6. Adverse Events Toxicity will be graded according to the NCI common toxicity criteria “ Common Terminology Criteria for Adverse Events” (NCI -CTCAE v3.0 can be accessed at website: http://ctep.cancer.gov/forms/CTCAE_Index.pdf). Non-hematologic and Hematologic dose limiting toxicity (DLT) will be defined as described in Section 8.5.1. 6.1 Definitions Adverse Event (AE) is any untoward medical occurrence in a patient or clinical investigation subject administered a pharmaceutical product and that does not necessarily have a causal relationship with this research intervention. An 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. This will also include intercurrent diseases and accidents observed during the research intervention period as well as corresponding events during drug-free, pre- and post- intervention periods, under placebo or in a reference group receiving drug or non-drug therapy. Serious adverse event (SAE) is any untoward medical occurrence that: a. results in death b. is life -threatening i c. requires inpatient hospitalization or prolongation of existing hospitalization d. results in persistent or significant disability or incapacity e. is a congenital anomaly / birth defect or f. is another medically important condition.ii 6.2 Procedures of documentation of AEs All AEs occurring during the study must be documented, regardless of the assumption of a causal relationship, on the respective AE CRF. All events, which occurred after signed informed consent, should be documented. The investigator should ensure that all events are recorded that occurred within at least 4 weeks after the last exposure to the study drug (through Day 90) . Documentation of AEs includes: date of onset and offset, intensity, frequency, seriousness, related interventions and outcome. The investigator will also evaluate the PROTOCOL #1 Lubaroff, page 19 probability of a causal relationship of the adverse event to the study medication as being: “definite, probable, possible, unlikely, or unrelated.” All unanticipated problems involving risk to subjects or others, serious adverse events related to participation in the study and subject deaths related to participation in the study will be promptly reported by phone (301-619-2165), by email (hsrrb@det.amedd.army.mil ), or by facsimile (301-6 19-7803) to the USAMRMC, Office of Research Protections, Human Research Protection Office. A complete written report will follow the initial notification. In addition to the methods above, the complete report will be sent to the U.S. Army Medical Research and Materiel Command, ATTN: MCMR - ZB-PH, 504 Scott Street, Fort Detrick, Maryland 21702-5012. The medical monitor is required to review all unanticipated problems involving risk to volunteers or others, serious adverse events , and all volunteer deaths associated with the protocol and provide an unbiased written report of the event. At a minimum, the medical monitor should comment on the outcomes of the event or problem, and in the case of a serious adverse event or death, comment on the relationship to participation in the study. The medical monitor should also indicate whether he/she concurs with the details of the report provided by the study investigator. Reports for events determined by either the investigator or medical monitor to be possibly or definitely related to participation and reports of events resulting in death should be promptly forwarded to the HSRRB. Expedited reporting The investigator must immediately report serious adverse events (SAE) occurring or observed during the course of the study and within 4 weeks of last administration of the study drug to the FDA, IRB, OBA, and CRU. The order of reporting of SAEs is the following: reported to the Principal Investigator within 24 hours of the event; the PI will then report the event to the FDA , OBA, Institutional Biosafety Committee (IBC) , and DOD within 7 days of the event and to the IRB within 10 days of the event. After notifying the proper agencies by telephone of an SAE the “Serious Adverse Event Report ”must also be sent by fax to the agencies whether or not complete information is available at the time. If complete information is unavailable the investigator must provide follow -up information to the agencies as soon as it is known. In particular, the investigator must inform the agencies and committees by phone and fax using the timeline described above of immediately life- threatening SAEs or SAEs with fatal outcome. Important: The investigator must report any SAE to the FDA, IRB, OBA, and CRU, regardless of causality. Reports will be evaluated by the Medical Monitor/Sponsor. FDA/HPB and investigators will be informed as required by the regulations. The same information will also be made available to all participating investigators as well as to other investigators participating in different clinical trials utilizing the same study medication. It should be noted that, although the Ad/PSA vaccine contains the gene for PSA, there is no need for patients to utilize contraceptive practices. The adenovirus will not be transmitted from patient to his partner. In addition, the side effects of androgen depletion therapy, fluid retention, hair loss, hot flashes, nausea, vomiting, bone pain, memory changes, and depression, were not PROTOCOL #1 Lubaroff, page 20 observed in vaccinated men our Phase I trial. Therefore, there should not be any confusion as to which side effects will be attributed to ADT and which to the Ad/PSA vaccine. However, subjects will be closely monitored by the research team for the development of ADT-related side effects. If side effects occur, investigators will take necessary steps to treat them, including discontinuation of the medication and/or discontinuation from the study. 7 MEASUREMENT OF CLINICAL AND IMMUNOLOGICAL EFFECT 7.1 Methods of Malignant Disease Evaluation - Each patient will have a baseline evaluation prior to the injection of the Ad/PSA vaccine. The measurements will include physical exam, temperature, weight, serum PSA, blood chemistries, urinalysis, a quantitative bone scan for bone metastases, chest x -ray, and CT for soft tissue metastases, and performance status for quality of life. PSA measurements, CT and bone scans are routinely used to follow disease recurrence and/or progression in individual prostate cancer patients and as such would be considered standard of care. Laboratory measurements such as hematology, liver function and kidney function chemistries, while are routinely used to follow the health of a prostate cancer patient, would not normally be performed at the frequency proposed in this trial to assess possible vaccination toxicities. Therefore, they would be considered part of the research protocol. Patients will be seen in the Urology and Oncology Clinics (see Table 6 for schedule). The injection site will be examined for evidence of erythema, induration and necrosis and patients will have their temperature and weight recorded and the patients will be interviewed to determine whether they experienced any adverse reactions. Blood samples will also be taken for standard laboratory testing and measurement of PSA and anti-PSA immune responses (see Table 6). Patients recruited from the DMMCC will return to that facility for their laboratory testing on days 44, 74, and at 6, 9, 12 months and all subsequent visits . At the 6 month, 9 month, 12 month, and subsequent semi - annual visits each patient will be evaluated comparing the baseline visit measurements to those obtained at the specific visit . Because changes to the clinical status of the patients will be prolonged, continued follow up will be important. Therefore, patients will be requested to return to the clinic every six months following the 12 month post-vaccination visit . The visits will continue until the patient demonstrates signs of progressive disease. Follow -up of patients for survival will occur every 6 months by telephone following progressive disease. 7.2 Use of Serum PSA for Disease Evaluation – Based upon our pre-clinical experiments and the results from the Phase I clinical trial we expect the immunized men to produce anti-PSA antibodies. The levels of antibody will be measured by a flow cytometry assay as described by Cavacini, et al. used i n our Phase I clinical trial (39 ). We will also explore the use of a second serum marker for prostate cancer, hK2 in collaboration with Donald Tindall, Charles Young, and George Clee at the Mayo Clinic. Investigators at Mayo, along with Hybritech, Inc. have been exploring hK2 and published a number of papers in recent years on the subject (70-73). Patient sera from each clinic visit will be sent to Mayo where they will measure the levels of hK2. We will use the data to evaluate the effect of anti -PSA antibodies on both PSA and hK2 in the sera of vaccinated patients. PROTOCOL #1 Lubaroff, page 21 7.3 Experimental Evaluation of the Ad/PSA Vaccination 7.3.1 Blood will be collected prior to each injection of the Ad/PSA vaccine and at return dates indicated in Table 6, page 26. Two separate samples will be collected; one in red top tubes to allow collection of serum from coagulated blood and a second in heparinized tubes to permit collection of lymphocytes. 7.3.2 Levels of PSA, hK2, anti -PSA antibodies, and anti -adenovirus antibodies will be measured in the serum. 7.3.3 Anti-PSA T cell immune responses will be measured by ELISPOT analysis using the methods developed for, and used in, our Phase I clinical trial. In addition to measuring the anti -PSA T cell activity, we will also measure anti -adenovirus T cell activity as well as reactivity to stimulation with cytomegalovirus (CMV). A non-specific stimulus will be provided by PMA and ionomycin for each patient’s lymphocytes. 7.4 Definitions of Response – 7.4.1 Arm A – Hormone Naïve – 7.4.1.1 Primary Endpoint - Development of Anti -PSA Immune Responses 7.4.1.1.1 Immunologic response – Definition: an increase of > 200% above pre-immunization levels of anti -PSA T cells as measured by ELISPOT analysis, measured at any point after vaccination. 7.4.1.2 Secondary Endpoints – PSA Responses 7.4.1.2.1 PSA response - Definition: a 50% reduction in the pre-research intervention PSA value, verified with a second measurement >/= 28 days later 7.4.1.2.2 A 50% increase in the PSADT compared to pre-enrollment PSADT. 7.4.1.2.3 PSADT will be calculated based on the MSKCC online calculator, available at http://www.mskcc.org/mskcc/html/10088.cfm . 7.4.1.2.4 PSADT response will be measured at 9 and 18 months after initiation of the research intervention. 7.4.1.2.5 Three measurements of PSA, spaced at least 2 weeks apart, will be required prior to study enrollment. Post-research intervention PSADT will be based on PSA levels at 3, 6 and 9 months (9 month PSADT calculation) and 3, 6, 9,12,15,18 month levels (18 month PSADT calculation). 7.4.2 Arm B – Androgen-Deprivation Therapy – 7.4.2.1 Primary Endpoint - Immunologic response PROTOCOL #1 Lubaroff, page 22 7.4.2.1.1 Definition: an increase of > 200% above pre-immunization levels of anti -PSA T cells as measured by ELISPOT analysis, measured at any point after vaccination. 7.4.2.2 Secondary Endpoint - PSA response - Definition: a 50% reduction in the pre-research intervention PSA value, verified with a second measurement >28 days later 7.5 Definition of Progression 7.5.1 Development of positive bone scan .B 7.5.2 Development of rising PSA abov e baseline, if existent. A rising PSA will be defined as a 50% increase above baseline measurement on two consecutive measurements, >28 days apart. 7.6 Timing of Toxicity Assessments - Toxicity assessment will occur as stated in the calendar. We will wait for the last patient of stage I to reach the 90 day toxicity assessment date (and review of safety data) prior to proceeding with stage II as outlined in the statistical plan. 8 STUDY PARAMETERS 8.1 Scans or x -rays must be done within 6 weeks prior to the initiation of treatment. 8.2 CBC with differential, LFT’s must be done < 2 weeks before the initiation of treatment. 8.3 All chemistries must be done < 2 weeks before the study entry, unless specifically required on day 1 as per protocol. If abnormal, they can be repeated within 48 hours prior to study entry. 8.4 Hgb, Hct, WBC, Plt must be done < 2 weeks before study entry but, if abnormal, they can be repeated <48 hours prior to study entry. 8.5 REMOVAL OF PATIENTS FROM STUDY (Criteria for discontinuation of a patient's study participation) 8.5.1 Adverse events: Study subjects will be monitored for adverse events for 30 days beyond the final study injection, or longer if existing unresolved AEs are being monitored. In the event of a vaccine-assoc iated unmanageable or irreversible toxicity, that would include hematological and non-hematological toxicities (see Section 8.5.1.1), the investigator will withdraw a patient from further research intervention and notify the Study Chair immediately. In addition, the FDA and the IRB and other agencies listed on page 18 will be notified of the adverse events. If unmanageable or irreversible toxicities occur the patients will receive the best possible medical care according to the recommendations of the treating physicians. The treatment plan will depend upon what unmanageable or irreversible toxicities may occur. In the event of an emergency the patient will be B Only patients with negative bone scans are eligible for the study PROTOCOL #1 Lubaroff, page 23 instructed to seek immediate care by calling 911, his local physician, the University of Iowa or Iowa City VA Health Care System urology staff on call. 8.5.1.1 Management of Toxicities 8.5.1.1.1 Hema tological Toxicity Management 8.5.1.1.1.1 Patients with grade 2 or 3 hematological toxicity will not receive the subsequent dose of vaccine until there is normalization of cbc parameters until grade 1 or less toxicity is reached. An exception to withholding a dose of vaccine would be if the cbc parameters were stable (at or near the pre-vaccination values). 8.5.1.1.1.2 In case of grade 2 or 3 hematological toxicity detected any time during protocol therapy, CBC with differential will be checked on a weekly basis until grade 1 or less toxicity is reached. 8.5.1.1.1.3 If the subsequent vaccine dose needs to be postponed for more than 2 weeks, tho se patients will be removed from protocol therapy. 8.5.1.1.1.4 Patients with grade 4 hematological toxicity at any time will be permanently removed from protocol therapy. 8.5.1.1.2 Non-Hematological Toxicity Management 8.5.1.1.2.1 Patients with grade 2 or 3 non-hematological toxicity will not have the subsequent dose of vaccine administered until the toxicity ameliorates down to a grade 1 level. 8.5.1.1.2.2 Patients will be evaluated once a week with study team assessments if a grade 3 non-hematol ogical toxicity occurs. 8.5.1.1.2.3 If the subsequent dose of vaccine needs to be postponed for more than 2 weeks, those patients will be permanently removed from protocol therapy. 8.5.1.1.2.4 Patients with grade 4 non-hematological toxicity at any time will be permanently removed from protocol therapy. Patients may also be removed from protocol therapy at any time based on assessment of any other risks, at the discretion of the study investigators. 8.5.2 Disease Progression: Patients will be taken off-study if they have progressive disease (PD) or clinically significant deterioration at any time during the study if the investigator feels that ( a) alternative prostate cancer therapy might benefit the patient, or (b) to continue on study might be unsafe for the patient. Patients receiving alternative prostate cancer therapies will be followed for toxicity for 30 days beyond the third AdPSA injection only unless existing unresolved AEs are being monitored. Patients were asked in the Informed Consent document whether they would return every three months up to 12 months from study entry PROTOCOL #1 Lubaroff, page 24 for immunologic evaluations . Patients who are being treated with prednisone at doses higher than 10 mg daily (or equipotent steroid doses) will be excluded from these every three month returns . 8.5.3 Allergic Reactions: Patients must be removed from the study should they develop grade II allergic reactions. 8.5.4 Personal Reasons: As stated in the informed consent, patients may withdraw from the study at any time. 8.5.5 Clinical Judgment: A patient may be withdrawn from the study, if, in the opinion of the investigators, it is not in the patient's best interest to continue (e.g. an adverse experience, intercurrent illness, non-compliance, etc.) 8.5.6 The date of discontinuation and the reason(s) for patient discontinuation from the study will be recorded in the CRF. All efforts will be made to conduct evaluations that are required at the follow -up for each patient who discontinues research intervention, regardless of the reason. Regulatory and Reporting Requirements The Data and Safety Monitoring Committee (DSMC) of the Holden Comprehensive Cancer Center will provide data and safety monitoring for this study. “The Data and Safety Monitoring Plan of the Holden Comprehensive Cancer Center” provides standard operating procedures to monitor all clinical cancer trials at the UIHC. All investigator -initiated trials are automatically monitored by the DSMC. A detailed data and safety monitoring plan for this study is on file with the DSMC and the Clinical Research Safety Officer (CRSO). Data Management, Quality Control and Data Security In order to protect confidentiality the subject will be assigned an identification number. This number will be used on all specimens from the subject and will be used for documentation purposes . Data management for the optimal entry, processing, storage, and retrieval for this protocol's data will be accomplished by the principal investigator. The database will be located on a computer or in a locked cabinet in a locked office. This computer will be secured, accessible only by the research team. There will be more than one copy of the database. The second, secured, copy of the protocol data will be stored in a locked room accessible only by the research team. For quality control, auditing, and checking data for integrity, there will be a regular accounting of data performed. The medical record and research record will be linked by the study identification number. The data managers in this trial will be responsible for verification of the accuracy of all data transferred from the medical record to the research record. These records will be audited quarterly by the Data Safety Monitoring Committee. All Data Safety Monitoring Committee reports will be provided to the USAMRMC Office of Research Protections, Human Research Protection Office as they become available. Data will be kept on file on each patient for at least two years past the termination of that patient’s participation in the trial. All records will be stored long-term in a secure location. UIHC records will be kept for at least 15 years and then be confidentially destroyed. VAHCS records will be retained until disposition instructions are approved by National Archives and Records Administration. PROTOCOL #1 Lubaroff, page 25 Information from the medical records of patients referred by physicians outside the University of Iowa and the VA Health Care System required to determine eligibility for this protocol will be placed in a research folder, identified by the patient code and will be available only to members of the clinical trial team (identified on pages 28 and 29). The signed HIPAA forms will be kept in the patient’s folder in the office of the referring physician. The r ecords of such patients that are deemed ineligible following a screening procedure will have their signed Release of Information forms, informed consent document, and eligibility form kept in a research folder under similar security conditions. The records for ineligible subjects will be stored with the other research records as indicated above. PROTOCOL #1 Lubaroff, page 26 Table 6 Study Design and Testing Std. of Care or Res. Prior to Reg.1 Day -14 Day 1 First Inj. 30 d. 2nd Inj. 44 d. 60 d. 3rd Inj. 74 d. 90 d. 6 mo 9 mo 12 mo Every 6 mo.