Meeting report: Considerations for trial design and endpoints in licensing therapeutic HPV16/18 vaccines to prevent cervical cancer

Abstract

Cervical cancer is a major cause of morbidity and mortality globally with a disproportionate impact on women in low- and middle-income countries. In 2021, the World Health Organization (WHO) called for increased vaccination, screening, and treatment to eliminate cervical cancer. However, even with widespread rollout of human papillomavirus (HPV) prophylactic vaccines, millions of women who previously acquired HPV infections will remain at risk for progression to cancer for decades to come. The development and licensing of an affordable, accessible therapeutic HPV vaccine, designed to clear or control carcinogenic HPV and/or to induce regression precancer could significantly contribute to the elimination efforts, particularly benefiting those who missed out on the prophylactic vaccine. One barrier to development of such vaccines is clarity around the regulatory pathway for licensure. In Washington, D.C. on September 12-13, 2023, a meeting was convened to provide input and guidance on trial design with associated ethical and regulatory considerations. This report summarizes the discussion and conclusions from the meeting. Expert presentation topics included the current state of research, potential regulatory challenges, WHO preferred product characteristics, modeling results of impact of vaccine implementation, epidemiology and natural history of HPV infection, immune responses related to viral clearance and/or precancer regression including potential biomarkers, and ethical considerations. Panel discussions were held to explore specific trial design recommendations to support the licensure process for two vaccine indications: (1) treatment of prevalent HPV infection or (2) treatment of cervical precancers. Discussion covered inclusion/exclusion criteria, study endpoints, sample size and power, safety, study length, and additional data needed, which are reported here. Further research of HPV natural history is needed to address identified gaps in regulatory guidance, especially for therapeutic vaccines intended to treat existing HPV infections.

Keywords: Cervical cancer; HPV; HPV therapeutic vaccine; Human papillomavirus.

Fig. 1

Average clearance, persistence, and progression of carcinogenic HPV infections. Carcinogenic HPV infections detected by DNA testing tend to resolve within one to two years of detection. Details vary by population, HPV type, and age, but this diagram of 777 infections found at enrolment visits of a large population-based cohort study (Guanacaste, Costa Rica) illustrates a typical pattern. Over time, the risk of a precancer diagnosis rises while the probability of eventual clearance among the still-persistent infections falls. This figure was published in The Lancet, Vol 370, Schiffman M, Castle PE, Jeronimo J, Rodriguez AC, Wacholder S, “Human papilloma virus and cervical cancer,” pp. 890–907, Copyright Elsevier. (2007).