IJC International Journal of Cancer
Impact of an HPV6/11/16/18 L1 virus-like particle vaccine on progression to cervical intraepithelial neoplasia in seropositive women with HPV16/18 infection Richard M. Haupt1, Cosette M. Wheeler2, Darron R. Brown3, Suzanne M. Garland4,5, Daron G. Ferris6, Jorma A. Paavonen7, Matti O. Lehtinen8, Marc Steben9, Elmar A. Joura10, Katherine E. D. Giacoletti1, David R. Radley1, Margaret K. James1, Alfred J. Saah1 and Heather L. Sings1 and for the FUTURE I and II Investigators 1
Department of Research, Merck Sharp & Dohme, Corp., Whitehouse Station, NJ Departments of Pathology and Obstetrics and Gynecology, University of New Mexico Health Sciences Center, Albuquerque NM 3 Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 4 Department of Microbiology and Infectious Diseases, Royal Women’s Hospital, Melbourne, Victoria, Australia 5 Department of Obstetrics and Gynecology, University of Melbourne, Melbourne, Victoria, Australia 6 Departments of Family Medicine and Obstetrics and Gynecology, Medical College of Georgia, Augusta, GA 7 Department of Obstetrics and Gynecology, University Central Hospital, Helsinki, Finland 8 Department of Microbiology, University of Tampere, Tampere, Finland 9 Direction Risques Biologiques et de la sante´ au travail, Institut National de Sante´ Publique du Que´bec, Montre´al, QC, Canada 10 Department of Gynecology and Obstetrics, Medical University of Vienna, Vienna, Austria
Infectious Causes of Cancer
2
Key words: HPV vaccine, cervical intraepithelial neoplasia, seropositive, HPV 16/18 infection Abbreviations: AGC: atypical glandular cells; AIS: adenocarcinoma in situ; ASC-H: atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion; ASC-US: atypical squamous cells of undetermined significance; CI: confidence interval; CIN: cervical intraepithelial neoplasia; DNA: deoxyribonucleic acid; FUTURE: females united to unilaterally reduce endo/ectocervical disease; HPV; human papillomavirus; HSIL: highgrade squamous intraepithelial lesion; LSIL: low-grade squamous intraepithelial lesion; STI: sexually transmitted infection Conflict of interest: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf. C.M.W., D.R.B., S.M.G., D.G.F., J.P., M.L., M.S. and E.A.J. have received funding through their institutions to conduct HPV vaccine studies for Merck Sharp & Dohme, Corp. C.M.W. has received funding through her institution for reagents and equipment from Roche Molecular Systems in support of HPV genotyping studies and to conduct HPV vaccine studies for GlaxoSmithKline. D.R.B. has received lecture fees, advisory board fees, and intellectual property fees from Merck Sharp & Dohme, Corp. M.S. has received lecture fees and grant support from Merck Sharp & Dohme, Corp. S.M.G. has received advisory board fees and grant support from Commonwealth Serum Laboratories and GlaxoSmithKline, lecture fees from Merck Sharp & Dohme, Corp., GlaxoSmithKline and Sanofi Pasteur MSD, as well as funding through her institution to conduct HPV vaccine study trials for GlaxoSmithKline. D.G.F. has received consultancy fees and funding through his institution to conduct HPV vaccine studies for GlaxoSmithKline, and advisory board fees, consultancy fees and lecture fees from Merck Sharp & Dohme, Corp. J.P. has received consultancy fees, advisory board fees, and lecture fees from Merck Sharp & Dohme, Corp. and has received funding through his institution to conduct HPV vaccine studies for GlaxoSmithKline. M.S. has received lecture fees and grant support from Merck Sharp & Dohme, Corp. E.A.J. has received lecture fees from Merck Sharp & Dohme, Corp., Sanofi Pasteur MSD and GlaxoSmithKline and advisory board fees from Merck Sharp & Dohme, Corp. and Sanofi Paster MSD. R.M.H., K.E.D.G., D.R., M.K.J., A.S. and H.L.S. are employees of Merck Sharp & Dohme, Corp. and potentially own stock and/or stock options in the company. Author contribution: This post-hoc analysis was designed by the sponsor in collaboration with external investigators. The sponsor performed the statistical analysis and coordinated the writing of the manuscript with all authors. All authors, external and internal, had full access to all of the data (including statistical reports and tables) in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis. All authors were actively involved in the collection, analysis or interpretation of the data, the revising of the manuscript for intellectual content, and approved the final manuscript. As corresponding author, Dr. Haupt assumes full responsibility for the overall content and integrity of the manuscript. Data sharing: no additional data available. Grant sponsor: Merck Sharp & Dohme, Corp. Grant numbers: NCT00092521, NCT00092534 DOI: 10.1002/ijc.25940 History: Received 2 Aug 2010; Accepted 3 Dec 2010; Online 20 Jan 2011 Correspondence to: Richard M. Haupt, Merck Sharp & Dohme, Corp., PO Box 1000, UG3CD-28, North Wales, PA 19454-1099, Tel: 267-305-1602, Fax: 267-305-6449, E-mail:
[email protected]
C 2011 UICC Int. J. Cancer: 129, 2632–2642 (2011) V
Haupt et al.
2633
Worldwide, cervical cancer is the second most common cancer in women, and the second most common cause of death from cancer among women aged 14–44 years.1 The fact that human papillomavirus (HPV) is a necessary cause of cervical cancer has been recognized for several years.2,3 This has led to the development of two prophylactic HPV vaccines, a bivalent vaccine targeting the oncogenic types HPV16 and HPV18 (HPV16/18 vaccine) and a quadrivalent vaccine (HPV6/11/16/18 vaccine) targeting these same oncogenic types in addition to the two HPV types that cause the majority of genital warts, HPV6 and HPV11.4 Both vaccines have been approved in over 100 countries for use in girls and women and the primary recommended target group for both is adolescent girls (i.e., less than 18 years). Nonetheless, some women in the population for whom the vaccines are approved will have been exposed to vaccine HPV types through sexual activity before vaccination.5,6 Though there have been extensive data published on the efficacy of both vaccines,7–15 less is known about the impact of HPV vaccination in women with ongoing HPV16 or 18 infections. Adequate knowledge of the HPV vaccines’ impact on such women has important clinical implications, particularly with respect to HPV16 and HPV18, as several studies have shown that women who are persistently or chronically infected with cervical HPV16 or HPV18 are at considerably higher risk for developing high grade cervical lesions and cancer, compared with women positive for nonHPV16/18 oncogenic types, oncogenic HPV-negative women, or those transiently infected with HPV16/18.16–18 Previous studies have shown that the HPV6/11/16/18 vaccine generates an anamnestic response in women who are seropositive to vaccine HPV types prevaccination (Fig. 1)19,20 and prevents reinfection or reactivation of disease that is related to vaccine HPV types.21 In contrast, the HPV6/11/16/18 vaccine does not impact progression of HPV16 or HPV18 infections to disease (i.e., there was no impact in women who were seronegative and DNA positive to HPV16 or HPV18).12,13 C 2011 UICC Int. J. Cancer: 129, 2632–2642 (2011) V
We have previously reported interim data (3 years of follow-up) on the impact of the HPV6/11/18/18 vaccine in women who were both seropositive and DNA positive to HPV16 or HPV18 at the time of the initial vaccination with the first dose (Fig. 1).12,13 Here we provide updated end of study data for these women who were enrolled in two phase 3 trials of the HPV6/11/16/18 vaccine. The objective of this post-hoc analysis was to determine if vaccine-induced immunity affects the progression of HPV infections to cervical intraepithelial neoplasia. In addition, it was important to evaluate any potential effect of vaccination on on-going infections (with either vaccine or nonvaccine genotypes) in this population of women.
Material and Methods Study objectives
The primary objective of this post-hoc analysis was to deterR/ mine whether administration of HPV6/11/16/18 (GardasilV R SilgardV, Merck Sharp & Dohme, Corp., Whitehouse Station, NJ) vaccine impacts the progression of HPV infections to cervical intraepithelial neoplasia (CIN) of any grade severity (i.e., CIN1, CIN2 and CIN3) or adenocarcinoma in situ (AIS) related to the same HPV type for which the woman was seropositive and DNA positive (i.e., both seropositive and DNA positive to HPV16, or both seropositive and DNA positive to HPV18) at the time of the initial vaccination with the first dose, hereafter referred to as prevaccination. The analysis population is described in Figure 1. For women seropositive and DNA positive to HPV16, we evaluated the following outcomes: HPV16-related disease and disease related to HPV types from the alpha-9 species (HPV31/33/35/52/58). For women seropositive and DNA positive to HPV18, we evaluated the following outcomes: HPV18-related disease, and disease related to HPV types from the alpha-7 species (HPV39/45/59). For women with type specific seropositivity and DNA positivity to any one of the four vaccine types, we
Infectious Causes of Cancer
The impact of a human papillomavirus (HPV) vaccine on development of cervical intraepithelial neoplasia grade 2-3 or adenocarcinoma in situ (CIN2-3/AIS) in women with ongoing HPV16 or 18 infections prevaccination is reported. Seventeen thousand six-hundred and twenty-two women aged 16–26 were enrolled in 1 of 2 randomized, placebo-controlled, efficacy trials (Protocols 013 and 015). Vaccine or placebo was given at day 1, month 2 and 6. Women were tested for HPV6/11/16/ 18 DNA and antibodies at day 1. We focus on the subset of women who were seropositive and DNA positive to HPV16 or HPV18 prevaccination. Incidence is expressed as the number of women with an endpoint per 100 person-years-at-risk. In total, 419 vaccine and 446 placebo recipients were both seropositive and DNA positive to HPV16 or HPV18 prevaccination and had at least one follow-up visit. In Protocol 013, the incidence of HPV16/18-related CIN2-3/AIS among these women was 10.9 in the vaccine arm and 7.0 in the placebo arm (vaccine efficacy 5 254.9; 95% CI: 2181.7, 13.0). In Protocol 015, the incidence of HPV16/18-related CIN2-3/AIS was 5.5 in the vaccine arm and 6.2 in the placebo arm (vaccine efficacy 5 12.2%; 95% CI: 229.8, 40.9). These data suggest HPV vaccination neither reduces nor enhances progression to HPV16/18-related high grade cervical lesions, and cervical cytology screening and corresponding management should continue as per local recommendations. Ultimately, population-based surveillance of vaccinated individuals beyond these clinical trials will be required to further address questions regarding the impact of vaccination in women exposed to vaccine HPV types before vaccination.
2634
HPV vaccination of seropositive and DNA positive women
Infectious Causes of Cancer
Figure 1. Analysis population.
evaluated disease related to any nonvaccine type. Here, a lesion was considered to be related to a nonvaccine type if it was positive to one or more of the nonvaccine HPV types for which testing was available (HPV31/33/35/39/45/51/52/56/58/59) or if the lesion was negative to all tested types (including vaccine types). In addition, we examined nonvaccine HPV type-related disease outcomes for women who were DNA positive (irrespective of serostatus) to the same nonvaccine type at day 1). Study design and populations
Between December 2001 and May 2003, 17,622 women, the majority aged 16–26 (there were two 15-year-olds) were enrolled in one of two randomized, double-blind, placebo-controlled trials of the quadrivalent HPV6/11/16/18 vaccine (Protocol 013, n ¼ 5,455 [FUTURE I] and Protocol 015, n ¼ 12,167 [FUTURE II]).12,13 The studies were conducted in accordance with principles of Good Clinical Practice and were approved by the appropriate institutional review boards and regulatory agencies and informed consent was received from all participants enrolled. The study designs and the results of the primary hypotheses have been described, following the CONSORT guidelines.12,13 The trials recruited women who, at enrollment (day 1), reported having had 0–4 sex partners during their lifetime, with the exception of Finland (872 vaccine; 873 placebo), which enrolled women aged 16–17 with no restrictions on sexual partner number. Participants with a history of an abnormal Pap test, a history of genital warts, or detection of genital warts at enrollment were excluded. Neither study included a screening phase for HPV infection or abnormal cytology; thus, the trials allowed the enrollment of women with undiagnosed CIN or abnormal cytology, or who had been previously infected with, or were currently infected with 1 of any of the HPV types which are known to infect the anogenital tract, including vaccine HPV types. The end-ofstudy data reported here include 3.6 years of follow-up on average, with 25th and 75th percentiles of 3.4 and 3.8 years,
respectively (maximum follow-up ¼ 4.6 years). In both trials, participants were randomly assigned (1:1) to receive intramuscular injections of HPV6/11/16/18 vaccine or visually indistinguishable placebo at day 1, months 2 and 6. Clinical follow-up and endpoints
Participants returned to the study sites at months 3, 7, 12, 18, 24, 30, 36, 42 and 48 (the end of study visit) in Protocol 013 and at months 7, 12, 24, 36 and 48 (the end of study visit) in Protocol 015. Comprehensive anogenital examinations were conducted at each scheduled visit at which time an endo/ectocervical swab (one specimen) and a combined labial/vulvar/perineal plus a perianal swab (pooled to become second specimen) were collected. ThinPrepTM Pap cervical cytology (Cytyc, Boxborough, MA) was also performed during scheduled visits. Cytology specimens were classified using The Bethesda System-2001.23 During examination, all genital lesions that were in the opinion of the investigator possibly, probably, or definitely HPV-related, or whose etiology was unknown, were to be biopsied. When multiple lesions were suspected to be HPVrelated, each lesion that was morphologically distinct and/or anatomically distinct was biopsied. All biopsy samples, regardless of location, were processed and adjacent histological sections of each biopsy were first read for clinical management by pathologists at a central laboratory (Diagnostic Cytology Laboratories, Indianapolis, IN) and then read for endpoint determination by a panel of up to four pathologists who were blinded to central laboratory and clinical diagnoses, treatment group and HPV status. Protocol-specified guidelines were used to triage participants with Pap abnormalities to colposcopy.12,13 Colposcopists were trained to locate and biopsy all discrete abnormal areas on the cervix. Women with CIN2, CIN3, or AIS (abbreviated as CIN2-3/AIS) or persistent CIN1 were referred for definitive therapy. Cervical biopsies, endocervical curettage specimens, specimens from loop electrosurgical excision C 2011 UICC Int. J. Cancer: 129, 2632–2642 (2011) V
Haupt et al.
Statistical methods
A point estimate of vaccine efficacy and the 95% confidence interval (CI) were calculated on the basis of the observed case split between vaccine and placebo recipients and the accrued person-time. An exact conditional procedure was used to evaluate vaccine efficacy under the assumption that the numbers of cases in the vaccine and placebo groups were independent Poisson random variables. Follow-up for endpoint ascertainment started 30 days post-dose 1. Incidence, or rate, is expressed as the number of women with an endpoint per 100-person-years-at-risk. A woman was considered to have developed an endpoint related to HPV6/11/16/18/31/33/35/39/45/51/52/56/58/59 if the respective HPV DNA was detected in the same lesion that was diagnosed by the pathology panel as a cervical lesion (CIN1, CIN2, CIN3, AIS and/or cervical cancer). In the analyses presented, a woman is counted only once for each endpoint, but a woman may have developed more than one endpoint during the trial. For example, those women who were seropositive and DNA positive to HPV16 prevaccination may have developed two distinct lesions with a single HPV type detected in each: an HPV16-related CIN2 lesion and an HPV31-related CIN2 lesion. Overall she would be counted as a case once each for: 1) HPV16/18-related CIN1-3/AIS; 2) HPV16/18-related CIN2-3/AIS; 3) HPV16related CIN2-3/AIS; and 4) HPV31/33/35/52/58-related CIN2-3/AIS. Likewise, a woman who was seropositive and DNA positive to HPV16 prevaccination may have developed one CIN2 lesion with both HPV31 and HPV33. Here she would be counted as a case only once for HPV31/33/35/52/ 58-related CIN2-3/AIS.
Results Analysis population
Protocol 013 and 015 enrolled 17,622 women, 99.9% of whom received 1 dose of vaccine or placebo (98.4% received at least 2 doses; 97.2% received all 3 doses). In Protocol 013, 4.4% of vaccine (121 of 2,723) and 4.2% of placebo (114 of 2,732) recipients were seropositive and DNA positive C 2011 UICC Int. J. Cancer: 129, 2632–2642 (2011) V
to HPV16/18 at enrollment and had at least one follow-up visit for HPV16/18-related cervical disease. In Protocol 015, 4.9% of vaccine (298 of 6,087) and 5.5% of placebo (332 of 6,080) recipients were seropositive and DNA positive to HPV16/18 at enrollment and had at least one follow-up visit for HPV16/18-related cervical disease. HPV16/18-related CIN2-3/AIS
In the combined studies, the incidence of CIN2-3/AIS related to HPV16/18 was 6.8 and 6.4 in vaccine and placebo recipients, respectively (vaccine efficacy of 6.6%, 95% CI: 46.4 to 22.4). Though the two studies followed similar rigorous procedures for referral of women to colposcopy, Protocol 013 was designed for maximal ascertainment of HPV disease and included frequent protocol-specified examinations and screening, and more aggressive colposcopy triage for suspected disease. In contrast, Protocol 015 followed a clinical protocol that was based on Pap screening intervals and management algorithms that constituted the standard-of-care in different communities. Because of these differences, it was therefore of interest to examine the incidence of disease in the individual studies. For the individual studies, the incidence of HPV16/18related CIN2-3/AIS for women who were seropositive and DNA positive to the respective type prevaccination and who had at least one follow-up visit are shown in Table 1. In Protocol 013 alone, the incidence of HPV16/18-related CIN2-3/AIS was 10.9 in the vaccine arm and 7.0 in the placebo arm (vaccine efficacy ¼ 54.9; 95% CI: 181.7, 13.0). The HPV16/18related CIN2-3/AIS cases observed in Protocol 013 were primarily HPV16-related (32 of the 33 vaccine cases and 19 of the 21 placebo cases). In an attempt to carefully examine the observed higher, nonsignificant, incidence of HPV16 related CIN2-3/AIS in the vaccine arm than the placebo arm of Protocol 013 among women seropositive and DNA positive to HPV16 prevaccination, we conducted a detailed analysis of this subset with respect to baseline characteristics and longitudinal HPV-associated cervical disease outcomes (Table 2). The vaccine arm of Protocol 013 had a nominally higher percentage of smokers (42 of 109 (38.5%) vaccine; 31 of 105 (29.5%) placebo) and HSIL (9 of 107 (8.4%) vaccine; 3 of 104 (2.9%) placebo) at enrollment compared with the placebo arm. However, the incidence of CIN2-3/AIS outcomes was inconsistently associated with abnormal baseline Pap diagnoses among vaccine and placebo groups (Table 3). We also found that fewer participants in the placebo arm of Protocol 013 who were seropositive and DNA positive to HPV16 prevaccination completed the scheduled visits than in the vaccine arm. That is, the placebo arm of this high-risk population had a higher rate of discontinuation, compared with the vaccine arm. As shown in Figure 2a, 24.8% (26/105) of the placebo arm did not complete the study, with 9.5% (10/105) having no post-vaccination follow-up for cervical endpoints. Thus, nearly 10% of the discontinuations occurred early in the study, eliminating the ability to ascertain for the development of cervical endpoints. In contrast, only 9.2%
Infectious Causes of Cancer
procedures and conization procedures, obtained at any time during the studies were tested for the four types in the vaccine (6/11/16/18) and 10 other oncogenic HPV types (31/33/ 35/39/45/51/52/56/58/59) using a PCR-based assay.22,24,25 For each participant, blood samples were obtained at enrollment and at defined intervals throughout the study for anti-HPV serology testing. Serum concentrations of antibodies to HPV 6, 11, 16 and 18 were measured by competitive immunoassay (Luminex Corporation, Austin, TX, USA).26 The competitive Luminex immunoassay was developed to monitor a single, type-specific, neutralizing epitope for each of HPV 6, 11, 16 and 18. The four mAbs which were chosen, H6.M48 for HPV 6, K11.B2 for HPV 11, H16.V5 for HPV 16 and H18.J4 for HPV 18 have been shown to recognize neutralizing epitopes on the associated HPV VLPs.
2635
0
62
HPV18-related
4
45
49
4
38
20
21
56
1
32
33
199.6
710.4
895.6
914.9
906.2
909.6
898.6
880.0
47.0
263.8
303.5
314.3
307.4
305.1
305.5
297.0
Person-years at risk
2.0
6.3
5.5
0.4
4.2
2.2
2.3
6.4
2.1
12.1
10.9
0
8.1
8.2
6.5
12.8
Rate1
72
267
332
332
332
332
332
332
22
95
114
114
114
114
114
114
n
7
55
62
3
47
36
36
77
2
19
21
0
14
12
18
29
No. of women with a lesion
230.5
786.1
994.9
1,018.1
1,004.6
1,008.6
991.6
971.1
74.0
235.2
299.2
304.6
302.2
301.4
286.8
282.9
Person-years at risk
Placebo
3.0
7.0
6.2
0.3
4.7
3.6
3.6
7.9
2.7
8.1
7.0
0
4.6
4.0
6.3
10.2
Rate1
75.5
(180.4, 17.4)
34.0
9.5
12.2
(159.6, 85.8)
(36.8, 40.3)
(29.8, 40.9)
(40.4, 43.1) (912.9, 74.9)
10.4
(9.3, 66.2)
(13.3, 64.3)
(14.7, 44.2)
48.4
38.4
35.6
19.7
(1413.0, 98.7)
50.1 21.2
(181.7, 13.0)
54.9
NA
(349.6, 0.4) (265.3, 12.2)
105.8 NA
(109.9, 25.0) (109.2, 47.6)
4.3
95% CI
24.8
Efficacy (%)
n ¼ number of women who were seropositive and DNA positive to the indicated HPV type and who had at least one follow-up visit post-day 30. 1 Number of women with a lesion per 100 person-years-at-risk.Abbreviations: AIS: adenocarcinoma in situ; CI: confidence interval; CIN: cervical intraepithelial neoplasia; HPV: human papillomavirus.
241
HPV16-related
298
298 298
CIN3
AIS
HPV16/18-related CIN2-3/AIS
298 298
CIN1
CIN2
HPV16/18-related CIN1-3/AIS
298
16
Protocol 015
107
HPV16-related
HPV18-related
121
121
AIS
HPV16/18-related CIN2-3/AIS
25 25
121 121
CIN2
CIN3
38 20
121
121
No. of women with a lesion
CIN1
HPV16/18-related CIN1-3/AIS
Protocol 013
n
Vaccine
Table 1. Vaccine efficacy in preventing HPV16 or HPV18-related CIN among women who were seropositive and DNA positive to the respective type prevaccination
Infectious Causes of Cancer
2636 HPV vaccination of seropositive and DNA positive women
C 2011 UICC Int. J. Cancer: 129, 2632–2642 (2011) V
Haupt et al.
2637
Table 2. Selected baseline characteristics of women who were seropositive and DNA positive to HPV16 prevaccination Protocol 013 Vaccine n 5 109
1
Placebo n 5 105
Protocol 015 1
Vaccine n 5 2501
Placebo n 5 2711
Number of new sex partners 6 months prior to study start (among nonvirgins) 0
67/108 (62.0)
73/105 (69.5)
168/249 (67.5)
191/270 (70.7)
1 or more
41/108 (38.0)
32/105 (30.5)
81/249 (32.5)
79/270 (29.3)
42/109 (38.5)
31/105 (29.5)
81/250 (32.4)
92/271 (33.9)
ASC-US
13/107 (12.1)
16/104 (15.4)
21/242 (8.7)
24/256 (9.4)
ASC-H
1/107 (0.9)
4/104 (3.8)
6/242 (2.5)
5/256 (2.0)
LSIL
24 /107 (22.4)
30/104 (28.8)
61/242 (25.2)
49/256 (19.1)
HSIL
9/107 (8.4)
3/104 (2.9)
14/242 (5.8)
13/256 (5.1)
36/109 (33.0)
34/105 (32.4)
74/250 (29.6)
68/271 (25.1)
HPV31, 33, 45, 52 or 58
35/109 (32.1)
36/105 (34.3)
94/250 (37.6)
106/271 (39.1)
Other HPV types
36/109 (33.0)
45/105 (42.9)
118/250 (47.2)
126/271 (46.5)
Current smoker (yes) Day 1 Pap test Result
History of genital tract infection or STI
HPV35
7/109 (6.4)
7/105 (6.7)
10/250 (4.0)
13/271 (4.8)
HPV39
12/109 (11.0)
15/105 (14.3)
33/250 (13.2)
32/271 (11.8)
HPV51
9/109 (8.3)
17/105 (16.2)
52/250 (20.8)
53/271 (19.6)
HPV56
13/109 (11.9)
19/105 (18.1)
62/250 (24.8)
60/271 (22.1)
HPV59
10/109 (9.2)
10/105 (9.5)
22/250 (8.8)
24/271 (8.9)
1
Characteristics are listed for all randomized participants with data for the particular characteristic. Of the 109 vaccine and 105 placebo recipients in Protocol 013 who were seropositive and DNA positive for HPV16, 107 and 95 had at least one follow-up visit for HPV16-related disease. Of the 250 vaccine and 271 placebo recipients in Protocol 015 who were seropositive and DNA positive for HPV16, 241 and 267 had at least one follow-up visit for HPV16-related disease. Abbreviations: ASC-H: atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion; ASC-US: atypical squamous cells of undetermined significance; HSIL: high-grade squamous intraepithelial lesion; HPV: human papillomavirus; LSIL: low-grade squamous intraepithelial lesion; STI: sexually transmitted infection.
(10/109) of the vaccine arm did not complete the study, and only 1.8% (2/109) had no post-vaccination follow-up for cervical endpoints. Assuming that the discontinued participants in Protocol 013 had the same event rates and average time at risk as we saw in those who completed the study, we would have expected to observe a total of 33 and 25 cases in the vaccine and placebo groups, respectively, instead of the observed 32 and 19, corresponding to a vaccine efficacy of 29.2%. As an exploratory analysis we calculated vaccine efficacy for the 99 vaccine and 79 placebo recipients who completed the study. Vaccine efficacy for the completers was 28.1% (95% CI: 140.8, 30.2), with rates of 11.7 and 9.1 in the vaccine and placebo groups, respectively. Corresponding analyses of this subset of women in the larger sister trial (Protocol 015) were also performed. Within the subset of women in Protocol 015 who were seropositive and DNA positive for HPV16 prevaccination, the incidence of HPV16/18-related CIN2-3/AIS was 5.5 in the vaccine arm and 6.2 in the placebo arm (vaccine efficacy ¼ 12.2%; 95% CI: 29.8, 40.9). As in Protocol 013, the cases were primarily HPV16-related (45 of the 49 vaccine cases and 55 of the 62 placebo cases), and the vaccine efficacy estimate for HPV16C 2011 UICC Int. J. Cancer: 129, 2632–2642 (2011) V
related CIN2-3/AIS was 9.5% (95% CI: 36.8, 40.3). In Protocol 015, the loss to follow-up was similar for vaccine (8.0%; 20/250) and placebo (6.3%; 17/271) recipients (Fig. 2b). Vaccine efficacy for the 230 vaccine and 254 placebo recipients who completed Protocol 015 was 10.1% (95% CI: 37.7, 41.6). CIN2-3/AIS related to nonvaccine types
Coinfection with nonvaccine types at day 1 was common in women who were seropositive and DNA positive to HPV16 prevaccination (Table 2). In Protocol 015, the incidence of CIN2-3/AIS related to the alpha-9 species (among those seropositive and DNA positive to HPV16) was 2.7 in the placebo arm and 2.3 in the vaccine arm (vaccine efficacy ¼ 14.2; 95% CI: 69.2, 57.2) (Fig. 3). In Protocol 013, the incidence was 2.6 in the placebo arm and 3.0 in the vaccine arm (vaccine efficacy ¼ 15.7; 95% CI: 304.5, 64.8) (Fig. 3). Nonsignificant differences in the incidence of CIN2-3/AIS related to the alpha-7 species (among those seropositive and DNA positive to HPV18) were also observed. The risk of developing CIN23/AIS related to a nonvaccine type was not different between vaccine and placebo recipients who were infected with any vaccine type (i.e., women who were seropositive and DNA
Infectious Causes of Cancer
Nonvaccine type DNA detected at day 1
2638
HPV vaccination of seropositive and DNA positive women
Table 3. Vaccine impact on development of HPV16-related CIN2/3 or AIS among women who were seropositive and DNA positive to HPV16 pre-vaccination, stratified by day 1 Pap test result Vaccine No. of women with a lesion
n
Placebo Rate1
No. of women with a lesion
n
Rate1
Protocol 013 Day 1 Pap Test Unsatisfactory Satisfactory Negative for SIL Normal Reactive/reparative
3
0
0.0
1
1
410.4
102
32
12.9
93
18
7.8
57
9
5.1
46
4
2.8
56
9
5.2
43
4
3.0
1
0
0.0
3
0
0.0
SIL present
45
23
32.0
47
14
15.5
ASC-US
13
4
11.9
15
2
5.1
1
0
0.0
3
1
60.5
LSIL
23
13
41.3
26
8
16.2
HSIL
8
6
92.2
3
3
2029.2
ASC-H
Protocol 015 Day 1 Pap Test Unsatisfactory
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Satisfactory Negative for SIL Normal Reactive/reparative
7
0
0.0
10
2
6.2
230
44
6.5
250
51
6.9
132
13
3.0
159
20
3.8
131
13
3.1
154
20
4.0
1
0
0.0
5
0
0.0
SIL present
98
31
12.7
91
31
14.5
ASC-US
20
3
4.8
23
6
9.9
6
6
111.5
5
3
51.3
LSIL
59
14
8.5
49
10
7.2
HSIL
13
8
65.4
13
11
184.6
AGC
0
0
1
1
40.5
ASC-H
NA
n ¼ Number of participants in the given day 1 Pap result group, who also have at least one follow-up visit. 1 Number of women with a lesion per 100 person-years-at-risk. Abbreviations: AGC: atypical glandular cells; ASC-H: atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion; AIS: adenocarcinoma in situ; ASC-US: atypical squamous cells of undetermined significance; CIN: cervical intraepithelial neoplasia; HSIL: high-grade squamous intraepithelial lesion; HPV: human papillomavirus; LSIL: low-grade squamous intraepithelial lesion.
positive to HPV6, 11, 16 or 18). Likewise, the risk of developing CIN2-3/AIS related to a nonvaccine type was not different for vaccine and placebo recipients who were infected with the respective nonvaccine type at day 1 (as measured by PCR only).
Discussion Previously there have been limited data available to carefully assess the impact of HPV vaccination in HPV positive women. Natural HPV infection does not always elicit a measurable immune response, due largely in part to the nonlytic nature of HPV viral replication.27 It is well known that with standard methods most HPV infections become undetectable, especially among younger women, and only a small fraction of infections progress to high grade lesions and an even smaller fraction to cervical cancer. Here, we considered
women who had evidence of an ongoing infection as determined by the presence of HPV16 or HPV18 DNA, and who had previously mounted a natural humoral immune response to this infection. Despite having generated a humoral immune response, these women had evidence of ongoing infections, as demonstrated by the presence of HPV16 or HPV18 DNA. Our data confirm that these women are at high risk for developing CIN2/3. HPV vaccination neither reduces nor enhances progression to HPV16/18-related high grade cervical lesions; however the study was not powered to assess vaccine impact in this subset of women. Our study has several limitations. Women were not randomized based on HPV status at study entry and the subgroup of seropositive and DNA positive women amounts to only 5% of the total population of the source studies. The four years of follow-up time was relatively short. In addition, C 2011 UICC Int. J. Cancer: 129, 2632–2642 (2011) V
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Haupt et al.
Figure 2. (a) Trial profile for those women who were seropositive and DNA positive to HPV16 at enrollment—Protocol 013; (b) Trial profile for those women who were seropositive and DNA positive to HPV16 at enrollment—Protocol 015.
the placebo arm of the HPV16 infected subpopulation of Protocol 013 had a higher rate of discontinuation (24.8%) than the vaccine arm (9.5%). It is possible that the placebo arm preferentially lost some higher-risk women who might have gone onto develop CIN2/3 during the course of the study. In an exploratory analysis which considered only those women who completed the study, vaccine efficacy for HPV16-related CIN2-3/AIS was 28.1% (95% CI: 140.8, 30.2). In the larger Protocol 015 trial, using the same exploratory analysis which considered only those women who completed the study, vaccine efficacy for HPV16-related CIN2-3/
C 2011 UICC Int. J. Cancer: 129, 2632–2642 (2011) V
AIS was 10.1% (95% CI: 37.7, 41.6). The nonsignificant efficacy estimates should be interpreted with caution, as the clinical trials were neither designed nor powered to assess vaccine efficacy in HPV positive women. Interpretation of the data is also confounded by coinfections. Coinfection with a vaccine HPV type and a nonvaccine HPV type was common in this subpopulation: consequently, assignment of causality in the case of multiple HPV infections is not always possible. The strengths of the study include the use of a highly sensitive PCR assay and pathology panel adjudication diagnoses of histologic endpoints.
2640
HPV vaccination of seropositive and DNA positive women
Figure 3. Incidence of CIN2-3/AIS related to nonvaccine types among women who were seropositive and DNA positive to the indicated types prevaccination. All comparisons of vaccine versus placebo with regard to incidence (the combined studies and the individual studies)
Infectious Causes of Cancer
were nonsignificant (95% CI included zero).
Among the subset of women in Protocol 013 who were seropositive and DNA positive to HPV16 at enrollment, there were some differences between the vaccine and placebo recipients with respect to baseline characteristics related to risk behaviors and HPV infection. For example, vaccine recipients had nominally higher rates of smoking than placebo recipients, and smoking has been shown to be an independent risk factor for cervical cancer in women infected with oncogenic HPV types.28 A nominally higher rate of HPV16/18-related CIN2-3/AIS among vaccine recipients, compared to placebo recipients, has also been observed for the bivalent (HPV16/ 18) vaccine in women who are HPV16/18 DNA positive and seropositive at study entry (vaccine efficacy of 13.8%, (95% CI: 77.6, 26.7). Although the authors of that study noted that these results could possibly be attributed to an imbalance in the baseline cytology diagnoses in this subgroup, no data correlating the imbalance with CIN2-3/AIS outcomes were provided.11 Imbalances in baseline cytology diagnoses detailed in our study were in fact inconsistently associated with the incidence of CIN2-3/AIS among vaccine and placebo groups. There has been one publication which has shown that in women seropositive or DNA positive for HPV16/18, the bivalent vaccine did not accelerate clearance of the virus and could not be used to treat prevalent infections.29 However, the bivalent vaccine study excluded those women who had evidence of high-grade squamous intraepithelial lesions at baseline, so the vaccine efficacy for viral clearance for women who were positive to HPV16/18 with HSIL could not be reported. HPV16 is a member of the alpha-9 species, which includes six cancer-causing types (16/31/33/35/52/58). HPV18 is a member of the alpha-7 species, which includes five cancer-causing types (18/39/45/59/66). Previous studies have shown that when the HPV6/11/16/18 vaccine is admin-
istered to women who are DNA negative to all of the 14 tested HPV types and who have normal cytology at day 1, vaccination provides some measure of protection against these phylogenetically related types.30 The data here demonstrated that women who were infected with HPV16 or HPV18 prevaccination did not benefit from a reduction in disease associated with the alpha-9 or alpha-7 species. Similar data have been observed for the bivalent vaccine.29 Vaccine efficacy for viral clearance for the bivalent vaccine among HPV16/18 positive women ranged from 8.7 to 12.2 for members of the alpha-7 and alpha-9 species, respectively, with no statistical significance observed. However, the authors did not examine cytologic or histologic outcomes, so the impact on rates of lesion progression for those women who were positive to HPV16/18 prevaccination is unknown. In Protocol 013 and 015 combined, the incidence of HPV16/18-related CIN2-3/AIS in the placebo arm was 6.4. By contrast, in women naı¨ve to HPV16/18, the incidence of CIN2-3/AIS in the clinical trials was dramatically lower, with a corresponding incidence of 0.4.14 It should be noted, however, that women who are infected with one or more vaccine HPV types derive residual benefit by the HPV6/11/16/18 vaccine’s prevention of infection and disease due to HPV type(s) to which the woman has not yet been exposed. A previous study has shown that vaccine efficacy for HPV16-related CIN was 94% (95% CI: 64, 100) for women who were infected with HPV6, 11, or 18 prevaccination and vaccine efficacy for HPV18-related CIN was 95% (95% CI: 72, 100) for women who were infected with HPV6, 11, or 16 prevaccination.31 Thus, on an individual level, vaccination of women with past or existing HPV-related disease can offer some benefit to women who are presumably previously unexposed to specific HPV vaccine types. However, the benefit of vaccination will be highest for women who are HPV negative before vaccination. C 2011 UICC Int. J. Cancer: 129, 2632–2642 (2011) V
Haupt et al.
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In summary, the data to date indicate HPV vaccination does not reduce progression to cervical precancers in women with ongoing HPV16/18 infection, and cervical cancer screening and corresponding management should continue as per local guidelines. Though these are final end-of-study data for protocols 013 and 015, results from these trials can be added to the public pool of evidence and potentially combined with data from other studies. As the large placebo con-
trolled trials of the current HPV vaccines are now concluded, ultimately, population-based surveillance of vaccinated individuals beyond these clinical trials will be required to further address questions of the impact of vaccination in women exposed to vaccine HPV types before vaccination.
Acknowledgements The authors thank Ms. Karyn Davis for publication support.
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