Radium Ra 223 Dichloride, Hormone Therapy and Stereotactic Body Radiation Therapy in Treating Patients with Metastatic Prostate Cancer, SHARP Trial

Inclusion Criteria

• Documented informed consent of participant and/or legally authorized representative
• Agreement to provide archival primary or metastatic tumor tissue if available
• Age: >= 18 years
• Eastern Cooperative Oncology Group (ECOG) =< 2
• Life expectancy > 12 months
• Histologic diagnosis of prostate adenocarcinoma * Pure small cell carcinoma will be excluded; however, component of neuroendocrine /small cell differentiation will be allowed provided that adenocarcinoma constitutes majority of the tissue specimen
• Stage M1 * Metastatic disease can be documented by bone scan or computed tomography (CT) scan or MRI or PET/CT or the combination of these tests
• Up to 5 metastatic lesions: * Must have at least 1 bone lesion AND each non-visceral lesion should be less than 5 cm * Visceral lesions will be limited to one lung lesion (< 2 cm) or one lymph node; no liver lesions allowed; lymph nodes allowed provided they are not in a field of prior radiation, and if amenable to SBRT (to be reviewed by principal investigator [PI]); (note: locoregional recurrence is not considered a “visceral metastatic lesion”)
• Two lesions can be in close proximity (i.e. within 5 cm of each other) if they meet radiation SBRT normal tissue toxicity requirements
• If have untreated primary prostate cancer: must undergo debulking prostatectomy at discretion of treating urologist or definitive radiation therapy; definitive radiation fields to include close proximity lymph nodes at discretion of treating radiation oncologist; definitive radiation dose at discretion of treating radiation oncologist (for patients presenting with untreated prostate primary along with oligomets, androgen deprivation therapy [ADT] may begin concurrently with the definitive radiation, for a total of approximately 36 weeks duration)
• If had prior treatment to the prostate primary (definitive radiation therapy or prostatectomy, and can include salvage radiation to the prostate bed +/- lymph nodes), no evidence of locally persistent or recurrent prostate cancer on digital rectal exam (DRE) OR imaging studies (CT or MRI) * Note: patients with asymptomatic low volume locoregional recurrent disease will be allowed to enroll on this study after discussion with the PI. In the case where the low volume recurrence is amenable to SBRT, it will be included in the SBRT treatment. In the case where the low volume recurrence is not amenable to SBRT based on reirradiation risk, then we will follow these lesions with re-imaging scans and reassess at later time points for further local control. Additionally, if these patients fail only at the untreated site (due to the untreated recurrence/disease not being amenable to SBRT) they will be censored in the primary efficacy analysis at that time
• Does not have castration resistant disease * Castration resistance defined as progression of disease despite serum testosterone level of < 50 ng/dL
• PSA >= 0.2 prior to start of androgen deprivation treatment
• Patients will be receiving approximately 36 weeks of ADT as part of this trial; the 36 weeks of ADT may start prior to consenting to this study; the patient may join the study at any point of the 36-week period of ADT treatment * Only luteinizing hormone-releasing hormone (LHRH) agonist/antagonist treatment is considered ADT, bicalutamide or other antiandrogens used alone do not count
• Patients must be willing to receive bisphosphonate or RANKL inhibitor bone health agents at the dose and schedule consistent with the treatment of bone metastases or prevention of osteoporosis, starting approximately from when the patient begins protocol therapy, until the patient’s testosterone reaches normal levels or at the discretion of the PI. Patients who are already on a bone health agent separate from the protocol may continue on this treatment regimen and will not be required to start treatment with an additional bone health agent.
• Patients may have received prior hormone therapy at the discretion of the PI; patients may have received prior targeted therapy in the context of definitive therapy
• Patients may have had one prior systemic non-chemotherapeutic treatment (i.e. immunotherapy, receptor tyrosine kinase inhibitor, antiangiogenic agent, differentiating agent) for recurrent or metastatic disease
• Must have refused standard of care treatment for metastatic disease
• Recovered from all acute side-effects (except alopecia) related to previous systemic therapy
• Absolute neutrophil count (ANC) >= 1,500/mm^3 (to be performed within 14 days prior to day 1 of protocol therapy) * NOTE: growth factor support is not permitted to normalize baseline ANC parameters, however subsequent growth factor administration is permitted as standard supportive care
• Platelets >= 100,000/mm^3 (to be performed within 14 days prior to day 1 of protocol therapy) * NOTE: transfusion of blood products are not allowed to normalize baseline blood parameters, however subsequent transfusions are allowed per standard supportive care guidelines
• Hemoglobin (HgB) >= 9.0 g/dL (to be performed within 14 days prior to day 1 of protocol therapy) * NOTE: transfusion of blood products are not allowed to normalize baseline blood parameters, however subsequent transfusions are allowed per standard supportive care guidelines
• Total serum bilirubin =< 2 x upper limit of normal (ULN) (to be performed within 14 days prior to day 1 of protocol therapy)
• Aspartate aminotransferase (AST) =< 2.5 x ULN (to be performed within 14 days prior to day 1 of protocol therapy)
• Alanine aminotransferase (ALT) =< 2.5 x ULN (to be performed within 14 days prior to day 1 of protocol therapy)
• Creatinine =< 2.5 mg/dL (to be performed within 14 days prior to day 1 of protocol therapy)

Exclusion Criteria

• Prior radium Ra 223 dichloride
• Prior or concomitant chemotherapy for metastatic or recurrent disease with the following exceptions: * Prior chemotherapy for local primary disease is permitted
• Prior radiation to prior metastatic sites is allowed provided that it is controlled and the total number of metastatic lesions does not exceed 5
• Concomitant radiation treatment to primary prostate site
• Bilateral orchiectomy; if unilateral orchiectomy, eligible if testosterone > 50 ng/ml
• Unstable medical comorbidities (i.e. uncontrolled cardiac comorbidities)
• Metastases that in the judgment of investigator-radiologist are not amenable to SBRT
• History of brain metastases or who currently have treated or untreated brain metastases
• Uncontrolled human immunodeficiency virus (HIV) infection
• Any other condition that would, in the investigator's judgement, contraindicate the patient's participation in the clinical study due to safety concerns with clinical study procedures
• Prospective participants who, in the opinion of the investigator, may not be able to comply with all study procedures (including compliance issues related to feasibility/logistics)