Advanced ChemoHormonal Therapy for Treatment Naive Metastatic Prostate Cancer

Inclusion Criteria:

Patients must have histologically or cytologically confirmed prostate cancer OR a strong suspicion of prostate cancer as evidenced by metastatic disease in a pattern consistent with prostate cancer (such as blastic lesions on a nuclear medicine bone scan or lymphadenopathy on the computed tomography [CT] scan) AND a PSA > 50 ng/mL

Patients must meet either of the definitions for high risk disease as follows:

Definition 1: Must have at least 2 of the following 3 at the time diagnosed metastatic:

visceral metastatic disease
>=3 bone lesions
Gleason 8-10 OR
Definition 2: >=4 bone lesions, including >=1 outside of the vertebral column or pelvis and/or visceral metastatic disease
If a patient has received androgen deprivation therapy (ADT) for neoadjuvant or adjuvant therapy at least 24 months MUST have elapsed since its use to day 1 of restarting ADT for metastatic castration sensitive disease
ADT sensitive disease- no evidence of PSA progression or new metastatic deposits since starting ADT; PSA progression is defined as an increase in PSA greater than 25% above nadir, and >2 ng/ml increase confirmed by a second value obtained at least 2 weeks apart
Have completed up to 6 cycles of docetaxel since developing metastatic castration sensitive disease with no more than 16 weeks elapsed since day 21 of the final cycle
All races and ethnic groups will be included
Life expectancy of greater than 18 months
Eastern Cooperative Oncology Group (ECOG) performance status =< 2
Hemoglobin > 9.0 g/dL, independent of transfusion and/or growth factors
Leukocytes > 3,000/uL
Absolute neutrophil count > 1,500/uL
Platelets >= 100,000 x 10^9/uL, independent of transfusion and/or growth factors
Total bilirubin =< 1.5 x upper limit of normal (ULN) (Note: In subjects with Gilbert's syndrome, if total bilirubin is > 1.5 x ULN, measure direct and indirect bilirubin and if direct bilirubin is =< 1.5 x ULN, subject may be eligible)
Aspartate aminotransferase (AST)(serum glutamic oxaloacetic transaminase [SGOT])/alanine aminotransferase (ALT)(serum glutamic pyruvic transaminase [SGPT]) < 2.5 x institutional upper limit of normal
Albumin > 3 g/dL
Estimated glomerular filtration rate (eGFR) > 30 mL/min/1.73 m^2; per Modification of Diet in Renal Disease (MDRD) calculation or institutional standard
Potassium >= 3.5 mmol/L
Medications known to lower the seizure threshold must be discontinued or substituted at least 4 weeks prior to day 1 of study
Agrees to use a condom (even men with vasectomies) and another effective method of birth control if he is having sex with a woman of childbearing potential or agrees to use a condom if he is having sex with a woman who is pregnant while on study drug and for 3 months following the last dose of study drug. Must also agree not to donate sperm during the study and for 3 months after receiving the last dose of study drug
Ability to understand, and the willingness to sign, a written informed consent document, as well as comply with study requirements

Exclusion Criteria:

Subjects who are unwilling to stop taking saw palmetto, PC-SPECs or other herbal agents known to affect the PSA
Patients may not have received any other investigational agents within 30 days prior to day 1 of study

Prior exposure to apalutamide, enzalutamide, abiraterone acetate, darolutamide, or any other second-generation antiandrogen therapy

Note: prior exposure to bicalutamide, flutamide, nilutamide, or any other first-generation androgen receptor antagonist is permitted. No washout is required. Subjects may be on one of these at the time of consent, but it must be stopped prior to day 1 of study treatment. These drugs are frequently used in the newly diagnosed metastatic setting to blunt the effect of the testosterone spike
History of allergic reactions attributed to compounds of similar chemical or biologic composition to apalutamide or other agents used in the study
Subject has another active malignancy other than non-melanomatous skin cancer (unless it is metastatic) or superficial bladder cancer

Either of the following:

Seizure or known condition that may pre-dispose to seizure (e.g. prior stroke within 1 year, brain arteriovenous malformation, Schwannoma, meningioma, or other benign central nervous system [CNS] or meningeal disease which may require treatment with surgery or radiation therapy)
Severe or unstable angina, myocardial infarction, symptomatic congestive heart failure or left ventricular ejection fraction < 50%, arterial or venous thromboembolic events (e.g. pulmonary embolism, cerebrovascular accident including transient ischemic attacks), or clinically significant ventricular arrhythmias within 6 months prior to day 1 of study

Current evidence of any of the following:

Uncontrolled hypertension
Gastrointestinal disorder affecting absorption
Active infection (e.g. human immunodeficiency virus [HIV] or viral hepatitis)
Any chronic medical condition requiring a higher dose of corticosteroid than a total of 10 mg prednisone/prednisolone daily
Any condition that in the opinion of the investigator, would preclude participation in this study.
Avoid concomitant strong CYP3A4 inducers during abiraterone acetate treatment. If a strong CYP3A4 inducer must be co-administered, increase the abiraterone acetate dosing frequency to twice a day only during the co-administration period (e.g., from 1,000 mg once daily to 1,000 mg twice a day).
Avoid co-administration of abiraterone acetate with CYP2D6 substrates that have a narrow therapeutic index. If an alternative treatment cannot be used, exercise caution and consider a dose reduction of the concomitant CYP2D6 substrate
Baseline moderate and severe hepatic impairment (Child Pugh Class B & C)

Inability to stop a prohibited medication:

Atypical antipsychotics (e.g. clozapine, olanzapine, risperidone, ziprasidone)
Bupropion
Lithium
Meperidine and pethidine
Phenothiazine antipsychotics (e.g. chlorpromazine, mesoridazine, thioridazine)
Tricyclic antidepressants (e.g. amitriptyline, desipramine, doxepin, imipramine, maprotiline, mirtazapine
Tramadol