRB Requirements for PI Reporting at Continuing Review ..............44 7.2.3 NCI-IRB Reporting of IND Safety Reports...............................................44 7.3 IND Sponsor Reporting Criteria ............................................................................45 7.3.1 Reporting Pregnancy..................................................................................45 7.4 Safety Reporting Criteria to th e Pharmaceutical Collaborators.............................45 7.4.1 Reporting to Astellas..................................................................................45 7.4.2 Reporting to Bavarian Nordic, Inc.............................................................46 7.5 Institutional Biosafety Committee (IBC) Reporting Criteria.................................46 7.5.1 Serious Adverse Event Reports to OSP/IBC .............................................46 7.5.2 Annual Reports to IBC...............................................................................46 7.6 Data and Safety Monitoring Plan...........................................................................47 7.6.1 Principal Investigator/Research Team .......................................................47 Version Date: 12/5/17 Abbreviated Title : Enzalutamide in non-met CSPC 97.6.2 Sponsor Monitoring Plan ...........................................................................48 8 STATISTICAL CONSIDERATIONS...............................................................................48 8.1.1 Cohort 1 .....................................................................................................48 8.1.2 Halting Rules .............................................................................................49 8.1.3 The regression-growth equation ................................................................49 8.1.4 Data Analysis.............................................................................................49 9 COLLABORATIVE AGREEMENTS ..............................................................................50 9.1 Agreement Type.....................................................................................................50 9.1.1 Cooperative Research and Deve lopment Agreement (CRADA)...............50 9.1.2 Material Transfer Agreement (MTA) ........................................................50 10 HUMAN SUBJECT PROTECTIONS ..............................................................................51 10.1 Rationale for Subject Selection..............................................................................51 10.1.1 Selection Based on Gender , Ethnicity, and Race.......................................51 10.1.2 Strategies/Procedures for Recruitment ......................................................51 10.1.3 Justification for Exclusions........................................................................51 10.2 Participation of Children........................................................................................51 10.3 Participation of NIH Subjects Unable to Give Consent.........................................51 10.4 Evaluation of Benefits /Risks/Discomforts.............................................................52 10.4.1 Alternative Approach es or Treatments ......................................................52 10.4.2 Procedures to Eliminate or Minimize Potential Risks ...............................52 10.4.3 Provisions for Monitoring Data Collection to Ensure Subject Safety 52 10.5 Risks/Benefits Analysis .........................................................................................52 10.6 Consent and Assent Proc ess and Documentation ..................................................53 10.6.1 Telephone Re-Consen t Procedure..............................................................53 10.6.2 Informed Consent of Non-English Speaking Subjects ..............................53 11 PHARMACEUTICAL AND INVESTIGATIONAL DEVICE INFORMATION ...........54 11.1 Recombinant Fowlpox-PSA(L155)/TRICOM ...................................................54 11.1.1 How Supplied.............................................................................................54 11.1.2 Preparation .................................................................................................55 11.1.3 Storage .......................................................................................................55 11.1.4 Stability......................................................................................................55 11.1.5 Route of Administration ............................................................................55 11.1.6 Special Handling........................................................................................55 11.2 Recombinant Vaccinia-PSA(L155)/TRICOM ...................................................57 11.2.1 How Supplied.............................................................................................58 11.2.2 Preparation .................................................................................................58 11.2.3 Storage .......................................................................................................58 11.2.4 Stability......................................................................................................58 11.2.5 Route of Administration ............................................................................58 11.2.6 Special Handling and Precautions .............................................................58 11.3 Cidofovir (Vistide®, Gilead Sciences) ..................................................................68 Version Date: 12/5/17 Abbreviated Title : Enzalutamide in non-met CSPC 1011.4 Enzalutamide..........................................................................................................68 11.4.1 Description and formulation ......................................................................68 11.4.2 Source 68 11.4.3 Storage .......................................................................................................68 11.4.4 Stability......................................................................................................68 11.4.5 Dosage and Administration........................................................................69 11.4.6 Adverse E ffects..........................................................................................69 11.4.7 Drug Interactions .......................................................................................70 12 REFERENCES ..................................................................................................................71 13 Appendix A: Performance Status Criteria .........................................................................76 14 Appendix B: Vaccinia-PSA(L155)/TRICOM Patient Instruction Sheet...........................77 15 Appendix C : On Study and Follow-Up Evaluations.........................................................80 16 Appendix D: Instructions for Pre- Study and Follow-Up Blood Tests...............................88 Version Date: 12/5/17 Abbreviated Title : Enzalutamide in non-met CSPC 111 INTRODUCTION 1.1 S TUDY OBJECTIVES 1.1.1 Primary1.1.1.1 Determine if PROSTVAC-V/F combined with the novel ARA enzalutamide will result in a decrease in PSA growth kinetics after enzalutamide discontinuation in patients with non-metastatic, castration se nsitive prostate cancer (i .e. patients with normal testosterone). 1.1.2 Secondary 1.1.2.1 Determine the impact of enzalutamide on PSA as a single agent in patients with normal testosterone and non-meta static, castration sens itive prostate cancer 1.1.2.2 Evaluate the immune response in patients treated with both the combination of PSA- TRICOM and enzalutamide compared to enzalutamide alone. Immune response evaluation will include CD4 cells, CD 8 cells, PSA-specific T-cells, natural killer cells, Regulatory T-cells, cytokines, anti-glycan antibodies and naïve thymic emigrants. 1.1.2.3 Associate immunologic outcomes with PSA responses. 1.1.2.4 Evaluate the toxicity of enzalutamid e and PSA-TRICOM combination in Arm B and compare to enzalutamide alone in Arm A. 1.1.2.5 Evaluate PSA responses to a second 3-month c ourse of enzalutamide in patients eligible for re-treatment based on the protocol. 1.1.2.6 Evaluate changes in testosterone and relat ed hormone levels and each follow up visit, and pre-Enzalutamide adminis tration, and 1 hour post, 24 hours post, 48 hours post, and 72 hours post administration, when logistically feasible. 1.1.2.7 Evaluate plasma VEGF levels at the st art and end of each patient’s second 12-week course of Enzalutamide. 1.1.2.8 Evaluate the immune response in patients treated with enzalutamide at 80 mg/day. Immune response evaluation will include CD 4 cells, CD 8 cells, PSA-specific T-cells, natural killer cells, Regulatory T-cells, cy tokines, anti-glycan antibodies and naïve thymic emigrants. 1.2 B ACKGROUND AND RATIONALE 1.2.1 Enzalutamide Enzalutamide is a modern update of the orig inal androgen receptor antagonists (ARAs), the last of which was developed over 2 decades ago. Since then, the prevailing focus shifted to chemotherapy and chemotherapy combinations ( 1). In addition to binding to the androgen receptor with greater affinity than standard ARAs, enzalutamide prevents downstream effects including nuclear translocation, DNA bindi ng, and signaling to co-activators ( 2). Furthermore, enzalutamide has not demonstrated any agonist properties unlike previous ARAs which showed agonist properties in approximately 15%-20% of patients ( 3,4). (Figure 1) . Another important Version Date: 12/5/17 Abbreviated Title : Enzalutamide in non-met CSPC 12characteristic is that unlike the modern androgen-biosynthesis inhibitor abiraterone, enzalutamide does not require daily prednisone. (Long-term prednisone could have additional side effects and could impact the immune re sponse.) The U.S. Food and Drug Administration (FDA) approved enzalutamide for metastatic prostate cancer in docetaxel-refractory patients in August, 2012 ( 5). Figure 1 A Phase I/II study of enzalutamide demonstrat ed safety and suggested efficacy in both chemotherapy-naïve and chemotherapy-treated castration-resistant prostate cancer (CRPC) patients, the vast majority of whom had metastatic disease ( 6). Two phase III studies were then launched in metastatic CRPC (mCRPC). One st udy enrolled chemotherapy-naïve patients; the other (AFFIRM) evaluated patients who had progressive disease on docetaxel. AFFIRM enrolled 1199 patients with progressive mCRPC on docetaxel and randomized them 2:1 to enzalutamide 160 mg/day (n=800) or placebo (n= 399). The overall survival favored patients randomized to the enzalutamide arm 18.4 to 13.6 months. This 4.8 months improvement in survival represented a 37% risk reduction in death (hazard ratio 0.63; 95% CI: 0.53 to 0.75; P<0.001) the largest relative and absolute improvement in overall survival in an appropriately powered phase III study in prostate cancer. Me dian TTP based on radiographic findings was 8.3 vs. 2.9 months; HR: 0.40; P<0.001). ( Figure 2 ) Modest increases in fatigue, hot flashes, diarrhea, musculoskeletal pain, and headaches re ported in the enzalutamide group, but this was possibly related to the substa ntially longer monitoring time for patients on this treatment compared to the placebo group. Therefore, ther e were no significant c oncerns about the side effect profile of enzalutamide compared to placebo ( 7). The U.S. FDA approved enzalutamide for chemotherapy-refractory mCRPC patients in August of 2012 ( 5). The second phase III trial in chemotherapy naïve patients is ongoing. Version Date: 12/5/17 Abbreviated Title : Enzalutamide in non-met CSPC 13Figure 2 . Enzalutamide demonstrates improved overall survival in mCRPC patients previously treated with docetaxel ( 7). The ultimate role of enzalutamide in the treatment of prostate cancer will likely be in earlier-stage disease. The minimal side effects of enzalutamide in patients with advanced disease will create strong interest in providing this therapy for chemotherapy- naïve mCRPC and even patients with non-metastatic disease, thus supplanting th e use of older ARAs such as bicalutamide which are commonly us ed in non-metastatic patients ( 8). Also, unlike the modern androgen-biosynthesis inhibitor abiraterone, en zalutamide does not requi re daily prednisone. Enzalutamide therapy will thus avoid prednisone ’s potential long-term side effects in earlier stage disease, an important cons ideration for future treatment st rategies in this population. Combination with immune based therapies is attractive because unlike abiraterone, this treatment does not require prednisone which can be immunosuppressive. In addition, given the data which suggest that hormonal therapies can enhance immune response, it would be valuable to gain a better understanding of the immune impact of enzalutamide given the emerging role of immunotherapy in prostate cancer ( 9). At this time, there is no data for the role of enzalutamide in non- metastatic, castration- sensitive prostate cancer (nmCSPC) patients with normal testosterone. (Hereafter in this document, nmCSPC will also refer to patients with a normal testoster one and thus presumed sensitivity to castration.) Previously, the first- generation ARA, bicalutamid e, has been evaluated in the nmCSPC setting as patients and clinicians seek ways to avoid/delay the symptoms associated with ADT. Forty-one patients with nmCSPC were treated with high-dose (150 mg) bicalutamide, with a secondary addition of finasteride but no androgen suppression therapy. Thirty-four of 36 evaluable patie nts reached a PSA nadir that re presented a decline of PSA by 95.5%. The median time to trea tment failure was 21.3 months ( 10). This time frame was consistent with other trials that evaluated high dose bicalutamide in castration-sensitive metastatic disease ( 11). Based on these findings, the use of single agent enzalutamide in this population would be interesting to evaluate given the limited favorable side effect profile and the possibility that enzalutamide is more efficacious than bicalutamide. 1.2.2 Therapeutic Cancer Vacc ines in Prostate Cancer The goal of therapeutic cancer vaccines is to generate a targeted immune response leading to immune-mediated anti-tumor activity. Sipuleucel-T is a therapeutic cancer vaccine generated from peripheral blood mononuclear cells obtained from individual patient s via leukapheresis. This vaccine is generated after a patient’s peripheral immune cells are collected via Version Date: 12/5/17 Abbreviated Title : Enzalutamide in non-met CSPC 14leukapheresis, transported to a regional processing center where they are exposed in vitro to a PAP/GM-CSF fusion protein. At the end of this process, the activated cellular product is re- infused into the patient. A full course of therapy repeats this process 3 times every 2 weeks for 1 month ( 12,13). A phase III trial (n = 512) demonstr ated an overall survival benefit for the vaccine (25.8 months vs. 21.7 months; P = 0.032) ( 14). Based on these overall survival findings, the FDA approved sipuleucel-T for the treatment of asymptomatic or minimally symptomatic mCRPC, making it the first FDA-approved therapeutic cancer vaccine for the treatment of any malignancy. 1.2.3 PSA-TRICOM PSA-TRICOM (Prostvac™; developed by the National Cancer Institute [NCI] and licensed to Bavarian Nordic, Mountain View, CA), an off-the-s helf therapeutic cancer vaccine, offers an alternative strategy ( 15,16). (The LTIB and Bavarian Nordichave an ongoing CRADA for the preclinical and clinical developm ent of PSA-TRICOM.) To target prostate-specific antigen (PSA), PSA-TRICOM vaccine employs genetically altered poxviruses to deliver targeting information to immune cells and generate an imm une response. Administered subcutaneously, the poxviruses deliver the transgenes for the tumor associated antigens (PSA) to antigen presenting cells through cellular infection. Once these pox viruses are within the cellu lar cytoplasm, the transgenes are processed. The end result is an antigen presenting cell expressing a PSA peptide within the major histocompatibilitycomplex, resulting in PSA-specific cy tolytic T lymphocytes activation ( 17,18). (Figure 4 ) This approach does not require expensive, labor-intensive ex vivo preparation of patients’ peripheral blood. PSA-TRICOM is thus potentially more logistically and financially feasible over the long-term than sipuleucel-T ( 19). PSA-TRICOM has been investigated in 2 pha se II trials in mCRPC, both of which administered the vaccine at monthly intervals until disease progression. An industry-sponsored, placebo-controlled, multicenter trial in 125 mCRPC patients randomized them 2:1 in favor of PSA-TRICOM; the placebo was an empty poxviral v ector containing no transgenes. As was seen in the sipuleucel-T studies, patients receiving vaccine showed no change in TTP, yet had an overall survival benefit (25.1 months with PSA-TRICOM vs. 16.6 months with placebo; P = 0.0061) ( 20). ( Figure 3 ) A second phase II study of PSA-TRI COM of 32 mCRPC patients at the NCI demonstrated that the vaccine was able to generate a T-cell specific immune response and patients with the greatest magnitude of this response had superior outcomes ( 21). Based on the findings in these trials, a phase III trial of PSA-TRICOM in mCRPC is currently underway ( 22). Version Date: 12/5/17 Abbreviated Title : Enzalutamide in non-met CSPC 15Figure 3. Poxviral vaccine strategy: Modified poxvirus contains transgenes for the tumor-associated antigen PSA and 3 T-cell costimulatory molecules ( 16) Figure 4. PSA-TRICOM improved survival in mCRPC patients in a randomized multi center phase II. ( 20) Like enzalutamide, PSA-TRICOM is very well-tolerated, with common side effects of grade 1 injection-site reactions or flu-like symptoms ( 20,21). Also like enzalutamide, favorable side effect profile and the potential ability to induce a sustained antitumor immune response, clinical trials are ongoing evaluating strategies to use PSA-TRICOM in earlier disease patients. A phase III trial (NCT01322490) of Prostvac monotherapy, however, was reported to have not met its primary endpoint of overa ll survival in September, 2017. Nonetheless, the combination of Prostvac and enzalutamide remains scientifically rational and this trial will continue. Furthermore, at this point neither this trial nor the phase III trial have su ggested a safety concern for Prostvac. 1.2.4 Rationale for Combining En zalutamide with PSA-TRICOM Accumulating data demonstrate that androgen-deprivation therapy (ADT) affects not only prostate cancer growth, but also the immune system and suggest that ADT in prostate cancer can augment the immune response by incr easing T-cell infiltrati on into the prostate (9). The impact of this T-cell trafficking would be even greater if T cells were primed by a vaccine prior to ADT ( 23). Furthermore, ADT has been shown to decrease immune tolerance of self antigens that are over-expressed in many canc ers, increase the production of new T-cells from Version Date: 12/5/17 Abbreviated Title : Enzalutamide in non-met CSPC 16the thymus ( Table 1 ), and enhance the Cytotoxic T-cell repertoire ( 9,24-26 ). Of the two modern anti-androgen therapies for prostate canc er that have emerged in the last few years, enzalutamide is preferred over abiraterone, beca use abiraterone requires prednisone which may influence the immune response in a vaccine-based combination regimen. Baseline After ADT Naïve CD4 cells 3.25% of CD3+ cells3.95% of CD3+ cellsp = 0.0060 T-Cell Receptor Excision Circles93 per 100,000 cells147 per 100,000 cellsp = 0.0025 Table 1. ADT Increases Naïve T-cell Emigrants from the Thymus. A previous NCI trial (NCT00514072) evaluated naïve T-cell emigrants from the thymus after 3 months of ADT. T-cell receptor excision circles are detectable by products of thymic generation of new T-cells and provide a way to quantify such cells. Naïve CD4 cells are defined by flow cytometry as described in the correlative studies section below. By both measures there was a significant increase in the number of naïve T-cells which potentially can be activated by vaccine. (unpublished) 1.2.5 Combining Androgen Receptor Antagonists with PSA-TRICOM, clinical evidence An ongoing clinical trial at the NCI is combining PSA-TRICOM with flutamide, an FDA approved ARA, in men with non-metastatic CRPC (N CT00450463) . Patients are randomized to either PSA-TRICOM with flutamide or flutam ide alone. The primary endpoint is TTP as determined by PSA (Bubley criteria) or development of metastatic disease ( 28). An interim analysis with about half the patients accrued de monstrated that these 2 agents can be safely combined with minimal toxicity. The interim TTP analysis favored the combination of PSA- TRICOM and flutamide compared to fl utamide alone (192 days vs. 108 days) ( 29).(Figure 5 ) The study is completing accrual at the NCI and the Cancer Institute of New Jersey, but the interim analysis provides a preliminary clinical rationale for the combination of PSA-TRICOM with a modern ARA in chemotherapy-naï ve patients with mCRPC. The proposed trial in mCRPC will use metastatic progression as an endpoint, which is a more establ ished therapeutic measure than criteria currently establishe d for nonmetastatic disease ( 30). 1.2.6 Enzalutamide’s Immune Effects in Preclinical Figure 5 . Patient Population: “Biochemical Recurrence” or Rising PSA after surgery or RT with normal testosterone (nmCSPC) Version Date: 12/5/17 Abbreviated Title : Enzalutamide in non-met CSPC 17Models Enzalutamide has been evaluated preclinically by Dr. James Hodge of the Laboratory of Tumor Immunology and Biology (LTIB) at the NC I.