Summary

This phase III trial compare the effects of adding definitive treatment (either radiation therapy or prostate removal surgery) to standard systemic therapy in treating patients with prostate cancer that has spread to other places in the body (advanced). Removing the prostate by either surgery or radiation therapy in addition to standard systemic therapy for prostate cancer may lower the chance of the cancer growing or spreading.

Objectives

PRIMARY OBJECTIVE:
I. To compare overall survival in metastatic prostate cancer participants who are randomized to standard systemic therapy (SST) plus definitive treatment of the primary tumor versus standard systemic therapy alone.

SECONDARY OBJECTIVES:
I. To compare the rate of symptomatic local progression between the treatment arms.
II. To compare progression-free survival (PFS) between the two treatment arms.
III. To compare rates of progression-free survival between arms for the subsets of participants with and without metastasis directed therapy (MDT) to oligometastatic sites.

QUALITY OF LIFE OBJECTIVE:
I. To compare between arms patient-reported urinary function and urinary bother over time (after initiation of SST at 6 months, 1, 2, and 3 years) using the Expanded Prostate Cancer Index Composite (EPIC) and patient-reported pain and physical functioning using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) between participants receiving standard systemic therapy and those receiving systemic therapy and definitive management of the primary prostate cancer.

OTHER OBJECTIVE:
I. To bank tissue and whole blood specimens for future use.

OUTLINE:

INDUCTION: Participants receive 1 of 6 acceptable forms of SST for 22-28 weeks.
I. Participants undergo a bilateral orchiectomy.
II. Participants receive goserelin acetate subcutaneously (SC) every 28 days or 12 weeks, histrelin acetate SC every 12 months, leuprolide acetate SC or intramuscularly (IM) every 1, 3, 4, or 6 months, and triptorelin every 1, 3, or 6 months.
III. Participants receive goserelin acetate SC every 28 days or 12 weeks, histrelin acetate SC every 12 months, leuprolide acetate SC or IM every 1, 3, 4, or 6 months, and triptorelin every 1, 3, or 6 months. Participants also receive nilutamide orally (PO) daily, flutamide PO every 8 hours, and bicalutamide PO daily.
IV. Participants receive degarelix via injection for 2 doses and then every 28 days.
V. Participants receive nilutamide PO daily, flutamide PO every 8 hours, and bicalutamide PO daily. Participants also receive docetaxel over 1 hour every 3 weeks with or without prednisone PO every 12 hours.
VI. Participants receive nilutamide PO daily, flutamide PO every 8 hours, and bicalutamide PO daily. Participants also receive abiraterone PO daily or prednisone PO every 12 hours.

After completion of 22-28 weeks of SST, participants are then randomized to 1 of 2 arms.

ARM I: Participants receive 1 acceptable form of SST as in Induction except for treatment with docetaxel and prednisone.

ARM II: Participants receive 1 acceptable form of SST as in Induction except for treatment with docetaxel and prednisone. Participants undergo prostatectomy within 8 weeks after randomization or radiation therapy within 4 weeks of randomization.

After completion of study treatment, participants are followed up for 8 years.

Eligibility

1. STEP 1 REGISTRATION: DISEASE-RELATED CRITERIA: All participants must have a histologically or cytologically proven diagnosis of adenocarcinoma of the prostate. Participants with pure small cell carcinoma* (SCC), sarcomatoid, or squamous cell carcinoma are not eligible. (*morphology must be consistent with SCC; synaptophysin or chromogranin positive by immunohistochemical staining is insufficient to diagnose SCC).
2. STEP 1 REGISTRATION: DISEASE-RELATED CRITERIA: Participants must have an intact prostate.
3. STEP 1 REGISTRATION: DISEASE-RELATED CRITERIA: Participants must have at least one of the following scans performed, showing evidence of metastatic disease: * Technetium bone scan OR * Computed tomography (CT) of abdomen & pelvis OR * Magnetic resonance imaging (MRI) of pelvis. The scan showing metastases must be performed in the range of 42 days before or 14 days following the start of SST. The start date of SST is considered the date of first hormonal therapy. (LHRH agonist or LHRH antagonist) or surgical castration. Metastatic disease that is detected by positron emission tomography (PET) scan only (sodium fluoride [NaF], prostate-specific membrane antigen [PSMA], FACBC, C11) but not conventional imaging (Tc99 bone scan, computed tomography [CT] or magnetic resonance imaging [MRI]) or solitary metastases by conventional imaging, must be confirmed histologically or cytologically unless the CT portion of the PET scan shows evidence clearly positive for metastatic disease and is also not a solitary lesion.
4. STEP 1 REGISTRATION: DISEASE-RELATED CRITERIA: Participants with known brain metastases are not eligible. Brain imaging studies are not required for eligibility if the participants has no neurologic signs or symptoms suggestive of brain metastasis. If brain imaging studies are performed, they must be negative for disease.
5. STEP 1 REGISTRATION: PRIOR/CONCURRENT THERAPY CRITERIA: Participants must have received no more than 28 weeks of SST, as measured from the date of first hormonal therapy (luteinizing hormone-releasing hormone [LHRH] agonist or LHRH antagonist) or surgical castration. SST is defined as current National Comprehensive Cancer Network (NCCN) guidelines for metastatic prostate cancer.
6. STEP 1 REGISTRATION: PRIOR/CONCURRENT THERAPY CRITERIA: No prior local therapy for prostate adenocarcinoma is allowed (e.g., brachytherapy, high-intensity focused ultrasound ablation [HIFU], cryotherapy, laser ablative therapies). Any prior therapy for benign conditions, such as obstruction, are acceptable (e.g., transurethral resection of the prostate, greenlight laser ablation, microwave ablation).
7. STEP 1 REGISTRATION: PRIOR/CONCURRENT THERAPY CRITERIA: Participants must not have received any prior systemic therapy for prostate cancer, outside of line of SST to be used for duration of study.
8. STEP 1 REGISTRATION: PRIOR/CONCURRENT THERAPY CRITERIA: Participants must not have progressed while on SST.
9. STEP 1 REGISTRATION: PRIOR/CONCURRENT THERAPY CRITERIA: Participants with oligometastatic prostate cancer may receive metastasis directed therapy to up to four sites of disease prior to randomization.
10. STEP 1 REGISTRATION: CLINICAL/LABORATORY CRITERIA: Participants must be >= 18 years of age.
11. STEP 1 REGISTRATION: CLINICAL/LABORATORY CRITERIA: Participants must have a complete physical examination and medical history within 28 days prior to registration.
12. STEP 1 REGISTRATION: CLINICAL/LABORATORY CRITERIA: Participants must have a documented prostate specific antigen (PSA): * Prior to initiation of SST * Within 52 days prior to registration * Any additional PSAs measured while receiving SST should be recorded.
13. STEP 1 REGISTRATION: CLINICAL/LABORATORY CRITERIA: No other prior malignancy is allowed except for the following: adequately treated basal cell or squamous cell skin cancer, adequately treated stage 0, I or II cancer from which the participant is currently in complete remission, or any other cancer from which the participant has been disease free for three years.
14. STEP 1 REGISTRATION: SPECIMEN SUBMISSION CRITERIA: Participants must be offered the opportunity to participate in translational medicine studies and specimen banking for future studies.
15. STEP 1 REGISTRATION: QUALITY OF LIFE CRITERIA: Participants who can complete Patient-Reported Outcome instruments in English, Spanish or French, must participate in the quality of life studies.
16. STEP 1 REGISTRATION: REGULATORY CRITERIA: Participants must be informed of the investigational nature of this study and must sign and give written informed consent in accordance with institutional and federal guidelines.
17. STEP 1 REGISTRATION: REGULATORY CRITERIA: As a part of the OPEN registration process the treating institution's identity is provided in order to ensure that the current (within 365 days) date of institutional review board approval for this study has been entered in the system.
18. STEP 2 RANDOMIZATION: DISEASE-RELATED CRITERIA: Participants must have no evidence of disease progression during the 28 weeks of SST by: * PSA measure * Imaging (bone scan and one of the following: CT of abdomen & pelvis, MRI of abdomen & pelvis, CT of abdomen & MRI of pelvis) within 42 days prior to randomization.
19. STEP 2 RANDOMIZATION: DISEASE-RELATED CRITERIA: Participants must have no evidence of symptomatic deterioration (as defined by physician discretion) within 28 days prior to randomization.
20. STEP 2 RANDOMIZATION: DISEASE-RELATED CRITERIA: Participants case must have been reviewed with a urologist and have surgically resectable disease regardless of definitive treatment intent or randomization.
21. STEP 2 RANDOMIZATION: PRIOR/CONCURRENT THERAPY CRITERIA: Participants must have received between 22 and no more than 28 weeks of SST, as measured from the date of first hormonal therapy (LHRH agonist or LHRH antagonist) or surgical castration. SST is defined by current NCCN guidelines for metastatic prostate cancer.
22. STEP 2 RANDOMIZATION: PRIOR/CONCURRENT THERAPY CRITERIA: Participants must not be planning to receive docetaxel after randomization.
23. STEP 2 RANDOMIZATION: PRIOR/CONCURRENT THERAPY CRITERIA: All SST-related toxicities must have resolved to =< grade 1 (Common Terminology Criteria for Adverse Events [CTCAE] version 5.0) except for fatigue, weight gain, and hot flashes, prior to randomization.
24. STEP 2 RANDOMIZATION: PRIOR/CONCURRENT THERAPY CRITERIA: Participants may have received elective metastasis directed therapy to oligometastatic sites (=< 4 sites). All treatment must be completed prior to randomization.
25. STEP 2 RANDOMIZATION: CLINICAL/LABORATORY CRITERIA: Participants must have a PSA performed within 28 days prior to randomization.
26. STEP 2 RANDOMIZATION: CLINICAL/LABORATORY CRITERIA: Participants must have a Zubrod performance status of 0 – 1 within 28 days prior to randomization.

Treatment Sites in Georgia