This research study is a Phase 2 clinical trial. Phase 2 clinical trials test the safety and
effectiveness of investigational drug(s) to learn whether the drug(s) work in treating a
specific disease. "Investigational" means that the drug(s) are being studied.
The U.S. Food and Drug Administration (FDA) has not approved nivolumab for hormone sensitive
prostate cancer. However, nivolumab has been approved for other uses, including for advanced
melanoma, lung cancer, head and neck cancer, kidney cancer, and bladder cancer.
The U.S. FDA has not approved docetaxel as a treatment option for hormone sensitive prostate
cancer. However, docetaxel is approved for advanced hormone resistant prostate cancer and
other cancers. There is also evidence from a high quality, phase 3 randomized clinical trial
supporting the use of docetaxel in metastatic hormone sensitive prostate cancer patients who
have a high burden of metastasis. Docetaxel is an off-label indication for hormone sensitive
prostate cancer.
The U.S. FDA has approved androgen deprivation therapy (ADT) agents, including leuprolide
(Lupron), goserelin acetate (Zoladex), or degarelix (Firmagon), as a treatment option for
hormone sensitive prostate cancer.
The combination of ADT, also called hormonal therapy, with docetaxel chemotherapy and
nivolumab immunotherapy is considered investigational. ADT cuts off the supply of
testosterone and is the standard of care for hormone sensitive prostate cancer. The addition
of docetaxel chemotherapy has been found to prolong life for prostate cancer patients
starting hormonal therapy for the first time for metastatic disease, who also have a large
volume of cancer.
Another anti-cancer treatment modality is called immunotherapy. The immune system can kill
cells that are recognized as different or dangerous, such as infected cells and cancer cells.
Nivolumab is an antibody (a type of human protein) that work to stimulate the body's immune
system to recognize and fight cancer cells.
Hormonal therapy and chemotherapy may make cancer cells more recognizable to the immune
system, and make cancer cells more susceptible to immunotherapy. The goal of this study is to
examine the activity and safety of hormonal therapy combined with docetaxel chemotherapy and
nivolumab immunotherapy for hormone sensitive prostate cancer. The study is designed to
enrich for patients whose tumors may be more most responsive to this treatment strategy. All
patients will receive the same treatment of ADT combined with docetaxel chemotherapy and
nivolumab immunotherapy.
Inclusion Criteria:
- Newly diagnosed histologically confirmed prostate adenocarcinoma within 6 months prior
to study registration with evidence of distant metastasis on conventional imaging
- Distant metastasis is defined by non-regional lymph node(s) metastasis (M1a), bone
metastasis (M1b), and/or other site(s) of metastatic disease (M1c).
- Conventional imaging consists of CT, MRI or radionuclide bone scan
- Age ≥18 years
- ECOG performance status ≤2 (Karnofsky ≥60%, see Appendix A)
- Subjects with ECOG performance status of 2 are only eligible if the performance status
decline is attributed to metastatic prostate cancer
- Serum PSA > 4.0 ng/mL before initiation of ADT
- Serum testosterone > 100 ng/dL before initiation of ADT
- Subjects whose testosterone level is unknown before initiation of ADT may be allowed
after discussion with Sponsor-Investigator.
- Grade ≤ 1 peripheral neuropathy, defined as asymptomatic or paresthesia and/or
decreased deep tendon reflexes is allowed.
- Subjects must have adequate organ and marrow function as defined below:
- Absolute neutrophil count ≥1,500 /mcL
- Platelets ≥100,000 /mcL
- Total bilirubin ≤1.5 × institutional upper limit of normal. Exception: Subjects
with confirmed Gilbert's syndrome (persistent or recurrent hyperbilirubinemia
that is predominantly unconjugated in the absence of hemolysis or hepatic
pathology) may be allowed after consultation with treating physician
- AST(SGOT) and ALT(SGPT) ≤2.5 × institutional upper limit of normal. Exception: ≤5
x institutional upper limit of normal in subjects with liver metastasis
- Creatinine (Cr) and creatinine clearance (CrCl) Cr <1.6 mg/dL or CrCl ≥30 mL/min;
CrCl should be calculated using the Cockcroft-Gault formula: CrCl (mL/min) =
(140-Age) x Body weight (Kg)/72 x Serum creatinine (mg/dL)
- PT, INR and PTT ≤ 1.5 x institutional upper limit of normal. Exception: Subjects
who are on a stable regimen of therapeutic anticoagulation for an appropriate
clinical indication may be enrolled
- Availability of adequate baseline prostate biopsy tissue for integral biomarker
analysis and correlative studies:
- For OncoPanel, submit at least one (1) H&E slide and ten (10) 5-micron thick
serially sectioned unstained formalin-fixed paraffin-embedded (FFPE) slides.
Biopsy should contain at least 20% tumor involvement with the highest Gleason
score(s). If requested tissue is unavailable, a lower number of 4-micron or 5-
micron slides and/or slides containing lower tumor involvement may be accepted
after discussion with the Sponsor-Investigator.
- For ImmunoProfile, submit at least one (1) H&E slide and one (1) 5-micron thick
serially sectioned unstained, freshly cut, FFPE slide. Biopsy should contain at
least 50% tumor involvement with the highest Gleason score(s). If requested
tissue is unavailable, a 5-micron slide containing lower tumor involvement may be
accepted after discussion with the study Sponsor-Investigator.
- Submission of one (1) H&E slide and at least one (1) FFPE tissue core block with
at least 3mm2 tumor area with the highest Gleason score is an acceptable
alternative to unstained FFPE slides.
- Subjects who have insufficient baseline prostate biopsy tissue for OncoPanel
analysis but have baseline metastatic biopsy tissue available may have OncoPanel
analysis performed using metastatic biopsy tissue.
- For Exploratory Correlative Studies, at least 1 tissue core block (preferred) or
one (1) H&E slide and twelve (12) 5-micron thick FFPE slides with unstained,
freshly cut, serial sections from biopsy cores containing at least 20% tumor
involvement with the highest Gleason score(s) will be requested, if available.
- Tissue should be submitted with redacted pathology report.
- Successful OncoPanel and ImmunoProfile biomarker analysis for allocation into a study
cohort during pre-screening
- Subjects whose tumors harbor somatic or germline homozygous deletions and/or
deleterious mutations in a DDR gene using OncoPanel will be assigned to Cohort 1,
regardless of ImmunoProfile results
- DDR genes include and are not limited to BRCA2, ATM, CHEK2, BRCA1, PALB2, RAD51D,
ATR, NBN, PMS2, GEN1, MLH1, MSH2, MSH6, RAD51C, MRE11A, BRIP1, FAM175A, and CDK12
- Deleterious mutations are defined as loss of function, splice site, nonsense, or
frameshift mutations, and determination will be made between DFCI molecular
pathology and study Sponsor-Investigator
- Tumors identified as mismatch repair deficient (MMR-d) or microsatellite
instability high (MSI-H) will also be included in Cohort 1
- Patients with germline DDRD or MMR-d/MSI-H (Lynch Syndrome) or tumors with DDRD
or MMR-d/MSI-H identified in another CLIAcertified laboratory (e.g., Foundation
Medicine) using prostate or metastatic tissue may be assigned to Cohort 1 after
discussion with the Sponsor-Investigator. If archival tissue is available, it
will be requested for OncoPanel testing; however, results will not influence
eligibility.
- Subjects whose tumors are PD-L1 positive and/or CD8+ T cell inflamed using
ImmunoProfile without the presence of DDRD will be assigned to Cohort 2
- PD-L1 positivity will be defined as Combined Positive Score (CPS) ≥ 1, which is
the number of PD-L1 staining cells (e.g., tumor cells, immune cells) divided by
the total number of tumor cells, multiplied by 100
- CD8+ T cell inflammation will be defined as CD8+ T cell density ≥ 200, which is
the number of CD8+ cells divided by the surface area of a region of interest
(mm2)
- Subjects whose tumors do not harbor DDRD and are PD-L1 negative with low CD8+ T
cell infiltration will be assigned to Cohort 3
- Subjects whose prescreening is unsuccessful for cohort allocation or whose
biomarker status matches that of a filled cohort will not be eligible
- Subjects who underwent successful ImmunoProfile pre-screening but failed
OncoPanel pre-screening may be allocated to Cohort 2 or Cohort 3 based on
ImmunoProfile results and assuming DDRD negativity, at the discretion of the
Sponsor-Investigator.
- Before one of the study cohorts enrolls 15 of 20 subjects (Cohort 3 is
anticipated to complete accrual first), subjects may undergo main study screening
when ImmunoProfile and OncoPanel analyses are ongoing, and may proceed to study
treatment if they meet all eligibility criteria with the exception that OncoPanel
analysis is ongoing. These patients will be allocated into their respective
cohort after OncoPanel results return.
- Willingness to provide leftover metastatic biopsy tissue for correlative studies, if
obtained for clinical purposes
- Based on its mechanism of action and data from animal studies, nivolumab can cause
fetal harm. For this reason non-sterilized men who are sexually active with a female
partner of childbearing potential treated or enrolled on this protocol must agree to
use adequate contraception prior to the study, for the duration of study
participation, and for 7 months after last dose of nivolumab administration
- Adequate contraception includes male condom plus spermicide
- Not engaging in sexual activity is an acceptable practice; however, occasional
abstinence, the rhythm method, and the withdrawal method are not acceptable
methods of contraception
- Subjects in this study should refrain from sperm donation
- Ability to understand and the willingness to sign a written informed consent document,
or have a legally authorized representative sign on the subject's behalf
Exclusion Criteria:
- Subjects must not have received prior ADT (LHRH analogue +/- antiandrogen),
chemotherapy, or immunotherapy for prostate cancer. The following exception is
allowed:
- Subjects who have initiated ADT prior to study registration and are able to
complete biomarker pre-screening, cohort allocation, and start C1D1 study
chemoimmunotherapy ≤120 days from initiation of ADT are allowed
- The 120-day window commences at the start of either the antiandrogen agent or
LHRH analogue, whichever is earlier
- Antiandrogens (e.g., bicalutamide or flutamide) may be used in addition to LHRH
analogue ≤60 days before initiation of LHRH analogue to cover the testosterone
surge associated with certain LHRH agonists but must be discontinued prior to
study registration
- Second-generation hormonal agents (e.g., abiraterone acetate) are not allowed
- Subjects must not have undergone prostatectomy
- Prostate radiation is allowed before or after study enrollment and may be
delivered concurrently with study chemoimmunotherapy, per provider discretion,
assuming adequate prostate biopsy tissue is collected before prostatic radiation
- Metastasis-directed radiation is allowed before or after study enrollment and may
be delivered concurrently with study chemoimmunotherapy, per provider discretion
- Subjects who are receiving any other investigational agents
- Any previous treatment with a PD-1 or PD-L1 inhibitor
- Subjects with known brain metastases should be excluded from this clinical trial
because of their poor prognosis and because they often develop progressive neurologic
dysfunction that would confound the evaluation of neurologic and other AEs
- History of allergic reactions attributed to compounds of similar chemical or biologic
composition to docetaxel (including any drugs formulated with polysorbate 80),
nivolumab, or LHRH analogue (e.g., leuprolide, goserelin acetate, degarelix)
- History of another primary malignancy, except for:
- Malignancy treated with curative intent and with no known active disease for ≥2
years before the first dose of study treatment and of low potential risk for
recurrence
- Adequately treated non-melanoma skin cancer or lentigo maligna without evidence
of disease
- Uncontrolled intercurrent illness including, but not limited to, ongoing or active
infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac
arrhythmia, or psychiatric illness/social situations that would limit compliance with
study requirements
- Major surgical procedure as defined by the Site Investigator within 28 days prior to
the first dose of chemoimmunotherapy
- Known history of testing positive for human immunodeficiency virus (HIV) or known
acquired immunodeficiency syndrome. HIV-positive subjects on combination
antiretroviral therapy are ineligible because of the potential for nivolumab to be
less clinically active in this population. In addition, these subjects are at
increased risk of lethal infections when treated with marrow-suppressive chemotherapy
- History of allogeneic bone marrow or organ transplantation
- Active or prior documented autoimmune or inflammatory disorders, including=
inflammatory bowel disease (e.g., Crohn's disease), systemic lupus erythematosus,
Sarcoidosis syndrome, Grave's disease, rheumatoid arthritis, hypophysitis, uveitis,
with the following exceptions:
- Vitiligo or alopecia
- Hypothyroidism stable on hormone replacement
- Chronic skin condition that does not require systemic therapy
- Celiac disease controlled by diet alone
- Subjects with inactive disease in the last 5 years may be included but only after
consultation with the study physician
- Active infection including tuberculosis, hepatitis B (known positive HBV surface
antigen [HBsAg]), or hepatitis C (HCV)
- Subjects with a past or resolved HBV infection (defined as the presence of
hepatitis B core antibody [anti-HBc] and absence of HBsAg) are eligible
- Subjects with positive HCV antibody are eligible if polymerase chain reaction is
negative for HCV RNA
- Concurrent or prior use of immunosuppressive medication within 14 days before the
first dose of study chemoimmunotherapy, with the following exceptions:
- Premedication for docetaxel with oral dexamethasone (See Section 5.1)
- Intranasal, inhaled, topical steroids, or local steroid injections (e.g.,
intraarticular injection)
- Systemic corticosteroids at physiologic doses not exceeding 10mg/day of
prednisone or its equivalent
- Steroids as premedication for hypersensitivity reactions (e.g., premedication for
iodinated contrast allergy before CT scan)
Inclusion of Minorities
• Men of all races and ethnic groups are eligible for this trial.
