Therapeutic DNA Vaccines against HPV-Related Malignancies: Promising Leads from Clinical Trials

In 2014 and 2021, two nucleic-acid vaccine candidates named MAV E2 and VGX-3100 completed phase III clinical trials in Mexico and U.S., respectively, for patients with human papillomavirus (HPV)-related, high-grade squamous intraepithelial lesions (HSIL). These well-tolerated but still unlicensed vaccines encode distinct HPV antigens (E2 versus E6+E7) to elicit cell-mediated immune responses; their clinical efficacy, as measured by HSIL regression or cure, was modest when compared with placebo or surgery (conization), but both proved highly effective in clearing HPV infection, which should help further optimize strategies for enhancing vaccine immunogenicity, toward an ultimate goal of preventing malignancies in millions of patients who are living with persistent, oncogenic HPV infection but are not expected to benefit from current, prophylactic vaccines. The major roadblocks to a highly efficacious and practical product remain challenging and can be classified into five categories: (i) getting the vaccines into the right cells for efficient expression and presentation of HPV antigens (fusion proteins or epitopes); (ii) having adequate coverage of oncogenic HPV types, beyond the current focus on HPV-16 and -18; (iii) directing immune protection to various epithelial niches, especially anogenital mucosa and upper aerodigestive tract where HPV-transformed cells wreak havoc; (iv) establishing the time window and vaccination regimen, including dosage, interval and even combination therapy, for achieving maximum efficacy; and (v) validating therapeutic efficacy in patients with poor prognosis because of advanced, recurrent or non-resectable malignancies. Overall, the room for improvements is still large enough that continuing efforts for research and development will very likely extend into the next decade.

Impact of Patient-Directed Cytology Results Correspondence Program on Follow-Up of High-Grade Pap Tests

OBJECTIVE

Proper follow-up of high-grade (HG) Pap tests is critical to the prevention of cervical cancer. This study evaluated the impact of a patient-directed cytology results correspondence program on follow-up of HG Pap tests among at-risk women aged 21 to 69 in Ontario.

METHODS

A cohort study with a historical control was used to investigate the impact of a result letter on adherence to follow-up after an HG Pap test. Analyses were conducted on an intention-to-treat basis. The intervention group was defined as women with an HG Pap test in 2014-2016, and the control group included women with an HG Pap test in 2010-2012. Follow-up was defined as a colposcopy or related treatments within 6 months of an HG Pap test. Factors that could influence adherence to follow-up were included as covariates in a multivariable logistic regression model (Canadian Task Force Classification II-2).

RESULTS

The study population comprised 7088 women in the intervention group and 6887 women in the non-intervention group. The follow-up rate in the intervention group was 86.2% compared with 81.0% in the non-intervention group. Controlling for covariates, women in the intervention group were more likely to have a follow-up (adjusted odds ratio 1.5; 95% confidence interval 1.3-1.6). Other significant factors included being registered to a family physician and the physician's gender.

CONCLUSIONS

A patient-directed correspondence program that provides Pap test results directly to the woman may reduce loss to follow-up for an HG abnormality, with an increased likelihood that these women will seek and complete a colposcopy and related treatment.

Human papillomavirus-related malignancies in HIV infection: anal and oropharyngeal cancers

Human papillomavirus (HPV)-related cancers, including anal cancer and oropharyngeal cancer, occur more frequently in individuals living with HIV infection than in the general population. Strategies for prevention among individuals with HIV infection include HPV vaccination, anal cancer screening programs, and early initiation of antiretroviral therapy (ART). HPV vaccination is not yet optimally used; a stronger and more persistent effort is needed to increase vaccination rates. Although anal cancer screening is not recommended by all authorities, there is a least some evidence that screening and treatment of anal high-grade squamous intraepithelial lesions may prevent progression to cancer. However, more definitive evidence is needed. Early initiation of ART reduces the risk of infection-related cancers, with some evidence of benefit in preventing HPV-associated cancer in individuals with HIV infection. This article summarizes a presentation by Timothy J. Wilkin, MD, MPH, at the IAS-USA continuing education program held in Los Angeles, California in April 2018.

Conservative management of biopsy confirmed high-grade squamous intraepithelial lesions

OBJECTIVES

Follow-up of women with biopsy-confirmed CIN2+ who were either treated immediately with LLETZ or managed conservatively to determine the rates of patients back on routine screening programme after a median of three years in two groups.

METHODS

In this retrospective study, 310 patients were involved who had undergone biopsy with result of CIN2+ between January 2011 and December 2014. Depending on the management, i.e. based on whether cytology and colposcopy follow-up or immediate treatment were performed, they were divided in two groups. Then the number of patients back on routine screening up to 15/2/2016 as well as the results of last cytology were compared within both groups.

RESULTS

A total of 310 women at average age of 30 years met the inclusion criteria. Of them, 230 (74 %) had immediate treatment whereas 80 (26 %) were managed conservatively. There were no statistically significant demographic differences between the two groups. The mean time of follow up was 1.091 days (2.98 years). The patients managed conservatively required more follow-up visits at colposcopy clinic (p<0.001). The last documented cytology in the immediate treatment group was negative in 93 % and low-grade/borderline in 7 % of patients, while in the conservative management group, it was negative in 84 %, low-grade/borderline in 15 % and high-grade in 1 % of patients (p = 0.015). Overall, the proportions of patients who are back on routine screening recall are 96 % and 87.5 % for the immediate treatment and conservatively managed groups, respectively (p=0.022).

CONCLUSION

The conservative management of high-grade CIN with cytology and colposcopic follow up is an OPTION in selected group of patients, but it cannot be routinely recommended (Tab. 2, Ref. 20).

[Analysis of histological type and staging of cervical cancer as prognostic factors among women treated in the Department of Gynecology and Oncology, Jagiellonian University in the years 2001-2014]

INTRODUCTION

Cervical cancer (CC) is the fourth most common, in terms of incidence of new cases, cancer in women and the third leading cause of cancer deaths in women worldwide. Survival of patients with CC depends on many factors, including the type of cancer, grading, FIGO staging and treatment.

MATERIAL AND METHODS

Analysis of survival of 524 patients diagnosed with invasive and non-invasive CC depending on histopathologic diagnosis, clinical staging, tumor grading and combination of therapy.

RESULTS

The 2-fold increase in the risk of death at diagnosis in order of HSIL> ca planoepitheliale> adenocarcinoma> sarcoma was noted. Grading 2 and 3 significantly reduces the average survival in patients diagnosed with CC. The higher staging, the shorter the average survival. Each pass by one FIGO stage was shown to increase the risk of death by 46%. The risk of death increases by 4% with every year of woman’s life. The longest average survival, 72 months, characterized a group of women undergoing curettage, followed by radical hysterectomy/ trachelectomy and lymphadenectomy without adiuvant radio-/ chemotherapy. The shortest survival, 26.9 months, was observed in the group treated with curettage followed by chemoradiation.

CONCLUSIONS

Histopathology, clinical staging, grading, age and combination of treatment proved to be significant factors affecting survival in women with CC.

Results of Further Diagnostic Procedures Among Patients with Cytological Characteristics of Minor Changes on Pap Smears

BACKGROUND

Atypical squamous cells of undetermined significance (ASCUS) and low-grade squamous intraepithelial lesion (LSIL) are the two most common results of positive Pap smears.

AIM

The aim of this study was to compare the management of patients with ASCUS and LSIL.

PATIENTS AND METHODS

All procedures were performed between 2003 and 2014 in an outpatient clinic affiliated to a tertiary referral center, and included Pap smears, colposcopy, histology and invasive treatment.

RESULTS

There were 131 patients in the ASCUS group and 84 in the LSIL group. Further negative cytological results were obtained more frequently among the ASCUS group than the LSIL group [relative risk (RR)=1.18, 95% confidence interval (CI)=1.33-2.40; p<0.001]. Histological results revealed higher occurrence of cervical intraepithelial neoplasia grade III or invasive squamous cancer in the LSIL group than the ASCUS group [RR=6.8 (95% CI=0.95-144.63), p=0.033]. Patients from the LSIL group more frequently required invasive treatment [RR=2.53, 95% CI=1.40-4.67, p=0.001].

CONCLUSION

Diagnosis of ASCUS is associated with more frequent cases of total remission in follow-up Pap smears and requires for less-invasive management.

'See and treat' approach for high-grade squamous intraepithelial cervical lesions

PURPOSE OF INVESTIGATION

Evaluation of the over-treatment percentage when choosing a 'see and treat' approach in patients with de- viant cervical smear test results.

MATERIALS AND METHODS

The authors performed a retrospective chart review among women who were treated for cytological low-grade squamous intraepithelial lesion (LSIL) or high-grade squamous intraepithelial lesion (HSIL) from January 2009 until December 2010. All patients who were treated for deviant Pap-smears were analyzed. Patient characteristics were taken into account when performing the analysis. Data were analyzed using SPSS. Logistic regression was performed to determine the influence of age, smoking, and the reason to perform the Pap-smear.

RESULTS

A total of 723 patients with deviant Pap-smear results were analysed. High-grade cervical intraepithelial neoplasia (CIN) was found in 70.3% of the patients with a Pap 3A average dysplasia (low-grade squamous intraepithelial lesion). This indicates that 29.7% of the patients would be over-treated with a 'see and treat' approach. For Pap 3B (high-grade intra-epithelial lesion) or higher the over-treatment percentage was 6.7% or less.

CONCLUSION

Potential risks of a loop electrosurgical excision procedure (LEEP) on future pregnancies and fertility should be taken into account when treating fertile patients for potential CIN. This should be part of the counseling process of patients with a Pap 3A average dysplasia. A 'see and treat' approach can and probably should be proposed to patients with a Pap 3B or higher.

Screening for Anal Cancer in Women

OBJECTIVE

The incidence of anal cancer is higher in women than men in the general population and has been increasing for several decades. Similar to cervical cancer, most anal cancers are associated with human papillomavirus (HPV), and it is believed that anal cancers are preceded by anal high-grade squamous intraepithelial lesions (HSIL). Our goals were to summarize the literature on anal cancer, HSIL, and HPV infection in women and to provide screening recommendations in women.

METHODS

A group of experts convened by the American Society for Colposcopy and Cervical Pathology and the International Anal Neoplasia Society reviewed the literature on anal HPV infection, anal SIL, and anal cancer in women.

RESULTS

Anal HPV infection is common in women but is relatively transient in most. The risk of anal HSIL and cancer varies considerably by risk group, with human immunodeficiency virus-infected women and those with a history of lower genital tract neoplasia at highest risk compared with the general population.

CONCLUSIONS

While there are no data yet to demonstrate that identification and treatment of anal HSIL leads to reduced risk of anal cancer, women in groups at the highest risk should be queried for anal cancer symptoms and required to have digital anorectal examinations to detect anal cancers. Human immunodeficiency virus-infected women and women with lower genital tract neoplasia may be considered for screening with anal cytology with triage to treatment if HSIL is diagnosed. Healthy women with no known risk factors or anal cancer symptoms do not need to be routinely screened for anal cancer or anal HSIL.