Randomized Phase II Study of Salvage XRT + ADT +/- Abiraterone and Apalutamide for Rising PSA After RP (FORMULA-509)

Inclusion Criteria:

Histologically confirmed prostate cancer

PSA ≥ 0.1 after radical prostatectomy (value w/in 3 months of registration) AND at least 1 unfavorable risk factor listed below.

Gleason 8-10
PSA > 0.5
Pathologically positive lymph nodes
pT3 or pT4
PSA doubling time (DT) < 10 months
Negative margins
Persistent PSA after RP (PSA never dropped below 0.1 after RP)
Local/regional recurrence on imaging
Decipher "High risk" (a Medicare-reimbursed test for risk of metastases after prostatectomy)
Candidate for salvage radiation and ADT treatment
Written informed consent and HIPAA authorization for release of personal health information prior to registration. NOTE: HIPAA authorization may be included in the informed consent or obtained separately. Subject must have the ability to understand and willingness to sign the written informed consent document.
18 ≤ Age ≤ 95 at the time of consent
ECOG Performance Status ≤ 2 (Appendix A)
Demonstrate adequate organ function as defined in the table below. All screening labs to be obtained within 3 months of registration.
System Laboratory Value

Hematological:

Platelet count (plt) ≥ 100,000/ µL
Hemoglobin (Hgb) ≥ 9 g/dL
Absolute neutrophil count (ANC) ≥ 1000 cells/µL

Renal:

--GFR1 ≥ 45 mL/min

Hepatic and Other:

Bilirubin2 ≤ 1.5 × upper limit of normal (ULN)
Aspartate aminotransferase (AST) ≤ 2.5 × ULN
Alanine aminotransferase (ALT) ≤ 2.5 × ULN
Serum Albumin > 3.0 g/dL
Serum potassium ≥ 3.5 mmol/L

Coagulation:

International Normalized Ratio (INR)
or Prothrombin Time (PT)

Activated Partial Thromboplastin Time

(aPTT) ≤ 1.5 × ULN (unless on prophylactic or therapeutic dosing with low molecular weight heparin)
Cockcroft-Gault formula will be used to calculate creatinine clearance (see study procedure manual SPM)
In subjects with Gilbert's syndrome, if total bilirubin is >1.5 × ULN, measure direct and indirect bilirubin; if direct bilirubin is ≤1.5 × ULN, subject may be eligible
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 comply with study procedures for the entire length of the study as determined by the site investigator or protocol designee
Medications known to lower the seizure threshold (see list under prohibited meds) must be discontinued or substituted at least 4 weeks prior to study entry (Section 5.5)
Use of CYP3A4 inhibitors or inducers and CYP2D6 substrates must be discontinued prior to study entry
Able to swallow pills

Exclusion Criteria:

Use of post-prostatectomy ADT for > 30 continuous days prior to registration (ADT defined as use of GnRH agonist, with or without an anti-androgen). However, patients with testosterone recovery after post-prostatectomy ADT are eligible (testosterone recovery defined as total testosterone > 190 ng/dL) regardless of how long they have been on ADT.
Prior pelvic radiation unless additional radiation can be safely delivered according to the treating physician
PSA > 15 ng/mL in screening

History of any of the following:

Seizure or known condition that may predispose to seizure (e.g., prior stroke within 1 year of randomization, brain arteriovenous malformation, Schwannoma, meningioma, or other benign CNS or meningeal disease which may require treatment with surgery or radiation therapy)
Severe or unstable angina, myocardial infarction, symptomatic congestive heart failure, 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 randomization

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 dose of corticosteroid higher than 10 mg prednisone/prednisolone once daily
Any condition that, in the opinion of the site investigator, would preclude participation in this study
Moderate or severe hepatic impairment (Child Pugh Class B or C)
History of allergic reactions attributed to compounds of similar chemical or biologic composition to study drugs
Uncontrolled intercurrent illness including, but not limited to, ongoing or active infection, psychiatric illness or social situations that would limit compliance with study requirements

Individuals with a history of another malignancy are not eligible if:

the cancer is under active treatment or
the cancer can be seen on radiology scans or
if they are off cancer treatment but in the opinion of their oncologist have a high risk of relapse within 5 years
Confirmed bone metastases on imaging