Study of Sipuleucel-T W/ or W/O Radium-223 in Men With Asymptomatic or Minimally Symptomatic Bone-MCRPC

This is a randomized study designed to assess the antigen-specific immune response of
sipuleucel-T with or without radium-223. Eligible subjects will be registered and randomly
assigned in a 1:1 ratio to receive sipuleucel-T and radium-223 or sipuleucel-T alone.

Subjects in both arms (sipuleucel-T and radium) will undergo a standard 1.5 to 2.0 blood
volume leukapheresis, followed approximately 3 days later by an IV infusion of sipuleucel-T.
This process will occur a total of 3 times at approximately 2-week intervals. Subjects in Arm
1 will receive a total of 6 infusions of radium-223 at IV dose of 50 kBq/kg at 4-week
interval.

All participants are allowed to receive the best supportive care which includes secondary
hormonal manipulation as required. No chemotherapy, external-beam radiation, or other
radionuclides are allowed while on active treatment but are permitted after completion of
active treatment. Glucocorticoid-containing treatments should be minimized to less than the
equivalent dose of prednisone 10mg daily if feasible for the 3 months following sipuleucel-T
therapy. All patients continue medical or surgical castration during treatment.

Inclusion Criteria:

1. Written informed consent provided prior to initiation of study procedures

2. Age ≥ 18 years

3. Histologically documented adenocarcinoma prostate cancer confirmed by a pathology
report from prostate biopsy or a radical prostatectomy specimen. If prostatic tumor is
of mixed histology, > 50% of the tumor must be adenocarcinoma

4. Bone metastases as manifested by one or more lesions on a bone scan performed within 2
months of screening

5. Castrate-resistant prostate cancer, in the setting of castrate levels of testosterone
(≤ 50 ng/dL), defined as current or historical evidence of disease progression
concomitant with surgical castration or androgen deprivation therapy (ADT), as
demonstrated by two consecutive rises in PSA OR new lesions on bone scan:

- PSA progression will be defined as 2 rising PSA values compared to a reference
value, measured at least 7 days apart and the second value is ≥ 2 ng/mL [1]. It
must be documented within 2 months of screening.

- Appearance of one or more new areas of abnormal uptake on bone scan when compared
to imaging studies acquired during castration therapy or against the
precastration studies if there was no response. Increased uptake of pre-existing
lesions on bone scan does not constitute progression. It must be documented
within 4 months of screening

6. Serum PSA ≥ 2.0 ng/mL

7. Screening ECOG perf status ≤ 1

8. Asymptomatic or minimally symptomatic disease (no narcotic analgesic; other analgesics
use is allowed)

9. Prior abiraterone and enzalutamide are permitted, but not required

10. Concurrent osteoclast-inhibitory therapies (zoledronic acid, denosumab) are permitted
if patients have been on a stable dose for at least 1 month

11. Adequate screening hematologic, renal, and liver function as evidenced by laboratory
test results within the following ranges ≤ 28 days prior to registration:

- Absolute neutrophil count (ANC) ≥ 1.5 x109/L

- Platelet count ≥ 100 x109/L

- Hemoglobin ≥ 10.0 g/dL

- Total bilirubin level ≤ 1.5 x institutional upper limit of normal (ULN)

- Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) ≤ 2.5 x ULN

- Creatinine ≤ 1.5 x ULN

- Albumin > 25 g/L

Exclusion Criteria:

1. The presence of known lung or liver metastases greater than 1.0 cm in the long axis
diameter

2. The presence of lymphadenopathy greater than 3 cm in the short-axis diameter

3. The presence of known brain metastases

4. Spinal cord compression, imminent long bone fracture, or any other condition that, in
the opinion of the investigator, is likely to require radiation therapy and/or
steroids for pain control during the active phase

5. Previous treatment with chemotherapy for mCRPC (adjuvant chemotherapy is permitted),
or chemotherapy for any reason within 2 years prior to registration

6. Intention to receive chemotherapy within 6 months after enrollment in protocol therapy

7. History of radiation therapy, either via external beam or brachytherapy within 28 days
prior to registration

8. Systemic radiotherapy with strontium-89, samarium-153, rhenium-186 or rhenium-188 for
the treatment of bony metastases within previous 24 weeks

9. Prior history of other cancers (except non-melanoma skin cancers or low-grade
low-stage urothelial cancers)

10. Use of prednisone or equivalent systemic corticosteroid within 2 weeks of treatment.
Use of inhaled, intranasal, intra-articular, and topical steroids is allowed. Oral or
IV steroids to prevent or treat IV contrast reactions are allowed

11. Use of opioid analgesics for cancer-related pain

12. Use of experimental drug within 4 weeks of treatment

13. Uncontrolled medical conditions including diabetes, heart failure, COPD, ulcerative
colitis, or Crohn's disease

14. Uncontrolled fecal incontinence

15. Any medical intervention, any other condition, or any other circumstance which, in the
opinion of the investigator, could compromise adherence with study requirements or
otherwise compromise the study's objectives