Neoadjuvant And Adjuvant Abiraterone Acetate + Apalutamide Prostate Cancer Undergoing Prostatectomy

This research study is a Phase II clinical trial. Phase II clinical trials test the safety
and effectiveness of an investigational intervention to learn whether the intervention works
in treating a specific disease. "Investigational" means that the intervention is being
studied.

The FDA (the U.S. Food and Drug Administration) has approved Abiraterone acetate with
prednisone as a treatment option for prostate cancer that has spread to other parts of the
body (metastatic castration-resistant prostate cancer).However, in this study it is being
investigated for the treatment of localized prostate cancer prior to surgical removal of the
prostate (prostatectomy).

Abiraterone acetate works by decreasing the production of androgens (male sex hormones),
which promote prostate cancer growth. Some steroids produced by the adrenal glands can turn
into testosterone, and prostate cancer cells feed on testosterone. Testosterone is suppressed
by an FDA approved drug called leuprolide or Lupron.

The FDA has not approved Apalutamide as a treatment for any disease. In this study,
Apalutamide is being investigated for the treatment of prostate cancer. Apalutamide also
works by blocking the effects of male sex hormones.

In this research study, the investigators are studying the effectiveness of one combination
of drugs (abiraterone acetate + prednisone + leuprolide) compared to another combination of
drugs (abiraterone acetate + prednisone + leuprolide + Apalutamide) before surgery to see if
this will improve surgical outcomes and reduce or eliminate Prostate Cancer.

Inclusion Criteria:

1. Male ≥ 18 years of age.

2. Histologically confirmed adenocarcinoma of the prostate without histological variants
comprising >50% of the sample as determined by academic center central review
(including neuroendocrine differentiation, small cell, sarcomatoid, ductal
adenocarcinoma, squamous or transitional cell carcinoma).

3. Must have 3 core biopsies involved with cancer (a minimum of 6 core biopsies must be
obtained). Prostate biopsy must be within seven months from screening. Less than 3
core biopsies are allowed if the patient has >1 cm or T3 disease on MRI.

4. Patients must have the following features:

- Gleason ≥ 4+3=7 OR

- Gleason 3+4=7 AND at least one of the following: PSA >20 ng/dL or T3 disease (as
determined by MRI).

5. No evidence of metastatic disease as determined by radionuclide bone scans and CT/MRI.
Lymph nodes must be less than 20 mm in the short (transverse) axis.

6. Participants must be candidates for RP and considered surgically resectable by
urologic evaluation.

7. Eastern Cooperative Oncology Group (ECOG) performance status of 0 to 1.

8. Participants must have normal organ and marrow function as defined below:

- Hemoglobin ≥ 9.0 g/dL

- Absolute neutrophil count (ANC) ≥ 1,500/mcL

- Platelets ≥ 100,000/mcL, independent of transfusions/growth factors within 3
months of treatment start

- Serum potassium ≥ 3.5 mmol/L

- Serum total bilirubin ≤ 2.0 x upper limit of normal (ULN) (except in subjects
with Gilbert's syndrome who have a total bilirubin > 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), alanine aminotransferase (ALT) ≤ 2.5 x ULN

- Serum albumin ≥ 3.0 g/dL

- Serum creatinine < 2.0 x ULN

- PTT≤60

9. Participant must agree to use a condom (even men with vasectomies) and another
effective method of birth control if having sex with a woman of childbearing potential
or must agree 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. Participant must
also agree not to donate sperm during the study and for 3 months after receiving the
last dose of study drug.

10. Medications known to lower the seizure threshold (see list under APPENDIX D:
Representative Medications that May Predispose to Seizure) must be discontinued or
substituted at least 1 week prior to study treatment.

Exclusion Criteria:

1. Prior hormone therapy for prostate cancer including orchiectomy, antiandrogens
(including first-generation antiandrogens, enzalutamide, Apalutamide and others),
CYP17 inhibitors (including abiraterone acetate, TAK-700, galeterone, ketoconazole,
and others), estrogens, Luteinizing Hormone Releasing Hormone (LHRH)
agonist/antagonists. Prior therapy with 5α-reductase inhibitors is allowed. LHRH
therapy allowed if begun within 4 weeks of day 1.

2. Prior chemotherapy, radiation therapy, or immunotherapy for prostate cancer.

3. Prior systemic treatment with an azole drug within two weeks of start of treatment.

4. Hypogonadism or severe androgen deficiency as defined by screening serum testosterone
< 200 ng/dL.

5. Clinically significant cardiovascular disease within 6 months of study treatment
including:

- Severe or unstable angina;

- Myocardial infarction;

- Symptomatic congestive heart failure;

- New York Heart Association (NYHA) class II-IV heart disease;

- Arterial or venous thromboembolic events (such as pulmonary embolism
cerebrovascular accident including transient ischemic attacks);

- 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
screening EKG > 470 msec;

- History of Mobitz II second degree or third degree heart block without a
permanent pacemaker in place;

- Uncontrolled hypertension (systolic blood pressure ≥ 140 mmHg or diastolic blood
pressure ≥ 90 mmHg). Participants with a history of hypertension are allowed
provided blood pressure is controlled by anti-hypertensive therapy.

6. History of seizure or any condition or concurrent medication that may predispose to
seizure (including but not limited to prior stroke, transient ischemic attack, loss of
consciousness within 1 year prior to randomization, brain arteriovenous malformation;
or intracranial masses such as schwannomas and meningiomas that are causing edema or
mass effect).

7. History of allergic reactions attributed to compounds of similar chemical or biologic
composition to Apalutamide, abiraterone acetate, or other study drugs.

8. Severe hepatic impairment (Child-Pugh Class C).

9. Active infection (such as human immunodeficiency virus (HIV) or viral hepatitis) or
other medical condition that would make prednisone / prednisolone corticosteroid use
contraindicated.

10. History of pituitary or adrenal dysfunction.

11. Gastrointestinal disorders (medical disorders or extensive surgery) which may
interfere with the absorption of the study drug.

12. Pre-existing condition that warrants long-term corticosteroid use greater than the
equivalent of 10 mg prednisone daily. Physiologic replacement is permitted. Topical,
intra-articular, or inhaled corticosteroids are permitted.

13. Concomitant use of medications that may alter pharmacokinetics of abiraterone acetate
or Apalutamide.

14. Individuals with a history of a different malignancy are ineligible except for the
following circumstances: 1) individuals with a history of other malignancies are
eligible if they have been disease-free for at least 5 years and are deemed by the
investigator to be at low risk for recurrence of that malignancy, or 2) individuals
with the following cancers are eligible if diagnosed and treated within the past 5
years: non-muscle invasive bladder cancer, basal cell or squamous cell carcinoma of
the skin.

15. Major surgery or radiation therapy within 30 days of screening visit. Participants who
have had a major surgery within 30 days of screening visit may be eligible provided
the treating investigator deems that the participant is at low risk for complications.

16. Any condition that in the opinion of the investigator would preclude participation in
this study.