Apalutamide, Abiraterone Acetate, and Prednisone in Treating Participants With Metastatic Castration Resistant Prostate Cancer

Inclusion Criteria:

Histologically or cytologically confirmed adenocarcinoma of the prostate without neuroendocrine differentiation or small cell features
Presence of metastatic disease that can be biopsied by any methodology applicable
Ongoing androgen deprivation therapy with a gonadotropin releasing hormone (GnRH) analogue or orchiectomy (i.e., surgical or medical castration)
Serum testosterone level =< 50 ng/dL at the screening visit

Progressive disease defined as one or more of the following three criteria (NOTE: Patients who received an antiandrogen must demonstrate disease progression following discontinuation of antiandrogen):

PSA progression defined by a minimum of two rising PSA levels with an interval of >= 1 weeks between each determination. The PSA value at the screening visit should be >= 2 ng/mL
Soft tissue disease progression as defined by the Response Evaluation Criteria in Solid Tumors (RECIST)
Bone disease progression defined by two or more new lesions on bone scan
Patients previously treated with chemotherapy must have no more than two prior chemotherapy regimens for the treatment of metastatic prostate cancer
Eastern Cooperative Oncology Group (ECOG) performance status of 0-1
Serum albumin >= 3.0 g/dL
Serum potassium >= 3.5 mmol/L
Estimated life expectancy of >= 6 months
Able to swallow the study drug and comply with study requirements
Willing and able to give informed consent

Tumor specimen obtained prior to treatment initiation by interventional radiology guided biopsy will be interrogated per immunohistochemistry (IHC) and features should be as follows for a patient to be eligible

Overexpression of androgen receptor (AR)-C terminal and AR-N terminal and PTEN with lack of ARV7 expression along with and ki67 =<10%
No combined RB loss and p53 mutation and
No expression of neuroendocrine markers CD56 and chromogranin (all markers assessed by standardized IHC protocols)

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

The methods must consist of a condom and the use of another barrier method (such as a diaphragm or cervical/vault caps) with a spermicidal agent. Your female partner can choose to use an intrauterine device or system (intrauterine device [IUD] or intrauterine system [IUS]) or use birth control pills, injections, or implants instead of a barrier method

Exclusion Criteria:

Known allergy to the study drugs or any of its components
Severe, concurrent disease, infection, or co-morbidity that, in the judgment of the investigator, would make the patient inappropriate for enrollment or other medical condition that would make prednisone/prednisolone (corticosteroid) use contraindicated
Known metastases to the brain
Absolute neutrophil count < 1000/uL at the screening visit
Platelet count =< 100,000 x 10^9/uL at the screening visit
Hemoglobin < 9 g/dL at the screening visit at the screening visit
NOTE: patients may not have received any growth factors or blood transfusions within seven days of the hematologic laboratory values obtained at the screening visit
Total bilirubin (Tbili) > 1.5 times the upper limit of normal at the screening visit
Alanine aminotransferase (ALT) or aspartate aminotransferase (AST) > 2.5 times the upper limit of normal at the screening visit
Creatinine (Cr) > 2 mg/dL at the screening visit
History of another malignancy within the previous 2 years with > 30 % probability of relapse other than curatively treated non-melanomatous skin cancer
Treatment with androgen receptor antagonists (bicalutamide, flutamide, nilutamide), 5-alpha reductase inhibitors (finasteride, dutasteride), estrogens, chemotherapy, or biologic therapy within 4 weeks of enrollment (day 1 visit)
Radiation therapy within 3 weeks (if single fraction of radiotherapy within 2 weeks) of enrollment (day 1 visit)
Planned palliative procedures for alleviation of bone pain such as radiation therapy or surgery
Structurally unstable bone lesions suggesting impending fracture
History of seizure or any condition that may increase the patient's seizure risk. Also, history of loss of consciousness or transient ischemic attack within 12 months of day 1

Clinically significant cardiovascular disease including:

Myocardial infarction within 6 months
Uncontrolled angina within 6 months
Congestive heart failure New York Heart Association (NYHA) class 3 or 4 in the past, or history of anthracycline or anthracenedione (mitoxantrone) treatment, unless a screening echocardiogram or multi-gated acquisition scan (MUGA) performed within three months results in a left ventricular ejection fraction that is >= 45%
History of clinically significant ventricular arrhythmias (e.g., ventricular tachycardia, ventricular fibrillation, torsades de pointes)
Prolonged corrected QT interval by the Fridericia correction formula (QTcF) on the screening electrocardiogram (ECG) > 470 msec
History of Mobitz II second degree or third degree heart block without a permanent pacemaker in place
Hypotension (systolic blood pressure < 86 millimeters of mercury or bradycardia with a heart rate of < 50 beats per minute on any ECG taken at the screening visit
Bradycardia with a heat rate of < 50 beats per minutes in the screening ECG, unless pharmaceutically induced and reversible
Chronically uncontrolled hypertension as indicated by consistently elevated resting blood pressure (systolic blood pressure > 170 mmHg or diastolic blood pressure > 105 mmHg) during screening

Have used or plan to use from 30 days prior to enrollment (day 1 visit) through the end of the study the following medications known to lower the seizure threshold:

Aminophylline/theophylline
Atypical antipsychotics (e.g., clozapine, olanzapine, risperidone, ziprasidone)
Bupropion
Insulin
Lithium
Pethidine
Phenothiazine antipsychotics (e.g., prochlorperazine [compazine], chlorpromazine, mesoridazine, thioridazine)
Tricyclic and tetracyclic antidepressants (e.g., amitriptyline, desipramine, doxepin, imipramine, maprotiline, mirtazapine)
Prior use of ketoconazloe, enzalutamide, abiraterone or apalutamide or participation in a previous clinical trial of ketoconazloe,enzalutamide, abiraterone or apalutamide unless within the neoadjuvant setting
Use of an investigational agent within 4 weeks of enrollment (day 1)
Gastrointestinal disorder affecting absorption (e.g., gastrectomy)
Major surgery within 4 weeks prior to enrollment (day 1)

History of significant bleeding disorder unrelated to cancer, including:

Diagnosed congenital bleeding disorders (e.g., von Willebrand's' disease)
Diagnosed acquired bleeding disorder within one year (e.g., acquired anti-factor VIII antibodies)
History of gastrointestinal (GI) bleeding within one year
Known active or symptomatic viral hepatitis or chronic liver disease
Known history of pituitary or adrenal dysfunction
Baseline moderate and severe hepatic impairment (Child Pugh class B & C)