A double-blind, randomised, placebo-controlled, Phase II study to evaluate ProCervix efficacy to clear HPV 16 and HPV 18 infection in women with normal cytology or ASCUS/LSIL

Human Papillomavirus (HPV) 16 and HPV 18 (the two genotypes targeted by the
ProCervix vaccine) are the most common HPV genotypes associated with cervical
cell abnormalities. They are present as either single or multiple infections in
at least 70% of squamous cell carcinomas and 82% of adenocarcinomas of the
cervix (de Sanjosé et al., 2010). HPV 16 is also the most common genotype found
in vulvar, vaginal, anal, penile and oropharyngeal cancers. Human
Papillomavirus genotyping tests are now available and allow identification of
women infected with oncogenic HPV genotypes before they develop high-grade
cervical intraepithelial neoplasia (CIN) (Castle, 2008). The current clinical
practice is to screen for the development of lesions by Papanicolaou (PAP)
testing in all women. In some countries, for women over 30 years old, the
practice is now to screen for lesions either by HPV testing or by simultaneous
PAP and HPV testing. Women diagnosed with high risk HPV (HR-HPV) genotypes with
or without cytological abnormalities are followed up by repeated cytology and
HPV testing 6-12 months later or are referred to colposcopy for CIN lesion
diagnosis (European Union [EU] Guidelines for Quality Assurance in Cervical
Cancer screening, 2012, ACOG, 2012; ACS/ASCCP/ASCP, 2012; Massad et al., 2013).
If pre-cancerous high grade lesions or cancerous lesions are found at
colposcopy and histology, they are treated preferentially by resection or other
ablative procedures (Wright et al., 2007a; Wright et al., 2007b). These
surgical procedures can induce certain complications. In the case of loop
electrosurgical excision procedure (LEEP), bleeding, cervical stenosis and
pelvic cellulitis can occur. In the case of conisation, these complications can
range from haemorrhage, sepsis, infertility, stenosis, and more rarely cervical
incompetence. This is of particular concern for preservation of future
fertility (Kyrgiou et al., 2006). The infected women for whom there are no
therapeutic interventions available before high grade CIN is developed could
benefit from an HPV therapeutic vaccination able to prevent the development of
high-grade lesions.
The early protein 7 (E7) antigen (Ag) is a target for therapeutic vaccination
because this oncoprotein plays a central role in cellular transformation (Banks
et al., 2012). It has been shown to be early and continuously expressed both by
HPV 16-infected cells and by cells of established HPV 16-induced tumours
(Howley and Lowy, 2007). E7 protein is recognized by murine and human T-cell
lines and clones and E7 specific-T-cell responses have been found associated
with HPV clearance or in disease spontaneous regression (Hopfl et al., 2000;
Van der Burg et al., 2001; Bourgault-Villada et al., 2004; Farhat et al., 2009;
Kadish et al., 2002; Peng et al., 2007; Kenter et al., 2009; Daayana et al.,
2010).
The strategy of therapeutic vaccination with ProCervix is to activate and
enhance the patient*s cellular immune response to HPV through recognition and
killing of cells expressing the E7 oncogenes. The Investigational Product (IP)
will be used for women infected by HPV 16, HPV 18, or both, which are the most
common oncogenic genotypes responsible for approximately 70% of cervical
cancers worldwide (de Sanjosé et al., 2010). The vaccine targets these HPV
infected women with normal or mild dyskariosis (i.e. with atypical squamous
cells of undetermined significance [ASCUS] or low-grade squamous epithelial
lesion [LSIL]) as detectable infections with oncogenic potential.
To optimise the T-cell response induced, ProCervix will be delivered with a
topical agent, imiquimod, applied to the injection sites as a vaccine adjuvant,
which activates antigen-presenting cells (APCs) present in the underlying
dermis (Janeway et al., 1999).
The population proposed for this study represents an otherwise healthy female
population who are infected with HPV 16 and/or HPV 18. The safety and
tolerability of this therapeutic vaccine has been shown in the ongoing Phase I
study, and the proposed population may in theory derive benefit from this IP.
Subjects with low grade cervical abnormalities are not judged to be at any
increased risk following exposure to ProCervix and imiquimod compared to
non-infected subjects.

Primary Objective
To evaluate the efficacy of ProCervix adjuvanted with imiquimod, in comparison
with placebo adjuvanted with imiquimod, to induce HPV 16 and 18 viral clearance
at 12 months in HPV 16 and/or 18 infected women using a type specific,
sensitive and quantitative HPV polymerase chain reaction (PCR) assay.

Secondary Objectives
The secondary objectives of this study are:
• To evaluate the efficacy of ProCervix adjuvanted with imiquimod, in
comparison with placebo adjuvanted with imiquimod, to induce HPV 16 and 18
sustained viral clearance in HPV 16 and/or 18 infected women using a type
specific, sensitive and quantitative HPV PCR assay.
• To evaluate the efficacy of ProCervix adjuvanted with imiquimod, in
comparison with placebo adjuvanted with imiquimod, to induce HPV 16 and/or 18
viral clearance at 6, 12, 15, 18 and 24 months in HPV 16 and/or 18 infected
women using a type specific, sensitive and quantitative HPV PCR assay.
• To evaluate the safety and tolerability of ProCervix adjuvanted with
imiquimod.
Exploratory Objectives
The exploratory objectives of this study are:
• To evaluate the efficacy of ProCervix adjuvanted with imiquimod, in
comparison with placebo adjuvanted with imiquimod, to induce HPV 16 viral
clearance at one or more timepoints up to 12, 18 and 24 months, respectively,
in HPV 16 infected women using a type specific, sensitive and quantitative HPV
PCR assay.
• To evaluate the efficacy of ProCervix adjuvanted with imiquimod, in
comparison with placebo adjuvanted with imiquimod, to induce HPV 18 viral
clearance at one or more timepoints up to 12, 18 and 24 months, respectively,
in HPV 18 infected women using a type specific, sensitive and quantitative HPV
PCR assay.
• To evaluate the cellular and humoral immunogenicity of ProCervix adjuvanted
with imiquimod.
• To evaluate the efficacy of ProCervix adjuvanted with imiquimod, in
comparison with placebo adjuvanted with imiquimod, to induce regression of
cytological abnormalities and histological lesions at 12, 18 and 24 months in
subjects with HPV 16 and/or HPV 18-associated ASCUS/LSIL at enrolment.
• To evaluate the efficacy of ProCervix adjuvanted with imiquimod, to prevent
progression to CIN2+ in HPV 16 and/or 18 infected women 18 and 24 months after
first immunisation.

This will be a double-blind, randomised, placebo-controlled, parallel group
study assessing the efficacy of ProCervix or placebo (concomitantly
administered with imiquimod cream).
Randomisation will be performed according to a 1:1 randomisation ratio.
Subjects will be stratified by:
• Cytology at baseline: normal or abnormal (i.e. ASCUS or LSIL) with the number
of subjects with ASCUS or LSIL abnormalities limited to no more than 20% of the
randomised subjects
• HPV status: HPV 16 only, HPV 18 only, HPV 16+18
• Age: 25-29 years old, 30-50 years old, with the number of subjects in the
25-29 year age group limited to no more than 30% of the randomised subjects
• Study site.
For each subject, the study will be divided in four study periods: a 4-week
Screening Period, an 8-week Vaccination Period, a 44-week Clinical Evaluation
Period, and a 52-week Follow-Up Period. The duration of the study after
randomisation is therefore 24 months per subject (from the first administration
of study product to the last planned visit). The study may be preceded by a
pre-selection phase of maximum 52 weeks.
After randomisation, each subject will receive two intradermal (i.d.)
administrations of either ProCervix or placebo (each followed by two
applications of imiquimod cream 15 minutes and 24 hours after injection) at an
interval of 6 weeks.
The key evaluations of the Vaccination Period include repeated assessments of
general and local reactions to vaccination; general safety will be assessed
through laboratory analysis of blood and urine samples. The immune response to
vaccination will also be determined.
The key evaluations of the Clinical Evaluation Period and the Follow-Up Period
include repeated gynaecological examinations for cytological/histological
assessment and determination of HPV infection. Samples for evaluation of the
immune response to vaccination will also be obtained. General safety will be
assessed through laboratory analysis of blood and urine samples and recording
of adverse events (AEs).
The primary statistical analyses will occur once all randomised subjects have
completed the Month 12 visit or have been withdrawn from the study. Secondary
analyses will be performed at Month 18 and Month 24.

ProCervix consists of two recombinant adenylate cyclase (CyaA) proteins,
CyaA-HPV 16E7 (C16-1) and CyaA-HPV 18E7 (C18-1) in a 50/50 ratio (C16C18-2 Ag
mixture). ProCervix is adjuvanted by Aldara*, a cream containing 5% of
imiquimod and approved in the EU and the United States (US) for topical
treatment of various skin conditions.
ProCervix Powder is provided as sterile, single use vials containing 1.5 mg of
a freeze-dried mix of C16-1 and C18-1 (C16C18-2) (0.75 mg for each drug
substance). At the time of use, the vaccine is reconstituted with 0.5 ml of
water for injections (WFI) to achieve a concentration of 3.0 mg/ml for a
vaccination dose of 600 mcg in 0.2 ml. Reconstituted ProCervix Powder will be
administered as a single i.d. injection of 0.2 ml delivered to the outer
surface of the upper thigh. The first i.d. injection will be delivered to one
thigh; the second injection will be delivered to the opposite thigh. Imiquimod
cream will be applied to a 2 cm-diameter area of skin centred on each injection
site. The first application of cream (15 minutes after vaccination) will be
performed by the study staff member. The second application of cream (24 hours
after vaccination) will be performed by the subjects themselves.

Exposure to id injected study vaccine (ProCervix Solution, ProCervix Powder, or
Placebo injection) plus topical study cream (imiquimod or placebo cream) was
generally well tolerated. Based on the clinical experience with ProCervix in 40
subjects, of whom 33 have been administered ProCervix (100 or 600 mcg) +
imiquimod, ADRs reported by more than 10% of the subjects (very common) include:
- local reactions at the site of vaccination: discoloration, erythema, pain,
swelling, induration, dryness, and pruritus
- inguinal lymphadenopathy, ipsilateral to id injection
- flu like-syndrome, including fatigue, myalgia, fever, chills, arthralgia, and
nausea.
All events were transient and most were reported as mild to moderate in
intensity. There were no treatment-related serious adverse events (SAEs).
Increasing the dose level of ProCervix or administration of ProCervix with
imiquimod did not appear to have a marked effect on reactogenicity.

Potential risks of vaccination.
All drugs may cause certain side effects and discomforts. Like for all
vaccines, theoretical risks of ProCervix administration include reactions such
as fever, hives, or rash. Intradermal injections of vaccines carry the
potential risk of anaphylaxis with respiratory failure and death, infection and
skin necrosis. Other possible side effects include headaches, nausea, and
vomiting.
Vaccine injections under the skin may cause pain at the injection site. After
one or two days, redness, swelling, itching and tenderness at these sites may
occur. These symptoms usually resolve over several days.
As for all new drugs/devices, there may also be side effects and discomforts
that are not yet known.

Potential risks of blood draws
Blood will be drawn during the study. Minor discomfort or pain may be
experienced from the needle stick. There is a slight risk of bruising,
swelling, redness, tenderness, or in rare circumstances infection at the site
of the blood draw. Some subjects may become dizzy and feel faint when they get
their blood drawn.

Potential risks of colposcopy and biopsy:
A colposcopy will be performed 4 to 5 times during study period. The main risk
associated to this exam is a vaginal irritation from the vinegar solution. In
case abnormalities are seen during the colposcopy, a biopsy will be performed
and the main risks for this procedure are bleeding and infection.

Potential risks of cervical sampling:
A cervical smear will be completed up to 6 times during the study period. Minor
discomfort or pain may be experienced when the speculum is inserted in the
vagina.

Are there any reproductive risks?
It is not known if the study treatment may affect an unborn child or nursing
infant. For this reason, if subjects are breast-feeding, pregnant or plan to
become pregnant, subjects may not participate in this study. If subjects are
capable of becoming pregnant, they must have used highly effective
contraception the month prior to the first vaccination and they must agree to
employ highly effective contraception for at least 12 months after the first
vaccination.

Birth control methods considered acceptable for this study include implants,
injectable, combined oral contraceptives, progestogen-only pill,
Levenorgestrel-releasing intrauterine system, intra-uterine devices (IUDs),
vasectomised partner, condoms with the use of spermicide or sexual abstinence.