Conventional ADT w/ or w/Out Abiraterone Acetate + Prednisone and Apalutamide Following a Detectable PSA After Radiation and ADT

This research study is a Phase III clinical trial. Phase III clinical trials test the
effectiveness of an investigational intervention to learn whether the intervention works in
treating a specific disease. "Investigational" means that an intervention is being studied.
In this study, the investigational agents are apalutamide and abiraterone acetate.
Abiraterone acetate (used in combination with prednisone) is an FDA (the U.S. Food and Drug
Administration) approved drug for prostate cancer, but is approved in patients that have
prostate cancer spread to other parts of their body and have been previously treated with
ADT. Apalutamide has also been approved by the FDA for men whose cancer does not respond to
hormone therapy but it is still investigational for this type of cancer.

In this research study, the investigators are looking at two methods of androgen deprivation
therapy (ADT), also known as hormonal therapy, to determine which method is better for
improving long term cure rates. ADT blocks the function of hormones, including testosterone
which prostate cancer uses to grow and spread. The first method of ADT includes prednisone,
apalutamide, and abiraterone acetate plus standard ADT and the second method of ADT is
standard ADT alone for men with this type of prostate cancer. Currently, the best standard
treatment for men with this type of prostate cancer includes standard ADT. All participants
in this study will receive the main standard form of ADT called a luteinizing
hormone-releasing hormone agonist or antagonist (LHRHA).

Inclusion Criteria:

- Histologically confirmed prostate cancer

- PSA> 0.1 after radiation and at least 6, but not more than 8 months of conventional
ADT (LHRH agonist or antagonist with or without oral anti-androgens, excluding
abiraterone acetate and apalutamide) in patients with non-metastatic high risk or N1
prostate cancer

- High risk is defined per the NCCN guidelines - clinical or radiographic T3a,
Gleason 8-10, or PSA > 20 ng/mL, and can be N0 or N1

- A month is defined as 28 days

- 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.

- Age ≥18 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)1 ≥ 100,000/ µL

- Hemoglobin (Hgb)1 ≥ 9 g/dL

- Absolute neutrophil count (ANC) ≥ 1000 cells/µL

- Renal:

--CrCl2 ≥ 45 mL/min

- Hepatic and Other:

- Bilirubin3 ≤ 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)

- Independent of transfusion and/or growth factors within 3 months prior to
randomization

- Cockcroft-Gault formula will be used to calculate creatinine clearance

- 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 (section 5.4.4) must be discontinued
or substituted prior to C1D1 of study treatment for patients on Arm 2

- Able to swallow pills

Exclusion Criteria:

- Prior radical prostatectomy (excluding TURP)

- 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 (eg, pulmonary embolism,
cerebrovascular accident including transient ischemic attacks), or clinically
significant ventricular arrhythmias within 6 months prior to randomization

- Known current evidence of any of the following:

- 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

- Gastrointestinal disorder affecting absorption

- Known history of testing positive for human immunodeficiency virus (HIV) or known
acquired immunodeficiency syndrome.

- Known active or chronic hepatitis B infection (defined as having a positive
hepatitis B surface antigen (HBsAg) test at screening). Subject with past or
resolved hepatitis B infection (defined as having a negative HBsAg test and
positive antibody to hepatitis B core antigen test) are eligible. Hepatitis B
viral DNA must be obtained in subjects with positive hepatitis B core antibody
prior to first treatment start.

- Active hepatitis C infection. Subjects positive hepatitis C antibody test are
eligible if PCR is negative for hepatitis C viral DNA.

- 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 steroids or inhaled corticosteroids are permitted.

- Any condition that, in the opinion of the site investigator, would preclude
participation in this study

- Baseline moderate or severe hepatic impairment (ChildPugh Class B or C)

- Avoid concomitant strong CYP3A4 inducers during abiraterone acetate treatment (section
5.4.3). If a strong CYP3A4 inducer must be co-administered, increase the abiraterone
acetate dosing frequency.

- Avoid co-administration of abiraterone acetate with CYP2D6 substrates that have a
narrow therapeutic index. If an alternative treatment cannot be used, exercise caution
and consider a dose reduction of the concomitant CYP2D6 substrate

- 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.