PROMIZE is an open-label, multi-centre, single-arm, Phase I/II clinical trial, evaluating the safety, tolerability and anti-tumuor efficacy of an antibiotic combination and enzalutamide in patients with metastatic castration-resistant prostate cancer (mCRPC).

Patients with histologically confirmed metastatic castration-resistant adenocarcinoma of the prostate refractory to conventional therapy (or for which no conventional therapy exists or is declined by the patient), that have progressed after at least 1 line of taxane based chemotherapy (or not fit or not willing to receive a taxane) and a NAAT are eligible for the study. The Phase I will evaluate the safety and tolerability of the combination of amoxicillin plus metronidazole (2 weeks) followed by ciprofloxacin plus vancomycin (2 weeks) administered for 2 cycles (i.e., 8 weeks) in addition to enzalutamide (160 mg daily). Enzalutamide will continue beyond the completion of the antibiotic combination until disease progression, intolerance, or withdrawal from the study. The DLT period is 4 weeks and commences at the time of combination treatment with antibiotics plus enzalutamide. Each cycle of treatment will be 4 weeks in length.

The design permits the safety monitoring of DLT regularly throughout the 2 phases. During the Phase I study, if 2 or more patients experience a DLT out of up to 6 patients, the schedule will be deemed intolerable, and a decision will be made by the SRC to modify the schedule depending on the timing and nature of toxicity observed and its causality. For any modified schedule, a further 6 patients will be treated, and the new dose and schedule will only be deemed tolerable if no more than 1 out of 6 patients experience a DLT.

The Phase II study will employ a 2-stage design. It will recruit a maximum of 33 patients with a desirable response level of 30% and an undesirable response rate of 10%. Patients enrolled to the Phase I who are treated at the RP2D and are evaluable for response will contribute to the Phase II study. Patients will receive the same dose and schedule deemed to be safe in the Phase I.

In the phase II study, the first stage will enrol 15 patients who are evaluable for response. If at least one patient responds during stage 1, a further 18 patients will be recruited (stage 2). The decision to proceed to stage 2 can be made once one response has been observed after thorough review of the cases where objective response was observed by the SRC. The trial will be terminated with the conclusion that the treatment is futile if no responses are observed in the first 15 patients. The second stage of the trial will enrol 18 patients who are evaluable for response. If >6 patients respond across the 2 stages, the study will have met its efficacy threshold. Further details of the Simon 2-stage design are specified in section 13. If <7 patients respond across the 2 stages, all samples will be analysed to identify predictive biomarkers of response. If a robust biomarker is identified, the study may be expanded in a biomarker-selected cohort following protocol amendment. Further safety analysis of safety (at least 2 further interim looks) will occur throughout the phase II trial.

Approximately 6 patients will be enrolled to the Phase I and up to a total of 33 response evaluable patients will be enrolled to the Phase II study. Patients in the Phase I study who are treated with the RP2D and are evaluable for response can contribute to the Phase II study. Based on this, up to 39 response evaluable patients will be recruited across the 2 phases. Based on a recruitment rate of 3 patients per month across the 2 sites, recruitment will be completed within 24 months.

Inclusion Criteria:

1. Histologically or cytologically proven metastatic castration-resistant prostate cancer or adenocarcinoma refractory to conventional treatment, or for which no conventional therapy exists or is declined by the patient.

2. Documented prostate cancer progression as assessed by the investigator with RECIST (v1.1) and PCWG3 criteria with at least one of the following criteria:

   1. Progression of soft tissue/visceral disease by RECIST (v1.1) and/or,
   2. Progression of bone disease by PCWG3 bone scan criteria and/or,
   3. Progression of PSA by PCWG3 PSA criteria and/or
   4. Clinical progression with worsening pain and need for palliative radiotherapy for bone metastases.

3. Phase I: Patients that have progressed after at least 12 weeks of treatment with a NAAT within the previous 6 months Phase II: Patients that have progressed after at least 12 weeks of treatment with a NAAT within the previous 6 months (for combination treatment) or more than 6 months prior to trial entry (for enzalutamide alone resistance run-in).

4. Previously progressed on at least one line of taxane chemotherapy (or not fit or not willing to receive a taxane).

5. Ongoing androgen deprivation maintaining serum testosterone of less than 50 ng/dL (less than 2.0 nM) is mandatory.

6. Life expectancy of at least 12-weeks.

7. Able to swallow tablets.

8. Archival tumour tissue must be available for analyses.

9. Willing to have pre- and post-treatment biopsies if biopsy is feasible.

10. World Health Organisation (WHO) performance status of 0-2 (Appendix 1).

11. Haematological and biochemical indices within the ranges shown below. These measurements must be performed within one week (Day -7 to Day 1) prior to the patient's first dose of IMP.

    Haemoglobin (Hb): ≥ 9.0 g/dL

    Absolute neutrophil count: ≥ 1.5 x 109/L

    Platelet count: ≥ 75 x 109/L

    Serum bilirubin: ≤ 1.5 x upper limit of normal (ULN)

    Alanine aminotransferase (ALT): ≤ 2.5 x (ULN) unless raised due to tumour in which case up to 5 x ULN is permissible

    Aspartate aminotransferase (AST): ≤ 2.5 x (ULN) unless raised due to tumour in which case up to 5 x ULN is permissible

    Serum creatinine / calculated creatinine clearance: ≤ 1.5 x upper limit of normal (ULN) / GFR ≥ 50 mL/min (uncorrected value)

    Serum albumin: >25 g/L

12. 18 years or over

13. Written (signed and dated) informed consent and be capable of co-operating with treatment and follow-up

14. Willing and able to comply with the study requirement including the collection of blood, fresh tumour biopsy, urine, rectal swab and stool samples.

Exclusion criteria:

1. Surgery, radiotherapy, chemotherapy, or other anti-cancer therapy within 4-weeks prior to trial entry into the study (6 weeks for bicalutamide). The use of bisphosphonates or RANK ligand inhibitors in patients with known osteopenia or osteoporosis or bone metastases is permitted. Prior antiandrogenic treatment exclusions as follows:

   • Patients receiving enzalutamide immediately preceding the trial will be able to continue on enzalutamide without washout.
   • Prior flutamide treatment during previous 4-weeks. N.B. Patients whose PSA did not decline in response to antiandrogens given as a second line or later intervention will only require a 14-day washout;
   • Prior bicalutamide (Casodex) and nilutimide (Nilandron) treatment during previous 6-weeks;
   • Prior progesterone, medroxyprogesterone, progestins, cyproterone acetate, tamoxifen, and 5-alpha reductase inhibitors during previous 2-weeks (14-days).

2. Ongoing toxic manifestations of previous treatments. Exceptions to this are alopecia or certain Grade 1 toxicities, which in the opinion of the Investigator and the DDU should not exclude the patient.

3. Previous treatment with any systemic antibiotic within 12 weeks of study entry.

4. Known hypersensitivity reaction or intolerance to any penicillin, amoxicillin, metronidazole, vancomycin, ciprofloxacin or enzalutamide.

5. History of tendon disorder secondary to quinolones

6. Use of drugs that are listed in the prohibited concomitant medications section including strong inducers and inhibitors of CYP450 (please refer to http://medicine.iupui.edu/clinpharm/ddis/table.aspx). Seville orange or grapefruit products and any herbal medications should be avoided for 4 weeks prior to starting trial treatment.

7. Concurrent treatment with prohibited medications which include medications that causes ototoxicity, neurotoxicity, and nephrotoxicity.

8. Known or suspected leptomeningeal metastases or untreated brain metastasis. Patients with brain metastases that have been treated and have been shown to be radiologically stable for more than 6 months may be considered for the trial.

9. History of stroke, epilepsy or current excessive alcohol intake. History of clinically significant hearing loss including but not limited to congenital hearing loss, need for hearing aids, ongoing acute or chronic ear infection, history of tympanic membrane perforation, tinnitus, vertigo, Meniere disease, cerebrovascular ischemia.

10. History of clinically significant hearing loss including but not limited to congenital hearing loss, need for hearing aids, ongoing acute or chronic ear infection, history of tympanic membrane perforation, tinnitus, vertigo, Meniere disease, cerebrovascular ischemia.

11. Patients with partners of child-bearing potential (unless they agree to use a barrier method of contraception [condom plus spermicide] or to sexual abstinence effective from the first administration of any of the investigational agents, throughout the trial and for 6 months afterwards. Patients with partners of child-bearing potential must also be willing to ensure that their partner uses an effective method of contraception for the same duration for example, hormonal contraception, intrauterine device, diaphragm with spermicidal gel or sexual abstinence). Patients with pregnant or lactating partners must be advised to use barrier method contraception (for example, condom plus spermicidal gel) to prevent exposure of the foetus or neonate.

    NB. Abstinence is only considered to be an acceptable method of contraception when this is in line with the preferred and usual lifestyle of the subject. Periodic abstinence (e.g., calendar, ovulation, symptothermal, post-ovulation methods) and withdrawal are not acceptable methods of contraception

12. Any condition that would increase enteral absorption in the opinion of the investigator, including but not limited to malabsorption syndromes, impaired GI motility, chronic pancreatitis, partial or complete gastric and/or bowel resections, history of clinically significant gastrointestinal bleeding in the last 6 months, history of mesenteric ischemia or bowel obstruction, chronic diarrhoea (≥Grade 2), inflammatory bowel disease (Crohn's disease, ulcerative colitis).

13. At high medical risk because of non-malignant systemic disease including active uncontrolled infection.

14. Clinically significant history of liver disease consistent with Child-Pugh Class B or C, including viral or other hepatitis, current alcohol abuse, or cirrhosis.

15. Known to be serologically positive for hepatitis B, hepatitis C or human immunodeficiency virus (HIV).

16. Any of the following cardiac criteria:

    • Clinically important abnormalities including rhythm, conduction or ECG changes (left bundle branch block, third degree heart block).
    • Factors predisposing to QT prolongation including congenital long QT syndrome; family history of prolonged QT syndrome, unexplained sudden death (under 40); concomitant medications known to prolong QT interval.
    • Concurrent congestive heart failure, prior history of class III/ IV cardiac disease (New York Heart Association [NYHA] - refer to Appendix 5), prior history of cardiac ischaemia or prior history of cardiac arrhythmia.
    • QTcF (corrected using Fredericia formula) of ≥460 ms.

17. Prior bone marrow transplant or have had extensive radiotherapy to greater than 25% of bone marrow within eight weeks.

18. Active or uncontrolled autoimmune disease requiring corticosteroid therapy or other forms of systemic immunosuppression.

19. Patient is a participant or plans to participate in another interventional clinical trial, whilst taking part in this study. Participation in an observational trial would be acceptable.

20. Any other condition which in the Investigator's opinion would not make the patient a good candidate for the clinical trial.

21. Malignancy other than prostate cancer within 3-years of trial entry with the exception of adequately treated basal cell carcinoma. Cancer survivors, who have undergone potentially curative therapy for a prior malignancy must have no evidence of that disease for at least-3 years and be deemed at negligible risk for recurrence, are deemed eligible.

22. Symptoms of COVID-19 and/or current documented COVID-19 infection.

Male