An International Prospective Open-label, Randomized, Phase III Study Comparing 177Lu-PSMA-617 in Combination With SoC, Versus SoC Alone, in Adult Male Patients With mHSPC

Inclusion Criteria:

Participants eligible for inclusion in this study must meet all of the following criteria:

   1. Signed informed consent must be obtained prior to participation in the study

   2. Patients must be adults ≥18 years of age

   3. Patients must have an ECOG performance status of 0 to 2

   4. Patients must have a life expectancy >9 months as determined by the study investigator

   5. Patients must have metastatic prostate cancer with histologically or cytologically
   confirmed adenocarcinoma (current or prior biopsy of the prostate and/or metastatic
   site)

   6. Patients must have evidence of PSMA-positive disease as seen on a 68Ga-PSMA-11 PET/CT
   scan, and eligible as determined by the sponsor's central reader

   7. Patients must have at least one documented metastatic bone and/or soft tissue/visceral
   lesion documented in the following manners within 28 days prior randomization:

      1. Metastatic disease to the bone (in any distribution) visible on 99Tc-MDP bone
      scintigraphy on either pre-ADT scans or baseline scans AND/OR

      2. Lymph node metastases of any size or distribution. If lymph nodes are the only
      site of metastasis, then at least one must be at least 1.5 cm in short axis AND
      outside of the pelvis AND/OR

      3. Visceral metastases of any size or distribution. If a participant has a history
      of visceral metastases at any time prior to randomization, he should be coded as
      having visceral metastases at baseline (i.e., patients with visceral metastases
      prior to ADT that disappear at baseline will be counted as having visceral
      metastases and would therefore have high volume disease for stratification
      purposes).

   8. Patients must have adequate organ function:

      - Bone marrow reserve ANC ≥1.5 x 109/L Platelets ≥100 x 109/L Hemoglobin ≥9 g/dL

      - Hepatic Total bilirubin ≤2 x the institutional upper limit of normal (ULN). For
      patients with known Gilbert's Syndrome ≤3 x ULN is permitted Alanine
      aminotransferase (ALT) or aspartate aminotransferase (AST) ≤3.0 x ULN OR ≤5.0 x
      ULN for patients with liver metastases

      - Renal eGFR ≥ 50 mL/min/1.73m2 using the Modification of Diet in Renal Disease
      (MDRD) equation

   9. Albumin ≥2.5 g/dL

10. Human immunodeficiency virus (HIV)-infected patients who are healthy and have a low
   risk of acquired immune deficiency syndrome (AIDS)-related outcomes can participate in
   this trial

11. Patients must be:

Treatment naïve OR minimally treated with:

   - Up to 45 days of luteinizing hormone-releasing hormone (LHRH) agonist /antagonists or
   bilateral orchiectomy with or without first generation anti-androgen (e.g.
   bicalutamide, flutamide) for metastatic prostate cancer is allowed prior to ICF
   signature. If given, first generation anti-androgen must be discontinued prior to
   start of study therapy or after 45 days whatever happens first.

   - If received, prior LHRH agonist/antagonist with or without first generation
   anti-androgen use in the adjuvant/neo-adjuvant setting must have been discontinued >
   12 months prior to ICF signature AND must not have exceeded 24 months of therapy AND
   must not have shown disease progression within 12 months of completing
   adjuvant/neo-adjuvant therapy.

   - Up to 45 days of CYP17 inhibitor or ARDT exposure for metastatic prostate cancer is
   allowed prior to ICF signature. No CYP17 inhibitor or ARDT exposure for earlier stages
   of prostate cancer is allowed.

Exclusion Criteria:

Participants meeting any of the following criteria are not eligible for inclusion in this
study.

   1. Participants with rapidly progressing tumor that requires urgent exposure to
   taxane-based chemotherapy

   2. Any prior systemic anti-prostate cancer therapy (with the exception of the drugs
   listed on inclusion criteria 11), including chemotherapy, Poly (adenosine
   diphosphate-ribose) polymerase (PARP) inhibitors, immunotherapy or biological therapy
   (including monoclonal antibodies).

   3. Concurrent cytotoxicity chemotherapy, immunotherapy, radioligand therapy, PARP
   inhibitor, biological therapy or investigational therapy

   4. Previous treatment with any of the following within 6 months of randomization:
   Strontium-89, Samarium-153, Rhenium-186, Rhenium-188, Radium-223, hemi-body
   irradiation. Previous PSMA-targeted radioligand therapy is not allowed

   5. Ongoing participation in any other clinical trial

   6. Use of other investigational drugs within 30 days prior to day of randomization

   7. Known hypersensitivity to any of the study treatments or its excipients or to drugs of
   similar chemical classes

   8. Transfusion for the sole purpose of making a participant eligible for study inclusion

   9. Participants with CNS metastases that are neurologically unstable, symptomatic, or
   receiving corticosteroids for the purpose of maintaining neurologic integrity.
   Participants with epidural disease, canal disease and prior cord involvement are
   allowed if those areas have been treated, are stable, and not neurologically impaired.
   Participants with parenchymal CNS metastasis (or a history of CNS metastasis), that
   have received prior therapy and are neurologically stable, asymptomatic and not
   receiving steroids for CNS metastases, are allowed, baseline and subsequent
   radiological imaging must include evaluation of the brain (magnetic resonance imaging
   (MRI) preferred or CT with contrast).

10. Diagnosed with other malignancies that are expected to alter life expectancy or may
   interfere with disease assessment. However, participants with a prior history of
   malignancy that has been adequately treated and who have been disease free, treatment
   free for more than 3 years prior to randomization, or participants with adequately
   treated non-melanoma skin cancer, superficial bladder cancer are eligible.

11. Concurrent serious (as determined by the Principal Investigator) medical conditions,
   including, but not limited to, uncontrolled infection, known active hepatitis B or C,
   or other significant co-morbid conditions that in the opinion of the investigator
   would impair study participation or cooperation. Participants with an active
   documented COVID-19 infection (any grade of disease severity) at time of informed
   consent may be included only when completely recovered (in accordance with local
   guidance).

12. Active clinically significant cardiac disease defined as any of the following:

      - NYHA class 3/4 congestive heart failure within 6 months prior to ICF signature
      unless treated with improvement and echocardiogram or MUGA demonstrates EF > 45%
      with improvement in symptoms to class < 3.

      - History or current diagnosis of ECG abnormalities indicating significant risk of
      safety for participants in the study such as: Concomitant clinically significant
      cardiac arrhythmias, e.g. sustained ventricular tachycardia, complete left bundle
      branch block, high-grade atrioventricular (AV) block (e.g., bifascicular block,
      Mobitz type II and third degree AV block)

      - History of familial long QT syndrome or known family history of Torsades de
      Pointes

      - Cardiac or cardiac repolarization abnormality, including any of the following:
      History of myocardial infarction (MI), angina pectoris, or coronary artery bypass
      graft (CABG) within 6 months prior to ICF signature

13. History of somatic or psychiatric disease/condition that may interfere with the
   objectives and assessments of the study

14. Symptomatic cord compression, or clinical or radiologic findings indicative of
   impending cord compression

15. Any condition that precludes raised arms position

16. Unmanageable concurrent bladder outflow obstruction or urinary incontinence. Note:
   participants with bladder outflow obstruction or urinary incontinence, which is
   manageable and controlled with best available standard of care (incl. pads, drainage)
   are allowed.

17. Sexually active males unwilling to use a condom during intercourse while taking study
   treatment and for 14 weeks after stopping study treatment. A condom is required for
   all sexually active male participants to prevent them from fathering a child AND to
   prevent delivery of study treatment via seminal fluid to their partner. In addition,
   male participants must not donate sperm for the time period specified above. If local
   regulations deviate from the contraception methods listed above to prevent pregnancy,
   local regulations apply and will be described in the ICF