Sequential Testosterone and Enzalutamide Prevents Unfavorable Progression

NCT ID: NCT04363164

Last Updated: 2025-07-14

Basic Information

• Recruitment Status: RECRUITING
• Clinical Phase: PHASE2
• Total Enrollment: 150 participants
• Study Classification: INTERVENTIONAL
• Study Start Date: 2020-08-19
• Study Completion Date: 2027-07-31

Brief Summary

Asymptomatic men without pain due to prostate cancer progressing with metastatic CRPC after treatment with combination or sequential ADT + Abi will be treated on a randomized, open label study to determine if sequential treatment with high dose T and Enza will improve primary and secondary objectives vs. continuous Enza as standard therapy.

Detailed Description

Eligible patients are those who have progressive disease after treatment with Abi either in combination with ADT as initial therapy or as second-line therapy after development of resistance to primary ADT. Patients will continue on ADT with LHRH agonist (i.e. Zoladex, Trelstar, Eligard or Lupron) or LHRH antagonist (Degarelix) if not surgically castrated throughout the duration of the study to inhibit endogenous testosterone production. Patients will be randomized 1:2:2 and stratified based on whether they received Abi in combination with ADT or in sequence after progression on ADT and based on duration of response to Abi (<6 or ≥ 6 months).

Patients randomized to Arm A will receive continuous therapy with standard dose Enza (160 mg po q day).

Patients randomized to Arm B will receive Sequential Testosterone and Enzalutamide (STE). Patients in Arm B will receive intramuscular injection with testosterone cypionate (T) at a dose of 400 mg every 28 days x 2 (i.e. cycle 1). This dose was selected based on data demonstrating that it produces an initial high dose serum level of T (i.e. > 1500 ng/dL or 3-10 times normal level) with eugonadal levels achieved at the end of two weeks and near castrate levels after 28 days. On Day 1 of cycle 2, patients will stop testosterone and begin enzalutamide 160 mg po q day for 56 days. Each cycle is 56 days. On Day 1 of cycle 3, patient will not take enzalutamide and will again receive injection of testosterone. Patients will continue to alternate one cycle of testosterone (2 injections) with one cycle of 56 days of enzalutamide.

Patients randomized to Arm C will receive Variable Sequential Testosterone and Enzalutamide (VSTE). Patients in Arm C will receive intramuscular injection with testosterone cypionate (T) at an FDA-approved dose of 400 mg every 28 days x 2 injections per cycle. Patients will remain on high dose T for at least one cycle. Each cycle is 56 days. Patients with PSA progression (≥25% increase in PSA from baseline PSA on BAT cycle) will stop T injection and begin Enzalutamide. Patients on T with initial with declining PSA decline PSA will remain on high dose T for additional cycles of 2 injections until PSA progression occurs (≥25% increase in PSA from PSA nadir on current BAT cycle)based on PCWG3 criteria. Patients with PSA progression (≥25% increase in PSA from baseline) will stop T injection. These patients will then be started on Enzalutamide. Patients with PSA progression (≥25% increase in PSA from baseline on enzalutamide cycle) will stop Enzalutamide and will restart injections of T with 2 injections/cycle. Patients on enzalutamide with initial PSA decline after one 56- day cycle will continue on Enzalutamide until PSA progression occurs (≥25% increase in PSA from PSA nadir on current Enzalutamide cycle). . Patients with PSA progression (≥25% increase in PSA from baseline) will stop Enzalutamide and will restart injections of T with 2 injections/cycle. These cycles of switching between T and Enza with onset of PSA progression will continue until clinical and/or radiographic progression occurs.

Patients will have prostate-specific antigen (PSA) level and symptoms assessment checked every cycle. Every 2 cycles (~4 months) patients will have repeat bone/CT scans to evaluate treatment response status. On CT scan, radiographic progression will be defined by RECIST criteria (i.e. >20% increase in the sum of target lesions). On bone scan, radiographic progression will be defined by PCWG3 criteria as ≥ 2 new bone lesions.

Patients with PSA progression but with disease response or stable disease on imaging studies will remain on study until clinical or radiographic progression criteria are met. Patients with radiographic disease progression will stop treatment and come off study. Patients with clinical progression due to pain flare after first two injection of testosterone can remain on study. If pain persists after first cycle of enzalutamide, patients will stop treatment and come off study. If pain resolves on enzalutamide, but returns with next or subsequent cycles of testosterone, patients will stop treatment and come off study.

Conditions

Castration Resistant Metastatic Prostate Cancer

Study Design

• Allocation Method: RANDOMIZED
• Intervention Model: PARALLEL
• Primary Study Purpose: TREATMENT
• Blinding Strategy: NONE

Study Groups

Arm A: Enzalutamide

Patients randomized to Arm A will receive continuous therapy with standard dose Enzalutamide (160 mg oral daily).

Group Type: EXPERIMENTAL

Enzalutamide

Intervention Type: DRUG

Enzalutamide is a white crystalline non-hygroscopic solid. It is practically insoluble in water. Enzalutamide is provided as liquid-filled soft gelatin capsules for oral administration. Each capsule contains 40 mg of enzalutamide as a solution in caprylocaproyl polyoxylglycerides. The inactive ingredients are caprylocaproyl polyoxylglycerides, butylated hydroxyanisole, butylated hydroxytoluene, gelatin, sorbitol sorbitan solution, glycerin, purified water, titanium dioxide, and black iron oxide.

Arm B: Sequential Testosterone and Enzalutamide

Patients in Arm B will receive intramuscular injection with testosterone cypionate (T) at a dose of 400 mg every 28 days x 2 (i.e. cycle 1). On Day 1 of cycle 2, patients will stop testosterone and begin enzalutamide 160 mg po q day for 56 days. Each cycle is 56 days. On Day 1 of cycle 3, patient will not take enzalutamide and will again receive injection of testosterone. Patients will continue to alternate one cycle of testosterone (2 injections) with one cycle of 56 days of enzalutamide.

Group Type: EXPERIMENTAL

Testosterone cypionate

Intervention Type: DRUG

Depo-Testosterone Injection, for intramuscular injection, contains testosterone cypionate which is the oil-soluble of the androgenic hormone testosterone. Testosterone cypionate is a white or creamy white crystalline powder, odorless or nearly so and stable in air. Depo-Testosterone Injection is available in two strengths, 100 mg/mL and 200 mg/mL testosterone cypionate.

Enzalutamide

Intervention Type: DRUG

Enzalutamide is a white crystalline non-hygroscopic solid. It is practically insoluble in water. Enzalutamide is provided as liquid-filled soft gelatin capsules for oral administration. Each capsule contains 40 mg of enzalutamide as a solution in caprylocaproyl polyoxylglycerides. The inactive ingredients are caprylocaproyl polyoxylglycerides, butylated hydroxyanisole, butylated hydroxytoluene, gelatin, sorbitol sorbitan solution, glycerin, purified water, titanium dioxide, and black iron oxide.

Testosterone enanthate

Intervention Type: DRUG

Testosterone Enanthate Injection, for intramuscular injection, contains testosterone enanthate which is the oil-soluble ester of the androgenic hormone testosterone. Enanthate Injection is available as a colorless to pale yellow solution. Each mL contains 200 mg testosterone enanthate in sesame oil with 5 mg chlorobutanol as a preservative.

Arm C: Variable Sequential Testosterone and Enzalutamide

Patients in Arm C will receive intramuscular injection with testosterone cypionate (T) at a dose of 400 mg every 28 days x 2 injections per cycle. Each cycle is 56 days. Patients with PSA progression will stop T injection and begin Enzalutamide. Patients on T with initial PSA decline will remain on high dose T for additional cycles of 2 injections until PSA progression occurs (≥25% increase in PSA from PSA nadir on current BAT cycle). These patients will then be started on Enzalutamide. Patients with PSA progression will stop Enzalutamide and will restart injections of T with 2 injections/cycle. Patients on enzalutamide with initial PSA decline after one 56-day cycle will continue on Enzalutamide until PSA progression occurs (≥25% increase in PSA from PSA nadir on current Enzalutamide cycle). These cycles of switching between T and Enza with onset of PSA progression will continue until clinical and/or radiographic progression occurs.

Group Type: EXPERIMENTAL

Testosterone cypionate

Intervention Type: DRUG

Depo-Testosterone Injection, for intramuscular injection, contains testosterone cypionate which is the oil-soluble of the androgenic hormone testosterone. Testosterone cypionate is a white or creamy white crystalline powder, odorless or nearly so and stable in air. Depo-Testosterone Injection is available in two strengths, 100 mg/mL and 200 mg/mL testosterone cypionate.

Enzalutamide

Intervention Type: DRUG

Enzalutamide is a white crystalline non-hygroscopic solid. It is practically insoluble in water. Enzalutamide is provided as liquid-filled soft gelatin capsules for oral administration. Each capsule contains 40 mg of enzalutamide as a solution in caprylocaproyl polyoxylglycerides. The inactive ingredients are caprylocaproyl polyoxylglycerides, butylated hydroxyanisole, butylated hydroxytoluene, gelatin, sorbitol sorbitan solution, glycerin, purified water, titanium dioxide, and black iron oxide.

Testosterone enanthate

Intervention Type: DRUG

Testosterone Enanthate Injection, for intramuscular injection, contains testosterone enanthate which is the oil-soluble ester of the androgenic hormone testosterone. Enanthate Injection is available as a colorless to pale yellow solution. Each mL contains 200 mg testosterone enanthate in sesame oil with 5 mg chlorobutanol as a preservative.

Interventions

Testosterone cypionate

Depo-Testosterone Injection, for intramuscular injection, contains testosterone cypionate which is the oil-soluble of the androgenic hormone testosterone. Testosterone cypionate is a white or creamy white crystalline powder, odorless or nearly so and stable in air. Depo-Testosterone Injection is available in two strengths, 100 mg/mL and 200 mg/mL testosterone cypionate.

Intervention Type: DRUG

Enzalutamide

Enzalutamide is a white crystalline non-hygroscopic solid. It is practically insoluble in water. Enzalutamide is provided as liquid-filled soft gelatin capsules for oral administration. Each capsule contains 40 mg of enzalutamide as a solution in caprylocaproyl polyoxylglycerides. The inactive ingredients are caprylocaproyl polyoxylglycerides, butylated hydroxyanisole, butylated hydroxytoluene, gelatin, sorbitol sorbitan solution, glycerin, purified water, titanium dioxide, and black iron oxide.

Intervention Type: DRUG

Testosterone enanthate

Testosterone Enanthate Injection, for intramuscular injection, contains testosterone enanthate which is the oil-soluble ester of the androgenic hormone testosterone. Enanthate Injection is available as a colorless to pale yellow solution. Each mL contains 200 mg testosterone enanthate in sesame oil with 5 mg chlorobutanol as a preservative.

Intervention Type: DRUG

Other Intervention Names

Depo-Testosterone Injection; Delatestryl

Eligibility Criteria

Inclusion Criteria

1. ECOG Performance status ≤2.

2. Age ≥18 years.

3. Histologically-confirmed adenocarcinoma of the prostate.

4. Treated with continuous androgen ablative therapy (either surgical castration or LHRH agonist/antagonist).

5. Documented castrate level of serum testosterone (<50 ng/dl).

6. Metastatic disease radiographically documented by CT or bone scan.

7. Must have had disease progression while on combination of abiraterone acetate plus ADT either given concurrently or sequentially based on:

• PSA progression defined as an increase in PSA, as determined by 2 separate measurements taken at least 1 week apart And/ Or
• Radiographic disease progression, based on RECIST 1.1 in patients with measurable soft tissue lesions or PCWG3 for patients with bone disease

8. Screening PSA must be ≥ 1.0 ng/mL.

9. Patients with soft tissue lesion amenable to biopsy must agree to biopsy collection pre-treatment and at a defined point on treatment to perform tumor tissue analysis.

10. No prior treatment with enzalutamide, apalutamide, darolutamide, or other investigational AR targeted treatment is allowed.

11. Prior treatment with testosterone is allowed.

12. Prior treatment with one chemotherapy regimen with docetaxel (≤ 6 doses) for hormonesensitive prostate cancer is allowed.

13. Prior treatment with Provenge vaccine and 223Radium (Xofigo) is allowed if >4 weeks from last dose.

14. Patients must be withdrawn from abiraterone for ≥ 2 weeks.

15. Attempts must be made to wean patients off prednisone prior to starting therapy. Patients who cannot be weaned due to symptoms may continue on lowest dose of prednisone achieved during weaning period.

16. Acceptable liver function:

1. Bilirubin < 2.5 times institutional upper limit of normal (ULN)

2. AST (SGOT) and ALT (SGPT) < 2.5 times ULN

17. Acceptable renal function:

a. Serum creatinine < 2.5 times ULN

18. Acceptable hematologic status:

1. Absolute neutrophil count (ANC) ≥ 1500 cells/mm3 (1.5 ×109/L)

2. Platelet count ≥ 100,000 platelet/mm3 (100 ×109/L)

3. Hemoglobin ≥ 8 g/dL.

19. At least 4 weeks since prior radiation or chemotherapy.

20. Ability to understand and willingness to sign a written informed consent document.

Exclusion Criteria

1. Pain due to metastatic prostate cancer requiring treatment intervention with pain medication.

2. ECOG Performance status ≥3

3. Prior treatment with enzalutamide is prohibited.

4. Prior chemotherapy with docetaxel or cabazitaxel for castration resistant prostate cancer is prohibited.

5. Requires urinary self-catheterization for voiding due to obstruction secondary to prostatic enlargement well documented to be due to prostate cancer or benign prostatic hyperplasia (BPH). Patients with indwelling Foley or suprapubic catheter for obstructive symptoms are eligible.

6. Evidence of disease in sites or extent that, in the opinion of the investigator, would put the patient at risk from therapy with testosterone (e.g. femoral metastases with concern over fracture risk, severe and extensive spinal metastases with concern over spinal cord compression, extensive liver metastases).

7. Evidence of serious and/or unstable pre-existing medical, psychiatric or other condition (including laboratory abnormalities) that could interfere with patient safety or provision of informed consent to participate in this study.

8. Active uncontrolled infection, including known history of HIV/AIDS or hepatitis B or C.

9. Any condition or mental impairment that may compromise the ability to give informed consent, patient's safety or compliance with study requirements as determined by the investigator.

10. Patients receiving anticoagulation therapy with warfarin, rivaroxaban, or apixaban are not eligible for study. [Patients on enoxaparin eligible for study. Patients on warfarin, rivaroxaban,or apixaban, who can be transitioned to enoxaparin prior to starting study treatments will be eligible].

11. Patients are excluded with prior history of a thromboembolic event within the last 12 months that are not being treated with systemic anticoagulation.

12. Hematocrit >51%, untreated severe obstructive sleep apnea, uncontrolled or poorly controlled heart failure [per Endocrine Society Clinical Practice Guidelines (34)]

13. Patients allergic to sesame seed oil or cottonseed oil are excluded.

14. Major surgery (eg, requiring general anesthesia) within 3 weeks before screening, or has not fully recovered from prior surgery (ie, unhealed wound). Note: subjects with planned surgical procedures to be conducted under local anesthesia may participate.

• Minimum Eligible Age: 18 Years
• Maximum Eligible Age: 90 Years
• Eligible Sex: MALE
• Accepts Healthy Volunteers: No

Sponsors

United States Department of Defense

FED

Sponsor Role: collaborator

Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins

OTHER

Sponsor Role: lead

Responsible Party

Responsibility Role: SPONSOR

Principal Investigators

Samuel Denmeade, MD

Role: PRINCIPAL_INVESTIGATOR

SKCCC at Johns Hopkins

Locations

University of California, San Diego (UCSD)

San Diego, California, United States

Site Status: RECRUITING

Johns Hopkins University/Sidney Kimmel Cancer Center

Baltimore, Maryland, United States

Site Status: RECRUITING

Dana-Faber Cancer Institute

Boston, Massachusetts, United States

Site Status: RECRUITING

University of Minnesota

Minneapolis, Minnesota, United States

Site Status: RECRUITING

University of Nebraska Medical Center

Omaha, Nebraska, United States

Site Status: RECRUITING

University of Washington/Fred Hutchinson Cancer Center

Seattle, Washington, United States

Site Status: RECRUITING

Countries

United States

Central Contacts

GU oncology

Role: CONTACT

ProstateCancerClinicalTrials@live.johnshopkins.edu

4109551239

Harry Cao, MA

Role: CONTACT

hcao7@jhmi.edu

443-287-6882

Facility Contacts

Rana McKay, MD

Role: primary

rmckay@health.ucsd.edu

Samuel R. Denmeade

Role: primary

denmesa@jhmi.edu

410-955-8875

Jacob Berchuck, MD

Role: primary

jacob_berchuck@dfci.harvard.edu

919-452-4199

Emmanuel Antonarakis, MD

Role: primary

anton401@umn.edu

Benjamin Teply, MD

Role: primary

ben.teply@unmc.edu

Michael Schweizer, MD

Role: primary

schweize@uw.edu

Other Identifiers

IRB00312725

Identifier Type: OTHER

Identifier Source: secondary_id

J2060sIRB

Identifier Type: -

Identifier Source: org_study_id