Relugolix or Leuprolide for the Treatment of Cardiac Function in Patients with Prostate Cancer

Inclusion Criteria

• Pathologically proven diagnosis of adenocarcinoma of the prostate within 270 days prior to registration.
• Unfavorable intermediate risk prostate cancer, defined as having ALL the following bulleted criteria: * Has at least one intermediate risk factor (IRF): ** Prostate-specific antigen (PSA) 10-20 ng/mL ** Clinical stage tumor (T)2b-c (digital rectal exam [DRE] and/or imaging) by American Joint Committee on Cancer (AJCC) 8th edition ** Gleason Score 7 (Gleason 3+4 or 4+3 [International Society of Urological Pathology [ISUP] grade group 2-3]) * Has one or more of the following "unfavorable" intermediate-risk designators: ** > 1 IRF ** Gleason 4+3=7 (ISUP grade group 3) ** ≥ 50% of biopsy cores positive *** Biopsies may include "sextant" sampling of right/left regions of the prostate, often labeled base, mid-gland and apex. All such "sextant" biopsy cores should be counted. Men may also undergo "targeted" sampling of prostate lesions (guided by MRI, ultrasound or other approaches). A targeted lesion that is biopsied more than once and demonstrates cancer (regardless of number of targeted cores involved) should count as a single additional positive core sampled and positive. In cases of uncertainty, count the biopsy sampling as sextant core(s). ** Absence of high-risk features
• Appropriate stage based on the following diagnostic workup: * History/physical examination within 120 days prior to registration * Negative bone imaging (M0) with Tc-99m bone scan or fluciclovine (18F) sodium fluoride (NaF) positron emission tomography (PET) within 120 days prior to registration * Clinically negative lymph nodes (N0) as established by conventional imaging (pelvic +/- abdominal CT or MRI), within 120 days prior to registration (lymph nodes equivocal or questionable by imaging are eligible if the nodes are ≤ 1.0 cm in short axis and/or if biopsy is negative) * Prostate specific membrane antigen (PSMA) or fluciclovine PET negative for nodal or distant metastatic disease is an acceptable substitute for the above bone and pelvic imaging
• Age ≥ 18
• Eastern Cooperative Oncology Group (ECOG) Performance Status of 0-1 within 120 days prior to registration.
• Non-castrate testosterone level (> 50 ng/dL) within 120 days prior to registration.
• Absolute neutrophil ≥ 1,000 cells/mm^3 (within 120 days prior to registration)
• Hemoglobin ≥ 10 g/dL (within 120 days prior to registration)
• Platelet count ≥ 100,000 cells/mm^3 (within 120 days prior to registration)
• Creatinine clearance (CrCl) ≥ 30 mL/min estimated by Cockcroft-Gault Equation (within 120 days prior to registration) * For African American patients, CrCl ≥ 30 mL/min is estimated by the alternative formula that takes race into account
• Total bilirubin: 1.5 ≤ institutional upper limit of normal (ULN) (within 120 days prior to registration)
• Aspartate aminotransferase (AST)(serum glutamic-oxaloacetic transaminase [SGOT]) and alanine aminotransferase (ALT)(serum glutamic-pyruvic transaminase [SGPT]) ≤ 2.5 × institutional ULN (within 120 days prior to registration)
• HIV-infected patients on effective anti-retroviral therapy with undetectable viral load within 6 months are eligible for this trial. Note: HIV testing is not required for eligibility for this protocol.
• For patients with evidence of chronic hepatitis B virus (HBV) infection, the HBV viral load must be undetectable on suppressive therapy, if indicated. Note: Known positive test for hepatitis B virus surface antigen (HBV sAg) indicating acute or chronic infection would make the patient ineligible unless the viral load becomes undetectable on suppressive therapy. Patients who are immune to hepatitis B (anti-Hepatitis B surface antibody positive) are eligible (e.g. patients immunized against hepatitis B).
• For patients with a history of hepatitis C virus (HCV) infection must have been treated and cured. For patients with HCV infection who are currently on treatment, they are eligible if they have an undetectable HCV viral load. * Note: Known positive test for hepatitis C virus ribonucleic acid (HCV RNA) indicating acute or chronic infection would make the patient ineligible unless the viral load becomes undetectable on suppressive therapy.
• The patient or a legally authorized representative must provide study-specific informed consent prior to study entry and, for patients treated in the United States (U.S.), authorization permitting release of personal health information.

Exclusion Criteria

• Previous radical surgery (prostatectomy) or any form of curative-intent ablation whether focal or whole-gland (e.g., cryosurgery, High-intensity focused ultrasound (HIFU), laser thermal ablation, etc.) for prostate cancer.
• Definitive clinical or radiologic evidence of metastatic disease (M1).
• Prior invasive malignancy (except non-melanomatous skin cancer) or hematologic malignancy unless disease free for a minimum of 3 years.
• Prior radiotherapy to the prostate/pelvis region that would result in overlap of radiation therapy fields.
• Previous bilateral orchiectomy.
• Previous hormonal therapy, such as luteinizing hormone-releasing hormone (LHRH) agonists (e.g., leuprolide, goserelin, buserelin, triptorelin) or LHRH antagonist (e.g. degarelix), anti-androgens (e.g., flutamide, bicalutamide, cyproterone acetate). ADT started prior to study registration is not allowed.
• Prior use of 5-alpha-reductase inhibitors is allowed; however, it must be stopped ≥ 30 days prior to the pre-registration PSA measure for determining enrollment eligibility.
• Prior testosterone replacement therapy is allowed; however, any replacement therapy must be stopped for at least 1 year prior to registration.
• Severe, active co-morbidity defined as follows: * Current/uncontrolled angina or arrhythmias * New York Heart Association Functional Classification II-IV (Note: Patients with known history or current symptoms of cardiac disease, or history of treatment with cardiotoxic agents, should have a clinical risk assessment of cardiac function using the New York Heart Association Functional Classification.) * History of any condition that in the opinion of the investigator, would preclude participation in this study
• Patients with significant obstructive urinary symptoms that are suspected to be secondary to prostate cancer and/or benign prostatic hypertrophy.
• Disabilities that prevent performing moderate intensity exercise test with exercise (treadmill) stress test and muscle function tests (walking/gait assessments and grip strength).
• Patients unable to tolerate MRI (e.g. claustrophobia), has contraindications to MRI (e.g. metals and implants incompatible with MRI), body habitus preventing MRI scanning, or allergy to gadolinium-based contrast.
• Significant uncontrolled gastrointestinal (e.g. Crohn’s disease, ulcerative colitis) or metabolic disease (e.g. diabetes, hyperlipidemia).
• Active inflammatory or immune-related disease treated with steroids or immunosuppressive agents.
• Inability to swallow oral pills.
• High risk features, which includes any of the following: * Gleason 8-10 [ISUP grade group 4-5] * PSA>20 * cT3-4 by digital exam OR gross extra-prostatic extension on imaging [indeterminate MRI evidence will not count and the patient will be eligible]