A Phase II Clinical Trial of PepCan Randomized and Double-Blinded to Two Therapy Arms for Treating Cervical High-Grade Squamous Intraepithelial Lesions
Phase: PHASE2
Conditions: Cervical Intraepithelial Neoplasia
Sponsor: University of Arkansas

IRB# 202790 A phase II clinical trial of PepCan 
PI: Mayumi Nakagawa, MD, PhD 
Site: UAMS OBGYN Clinics, UAMS Winthrop P. Rockefeller Cancer Institute 
Funding Source: NIH (NCI) 
Sponsor: UAMS 
Version: 19 
Date: January 19, 2023 
Page 1 
A Phase II Clinical Trial of PepCan 
Randomized and Double-Blinded to Two Therapy Arms for 
Treating Cervical High-Grade Squamous Intraepithelial Lesions 
 
UAMS IRB 202790 
 
NCT Number: NCT02481414 
 
PRINCIPAL INVESTIGATOR: 
Mayumi Nakagawa, MD, PhD 
Professor, Dept. Pathology, College of Medicine 
University of Arkansas for Medical Sciences 
 
CO-INVESTIGATOR: 
William Greenfield, MD 
Professor, Division Director 
Dept. Obstetrics and Gynecology, College of Medicine 
University of Arkansas for Medical Sciences 
 
SUB-INVESTIGATORS: 
Charles M. Quick, MD – Professor, Department of Pathology 
Susan (Buffy) Miller, APN – Department of Gynecology Oncology 
Kimberly Spickes, APN – Department of Gynecology Oncology 
Tina Butler, APN – Department of Gynecology Oncology 
 
MEDICAL MONITOR: 
Heather Williams, MD 
Assistant Professor, Dept. of Obstetrics and Gynecology, Gynecologic Oncology 
College of Medicine 
University of Arkansas for Medical Sciences 
 
STUDY STATISTICIAN: 
Horace J. Spencer, III 
Biostatistics Project Manager, Dept. Biostatistics 
College of Medicine 
 
University of Arkansas for Medical Sciences 
 
SPONSOR: 
University of Arkansas for Medical Sciences 
 
FUNDING SOURCE: 
National Institutes of Health (National Cancer Institute) 
 
LOCATION OF STUDY: 
University of Arkansas for Medical Sciences 
Obstetrics and Gynecology Clinics 
UAMS Winthrop P. Rockefeller Cancer Institute (WPRCI) 
 

IRB# 202790 A phase II clinical trial of PepCan 
PI: Mayumi Nakagawa, MD, PhD 
Site: UAMS OBGYN Clinics, UAMS Winthrop P. Rockefeller Cancer Institute 
Funding Source: NIH (NCI) 
Sponsor: UAMS 
Version: 19 
Date: January 19, 2023 
Page 2 
TABLE OF CONTENTS 
1 
BACKGROUND 
6 
1.1 
STUDY SYNOPSIS 
6 
1.2 
SUMMARY 
7 
1.3 
SCIENTIFIC RATIONALE 
8 
1.4 
SUMMARY OF PHASE I CLINICAL TRIAL 
13 
1.5 
RATIONALE FOR PHASE II CLINICAL TRIAL 
17 
1.6 
POTENTIAL BENEFITS AND RISKS TO SUBJECTS 
20 
2 
OBJECTIVES 
20 
2.1 
PRIMARY OBJECTIVE: EFFICACY 
20 
2.2 
SECONDARY OBJECTIVE: SAFETY 
20 
2.3 
TERTIARY OBJECTIVES: IMMUNOLOGICAL RESPONSE AND VIRAL CLEARANCE 21 
2.4 
OTHER OBJECTIVES 
21 
3 
INVESTIGATIONAL PRODUCT 
21 
3.1 
TEST ARTICLE 
21 
3.2 
TREATMENT REGIMEN 
22 
4 
STUDY DESIGN 
24 
4.1 
OVERVIEW 
22 
4.2 
RANDOMIZATION TO TREATMENTS 
23 
4.3 
MONITORING TOXICITY 
23 
4.4 
INTERRUPTION 
24 
4.5 
STOPPING RULES 
24 
4.6 
EMERGENCY UNBLINDING 
24 
5 
SUBJECT ENROLLMENT AND STUDY DURATION 
26 
5.1 
SUBJECT POPULATION, RECRUITMENT, AND INFORMED CONSENT PROCESS 
26 
5.2 
PACE OF ENROLLMENT 
28 
5.3 
STUDY DURATION 
28 
6 
STUDY VISITS 
26 
6.1 
SCHEDULING STUDY VISITS 
26 
6.2 
STUDY VISIT WINDOWS 
26 
6.3 
STUDY VISIT LOCATIONS 
27 
6.4 
SCREENING VISIT 
28 
6.5 
VACCINATION VISITS (VISITS 1-4) 
29 
6.6 
INTERIM CONTRACEPTIVE USE REMINDER LETTER 
30 

IRB# 202790 A phase II clinical trial of PepCan 
PI: Mayumi Nakagawa, MD, PhD 
Site: UAMS OBGYN Clinics, UAMS Winthrop P. Rockefeller Cancer Institute 
Funding Source: NIH (NCI) 
Sponsor: UAMS 
Version: 19 
Date: January 19, 2023 
Page 3 
6.7 
6-MONTH VISIT 
31 
6.8 
INTERIM CONTRACETIVE USE REMINDER LETTER 
31 
6.9 
12-MONTH VISIT 
33 
6.10 OPTIONAL LEEP VISIT 
32 
6.11 OPTIONAL FOLLOW-UP VISITS 
35 
6.12 IF THE SUBJECT DID NOT COMPLETE THE STUDY 
33 
7 
SUBJECT COMPENSATION 
33 
7.1 
COMPLETERS AND NON-COMPLETERS, TRAVEL STIPENDS AND ANNUAL LIMITS 33 
8 
OUTCOME MEASURES 
37 
8.1 
CLINICAL ASSESSMENTS (UAMS PATHOLOGY LABORATORY) 
34 
8.2 
VIROLOGICAL STUDY-HPV-DNA TESTING (NAKAGAWA LABORATORY) 
34 
8.3 
IMMUNOLOGICAL ASSESSMENTS 
37 
9 
DATA ANALYSIS 
36 
9.1 
ASSESSING EFFICACY 
36 
9.2 
ASSESSING SAFETY: SUMMMARY OF ADVERSE EVENTS 
36 
9.3 
ASSESSING IMMUNOLOGICAL RESPONSE AND VIRAL CLEARANCE 
36 
9.4 
FACTORS CONTRIBUTIONG TO STUDY RECRUITMENT AND RETENTION 
37 
9.5 
FACTORS PREDICTING CLINICAL RESPONSE AND VIRAL CLEARANCE 
37 
10 
DATA AND SAFETY MONITORING PLAN 
37 
10.1 DEFINITIONS 
37 
10.2 ADVERSE EVENTS MONITORING 
38 
10.3 REPORTING ADVERSE EVENTS 
38 
11 
PROTOCOL DEVIATION AND PROTOCOL VIOLATION 
39 
11.1 
DEFINITIONS 
43 
11.2 
REPORTING PROTOCOL DEVIATIONS AND PROTOCOL VIOLATIONS 
43 
12 
ETHICAL CONSIDERATIONS AND REGULATORY COMPLIANCE 
39 
12.1 
HUMAN SUBJECT PROTECTION 
39 
12.2 
UAMS IRB AND PROTOCOL REVIEW AND MONITORING COMMITTEE (PRMC) 
39 
12.3 
INFORMED CONSENT 
44 
12.4 
STUDY DOCUMENTATION AND STORAGE 
44 
12.5 
STUDY REGISTRATION AND PUBLICATIONS 
44 
13 
REFERENCES 
45 
14 
APPENDIX 
46 
14.1 APPENDIX 1. SCHEDULE OF STUDY ASSESSMENTS 
49 
 
 

IRB# 202790 A phase II clinical trial of PepCan 
PI: Mayumi Nakagawa, MD, PhD 
Site: UAMS OBGYN Clinics, UAMS Winthrop P. Rockefeller Cancer Institute 
Funding Source: NIH (NCI) 
Sponsor: UAMS 
Version: 19 
Date: January 19, 2023 
Page 4 
GLOSSARY OF ABBREVIATIONS 
 
AE 
Adverse Event 
ALT 
alanine transaminase 
ANGELS 
UAMS Antenatal Guidelines, Education and Learning System 
AST 
aspartate transaminase 
BMI 
body mass index 
Bx 
biopsy 
cGMP 
current good manufacturing practice 
CBC 
complete blood count 
CIN 
cervical intraepithelial neoplasia (Grade 1, 2, or 3) 
CLARA 
CLinicAl Research Administrator 
COD 
clinically optimal dose 
CRF 
case reporting form 
CTCAE 
Common Terminology Criteria for Adverse Events 
CTL 
cytotoxic T-lymphocyte 
DNA 
deoxyribonucleic acid 
DC 
dendritic cell 
DLT 
dose limiting toxicity 
ECC 
endocervical curettage 
EDTA 
ethylenediaminetetraacetic acid 
ELISPOT 
enzyme-linked immunospot 
FACS 
fluorescence-activated cell sorting 
FDA 
United States Food and Drug Administration 
GCP 
good clinical practice 
GGT 
gamma-glutamyl transpeptidase 
GLP 
good laboratory practice 
HIV 
human immunodeficiency virus 
HLA 
human leukocyte antigen 
HSIL 
high-grade squamous intraepithelial lesion 
HPV 
human papillomavirus 
HPV 16 
human papillomavirus type 16 
IFN-γ 
interferon-γ 
IND 
investigational new drug 
IOD 
immunologically optimal dose 

IRB# 202790 A phase II clinical trial of PepCan 
PI: Mayumi Nakagawa, MD, PhD 
Site: UAMS OBGYN Clinics, UAMS Winthrop P. Rockefeller Cancer Institute 
Funding Source: NIH (NCI) 
Sponsor: UAMS 
Version: 19 
Date: January 19, 2023 
Page 5 
IRB 
institutional review board 
LEEP 
loop electrical excision procedure 
LCs 
Langerhans cells 
LSIL 
low-grade squamous intraepithelial lesion 
MDSC 
myeloid-derived suppressor cells 
MTD 
maximum tolerated dose 
NIH 
National Institutes of Health 
NCI 
National Cancer Institute 
NS 
not significant 
NSAIDS 
non-steroidal anti-inflammatory drugs 
OBGYN 
Obstetrics and Gynecology 
OR 
Operating Room 
Pap 
Papanicolaou 
PBMC 
peripheral blood mononuclear cell 
PCR 
polymerase chain reaction 
PI 
principal investigator 
PPD 
purified protein derivative  
PRMC 
Protocol Review and Monitoring Committee 
SIL 
squamous intraepithelial lesion 
Treg 
regulatory T-cells 
UAMS 
University of Arkansas for Medical Sciences 
UPT 
urine pregnancy test 
WPRCI 
Winthrop P. Rockefeller Cancer Institute 
 
 

IRB# 202790 A phase II clinical trial of PepCan 
PI: Mayumi Nakagawa, MD, PhD 
Site: UAMS OBGYN Clinics, UAMS Winthrop P. Rockefeller Cancer Institute 
Funding Source: NIH (NCI) 
Sponsor: UAMS 
Version: 19 
Date: January 19, 2023 
Page 6 
1 
BACKGROUND 
 
STUDY SYNOPSIS 
Title 
A Phase II Clinical Trial of PepCan Randomized and Double-Blinded to Two 
Therapy Arms for Treating Cervical High-Grade Squamous Intraepithelial Lesions 
IRB Number 
202790 
Methodology 
This is a Phase II study to evaluate the efficacy and safety of an HPV therapeutic 
vaccine called PepCan (HPV 16 E6 peptides combined with Candida skin testing 
reagent called Candin®) in adult females over a 12-month time period. As the 
results from the Phase I trial demonstrated some efficacy against non-16 HPV types, 
Candin® alone will also be tested. Therefore, there will be two treatment arms: (1) 
PepCan and (2) Candin®. Subjects found to be eligible for vaccination will be 
randomized in a double-blinded fashion at a 1:1 ratio. Each subject will be receiving 
injections four times with three weeks between injections. Clinical and virological 
responses will be assessed at 6- and 12-months. Safety will be assessed from the 
time of enrollment to 12-Month Visit. Immunological assessments will be made at 
4 time points (prevaccination, after 2 injections, 6 months after 4 injections and 12 
months after 4 vaccinations). 
Study Duration 
66 months 
Study Center 
University of Arkansas for Medical Sciences 
Objectives 
Primary Objective - To evaluate the efficacy of PepCan in humans 
Secondary Objectives - To evaluate the safety of PepCan in humans 
Tertiary Objective - To evaluate immunological response and viral clearance 
Other Outcome Measures - To identify factors predicting clinical and virological 
responses to PepCan; to evaluate vaccine effect; to examine mechanisms of cross-
protection 
Outcome Measures 
Primary Outcome Measure: Clinical response as assessed by histological regression 
of HSIL at 12 months 
Secondary Outcome Measure: Safety 
Tertiary Outcome Measures: Immunological response and viral clearance 
Other Outcome Measures: Predicting vaccine response using various factors such 
as age, oral contraceptive use, smoking history, circulating immune cells, HLA 
types, HPV types, bacterial taxa, and cytokine/chemokine profiling; evaluating 
vaccine effect; determining cross-protection and examining epitope-spreading and 
cross-reactivity as possible mechanisms 
Number of Subjects 
125 adult women will be screened; up to 80 women will participate in the 
vaccination phase and will be randomized to PepCan and Candin® arms 
Diagnosis 
and 
Main 
Inclusion Criteria 
Recent Pap smear result consistent with HSIL or “cannot rule out HSIL” or recent 
untreated colposcopy guided biopsy-confirmed HSIL 
Eligibility for Vaccination 
Recent untreated colposcopy guided biopsy-confirmed HSIL 
Study 
Product(s), 
Dose, 
Route, Regimen 
Test Article: Vaccine consisting of four HPV 16 E6 peptides in combination with 
Candin® (PepCan) or Candin® alone 
Route of Administration: Intradermal injection 
Peptide Dose Level: 50 µg/peptide/injection based on the clinically optimal dose 
from the Phase I study 
Candin® Dose Level: 300 µl/injection for PepCan and Candin® groups 
Dosing Regimen: 4 injections; three weeks between each injection 
Injection site: Limbs 
Statistical Methodology 
Clinical response data (PepCan or Candin®) will be compared to a historical 
placebo control group from a similarly designed clinical trial using appropriate 
statistical tests; measures of safety will be evaluated using descriptive statistics. 
 
 

IRB# 202790 A phase II clinical trial of PepCan 
PI: Mayumi Nakagawa, MD, PhD 
Site: UAMS OBGYN Clinics, UAMS Winthrop P. Rockefeller Cancer Institute 
Funding Source: NIH (NCI) 
Sponsor: UAMS 
Version: 19 
Date: January 19, 2023 
Page 7 
 
SUMMARY 
Cervical cancer is the fourth most common malignancy in women worldwide, and 528,000 new 
cases are diagnosed annually and approximately 266,000 deaths occur annually from the disease 
[1]. The link between human papillomavirus (HPV) infection and the development of cervical 
cancer is well known [2]. Among more than 100 different types of HPV, at least 15 are strongly 
associated with invasive squamous cell cancer of the cervix [3], with human papillomavirus type 
16 (HPV 16) being the most common of these [4-6]. HPV infection is also associated with the 
precursor lesion of cervical cancer, squamous intraepithelial lesion (SIL) [4-9]. Most low-grade 
squamous intraepithelial lesions (LSILs) regress spontaneously [10, 11], though some do progress 
to high-grade squamous intraepithelial lesions (HSILs). These high-grade lesions, particularly 
cervical intraepithelial neoplasia (CIN) 3, are associated with high rates of progression to invasive 
cervical cancer [12, 13]. 
 
Although prophylactic vaccines that would prevent HPV infection and subsequent development of 
cervical cancer are available, they are not effective in individuals who already have acquired HPV. 
Therefore, a therapeutic vaccine, which can treat those who are already infected, including women 
diagnosed with HSIL, is needed but none is clinically available. Such a vaccine would be expected 
to benefit young women (narrowly defined as ≤24 years old and broadly defined as any women 
who still plans to become pregnant[14]) since a recently recognized and unintended side effect of 
surgical treatments for HSIL such as LEEP is increased incidence of preterm delivery from 4.4% 
to 8.9%[14, 15]. Therefore, the new treatment guidelines published in 2013 recommends one to 
two years of close observation in young women with cervical intraepithelial neoplasia (CIN) 2. 
Furthermore, an HPV therapeutic vaccine, which only requires injections, can benefit women from 
developing regions where surgical expertise may not be available to perform excisional procedures. 
 
Our group has developed a vaccine consisting of four clinical good manufacturing practice (cGMP) 
grade synthetic peptides covering the HPV type 16 E6 protein and Candida skin test reagent as a 
novel vaccine adjuvant (named PepCan). The dose-escalation portion of the Phase I clinical trial of 
the therapeutic vaccine treating women with biopsy-confirmed HSILs has recently been completed 
(the final dose phase using the clinically optimal dose of 50 g per peptide is still ongoing). No 
dose-limiting toxicities (DLTs) [vaccine-related allergic and autoimmune adverse events (AEs) > 
Grade 1 and any other AEs > 2 Grade 2] have been observed. The highest % of histological 
regression was observed in the lowest dose (50 g per peptide) group (5 of 6 or 83%) with the 
overall (50, 100, 250, and 500g per peptide doses were tested) response rate of 52% (12 of 23). 
Both these rates are above that of a historical placebo group of 22% [16]. Both subjects with HPV 
16 and non-16 HPV-positive HSILs responded to PepCan. While we are assessing histological 
response 3 months after vaccination, the full effect takes 1 year [17-19] to manifest as demonstrated 
by increase in histological regression from 25% to 47% of vulvar intraepithelial lesions treated by 
a similar vaccine [18]. 
 
This phase II clinical trial aims to assess the full clinical efficacy of PepCan by assessing response 
at 1 year, to identify factors, which can predict favorable vaccine response, examine vaccine effects, 
and to define against which non-16 HPV types this vaccine is effective. Candin® alone will also 
be examined. Approximately 125 subjects will be screened and 80 subjects will be vaccinated over 
3.5 to 4.5 years. If needed additional year can be added. 
 
 

IRB# 202790 A phase II clinical trial of PepCan 
PI: Mayumi Nakagawa, MD, PhD 
Site: UAMS OBGYN Clinics, UAMS Winthrop P. Rockefeller Cancer Institute 
Funding Source: NIH (NCI) 
Sponsor: UAMS 
Version: 19 
Date: January 19, 2023 
Page 8 
 
SCIENTIFIC RATIONALE 
1.3.1 
Rationale for Using HPV Peptides as the Antigen 
1.3.1.1 Importance of the T-Cell Responses to HPV 16 E6 Protein in Viral Clearance 
The National Cancer Institute (NCI)-supported study conducted by Anna-Barbara Moscicki, MD, 
was one of the first to describe the relationship between viral persistence and development of SILs 
[20-22]. Women were recruited at the San Francisco State University Medical Clinic and the 
Hayward Planned Parenthood Clinic. A total of 654 women were actively followed via clinic visits 
every 4 months. At these visits, a sexual-history interview, Pap smear, colposcopy, and HPV-
deoxyribonucleoic acid (DNA) testing on cervical lavage specimens were performed. Mayumi 
Nakagawa, MD, PhD [principal investigator (PI)], first studied T-cell immunity against HPV in 
this cohort. 
 
HPV 16 E6- and E7-specific cytotoxic T lymphocytes (CTLs) were demonstrated in subjects who 
had evidence of HPV 16 infections but had not developed SILs [23-25]. In a small cross-sectional 
study, the percentage of subjects who demonstrated HPV 16 E6- and/or E7-specific CTLs was 
higher in the group of women with HPV 16 infections without SILs than in the group of women 
with HPV 16 infections who developed SILs [23]. 
 
In women with polymerase chain reaction (PCR)-detected cervical HPV 16 infections (from the 
same cohort described above), we examined the association between HPV 16 E6- and E7-specific 
CTLs and HPV 16 persistence, using a longitudinal study design involving multiple CTL assays 
[25]. Women with HPV 16 infections (n=51) were enrolled, along with women who were HPV 16 
negative as controls (n=3). Twenty-two of 40 (55%) women whose HPV 16 infections had cleared 
each had at least one E6 CTL response, while none of the nine women who had HPV 16 persistence 
had such a response (p=.003). This difference was not demonstrated for E7; 25 of 40 (63%) women 
whose HPV 16 infections cleared had E7 CTL responses, and five of nine (56%) women with 
persistent infections had responses (p=.720). Therefore, the CTL response to E6 appears to be 
important in clearing HPV 16 infection. We also examined whether these T-cells were CD4- 
and/or CD8-positive using antibody blocking and T-cell subset separation experiments, and we 
demonstrated that both CD4- and CD8-positive T-lymphocytes demonstrated anti-HPV activities 
[24]. 
 
In a subsequent study (same cohort) with the same design, we found similar results using ex vivo 
interferon (IFN)-γ enzyme-linked immunospot (ELISPOT) assays instead of CTL assays [26]. 
Fourteen of 24 (58%) women whose HPV 16 infections cleared each had an E6 response at least 
once, while none of 10 (0%) women who had HPV 16 persistence had a response (p=.002). For E7, 
8 of 24 (33%) women whose HPV 16 infections cleared each had an E7 CTL response, and none 
of 10 (0%) women with persistence had such a response (p=.04). These results confirmed the 
importance of T-cell responses to E6 and indicated that E7 may also play a role. 
 
1.3.1.2 Importance of the CD8 and CD4 T-Cell Responses to HPV 16 E6 in Regression of Cervical 
Lesions 
Eighty-five subjects with recent histories of untreated abnormal Pap smears were recruited from 
the University of Arkansas for Medical Sciences (UAMS) Obstetrics and Gynecology Clinics 
between 1/11/07 and 7/15/08. HPV-DNA tests using the Linear Array HPV Genotyping Test 
(Roche Diagnostics, Indianapolis, IN) and ELISPOT assays using the HPV 16 antigens were 
performed on cervical cytology specimens (ThinPrep, Cytyc Corporation, Marlborough, MA) [27, 
28]. From whole-blood–derived peripheral blood mononuclear cells (PBMCs), CD8 T-cell lines 
were established by two rounds of in vitro stimulation of magnetically selected CD8 T-cells with 
autologous mature DCs infected with recombinant vaccinia viruses expressing E6 or E7 (E6-vac 

IRB# 202790 A phase II clinical trial of PepCan 
PI: Mayumi Nakagawa, MD, PhD 
Site: UAMS OBGYN Clinics, UAMS Winthrop P. Rockefeller Cancer Institute 
Funding Source: NIH (NCI) 
Sponsor: UAMS 
Version: 19 
Date: January 19, 2023 
Page 9 
or E7-vac), and the pattern of immunodominance was examined with ELISPOT assays using 15-
mer peptides that overlap by 10 amino acids [28]. Evidence of potential antigenic epitopes was 
defined by spot-forming units greater than twice the amount for the no-peptide control. The subjects 
with subsequent normal histological diagnoses were considered to be regressors (n=28) while those 
with histological diagnoses of CIN 1, 2, or 3 were considered to be persistors (n=37). The 
indeterminate group included subjects (n=20) for whom diagnoses were equivocal (such as atypical 
squamous cells of undetermined significance but not excluding HSIL) or for whom insufficient 
samples were submitted. 
 
CD8 T-cell responses to the HPV 16 E6 antigen were significantly higher for the regressor group 
compared to the persistor group (54% vs. 24%, p=.04), but this was not observed for the E7 antigen 
(11% for the regressor group, 12% for the persistor group; p=1.00). The results were the same when 
the analyses included only subjects who were positive for high-risk HPV (n=48, p=0.01 for E6 and 
p=0.64 for E7). These results suggest not only that CD8 T-cell responses to HPV 16 E6 are 
significantly associated with regression of cervical lesions, but also that such protective responses 
may be cross-reactive among high-risk HPV types. All regions were shown to be immunogenic, 
but immune responses were most frequently detected against E6 91–115 (n=11), E7 46–70 (n=10), 
and E6 46–70 (n=8). Similar results were obtained when CD4 T-cell responses were studied in 84 
additional subjects from the same clinic [29]. Significantly higher responses were seen in the 
regressor group for the E6 antigen compared to the persistor group (45% vs. 20%, p=0.02). Again 
no such difference was seen for E7 (15% vs. 6%, p=0.25). Therefore, HPV 16 E6 protein would be 
an ideal antigen for a therapeutic HPV vaccine. 
 
In vitro investigation has 
unexpectedly revealed that 
the four cGMP peptides 
covering the HPV 16 E6 
protein 
has 
maturation 
effects on Langerhans cells 
(LCs) as measured by up-
regulated 
CD40 
(p=0.00007) 
and 
CD80 
(p<0.00001) levels [30]. 
These maturation effects 
are likely to be due to the 
formation of microparticles 
(Fig. 1) by peptides (which 
are soluble in acidic pH of 
the formulation) at a neutral 
pH. 
As 
insoluble 
microparticles are likely to 
be phagocytosed by LCs 
resulting in their activation and antigen presentation, the immediate and delayed injection site 
reactions observed during the Phase I clinical trial (Fig. 1) may be due to these microparticles. 
 
 
Fig. 1 Vaccine properties. A. Microparticles formed when the vaccine 
peptides with and without adjuvant were placed in neutral pH in vitro. B. 
A delayed injection site reaction appearing 5 days after the 1st injection 
at the 50-µg dose. Such reactions are treated with ice packs and topical 
steroid cream. 
A 
B 
 
 

IRB# 202790 A phase II clinical trial of PepCan 
PI: Mayumi Nakagawa, MD, PhD 
Site: UAMS OBGYN Clinics, UAMS Winthrop P. Rockefeller Cancer Institute 
Funding Source: NIH (NCI) 
Sponsor: UAMS 
Version: 19 
Date: January 19, 2023 
Page 10 
1.3.2 
Rationale for Using Candin® as a Vaccine Adjuvant 
1.3.2.1 Search for a New and Effective Vaccine Adjuvant 
Four current good manufacturing practice (cGMP)-grade synthetic peptides, covering the HPV 16 
E6 protein, are incorporated into PepCan since it has been shown to contain CD8 and CD4 epitopes 
associated with SIL regression. The advantages of using synthetic peptides are (1) ease of 
producing cGMP-grade material, (2) general safety profiles in previous clinical trials [31-38], and 
(3) much lower concern for oncogenicity of the E6 protein, which have mutagenic properties as 
whole proteins. 
 
The most widely used adjuvant in approved human vaccines is an alum-based adjuvant that has 
been shown to elicit a predominantly Th2 immune response [39]. Therefore, the alum-based 
adjuvant would be useful in a vaccine designed to boost antibody responses, but not for a vaccine 
designed to stimulate cellular immune responses. Since successful clearance of HPV infection is 
believed to be induced by cell-mediated immunity 17, 18, an adjuvant that would promote such 
immunity is necessary. 
 
Traditionally, recall antigens, which typically include a panel of Candida, mumps, and 
Trichophyton, were used as a control to indicate an intact cellular immunity when patients were 
being tested for Tuberculosis by placement of PPD intradermally. T-cell mediated inflammation 
would become evident in 24 to 48 hours [40]. A number of studies, mostly from UAMS, have 
demonstrated that recall antigen injections can also be used to treat common warts [41-46]. 
Furthermore, several studies have shown that the treatment of warts with recall antigens to be 
effective for not only injected warts but also distant untreated warts [41-45, 47]. This suggested 
that T-cells may have a role in wart regression. In a recently completed Phase I investigational new 
drug study (NCT00569231) in which the largest wart was treated with Candin® (Allermed, San 
Diego, CA), a colorless extract of Candida albicans, our group reported complete resolution of the 
treated warts in 82% (nine of 11) of the subjects, and complete resolution of distant untreated warts 
in 75% (six of eight) of the subjects [47] Furthermore, T-cell responses to the HPV 57 L1 peptide 
were detected in 67% (six of nine) of the complete responders. Because of these immune-enhancing 
and possible anti-HPV effects of Candin®, the idea of using Candin® as a vaccine adjuvant came 
about. In vitro work performed by Dr. Nakagawa’s group showed that Candin® has T-cell 
proliferative effect, and that the most frequently produced cytokine by LCs exposed to Candin® 
with and without vaccine peptides was interleukin -12 (IL-12), which promotes T-cell response 
[30, 48] 
 
1.3.3 
Preclinical Safety Data for the Use of HPV Peptides-Candin® Vaccine in Mice 
1.3.3.1 Rationale 
Although Candin® antigen is FDA-approved for human use, the HPV peptide-Candin® 
combination has never been tested. HPV 16 E6 protein has been known to mount T-cell immunity 
in C57BL/6 mice, so we chose this animal model to evaluate safety and immunogenicity of the 
putative vaccine [49]. Only female mice were examined because the vaccine is being developed 
for women. 
 
1.3.3.2 Approach 
The safety of the HPV peptide-Candin® combination was examined in mice by a multiple-dose 
toxicity study (GLP). The 25 and 50 g per peptide doses (corresponding to the two highest doses 
to be used in the human clinical trial) were used, which were 25 times the human equivalent when 
adjusted for body surface area. These studies were conducted at the Southern Research Institute. 
 
 

IRB# 202790 A phase II clinical trial of PepCan 
PI: Mayumi Nakagawa, MD, PhD 
Site: UAMS OBGYN Clinics, UAMS Winthrop P. Rockefeller Cancer Institute 
Funding Source: NIH (NCI) 
Sponsor: UAMS 
Version: 19 
Date: January 19, 2023 
Page 11 
1.3.3.3 Methods 
Formulation: Because the CD4 and CD8 T-cell responses to HPV 16 E6 protein are significantly 
associated with cervical lesion regression [27, 29], the proposed vaccine will consist of four HPV 
16 E6 peptides: 
 
E6 1–45 (Ac-MHQKRTAMFQDPQERPRKLPQLCTELQTTIHDIILECVYCKQQLL-NH2) 
E6 46–80 (Ac-RREVYDFAFRDLCIVYRDGNPYAVCDKCLKFYSKI-NH2) 
E6 81–115 (Ac-SEYRHYCYSLYGTTLEQQYNKPLCDLLIRCINCQK-NH2) 
E6 116–158 (Ac-PLCPEEKQRHLDKKQRFHNIRGRWTGRCMSCCRSSRTRRETQL-NH2) 
(US Patent No. 8,652,482). 
 
The cGMP-grade peptides were produced by CPC Scientific (San Jose, CA). They were 
formulated, vialed, and lyophilized at 550 µg per peptide by Integrity Bio, Inc. (Camarillo, CA), 
and were reconstituted with 770 µL of sterile water per vial. After adding Candin®, the mixture 
was mixed lightly prior to inoculation. 
 
Schedule: Four administrations 3 weeks apart were planned for the 
Phase I trial; therefore, we performed five administrations in the 
animal study as recommended, but the frequency was shortened to 
weekly inoculations (days 1, 8, 15, 22, and 29). The dorsal side of 
each animal was divided into four areas, and the animals were dosed 
using a volume of 100 µL/mouse on each dosing day. The dose on 
each day was split approximately equally between two sites (areas 
1 and 2 on days1, 15, and 29; areas 3 and 4 on days 8 and 22) as 
shown in Fig. 2. 
 
Route: Intradermal administration. 
 
1.3.3.4 Results 
All mice in all dose groups survived to scheduled necropsy. 
Administration of vehicle, Candin®, low or high dose peptides 
without Candin®, or low or high dose peptides with Candin® had 
no effect on body weights, body temperatures, food consumption, 
or absolute or relative organ weights of mice. Clinical signs 
associated with treatment included scabs and sore/ulcer at the 
dosing sites; these signs appeared shortly after dosing, and resolved within a few days after 
appearance. Scabs and sore/ulcer at the dosing sites appeared sporadically in all dose groups 
(including the vehicle control) with no dose response in incidence, and were therefore considered 
to have been due to the treatment procedure itself rather than to the peptides, Candin®, or the 
combination. The only change in clinical pathology parameters that was considered to be 
potentially related to peptide and adjuvant administration was a statistically significant but minimal 
elevation in the mean eosinophil count that was observed on Day 32 for mice treated with 50 µg of 
each of the four peptides with Candin®, compared to the mean value for mice in the vehicle control 
group. This finding was transient and was not reported on Day 60. Microscopic observations on 
Day 32 of test article-related lesions were found in mice that received any formulations containing 
peptides (Groups 3-6) and included chronic-active inflammation consisted of infiltrations of 
neutrophils, eosinophils, and mononuclear cells. The findings on Day 60 were more chronic in 
nature. Primarily mononuclear cells were seen with scattered neutrophils and eosinophils. 
Treatment with the peptides with or without Candin®, and treatment with Candin® alone had no 
effect on the ability of spleen cells to secrete IFN-γ following overnight stimulation. The only test 
Fig. 2. Areas of serial 
injections in mice. 
 

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Site: UAMS OBGYN Clinics, UAMS Winthrop P. Rockefeller Cancer Institute 
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Version: 19 
Date: January 19, 2023 
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article-related macroscopic lesion observed was a crust on Day 32 at the cranial injection site of 
one animal that was treated with 50 µg of each peptide without Candin®, and one animal that was 
treated with 50 µg of each peptide with Candin®. In conclusion, the only toxicity observed was 
transient minimal eosinophil elevation in animals receiving 50-µg peptide with Candin® compared 
to the vehicle control. This was accompanied by local injection site inflammation (including 
eosinophil infiltration) on Day 32. 
 
Table 1. Six groups examined in the multiple-dose toxicology study 
Group 
Treatment 
Antigens Dose 
(μg/mouse) 
Adjuvant Dose 
(μL/mouse) 
Total Volume 
(μL/mouse) 
Number of Animals 
Day 32 
Core 
Day 60 
Recovery 
1 
Vehicle control 
0 
0 
100 
10 F 
10 F 
2 
Adjuvant alone 
0 
30 
100 
10 F 
10 F 
3 
Antigens alone 
25 
0 
100 
10 F 
10 F 
4 
Antigens alone 
50 
0 
100 
10 F 
10 F 
5 
Antigens + Adjuvant 
25 
30 
100 
10 F 
10 F 
6 
Antigens + Adjuvant 
50 
30 
100 
10 F 
10 F 
*Core, sacrificed 3 days after injection. †Recovery, sacrificed 4 weeks after the last injection. F, female. 
 
Table 2. Summary of adverse events from the Phase I clinical trial of PepCan 
 

IRB# 202790 A phase II clinical trial of PepCan 
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Site: UAMS OBGYN Clinics, UAMS Winthrop P. Rockefeller Cancer Institute 
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Sponsor: UAMS 
Version: 19 
Date: January 19, 2023 
Page 13 
 
 
a appearing < 24 hours from time of vaccination includes site pain, redness, swelling, welt, tenderness, itching. burning, warmness of various grades 
b appearing ≥ 24 hours from time of vaccination; Includes site pain, redness, swelling, welt, tenderness, itching, burning. warmness of various grades 
c feeling warm without evidence of temperature ≥ 38.0° 
u Unrelated adverse event; number of events and subjects presented 
 
 

IRB# 202790 A phase II clinical trial of PepCan 
PI: Mayumi Nakagawa, MD, PhD 
Site: UAMS OBGYN Clinics, UAMS Winthrop P. Rockefeller Cancer Institute 
Funding Source: NIH (NCI) 
Sponsor: UAMS 
Version: 19 
Date: January 19, 2023 
Page 14 
 
SUMMARY OF PHASE I CLINICAL TRIAL 
1.4.1 
Methods 
A single-arm, open-label, phase I clinical trial was performed to evaluate the safety of PepCan in 
adult females with biopsy-confirmed HSIL. A dose-escalation phase has been completed in which 
doses of 50, 100, 250, and 500 g/peptide/dose (6 subjects/dose level; 4 doses/subject with 3 weeks 
between each dose) were evaluated to determine the maximum tolerated dose (MTD), the clinically 
optimal dose (COD), and the immunologically optimal dose (IOD). Blood was drawn for CD3 
ELISPOT (to assess CD4 and CD8 responses) and immune suppressor cell analysis before and after 
the second and fourth injections. HPV-DNA testing was performed before and after the four 
injections. Clinical response was assessed by performing LEEP excision approximately 3 months 
after the fourth injection. Subjects who no longer had HSILs were considered to be complete 
responders, and those with HSILs measuring ≤ 0.2mm2 were considered to be partial responders. 
The final dose phase in which additional 10 subjects were vaccinated at the COD dose of 50 
g/peptide/dose was also performed. 
 
1.4.2 
Accrual 
At the end of the Phase I study, 52 subjects were enrolled, and 34 received the vaccine. Thirty-one 
subjects completed the study (mean age of 30.8 ± 6.7 years old). 
 
1.4.3 
Safety 
One hundred thirty-two injections have been given to 34 subjects. No vaccine-related DLTs were 
reported. The most common AEs were injection-site reactions both immediate and delayed (Table 
2, Fig. 1). Although delayed injection-site reaction was defined as occurring at or more than 24 
hours after injection, it was not uncommon for it to appear a few to several days after injection. 
More Grade 2 immediate and delayed injection site reactions, but not delayed injection-site 
reactions, were recorded at the higher two doses compared to the lower two doses(odds ratio of 6.3 
[1.98, 20.3], p<0.0001, for the immediate reaction; and 2.0 [0.6, 7.1], p=0.3, for the delayed 
reaction). In most cases, the injection-site reactions were are easily managed by applying icepacks 
and topical over-the-counter steroid cream. These reactions do not seem to be delayed-type 
hypersensitivity reaction, which should appear within 72 hours. Based on the timing of their 
appearance, these reactions may be manifestation of de novo immune stimulation [50]. 
 
Other vaccine-related or possibly vaccine-related adverse events, which occurred with ≥ 5% of 
injections, in the order of decreasing number of occurrences, were myalgia, headache, nausea, 
fatigue, hypokalemia, feeling feverish, and flu-like symptoms (Table 2). None of these adverse 
events was more than grade 2; these adverse events were self-limiting. One subject experienced 
asymptomatic hypokalemia requiring treatment with oral replacement potassium (Micro-K 10 mEq 
per day for 7 days) during the vaccination phase. Her potassium level increased from 3.0 mEq/L to 
3.4 mEq/L within 3 weeks, and normalized to 3.8 mEq/L within 3 months. 
 
1.4.4 
Clinical response 
The histological response rates in order of increasing doses were 50%, 50%, and 33%, and 40% 
(Table 3). The overall histological response rate was 45%, and none progressed to cervical 
squamous cell carcinoma. In comparison, a historical placebo group in another clinical trial of HPV 
therapeutic vaccine with a similar study reported a regression rate of 22% [No statistically 
significant differences were detected when histological response rates were compared (1) between 
subjects with entry diagnosis of CIN 2 versus CIN3, (2) between subjects ≤ 25 years of age versus 
> 25 years of age, and (3) between subjects who were HPV-16-positive versus those who were not. 

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Site: UAMS OBGYN Clinics, UAMS Winthrop P. Rockefeller Cancer Institute 
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The mean number of cervical quadrants with visible lesions decreased significantly from 1.9 
quadrants to 0.8 quadrants after vaccination (p=0.001). 
 
1.4.5 
Viral clearance 
At least one HPV type present at entry became undetectable in 21 of 31 (70%) patients (Table 3). 
By doses, the rates were 85%, 50%, 50%, and 40% with the highest undetectability at the lowest 
dose. 
 
1.4.6 
Immunological response 
1.4.6.1 Systemic 
Immunological responses to HPV-16 E6, as measured by IFN-γ ELISPOT assay, were similar 
among the first 3 dose levels in terms of detecting positive response to at least one new E6 region 
and for the increase in response being statistically significant (Table 3). The lowest response rate 
was observed in the 500-μg dose level. No immunodominant HPV-16 E6 region was identified and 
the number of regions to which new immune responses were detected was also variable (Fig. 3). 
 
Immune profiling (Fig. 4, upper panel) showed statistically significant increases in circulating Th1 
cells after 2 (p=0.02) and 4 vaccinations (p=0.0004). Th2 cells initially increased significantly 
(p=0.01) but decreased to below baseline level after 4 vaccinations, although not significantly. Treg 
levels were minimally changed. The differences in Treg levels prevaccination (p=0.03) and post-2 
vaccinations (p=0.04) between these two groups were statistically significant (Fig. 4, lower panel). 
 
Fig. 3 HPV 16 E6- and E7-specific CD3 T-cell responses before vaccinations, after 2 vaccinations, and after 4 
vaccinations. T-cell lines were established by stimulating CD3 T-cells with autologous dendritic cells pulsed with 
HPV 16 E6-vac, E6-GST, E7-vac, and E7-GST. Samples from different visits were tested with overlapping peptides 
in the same ELISPOT assay, and each region was tested in triplicate. Results are shown for subjects with statistically 
significant increases to the E6 peptides, and the regions with significant increases (paired t-test) are marked by “*”. 
Subjects 4 and 11 also had a significant increase to E7 (marked by “e”), which may represent the first examples of 
d
h
 
 

IRB# 202790 A phase II clinical trial of PepCan 
PI: Mayumi Nakagawa, MD, PhD 
Site: UAMS OBGYN Clinics, UAMS Winthrop P. Rockefeller Cancer Institute 
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Page 16 
Table 3. Summary of results from the dose-escalation Phase I clinical trial 
Characteristics\Dose (n) 
50 μg (14) 
100 μg (6) 
250 μg (6) 
500 μg (5) 
All (31) 
Histological regression, % (n) 
 
 
 
 
 
Responders 
50 (7) 
50 (3) 
33 (2) 
40 (2) 
45 (14) 
Virological responsea,b, % (n) 
 
 
 
 
 
Responders 
85 (11) 
50 (3) 
50 (3) 
40 (2) 
70 (21) 
Immunological response, % (n) 
 
 
 
 
 
New responsec to HPV-16 E6 
64 (9) 
67 (4) 
83 (5) 
20 (1) 
61 (19) 
Significant responsed to HPV-16 E6 
43 (6) 
50 (3) 
50 (3) 
20 (1) 
42 (13) 
a At least one HPV type detected at entry became undetectable at exit 
b One subject had no HPV detected at entry in the 50 μg group 
c New response was detected after vaccination but not prior to initiation of vaccination 
d Significant response had p < 0.05 using Student’s t-test comparing values before and after vaccination 
 
 
1.4.6.2 Cervical 
In the cervix, the number of Tregs were lower in histological responders in the epithelium and the 
underlying stroma, but not significantly (Fig. 5). 
 
 
Fig. 4 FACS analysis of peripheral immune cells. The upper panel show systemic Th1, Th2, and Treg before, after 
2, and after 4 vaccinations. In the lower panel, responders are indicated by filled circles while non-responders are 
indicated by filled squares. None of the subjects with prevaccination Treg levels ≥ 0.7% was a vaccine responder. 
Cells were first stained with antibodies for surface markers CD3, CD4, and CD25. Staining for intracellular T-bet, 
GATA3, and Foxp3 was performed with the Foxp3 staining kit according to the manufacturer’s instructions 
(eBioscience). Th1 cells were expressed as a percentage of CD4 cells positive for T-bet, Th2 cells as a percentage 
of CD4 cells positive for GATA3, and Treg cells as a percentage of CD4 cells positive for CD25 and Foxp3. Paired 
t-test (upper panel) or Wilcoxon rank-sum test (lower panel) was used. 
 
 

IRB# 202790 A phase II clinical trial of PepCan 
PI: Mayumi Nakagawa, MD, PhD 
Site: UAMS OBGYN Clinics, UAMS Winthrop P. Rockefeller Cancer Institute 
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Sponsor: UAMS 
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Date: January 19, 2023 
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Fig. 5 Regulatory T-cells in lesional cervical epithelium and the underlying stroma. FoxP3 nuclear staining cells, 
in lesions (cervical intraepithelial neoplasia 1, 2, and/or3) remaining after vaccination or representative region if 
no lesions remaining, were counted. The FoxP3 staining cells were also counted in the underlying stroma. The bars 
represent stand error of means. 
 
 
 
RATIONALE FOR PHASE II CLINICAL TRIAL 
1.5.1 
Need for HPV Therapeutic Vaccines 
Although numerous preclinical and clinical trials have evaluated prophylactic HPV vaccines during 
the past few decades, these vaccines do not help those who already have established HPV infections 
[51]. Gardasil, a quadrivalent HPV L1 virus-like particle prophylactic vaccine (HPV types 16, 18, 
6, and 11), was the first to be FDA-approved in 2006; a bivalent version (HPV types 16 and 18), 
Cervarix, was approved by the FDA three years later. Clinical trials have demonstrated excellent 
vaccine efficacy in women negative for HPV 16 or HPV 18[52, 53], but the duration of protection 
remains to be determined, and a study of the bivalent vaccine showed no evidence of enhanced 
viral clearance in women with pre-existing HPV infections (n=1,259; 35.5% clearance in 
vaccinated group, 31.5% in a group receiving a negative control vaccine, p=NS) [51]. Therefore, 
therapeutic vaccines are needed for cases in which HPV infection is already established and in 
which HPV-related diseases have already developed. This is the particularly true because the 
prophylactic vaccine coverage rate in the targeted group (girls aged 13–17 years) has been reported 
to be only 32% nationally [54]. Although the standard surgical treatments for HSILs such as LEEP 
are very effective [14], their unintended side effect of increased incidence of preterm delivery from 
4.4% to 8.9% [14, 15] has become a concern. Henceforth, the latest guideline no longer 
recommends treatment for CIN2 in young women (narrowly defined as ≤24 years old and broadly 
defined as any women who still plans to become pregnant [14]). Treatment is still recommended 
for CIN3 but observation is now considered acceptable. A new treatment, which does not alter the 
anatomical integrity of the cervix like the HPV therapeutic vaccine, is very much needed. In short, 
HPV therapeutic vaccines are needed because (1) prophylactic vaccines are not effective against 
established HPV infection, (2) utilization of the prophylactic vaccines has been low, (3) therapeutic 
vaccines would leave the cervix intact and would likely not increase the risk of preterm deliveries, 
and (4) therapeutic vaccine maybe effective against other cancers caused by HPV such as anal, 
oropharyngeal, penile, vaginal, and vulvar cancers. 

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PI: Mayumi Nakagawa, MD, PhD 
Site: UAMS OBGYN Clinics, UAMS Winthrop P. Rockefeller Cancer Institute 
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Sponsor: UAMS 
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Date: January 19, 2023 
Page 18 
1.5.2 
Rationale for Proposed Dose of HPV Peptides 
In the Phase I clinical trial, four dose levels (50, 100, 250, and 500 g per peptide) were tested. 
These four dose levels were chosen based on information available in the literature. Published 
studies of clinical trials using various peptide vaccines reported using doses that range from 5–
3,000 g per peptide [31-38]. Optimal doses (and smaller doses if two dose levels were the same) 
for achieving immunogenicity differed greatly among the vaccines: 30 g of 96-mer malaria 
peptide [31], 500 g of 9-mer peptide for treating prostate cancer [34], 50 g each of 13 HPV 16 
E6 and E7 peptides ranging from 25 to 35 amino acids long [35]. Therefore, the dose levels likely 
to elicit the optimal immunogenicity were chosen. 
 
The dose-escalation portion of the Phase I clinical trial has demonstrated that the 50 
g/peptide/injection was optimal in terms of histological regression, viral clearance, and vaccine-
induced immune responses (Table 3). Therefore, this dose will be used for the Phase II clinical 
trial. 
 
1.5.3 
Rationale for Proposed Dose of Candin® 
Three hundred (300) µL of Candin® will be administered per injection, which was the amount used 
for intralesional injection of warts [47, 55], as well as the amount of Candin® as a vaccine adjuvant 
in the Phase I clinical trial. The same amount will be used for the Phase II clinical trial as this 
amount has been shown to be safe and effective. 
 
1.5.4 
Rationale for Proposed Route of Injections 
Intradermal route of administration will be used to make use of LCs as antigen-presenting cells. A 
Phase I clinical trial of a peptide vaccine for prostate cancer administered through this route has 
shown promising immunogenicity [34]. This route has also been shown to be safe, effective, and 
immunogenic in the Phase I clinical trial, and will be used for the Phase II clinical trial. 
 
1.5.5 
Rationale for Proposed Site of Injections 
Extremities have been chosen as the site of administration because of the ease of access as well as 
availability of sufficient data demonstrating efficacy of HPV peptides delivered at these sites [35, 
56]. As injecting in limbs has shown to be safe, effective, and immunogenic in the Phase I clinical 
trial, the same sites will be used for injection in the Phase II clinical trial. 
 
1.5.6 
Rationale for Number of Injections 
In published studies of peptide vaccines, the total number of injections ranged from 2 to 17 [31-
38]. We proposed to use four injections because Hueman et al. demonstrated that immunogenicity 
peaked after four injections (six injections in total were given in the study) [34], and four injections 
appeared to be sufficient in the Phase I clinical trial. 
 
1.5.7 
Rationale for Interval between Injections 
The interval between injections ranged from 2 weeks to 90 days in the published studies [31-38], 
but most used a 3-week interval. Kenter and colleagues reported that peptide vaccine 
immunogenicity measured by IFN- ELISPOT assay was less prevalent when blood samples were 
drawn 7 days after the last vaccination but was higher when they were drawn 3 weeks after the last 
vaccination [35]. Therefore, we chose the 3-week (± 7 days) interval because it appears to be long 
enough to allow sufficient mounting of immune responses. As this interval has been shown to be 
safe, effective, and immunogenic, the same interval will be used in the Phase II clinical trial. 
 
 

IRB# 202790 A phase II clinical trial of PepCan 
PI: Mayumi Nakagawa, MD, PhD 
Site: UAMS OBGYN Clinics, UAMS Winthrop P. Rockefeller Cancer Institute 
Funding Source: NIH (NCI) 
Sponsor: UAMS 
Version: 19 
Date: January 19, 2023 
Page 19 
1.5.8 
Rationale for Interval between the Last Injection and Final Histologic Assessment 
While histological response was assessed 3 months after the last vaccination by performing LEEP 
in the Phase I clinical trial, the full effect is known to take 1 year [17-19] . In the Phase II clinical 
trial, PepCan will be administered as an alternative to LEEP, and histological response will be 
assessed by obtaining colposcopy-guided quadrant biopsies 12 months after the last injection (Fig. 
6). In a clinical trial which used a similar peptide-based HPV therapeutic vaccine to treat high-
grade vulvar intraepithelial lesions, histological regression increased from 25% to 47% between 3 
months and 12 months post-vaccinations [18]. 
 
1.5.9 
Rationale for Primary Outcome Measure: Efficacy 
The clinical response to evaluate the vaccine efficacy will be assessed by comparing the punch 
biopsy results between the Screening Visit (having had HSIL to qualify for vaccination) and the 
12-Month Visit (± 2 weeks) (Fig. 6). LEEP will not be performed to assess efficacy, but it will be 
offered at no cost to subjects who have persistent HSILs at the 12 Mo Visit. 
 
The design of the proposed Phase II trial is single-site, and randomized to 2 treatment arms in a 
double-blinded fashion. We will use a historical placebo group from a clinical trial with similar 
design (i.e., enrollment of subjects with biopsy-proven CIN2/3, and clinical response assessed by 
biopsy in 15 month) for comparison [57]. The overall histological regression rate in the dose-
escalation Phase I clinical trial was 52% three months after the last vaccination, and this is expected 
to substantially increase with an extended 12-month observation period.[18] Assuming a 
conservative rate of 60%, n=35 in the PepCan arm would give 91% power (two-tailed, =0.05) for 
detecting a statistically significant difference from the historical placebo group which had a 29% 
(34 of 117) regression rate [57]. Although there is greater uncertainty regarding the Candin®-only 
arm, there is ≥90% power to detect a significant differences between the PepCan and Candin® 
arms under multiple plausible scenarios (for example, regression rates of 67% vs. 29%, or 85% vs. 
50%). Forty subjects in each arm will be enrolled to ensure that at least 35 subjects in each would 
complete the study. While the use of historical placebo group is not as rigorous as having a 
concurrent placebo group, a concurrent placebo group with biopsy-proven CIN2/3 that would go 
untreated for 12 months would be difficult to ethically justify. 
 
1.5.10 Rationale for Secondary Outcome Measure: Safety 
The combination of HPV peptides and Candin® was first tested in the Phase I clinical trial, and 
appears to be safe as no DLTs have been reported (Table 2). Safety will be assessed in the same 
manner in the Phase II clinical trial using CTCAE 4.03. 
 
1.5.11 Rationale for Tertiary Outcome Measures: Immunological Response and Viral Clearance 
1.5.11.1 Rationale for Measuring HPV-specific T-Cell Response 
HPV-specific CD3 T-cell responses will be assessed using immune assay such as the IFN-γ 
ELISPOT assay before vaccination, after 2 vaccinations, 6 months after 4 vaccinations, and 12 
months after 4 vaccinations (Fig. 6). In order to evaluate the role of CD3 T-cells in vaccine efficacy, 
whether clinical response and viral clearance can be predicted based on the CD3 T-cell activities 
will be assessed. 
 
1.5.11.2 Rationale for Measuring Circulating Immune Cells 
The level of circulating immune cells, including Th1 cells, Th2 cells, regulatory T-cells (Treg), and 
myeloid-derived suppressor cells (MDSC), will be assessed before vaccination, after 2 
vaccinations, 6 months after 4 vaccinations, and 12 months after 4 vaccinations. The data from the 
Phase I clinical trial indicated that PepCan may increase Th1 responses (p=0.02) and decrease Th2 

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PI: Mayumi Nakagawa, MD, PhD 
Site: UAMS OBGYN Clinics, UAMS Winthrop P. Rockefeller Cancer Institute 
Funding Source: NIH (NCI) 
Sponsor: UAMS 
Version: 19 
Date: January 19, 2023 
Page 20 
responses resulting in increased effector immune activity (Fig. 4). Whether the levels of these 
circulating immune cells can be used to predict vaccine efficacy in terms of clinical response and 
viral clearance will be investigated. Vaccine effects on these factors will also be examined 
throughout the study (i.e., 6 and 12 months instead of 3 months). 
 
1.5.11.3 Rationale for Measuring Viral Clearance 
HPV-DNA testing will be performed at the Screening Visit, 6-Month Visit, and 12-Month Visit 
(Fig. 6). In the Phase II study, an HPV type would be considered to be cleared if it is present at the 
Screening Visit but not at the 6-Month and 12-Month Visits. 
 
1.5.12 Rationale of Other Outcome Measures: Predicting Vaccine Response Using Various Factors 
Such as Age, Oral Contraceptive Use, Smoking History, Circulating Immune Cells, HLA 
Types, HPV Types, Cytokine/Chemokine, and Metabolomic Profiling; Evaluating Vaccine 
Effect; Determining Cross-Protection and Examining Epitope-Spreading and Cross-
Reactivity as Possible Mechanisms 
Not all vaccine recipients are expected to have clinical response. Some may have persistent HSIL, 
and some may progress to invasive squamous cell carcinoma. It would be valuable to identify 
factors that are associated with a favorable response so an educated decision can be made as to who 
should receive the vaccine. 
 
The Phase I clinical trial has indicated that PepCan is effective in HSILs with HPV 16 and non-16 
HPV types. In the Phase II clinical trial, against which non-16 HPV types it is effective may be 
determined. Furthermore, epitope spreading and cross-reactivity may be investigated as possible 
mechanisms behind cross-protection. 
 
1.5.13 Rationale for Adding a Candin® Arm 
The results of the dose-escalation portion of the Phase I clinical trial showed similar rates of clinical 
responses in subjects with HSILs associated (4 of 9 or 44%) and not associated (8 of 14 or 57%) 
with HPV 16 suggesting that de novo immune stimulation presumably from Candin® plays a major 
role. Therefore, Candin® only treatment arm will be added to compare efficacy between PepCan 
and Candin®. 
 
1.5.14 Rationale for Randomization and Double-Blinding 
In order to minimize bias, subjects who are eligible for vaccination will be randomly assigned to 
one of the two treatment arms (PepCan or Candin®) in a double-blinded fashion so the subjects 
and study staff (except for pharmacy staff) will not know which treatment is being administered. 
PepCan and Candin® are both clear solutions prepared in the same 1 mL syringe. 
 
 
POTENTIAL BENEFITS AND RISKS TO SUBJECTS 
1.6.1 
Potential Benefits 
The intended benefit is global with the development of a novel HPV therapeutic vaccine for 
treatment of HSIL preventing the development of cervical cancer. This study will contribute to this 
goal by evaluating the efficacy and safety of a version of HPV therapeutic vaccine, PepCan. 
It is not known whether a particular study subject will benefit, as it is not possible to predict which 
subjects will qualify for vaccination and of those vaccinated, who will achieve clinical response. 
However, a subset of subjects who qualify for vaccinations are expected to show clinical response 
enabling them to avoid a surgical treatment such as LEEP. This would be particularly beneficial to 
those who plan to conceive after study participation. 
 

IRB# 202790 A phase II clinical trial of PepCan 
PI: Mayumi Nakagawa, MD, PhD 
Site: UAMS OBGYN Clinics, UAMS Winthrop P. Rockefeller Cancer Institute 
Funding Source: NIH (NCI) 
Sponsor: UAMS 
Version: 19 
Date: January 19, 2023 
Page 21 
1.6.2 
Risks of PepCan 
No DLTs were observed in the phase I trial (Table 2). However, the total number of individuals 
who have received the vaccine is small, and there may be relatively rare complications that have 
not surfaced. The most commonly reported side effects were local swelling, redness, increased skin 
temperature, and local pain at injection sites. 
 
1.6.3 
Strategies to Minimize Risks 
All subjects will be screened before enrollment. Thereafter, a pregnancy test will be performed 
prior to each vaccination, and they will be asked to stay in the clinic for a minimum of 30 min after 
each injection. To ameliorate possible and anticipated localized minor vaccination site reactions, 
subjects will be offered a dose of ibuprofen or naproxen after the 30 min observation period. It is 
generally recommended to start with the lowest dose of these medications after experiencing a prior 
injection site reaction. However, any dose available can be given. 
 
1.6.4 
Strategies to Minimize Bias 
The subjects who are eligible for vaccination will be randomized to two treatment groups (PepCan 
and Candida) at a 1:1 ratio in a double-blinded fashion. A computer generated randomization 
scheme will be created by a study statistician, which will assign subjects to one of the treatment 
groups based on the order of first vaccination dates. This information will be forwarded to research 
pharmacy. A subject will be vaccinated with the same agent for all 4 vaccinations. After the subject 
completes her 12-Month Visit, a study coordinator will obtain information on which treatment she 
received from the research pharmacy, and will inform the subject, so she can make informed 
decisions about her future treatment plans. For a subject who exits the study early for any reason, 
the treatment she received will be revealed after completing the Early Termination Questionnaire. 
 
2 
OBJECTIVES 
 
PRIMARY OBJECTIVE: EFFICACY 
To assess the efficacy of PepCan and Candin® in a Phase II clinical trial by determining clinical 
response which will be assessed by obtaining colposcopy-guided quadrant biopsies at the 12-Month 
Visit. Responses will be compared between (1) the PepCan group and a historical placebo group 
[57], (2) the Candin® group and the same historical placebo group, and (3) the PepCan and 
Candin® groups. If, upon the 12-Month Visit quadrant biopsies, a subject does not have any 
evidence of CIN, she would be considered a “complete responder”. If the lesion(s) has(have) 
regressed to CIN 1, the subject will be considered to be a “partial responder”. If there is still CIN 2 
and/or 3 present at the 12-Month Visit, the subject will be considered a “non-responder”. The 
highest grade among the biopsies will be recorded. In addition to the above analysis of subjects 
who exited after the 12-Month Visit, another analysis may be performed with addition of subjects 
who exited the study after the 6-Month Visit if histological results (biopsy and/or LEEP) are 
available at 6 months.   
 
 
SECONDARY OBJECTIVE: SAFETY 
Safety will be assessed by documenting AEs from the time of enrollment until the 12-Month Visit 
according to CTCAE v4.03. 
 
 
TERTIARY OBJECTIVES: IMMUNOLOGICAL RESPONSE & VIRAL CLEARANCE 

IRB# 202790 A phase II clinical trial of PepCan 
PI: Mayumi Nakagawa, MD, PhD 
Site: UAMS OBGYN Clinics, UAMS Winthrop P. Rockefeller Cancer Institute 
Funding Source: NIH (NCI) 
Sponsor: UAMS 
Version: 19 
Date: January 19, 2023 
Page 22 
Immunological assessment in terms of HPV-specific CD3 T-cell responses will be assessed using 
an IFN-ELISPOT assay while circulating levels of CD4, Th1, Th2, Treg, and MDSC cells will 
be assessed by FACS analysis before vaccination, after 2 vaccinations, 6 months after 4 
vaccinations, and 12 months after 4 vaccinations. Virological assessments will be made at 
Screening, 6-Month, and 12-Month Visits. 
 

IRB# 202790 A phase II clinical trial of PepCan 
PI: Mayumi Nakagawa, MD, PhD 
Site: UAMS OBGYN Clinics, UAMS Winthrop P. Rockefeller Cancer Institute 
Funding Source: NIH (NCI) 
Sponsor: UAMS 
Version: 19 
Date: January 19, 2023 
Page 23 
 
OTHER OBJECTIVES 
To evaluate predictive factors for response to PepCan or Candin®, various parameters such as age, 
oral contraceptive use, smoking history, circulating immune cells, HLA types, HPV types, bacterial 
taxa, cytokine/chemokine, metabolomic profiling, and other factors may be analyzed. Vaccine 
effects over time on some of these factors will also be assessed. 
 
Cross-protection by PepCan in terms of viral clearance will be determined by tallying each HPV 
event that is present at Screening Visit but becomes undetectable at both 6-Month and 12-Month 
Visits for each of the 37 HPV types tested. Viral clearance by de novo immune stimulation by 
Candin® will be determined by tallying each HPV event that is present at Screening Visit but 
becomes undetectable at both 6-Month and 12-Month Visits for each of the 37 HPV types tested. 
 
Epitope spreading and cross-reactivity may be examined in selected subjects in the PepCan arm. 
 
3 
INVESTIGATIONAL PRODUCT 
 
TEST ARTICLE 
3.1.1 
HPV Peptides 
PepCan will contain four HPV 16 E6 peptides: E6 1-45 (Ac-MHQKRTAMFQDPQERPRKLPQLCT 
ELQTTIHDIILECVYCKQQLL-NH2), E6 46-80 (Ac-RREVYDFAFRDLCIVYRDGNPYAVCDKC 
LKFYSKI-NH2), E6 81-115 (Ac-SEYRHYCYSLYGTTLEQQYNKPLCDLLIRCINCQK-NH2), and 
E6 116-158 (Ac-PLCPEEKQRHLDKKQRFHNIRGRWTGRCMSCCRSSRTRRETQL-NH2) (US 
Patent No. 8,652,482). Commercially produced cGMP-grade peptides (CPC Scientific, San Jose, 
CA) will be examined. 
 
The four peptides will be provided in a single vial in lyophilized form at the 50 μg/peptide/dose, 
and will be stored at -80°C (±10°C) except during shipping and immediately prior to use. 
 
The UAMS Research Pharmacy will be responsible for peptide receipt, storage, and preparation 
prior to vaccination visits. 
 
3.1.2 
Candin® 
Candida Albicans Skin Test Antigen for Cellular Hypersensitivity will be supplied in the 
commercially marketed drug Candin®. The vials will be stored at 2°C to 8°C as directed by the 
package insert until use. This product is approved for multi-dosing. The dose of Candin® per 
injections for this study is 0.3 mL. 
 
3.1.3 
Combining HPV Peptides and Candin® 
Sterile water will be added to a vial containing the four cGMP peptides on the day of use. 
Reconstituted peptides will be drawn in a syringe depending on the dose level, and 0.3 mL of 
Candin® will be drawn into the same syringe. The combined peptide-Candin® mixture should be 
kept on ice or in refrigerator until immediately before injection. 
 
3.1.4 
Temperature Logs 
Daily temperature logs will be maintained by the Pharmacy per standard operating procedures of 
the Pharmacy. Any deviations in temperature range will be reported to the Sponsor and Principal 
Investigator. 
 

IRB# 202790 A phase II clinical trial of PepCan 
PI: Mayumi Nakagawa, MD, PhD 
Site: UAMS OBGYN Clinics, UAMS Winthrop P. Rockefeller Cancer Institute 
Funding Source: NIH (NCI) 
Sponsor: UAMS 
Version: 19 
Date: January 19, 2023 
Page 24 
3.1.5 
Drug Accountability Records 
Drug accountability records will be maintained per Pharmacy, Institutional, FDA, NIH, and other 
applicable policies. 
 
 
TREATMENT REGIMEN 
Subjects will receive four injections of PepCan (50 µg/peptide/injection) via intradermal injection 
in the extremities with three weeks between each injection. 
 
4 
STUDY DESIGN 
 
OVERVIEW 
This is a single site Phase II clinical trial of PepCan for treating women with biopsy-proven HSILs 
randomized and double-blinded to two treatment arms. Half of the subjects will receive PepCan, 
and the other half will receive Candin® alone. The study design closely resembles the latest 
guidelines for treating young women with HSIL [14]. Study subjects will be patients attending the 
UAMS Obstetrics and Gynecology Clinics with untreated biopsy-proven HSILs and patients 
referred from other clinics. Four injections (one every 3 weeks) of PepCan or Candin® will be 
intradermally administered in the extremities. Clinical response will be assessed by comparison of 
colposcopy-guided biopsy results obtained prior to vaccination and at 12-Month Visit. Safety will 
be monitored from the time of enrollment through the 12-Month Visit. Blood will be drawn for 
laboratory testing and immunological analyses (“blood test”) prior to injection, after the second 
vaccination, 6 months after the fourth vaccination, and 12 months after the fourth vaccination. 
Blood will be drawn to aid T-cell analyses (“blood draw”) after the first and third vaccinations, and 
possibly at the Optional Follow-Up and/or Optional LEEP visits. HPV-DNA testing will be 
performed at Screening and 6- and 12-Month Visits (Fig. 6). If a subject has persistent HSIL at the 
12-Month Visit or if a subject is withdrawn due to excessive toxicity, she will be given an option 
to return for a LEEP visit. Alternatively, she may choose to exit the study and be followed by a 
gynecologist for up to 2 years of observation as recommended before surgical treatment [14]. 
 
 
RANDOMIZATION TO TREATMENTS 
The study randomization schematic will be constructed by the study Statistician. Randomization 
will occur after Subject eligibility for vaccinations has been confirmed. Subjects will be 
randomized in a 1:1 ratio to PepCan or Candin® alone. Randomization will be done in book form 
by Research Pharmacy. 
 
 

IRB# 202790 A phase II clinical trial of PepCan 
PI: Mayumi Nakagawa, MD, PhD 
Site: UAMS OBGYN Clinics, UAMS Winthrop P. Rockefeller Cancer Institute 
Funding Source: NIH (NCI) 
Sponsor: UAMS 
Version: 19 
Date: January 19, 2023 
Page 25 
Fig. 6 Schematic presentation of study visits scheduled for the Phase II clinical trial of our HPV therapeutic 
vaccine. Colpo, colposcopy, Bx, biopsy, ECC, endocervical curettage, LEEP, loop electrosurgical excision 
procedure. †These blood tests are for clinical analyses only. *These blood tests are for scientific analyses only. 
Blood tests may be drawn as needed for clinical and/or scientific analyses during any optional visit. 
 
 
MONITORING TOXICITY 
Serious toxicity will be defined (using CTCAE v 4.03) as drug-related: 
 
Grade II or higher allergic reactions. Grade II is defined as “intervention or infusion 
interruption indicated; responds promptly to symptomatic treatment (e.g., antihistamines, 
NSAIDS, narcotics); prophylactic medications indicated for ≤ 24 hours”. Grade III is defined 
as “prolonged (e.g., not rapidly responsive to symptomatic medication and/or brief interruption 
of infusion); recurrence of symptoms following initial improvement; hospitalization indicated 
for clinical sequelae (e.g., renal impairment, pulmonary infiltrates)”. 
 
Grade II or higher autoimmune reactions. Grade II is defined as “evidence of autoimmune 
reaction involving a non-essential organ or function (e.g., hypothyroidism)”. Grade III is 
defined as “autoimmune reactions involving major organ (e.g., colitis, anemia, myocarditis, 
kidney)”. 
 
Any Grade III or higher event. 
 
Any subject who experiences serious toxicity will be discontinued from the study. 
 
 
INTERRUPTION 
In case of prolonged unavailability of vaccine peptides, such as due to failing stability testing and 
need to manufacture a new lot, all subjects being vaccinated will receive Candin® for the remaining 
injections. Subjects starting vaccination will be assigned to the Candin® group. After a new lot of 
peptides become available, randomization will resume with the following possible modifications: 
(1) the number of subjects to be recruited in the Candin® group will be decreased by the number 

IRB# 202790 A phase II clinical trial of PepCan 
PI: Mayumi Nakagawa, MD, PhD 
Site: UAMS OBGYN Clinics, UAMS Winthrop P. Rockefeller Cancer Institute 
Funding Source: NIH (NCI) 
Sponsor: UAMS 
Version: 19 
Date: January 19, 2023 
Page 26 
of subjects recruited into the Candin® group during the interruption, and (2) the number of subjects 
in the PepCan group will be increased by the number of subjects who started out receiving PepCan 
but received Candin® during the interruption. To protect study blinding, UAMS ORRA Quality 
Assurance will communicate directly with Research Pharmacy and the statistical team. No 
information regarding which vaccination (PepCan or Candin®) any subjects are receiving will be 
revealed to the rest of the study team including the Principal Investigator. 
 
 
STOPPING RULES 
4.5.1 
For subject 
 
A subject should be withdrawn from the study at any point if pelvic examination and 
histological analysis show evidence of an invasive squamous cell cervical carcinoma or if there 
is a clinical suspicion of having developed it based on signs and symptoms such as unexplained, 
prolonged vaginal bleeding. This is to allow the subject to receive the proper work-up and 
treatment. The subject may proceed to the optional LEEP visit if determined to be beneficial 
by a study physician. Should a cervical cancer diagnosis be confirmed during the subject’s 
study participation, the subject may receive a hysterectomy if it is determined to be medically 
necessary. 
 
If a subject becomes pregnant during her participation in the study, a medical monitor will 
determine whether or not she should be removed from the study. Medical records will be 
requested to determine the health of the mother and child. 
 
4.5.2 
For study 
 
The study enrollment and vaccine administration will be suspended if any subject experiences 
vaccine-related Grade IV or higher AE. These activities can re-start only after notifying the 
applicable regulatory authorities and with a permission to resume from the Medical Monitor. 
 
The sponsor may decide to stop the study at any point, for any reason. 
 
 
EMERGENCY UNBLINDING 
If a medical emergency necessitating the identity of the vaccine administered occurs, the PI will 
notify Research Pharmacy and the study Statistician. Research Pharmacy will give identity of 
vaccine to PI and Study Coordinator and note any incidence in the Randomization book. 
 
5 
SUBJECT ENROLLMENT AND STUDY DURATION 
 
SUBJECT POPULATION, RECRUITMENT, AND INFORMED CONSENT PROCESS 
 
Women, aged 18 to 50 years, seen at the UAMS Obstetrics and Gynecology Clinics and 
ANGELS Telecolposcopy program with recent Pap smear results positive for HSIL or “Cannot 
rule out HSIL” will be recruited through Physician referral, brochures, flyers, UAMS website, 
letters, phone calls, and word of mouth by study team; interested potential subjects will contact 
the study coordinator to discuss study; coordinator will conduct initial inclusion/exclusion 
criteria assessment, schedule subject for screening visit, and send a copy of the informed 
consent document for the subject to review. 
 
Other women with recent abnormal Pap smear results positive for HSIL or “Cannot rule out 
HSIL” will be recruited through clinic referral, brochures, flyers (distributed on and off 
campus), UAMS website, and advertisements in newspaper, radio, Google ad, and/or social 
networking site; interested potential subjects will contact the study coordinator to discuss study; 
coordinator will conduct inclusion/exclusion criteria assessment, schedule subject for 

IRB# 202790 A phase II clinical trial of PepCan 
PI: Mayumi Nakagawa, MD, PhD 
Site: UAMS OBGYN Clinics, UAMS Winthrop P. Rockefeller Cancer Institute 
Funding Source: NIH (NCI) 
Sponsor: UAMS 
Version: 19 
Date: January 19, 2023 
Page 27 
screening visit, and send a copy of the informed consent document for the subject to review; 
coordinator will request that subject obtain copy of Pap smear result from their physician’s 
office and bring with them to the screening visit. 
 
Women with recent diagnosis (the duration between the day of diagnosis and the day of 1st 
injection needs to be ≤ 60 days) of HSIL on colposcopy guided punch biopsy will be recruited 
through clinic referral, brochures, flyers (distributed on and off campus), UAMS website, and 
advertisements in newspaper, radio, letters, phone calls, Google ad, and/or social networking 
site; interested potential subjects will contact the study coordinator to discuss study; 
coordinator will conduct inclusion/exclusion criteria assessment, schedule subject for 
screening visit, and send a copy of the informed consent document for the subject to review; 
coordinator will request that subject obtain copies of medical records of abnormal biopsy from 
their physician’s office and bring it with them to the screening visit. 
 
5.1.1 
Inclusion Criteria 
 
Aged 18-50 years 
 
Had recent (≤ 60 days) Pap smear result consistent with HSIL or “cannot rule out HSIL” or 
HSIL on colposcopy guided biopsy 
 
Untreated for HSIL or “Cannot rule out HSIL” 
 
Able to provide informed consent 
 
Willingness and able to comply with the requirements of the protocol 
 
5.1.2 
Exclusion Criteria 
 
History of disease or treatment causing immunosuppression (e.g., cancer, HIV, organ 
transplant, autoimmune disease) 
 
Being pregnant or attempting to be pregnant within the period of study participation 
 
Breast feeding or planning to breast feed within the period of study participation 
 
Allergy to Candida antigen 
 
History of severe asthma requiring emergency room visit or hospitalization within the past 5 
years 
 
History of invasive squamous cell carcinoma of the cervix 
 
History of having received PepCan 
 
If in the opinion of the Principal Investigator or other Investigators, it is not in the best interest 
of the patient to enter this study 
 
5.1.3 
Informed Consent Process 
 
Potential subjects will be provided the informed consent form before the screening visit and 
allowed as much time as needed to make decisions regarding study participation. 
 
The study coordinator/study team member authorized by PI to administer informed consent 
discussion will discuss the study in detail (including the age-specific standard of care guidelines 
as periodically released by the American Society of Colposcopy and Cervical Pathology) with 
the potential subject at any time before the screening visit or at a UAMS Gynecology clinic 
when she arrives for the screening visit (prior to any study-related procedures), and answer any 
questions the subject may have about the study; discussions will be conducted in English or in 
Spanish by Spanish speaking interpreters. 
 
Should an enrolled subject become pregnant during the study period she will be provided with 
an informed consent addendum to verify whether or not the subject would agree to the 

IRB# 202790 A phase II clinical trial of PepCan 
PI: Mayumi Nakagawa, MD, PhD 
Site: UAMS OBGYN Clinics, UAMS Winthrop P. Rockefeller Cancer Institute 
Funding Source: NIH (NCI) 
Sponsor: UAMS 
Version: 19 
Date: January 19, 2023 
Page 28 
collection, storage and use of data about the pregnancy, birth and health of the baby. If the 
subject agrees, they will be asked to fill out an authorization form for release of information to 
UAMS. 
 
As consent is an ongoing process, subjects will be asked if they still wish to participate in the 
study prior to study procedures conducted at each study visit. 
 
 
PACE OF ENROLLMENT 
During the Phase I study, approximately two thirds of subjects enrolled qualified for vaccination. 
Taking into account the screen-failure rate and attrition rate (currently about 5% per year), we plan 
to enroll 125 subjects for screening, and to initiate vaccination in 80 subjects. 
 
 
STUDY DURATION 
The study duration will be up to 66 months. Each subject is expected to be in the study for 
approximately 16 months or longer if LEEP is performed. 
 
6 
STUDY VISITS 
 
SCHEDULING STUDY VISITS 
The Study Coordinator will schedule study visits (Screening, Vaccination, 6-Month, 12-Month, 
and Optional LEEP Visits) at the UAMS Obstetrics and Gynecology Clinics and the UAMS 
Winthrop P. Rockefeller Cancer Institute (WPRCI). The Screening, 6-Month, 12-Month, and 
Optional LEEP Visits are expected to take approximately 90 minutes. However, they may be longer 
on busy clinic days. Vaccination Visits are expected to take approximately 60 minutes. 
 
 
STUDY VISIT WINDOWS 
6.2.1 
Between Visits of an Individual Subject 
 
The first vaccination visit (Visit 1) should be scheduled as soon as possible after all results 
from the screening visit are available, and subjects are deemed qualified to continue to the 
vaccination phase of the study, but no later than 60 days after the day punch biopsy was 
obtained (the screening day for most of the subjects). 
 
The subsequent vaccination visits (Visits 2-4) should be scheduled 3 weeks ± 7 days apart. 
 
The 6-Month Visit should be scheduled 6 months ± 2 weeks following Visit 4 
 
The 12-Month Visit should be scheduled 6 months ± 2 weeks following 6-Month Visit. 
 
Optional LEEP visit (if subject chooses) should be scheduled as soon as possible after 12-
Month Visit or after determining a subject needs to be withdrawn due to serious toxicity. 
 
 
STUDY VISIT LOCATIONS 
6.3.1 
Screening Visit 
UAMS Obstetrics and Gynecology Clinics 
 
6.3.2 
Vaccination Visits 
WPRCI Infusion center 1 
 
 

IRB# 202790 A phase II clinical trial of PepCan 
PI: Mayumi Nakagawa, MD, PhD 
Site: UAMS OBGYN Clinics, UAMS Winthrop P. Rockefeller Cancer Institute 
Funding Source: NIH (NCI) 
Sponsor: UAMS 
Version: 19 
Date: January 19, 2023 
Page 29 
6.3.3 
6-Month, 12-Month, Optional LEEP Visits 
UAMS Obstetrics and Gynecology Clinics 
 
6.3.4 
Optional Follow-Up Visits (If necessary) 
UAMS Obstetrics and Gynecology Clinics or UAMS WPRCI 
 
 
SCREENING VISIT 
6.4.1 
Procedures for Screening Visit 
 
Review inclusion/exclusion criteria 
 
Obtain informed consent (if not previously obtained) 
 
Have the subject fill out “Subject Contact Information” during the visit 
 
Have the subject fill out “Screening Visit Questionnaire” during the visit 
 
Obtain demographic information 
 
Obtain subject’s history 
 
Medical history: Be sure to ask for history of previous abnormal Pap smears and how they 
were treated 
 
Drug allergies 
 
Concomitant medications 
 
Perform a physical examination 
 
Obtain vital signs 
 
Blood pressure (<200/120 mm Hg acceptable) 
 
Heart rate (50–120 beats per min acceptable) 
 
Respiratory rate (<25 breaths per min acceptable) 
 
Temperature (<100.4°F) 
 
Weight (no restriction) 
 
For a subject with child-bearing potential 
 
Discuss the risks involved in becoming pregnant while receiving vaccine 
 
Ask which birth-control method she will be using while participating in the vaccine trial; 
FDA acceptable forms of preventing pregnancy include oral contraceptives, contraceptive 
patches/rings/implants/shots, double-barrier methods (e.g. condoms and spermicide), 
abstinence and/or vasectomies of a male partner with a documented second acceptable 
method of birth control 
 
Ask if subjects need the study to provide birth control and discuss options. All of the 
options below are available to subjects free of charge while participating in the study. 
 
Sprintec is an oral contraceptive and it is available throughout the study. 
 
Low-Ogestrel is an oral contraceptive and it is available throughout the study for 
subjects who need to be taken off Sprintec for medical reasons. 
 
Depo-Provera is a contraceptive given as a shot every 3 months and it is available 
throughout the study. 
 
Liletta is an intrauterine device contraceptive and is available only during the first 3 
months of participation. An exception would be allowed if an existing IUD were 

IRB# 202790 A phase II clinical trial of PepCan 
PI: Mayumi Nakagawa, MD, PhD 
Site: UAMS OBGYN Clinics, UAMS Winthrop P. Rockefeller Cancer Institute 
Funding Source: NIH (NCI) 
Sponsor: UAMS 
Version: 19 
Date: January 19, 2023 
Page 30 
removed during one of the study visits. In this situation, the IUD may be replaced with 
Liletta throughout the study. 
 
The study will cover the cost of the IUD, IUD placement within the first 3 months 
of study participation (with the exception of replacing an IUD removed during 
study visits), and IUD removal during your study participation, but not afterwards. 
 
Perform colposcopy 
 
Obtain ThinPrep for HPV-DNA testing 
 
Obtain punch biopsy and endocervical curettage if determined to be necessary by the 
physician (HSIL needs to be confirmed to be eligible) 
 
Physician may acquire four-quadrant blind biopsy if no areas of lesions are visible upon 
colposcopy 
 
Record the lesion(s), locations on the cervix, image cervix using the colposcope-mounted 
image capture system (if available), and indicate where biopsy was taken 
 
Record in how many cervical quadrants the lesions are visible 
 
If the subject has already been diagnosed with HSIL by biopsy, there is no need to repeat 
it. However, colposcopy could be repeated to document the location of the lesion(s), and 
to collect ThinPrep for HPV-DNA and bacterial testing. 
 
Colposcopy may be performed in the OR if medically necessary. A COVID-19 test may 
be required per hospital policy prior to intervention in the OR. 
 
Draw blood tubes for complete blood count (CBC), and comprehensive metabolic panel (CMP) 
(to be performed in UAMS clinical laboratory) 
 
Comprehensive metabolic panel (CMP) testing 
 
Alanine transaminase (no restriction) 
 
Aspartate transaminase (no restriction) 
 
Albumin (no restriction) 
 
Alkaline phosphatase (no restriction) 
 
Total bilirubin (no restriction) 
 
Total protein (no restriction) 
 
Sodium (no restriction) 
 
Potassium (no restriction) 
 
Chloride (no restriction) 
 
CO2 (no restriction) 
 
Blood urea nitrogen (no restriction) 
 
Creatinine (no restriction) 
 
Calcium (no restriction) 
 
Glucose (no restriction) 
 
Complete Blood Count (CBC) testing 
 
White count (>3x109/L acceptable) 
 
Hemoglobin (>8 g/dL acceptable) 
 
Hematocrit (no restriction) 
 
Platelet count (>50x109/L acceptable) 
 
 

IRB# 202790 A phase II clinical trial of PepCan 
PI: Mayumi Nakagawa, MD, PhD 
Site: UAMS OBGYN Clinics, UAMS Winthrop P. Rockefeller Cancer Institute 
Funding Source: NIH (NCI) 
Sponsor: UAMS 
Version: 19 
Date: January 19, 2023 
Page 31 
6.4.2 
Follow-Up to the Screening Visit 
The Study Coordinator and Principal Investigator or Co-Investigator will review all information 
and test results from the screening visit, and will determine whether the subject is eligible to receive 
vaccination. Eligibility for vaccination includes presence of HSIL or “cannot rule out HSIL” by 
colposcopy guided biopsy, no evidence of invasive squamous cell carcinoma, vital signs within 
certain limits, and certain blood tests within acceptable ranges. 
 
 
If eligible for vaccination, schedule vaccination visits at WPRCI Infusion center 1 
 
If not eligible for vaccination, inform subject via phone call, and schedule a follow-up visit if 
necessary. If a subject has a condition, which requires further medical care, including invasive 
squamous cell carcinoma, study physicians will refer her to receive appropriate medical care. 
 
 
VACCINATION VISITS (VISITS 1-4) 
6.5.1 
Procedures for Visit 1 
 
Ask if any medications have been started or stopped since the last visit 
 
Urine pregnancy test prior to vaccination 
 
Measure height and weight to determine BMI 
 
Take vital signs prior to injection 
 
Blood will be drawn for: 
 
Immunomonitoring and other analyses (eight 10.0 mL rubber green top sodium heparin 
tubes unless pregnant then draw only 2 tubes) 
 
CBC (to be performed in UAMS clinical laboratory) 
 
CMP (to be performed in UAMS clinical laboratory) 
 
Administer vaccination injection 
 
Repeat vital signs after at least 30 min has passed since the injection 
 
Monitor for any immediate adverse reactions 
 
Offer dose of ibuprofen or naproxen 
 
Hand out “Subject Diary” and ask the subject to fill it out and bring it back at the next visit 
 
6.5.2 
Procedures for Visit 2 
 
Ask for the filled out “Subject Diary”. If the subject did not return it, ask “Have you 
experienced any side effects since the last injection?” 
 
Ask if any medications have been started or stopped since the last visit 
 
Urine pregnancy test prior to vaccination 
 
Take vital signs prior to injection 
 
Blood will be drawn for 
 
Immunomonitoring and other analyses (eight 10.0 mL rubber green top sodium heparin 
tubes unless pregnant then draw only 2 tubes) 
 
Administer vaccination injection 
 
Repeat vital signs after at least 30 min has passed since the injection 
 
Monitor for any immediate adverse reactions 
 
Offer dose of ibuprofen or naproxen 
 
Hand out “Subject Diary” and ask the subject to fill it out and bring it back at the next visit 
 
 

IRB# 202790 A phase II clinical trial of PepCan 
PI: Mayumi Nakagawa, MD, PhD 
Site: UAMS OBGYN Clinics, UAMS Winthrop P. Rockefeller Cancer Institute 
Funding Source: NIH (NCI) 
Sponsor: UAMS 
Version: 19 
Date: January 19, 2023 
Page 32 
6.5.3 
Procedures for Visit 3 
 
Ask for the filled out “Subject Diary”. If the subject did not return it, ask “Have you 
experienced any side effects since the last injection?” 
 
Ask if any medications have been started or stopped since the last visit 
 
Urine pregnancy test prior to vaccination 
 
Take vital signs prior to injection 
 
Blood will be drawn for: 
 
Immunomonitoring and other analyses (eight 10.0 mL rubber green top sodium heparin 
tubes unless pregnant then draw only 2 tubes) 
 
CBC (to be performed in UAMS clinical laboratory) 
 
CMP (to be performed in UAMS clinical laboratory) 
 
Administer vaccination injection 
 
Repeat vital signs after at least 30 min has passed since the injection 
 
Offer dose of ibuprofen or naproxen 
 
Monitor for any immediate adverse reactions 
 
Hand out “Subject Diary” and ask the subject to fill it out and bring it back at the next visit 
 
6.5.4 
Procedures for Visit 4 
 
Ask for the filled out “Subject Diary”. If the subject did not return it, ask “Have you 
experienced any side effects since the last injection?” 
 
Ask if any medications have been started or stopped since the last visit 
 
Urine pregnancy test prior to vaccination 
 
Take vital signs prior to injection 
 
Blood will be drawn for: 
 
Immunomonitoring and other analyses (eight 10.0 mL rubber green top sodium heparin 
tubes unless pregnant then draw only 2 tubes) 
 
Administer vaccination injection 
 
Repeat vital signs after at least 30 min has passed since the injection 
 
Monitor for any immediate adverse reactions 
 
Offer dose of ibuprofen or naproxen 
 
Hand out “Subject Diary” and ask the subject to fill it out and bring it back at the next visit 
 
 
Interim Contraceptive Use Reminder Letter 
6.6.1 
Procedure: Mail the Reminder Letter to the subject after vaccination 4 
 
 
6-MONTH VISIT 
The 6-Month Visit will be scheduled about six months (± 2 weeks) after Vaccination Visit 4. 
 
6.7.1 
Procedures for 6-Month Visit 
 
Perform a physical examination 
 
Obtain vital signs 
 
Blood pressure 

IRB# 202790 A phase II clinical trial of PepCan 
PI: Mayumi Nakagawa, MD, PhD 
Site: UAMS OBGYN Clinics, UAMS Winthrop P. Rockefeller Cancer Institute 
Funding Source: NIH (NCI) 
Sponsor: UAMS 
Version: 19 
Date: January 19, 2023 
Page 33 
 
Heart rate 
 
Respiratory rate 
 
Temperature 
 
Weight 
 
Ask if any medications have been started or stopped since last visit 
 
Perform colposcopy 
 
Obtain ThinPrep for Pap smear, HPV-DNA and bacterial testing 
 
Record the lesion(s), locations on the cervix, image cervix using the colposcope-mounted 
image capture system (if available) 
 
Record in how many cervical quadrants the lesions are visible 
 
Colposcopy may be performed in the OR if medically necessary. A COVID-19 test may be 
required per hospital policy prior to intervention in the OR. 
 
If determined to be necessary by the physician (ONLY in cases where there is a suspicion of 
progressive disease), obtain punch biopsy and endocervical curettage 
 
Blood will be drawn for: 
 
Immunomonitoring and other analyses (eight 10.0 mL rubber green top sodium heparin 
tubes unless pregnant then draw only 2 tubes) 
 
CBC (to be performed in UAMS clinical laboratory) 
 
CMP (be performed in UAMS clinical laboratory) 
 
If Pap smear and/or biopsy results are suspicious for or consistent with HSIL and if the subject 
decides not to return for the 12-Month Visit, the optional LEEP visit may be offered as long as 
a study physician determines doing so would be beneficial. 
 
If a cervical cancer diagnosis is confirmed prior to being withdrawn from the study, the subject 
may be offered a hysterectomy if a study physician determines it to be medically necessary. 
 
 
Interim Contraceptive Use Reminder Letter 
6.8.1 
Procedure: Mail the reminder letter after the 6-month visit 
 
 
12-MONTH VISIT 
The 12-Month Visit will be scheduled approximately six months (±2 weeks) after the 6-Month 
Visit. 
 
6.9.1 
Procedures for 12-Month Visit 
 
Perform a physical examination 
 
Obtain vital signs 
 
Blood pressure 
 
Heart rate 
 
Respiratory rate 
 
Temperature 
 
Weight 
 
Ask if any medications have been started or stopped since last visit 
 
Perform colposcopy 
 
Obtain ThinPrep for HPV-DNA and bacterial testing 

IRB# 202790 A phase II clinical trial of PepCan 
PI: Mayumi Nakagawa, MD, PhD 
Site: UAMS OBGYN Clinics, UAMS Winthrop P. Rockefeller Cancer Institute 
Funding Source: NIH (NCI) 
Sponsor: UAMS 
Version: 19 
Date: January 19, 2023 
Page 34 
 
Record the lesion(s), locations on the cervix, image cervix using the colposcope-mounted 
image capture system (if available) 
 
Record in how many cervical quadrants the lesions are visible 
 
Obtain at least one punch biopsy from each of the 4 quadrants and possibly endocervical 
curettage (these biopsies will be evaluated by 2 pathologists who are blinded to each other’s 
diagnosis, and consensus will be reached in case of non-concordant initial interpretations) 
 
Obtain at least one biopsy from each quadrant with visible lesions 
 
In a quadrant without visible lesions, obtain at least one biopsy from each quadrant 
described to have had HSIL lesions at the Screening Visit 
 
In a quadrant without visible lesions and without a record of having had HSIL lesions 
at the Screening Visit, obtain one blind biopsy 
 
Colposcopy may be performed in the OR if medically necessary. A COVID-19 test may be 
required per hospital policy prior to intervention in the OR. 
 
ECC is required at 12 month visit if the entire squamocolumnar junction is not visualized 
 
Blood will be drawn for: 
 
Immunomonitoring and other analyses (eight 10.0 mL rubber green top sodium heparin 
tubes unless pregnant then draw only 2 tubes) 
 
CBC (to be performed in UAMS clinical laboratory) 
 
CMP (to be performed in UAMS clinical laboratory) 
 
Have the subject fill out “12-Month Visit Questionnaire” during the visit 
 
6.9.2 
Follow-Up to the 12-Month Visit 
The Study Coordinator and Principal Investigator or Co-Investigator will review all information 
and test results from the 12-Month Visit and schedule any optional follow-up visits as soon as 
possible following this visit. 
 
 
If no evidence of HSIL upon biopsy, the subject will complete the study. 
 
If persistent HSIL is present, the subject may choose either to (1) have LEEP performed as a 
part of the study or (2) complete the study and be followed by a gynecologist. 
 
If a cervical cancer diagnosis is confirmed prior to being withdrawn from the study, the subject 
may be offered a hysterectomy if a study physician determines it to be medically necessary. 
 
 
OPTIONAL LEEP VISIT 
6.10.1 Procedures for LEEP Visit 
 
Blood may be drawn from some subjects as explained above for: 
 
Immunomonitoring and other analyses (eight 10.0 mL rubber green top sodium heparin 
tubes) 
 
CBC, CMP or other tests as needed (to be performed in UAMS clinical laboratory) 
 
Perform LEEP biopsy 
 
ThinPrep specimen for HPV-DNA and bacterial testing may be obtained 
 
Excise visible lesion or, if no visible lesion seen, excise from an area where biopsies 
positive for HSIL were obtained at the 12-Month Visit 
 
LEEP may be performed in the OR if medically necessary A COVID-19 test will be 
required per hospital policy prior to intervention in the OR. 

IRB# 202790 A phase II clinical trial of PepCan 
PI: Mayumi Nakagawa, MD, PhD 
Site: UAMS OBGYN Clinics, UAMS Winthrop P. Rockefeller Cancer Institute 
Funding Source: NIH (NCI) 
Sponsor: UAMS 
Version: 19 
Date: January 19, 2023 
Page 35 
 
If a cervical cancer diagnosis is confirmed prior to being withdrawn from the study, the subject 
may be offered a hysterectomy if a study physician determines it to be medically necessary. 
 
6.10.2 Follow-Up to the LEEP Visit 
The study coordinator will contact the subject and review the LEEP biopsy results (after examined 
and signed out by hospital pathologist on service) (Record in CRF). In the event of inconclusive 
LEEP results, a repeat LEEP will be offered if a study physician determines it to be medically 
necessary. Additional follow-up visits will be scheduled as necessary. Blood may be drawn from 
some subjects as explained above for immunomonitoring and other analyses (eight 10.0 mL rubber 
green top sodium heparin tubes). 
 
 
OPTIONAL FOLLOW-UP VISITS 
6.11.1 When Optional Follow-Up Visits should be scheduled 
Since a majority would prefer to receive test results and to have the follow-up plan explained over 
the phone, most subjects will not be scheduled for a follow-up visit after a screening visit. It would 
be common to schedule a follow-up visit after an Optional LEEP Visit since a gynecologist may 
need to examine recovery after LEEP. In rare instances, if a diagnosis of invasive cervical cancer 
is confirmed, a hysterectomy may be offered if a study physician determines it to be medically 
necessary prior to withdrawing the subject from the study. Follow-up visits can be scheduled: 
 
 
After being informed that the subject is not eligible for vaccinations 
 
Anytime during study participation 
 
After completing the Optional LEEP Visit 
 
After exiting the study without completing all the visits 
 
For evaluation of AEs 
 
To obtain contraceptives including: 
 
Oral contraceptive pick up 
 
Depo Provera injections 
 
Placement/removal of IUD 
 
For diagnostic purposes and surgical intervention deemed medically necessary during the 
subjects’ study participation, including but not limited to, colposcopy or LEEP performed in 
the OR, hysterectomy due to invasive cervical cancer, cone biopsy or medical imaging such as 
ultrasound, computed tomography (CT) scan, or magnetic resonance imaging (MRI) scan. 
 
Surgical intervention required after the subject’s study participation has ended will be the 
responsibility of the subject. 
 
For any procedures performed in the OR, a COVID-19 test may be required per hospital 
policy prior to intervention. The study will cover the cost of mandatory pre-operative 
COVID-19 testing while institutional COVID-19 precautions are in effect. 
 
6.11.2 Procedure at the Follow-Up Visit 
 
Gynecologists may perform a pelvic examination if indicated. 
 
The study coordinator, a clinic nurse, a study nurse, or one of the investigators may explain the 
subject’s condition 
 
Directions for following up on the condition may be provided 
 
Blood may be drawn from some subjects as explained above for: 

IRB# 202790 A phase II clinical trial of PepCan 
PI: Mayumi Nakagawa, MD, PhD 
Site: UAMS OBGYN Clinics, UAMS Winthrop P. Rockefeller Cancer Institute 
Funding Source: NIH (NCI) 
Sponsor: UAMS 
Version: 19 
Date: January 19, 2023 
Page 36 
 
Immunomonitoring and other analyses (eight 10.0 mL rubber green top sodium heparin 
tubes) 
 
CBC, CMP or other tests for evaluation of the AEs as needed (to be performed in UAMS 
clinical laboratory) 
 
 
IF THE SUBJECT DID NOT COMPLETE THE STUDY 
Subjects may not complete the study for a variety of reasons including serious toxicity, non-
compliance, lost to follow-up, etc. In these instances, and for subjects who completed at least one 
vaccination visit, the study coordinator will ensure that subjects complete the “Early Termination 
Questionnaire” over the phone, via e-mail, or by mail (no stamp will be provided). 
 
7 
SUBJECT COMPENSATION 
 
COMPLETERS AND NON-COMPLETERS, TRAVEL STIPENDS AND ANNUAL 
LIMITS 
7.1.1 
Subjects Who Complete the Study 
A check or gift cards for $300 will be mailed after the completion of the study (after the 12-Month 
Visit) to a mailing address provided by the subject. 
 
7.1.2 
Subjects Who Do Not Complete the Study 
 
If a subject is withdrawn due to vaccine-related toxicity (see stopping rules), due to becoming 
pregnant because contraception failure, or in cases of advancing disease after at least one 
completed vaccination visit, a check in the amount of $300 will be mailed to an address 
provided by the subject once the “Early Termination Questionnaire” has been completed. 
 
For subjects who terminated early but not because of toxicity or due to non-compliance 
including cases of consequent pregnancies, $50 per visit for each of Visits 1-4, the 6-Month 
Visit, and 12-Month Visit completed will be mailed if the subject completes the “Early 
Termination Questionnaire”. No compensation will be provided for the Screening Visit, 
Optional Follow-Up Visit(s), and Optional LEEP Visit. 
 
7.1.3 
Travel Stipends 
 
For subjects travelling more than 50 miles one-way to come for appointments, pre-visit travel 
stipends will be available. 
 
Stipends will be calculated and verified (by study staff) based on mileage from point of origin 
to the appointment location using internet mapping software, such as Google Maps or 
MapQuest. 
 
Stipends will be provided in the form of a pre-loaded gift card. 
 
Stipend amounts: 
 
$40 per visit for those travelling > 50 miles but < 100 miles 
 
$60 per visit for those travelling ≥ 100 miles but < 150 miles 
 
$80 per visit for those travelling ≥ 150 miles but < 200 miles 
 
$100 per visit for those travelling ≥ 200 miles 
 
 

IRB# 202790 A phase II clinical trial of PepCan 
PI: Mayumi Nakagawa, MD, PhD 
Site: UAMS OBGYN Clinics, UAMS Winthrop P. Rockefeller Cancer Institute 
Funding Source: NIH (NCI) 
Sponsor: UAMS 
Version: 19 
Date: January 19, 2023 
Page 37 
7.1.4 
Annual Limit on Gift Cards 
The maximum amount of gift cards that can be dispensed to each subject is $600 per calendar year. 
If more than $600 is owed to a subject (very unlikely to ever happen), the amount exceeding $600 
will be paid in the next calendar year. 
 
8 
OUTCOME MEASURES 
 
CLINICAL ASSESSMENTS (UAMS Pathology Laboratory) 
Clinical response will be assessed (by Pathologists on service in the Pathology Department) by 
comparing punch biopsy results from screening (having had HSIL is the inclusion criterion) with 
the quadrant biopsies performed at the 12-Month visit. The result of the highest grade will be 
recorded. The subject will be considered a “complete responder” if the 12-Month quadrant biopsies 
are negative for CIN, a “partial responder” if the show show CIN 1 or a “non-responder” if the 
biopsy shows HSIL (CIN 2 and/or 3). In addition to the above analysis of subjects who exited after 
the 12-Month Visit, another analysis may be performed with addition of subjects who exited the 
study after the 6-Month Visit if histological results (biopsy and/or LEEP) are available at 6 months. 
 
 
VIROLOGICAL 
STUDY 
(HPV-DNA 
TESTING 
(Nakagawa 
Laboratory) 
AND 
BACTERIAL TESTING (University of Chicago Argonne Laboratory) 
The ThinPrep samples will be tested for the presence of HPV-DNA. A commercially available kit 
such as the “Linear Array HPV Genotyping Test” may be used (Roche Molecular Diagnostics, Inc., 
Alameda, CA). This kit tests for 37 HPV types (6, 11, 16, 18, 26, 31, 33, 35, 39, 40, 42, 45, 51, 52, 
53, 54, 55, 56, 58, 59, 61, 62, 64, 66, 67, 68, 69, 70, 71, 72, 73, 81, 82, 83, 84, IS39, and CP6108). 
The human -globin signal will also be assayed as a positive control for sample adequacy for DNA 
content from each sample. Positive-control samples (with added HPV plasmid DNA and plasmid-
encoded human -globin gene) and negative-control samples (no HPV plasmid DNA and no human 
-globin gene) will be provided by the manufacturer and will be included in each experiment. HPV 
types 31, 33, 35, 52, 58, and 67 will be considered “HPV 16-Related”, additionally HPV types 18, 
39, 45, 51, 53, 56, 59, 66, 68, 69, 70, 73, and 82 will be considered “High Risk”, and types 6, 11, 
40, 42, 54, 61, 62, 71, 72, 81, 83, 84, and CP6108 will be considered “Low Risk” [58]. If samples 
are still available after HPV testing, other gene sequencing and gene expression studies may be 
performed for subjects who agreed in the consent for future use of remaining samples. 
 
The virological response will be assessed by comparing HPV-DNA testing results before and after 
vaccination. The subject will be considered a “clearer” if at least one HPV type(s) present before 
vaccination becomes undetectable at both 6-Month and 12-Month Visits. Otherwise, a subject will 
be considered a “persistor” as long as at least one HPV type was detected at baseline. 
 
The ThinPrep samples will also be 16S rRNA DNA tested to assess the nature and the diversity of 
the cervical microbial community. A commercially available Vaginal Microbiome Genome Mix 
will be used as a positive control, and a liquid in ThinPrep without cervical sampling will be used 
as a negative control. Illumina MiSeq platform will be used for sequencing. The presence and 
abundance of microbiome at the species to phylum levels will be correlated with the vaccine 
response and other immunological parameters. 
 
 
IMMUNOLOGICAL ASSESSMENTS 
8.3.1 
ELISPOT Assay (Nakagawa Laboratory) 

IRB# 202790 A phase II clinical trial of PepCan 
PI: Mayumi Nakagawa, MD, PhD 
Site: UAMS OBGYN Clinics, UAMS Winthrop P. Rockefeller Cancer Institute 
Funding Source: NIH (NCI) 
Sponsor: UAMS 
Version: 19 
Date: January 19, 2023 
Page 38 
An immune assay such as an ELISPOT assay to assess the presence of HPV-specific T-cells will 
be performed. After each blood draw, PBMCs will be separated into CD14+ and CD14– 
populations and cryopreserved. To eliminate interassay variability, all three blood samples (before 
vaccination, after two vaccinations, and after four vaccinations) will be used to establish T-cell 
lines and to perform ELISPOT assays. CD3 T-cell lines will be established by stimulating in vitro 
magnetically selected CD3 cells with autologous mature dendritic cells exposed to HPV 16 E6-vac 
and E6-GST. ELISPOT assays will be performed as previously described [28]. We typically 
examine 10 regions within the HPV 16 E6 protein (E6 1–25, E6 16–40, E6 31–55, E6 46–70, E6 
61–85, E6 76–100, E6 91–115, E6 106–130, E6 121–145, and E6 136–158). The assay will be 
performed in triplicate if sufficient cells are available. In order to compare each region before 
vaccination and after 2 or 4 injections, a t test for paired samples will be performed, as described 
previously [59]. Therefore, each subject will be assessed in terms of the number of regions with 
statistically significant increased T-cell responses after two injections or four injections determined 
by using Student’s paired t-test. Remaining CD3 T-cells may be used to assess the recognition of 
homologous epitopes from other high-risk HPV types, to describe novel epitopes, and/or to assess 
the endogenous processing of such epitopes. 
 
8.3.2 
Measuring Immune Cells 
8.3.2.1 Circulating Immune Cells (Nakagawa Laboratory) 
A small amount of PBMCs (approximately 3 x 106 cells) from blood draws at Visit 1, Visit 3, and 
Visit 5 will also be used to monitor levels of circulating immune cells such as Tregs and MDSC to 
assess whether vaccination may decrease their levels [60]. Flow cytometry will be used to 
determine 
the 
number 
of 
CD4+ 
CD25+ 
FOXP3+ 
(Treg) 
[29] 
and 
CD11b+CD14+CD33+IL4R +HLA-DRint/neg (MDSC) cells [29, 61, 62]. T-bet (Th1), GATA3 
(Th2), and/or ROR gammaT (TH17) positive cells may also be examined. The number of 
circulating immune cells will be determined before vaccination, after two, and after four injections. 
 
8.3.2.2 Cervical Immune Cells (UAMS Experimental Pathology Core) 
After routine pathological diagnosis has been made from LEEP sample obtained at the Optional 
LEEP Visit, additional sections may be examined for cervical immune cells such as those positive 
for CD3 (T-cell), CD4 (helper T-cell), CD8 (cytotoxic T-cell), CD56 (NK cell), CD1a (Langerhan 
cells important in antigen presentation), CD20 (B-cell), CD68 (macrophage), FOXP3 (Treg), T-bet 
(Th1), and MadCAM-1 (addressing involved with T-cell infiltration). Eosinophils (Th2) may also 
be examined. 
 
8.3.2.3 Others 
Additional analyses that may be performed using blood samples to assess vaccine response include 
antibody production to HPV proteins, cytokine/chemokine, and metabolomic responses (Nakagawa 
and Metabolon laboratories). 
 
9 
DATA ANALYSIS 
 
ASSESSING EFFICACY 
A historical placebo group, from a previously reported study with a similar study design (i.e., 
enrollment of subjects with biopsy-proven CIN2/3, and clinical response assessed by biopsy in 15 
months), will be used for comparison [57]. The strict definition of histological response which only 
considers “complete responders” to be “responders” will be used. Those with any CIN remaining 
would be considered as “non-responders” for the purpose of comparing with the historical placebo 
group. The response rate in PepCan or Candin® recipients who completed the trial after the 12-

IRB# 202790 A phase II clinical trial of PepCan 
PI: Mayumi Nakagawa, MD, PhD 
Site: UAMS OBGYN Clinics, UAMS Winthrop P. Rockefeller Cancer Institute 
Funding Source: NIH (NCI) 
Sponsor: UAMS 
Version: 19 
Date: January 19, 2023 
Page 39 
Month-Visit will be compared with that of the historical placebo group which was 29.1% (34 of 
117) using binomial test. The response rates between the PepCan and Candin® groups will be 
compared using the Fisher’s exact test. See “Rationale for Primary Outcome Measure: Efficacy” 
(Section 1.5.9) for power analysis and sample size justification. 
 
In addition to the above analysis of subjects who exited after the 12-Month Visit, another analysis 
may be performed with addition ofsubjects who exited the study after the 6-Month Visit if 
histological results (biopsy and/or LEEP) are available at 6 months. As 21 patients in the placebo 
arm were removed from the study at 3 or 6 months for having persistent biopsy-proven CIN3 [57], 
the response rate of 24.6% (34 of 138) will be used for this comparison. 
 
For an intention-to-treat analysis, all subjects who qualified for vaccination will be included 
regardless of whether any vaccinations were received. In the historical placebo group, 149 subjects 
were randomized and qualified for vaccination [57]. Therefore, the placebo response rate for this 
analysis will be 22.8% (34 of 149).  
 
ASSESSING SAFETY: SUMMARY OF ADVERSE EVENTS 
Subjects who received at least one dose of PepCan or Candin® will be included in safety 
assessments. Results will be tabulated as shown in Table 2. The type of adverse reactions, the 
CTCAE grades, and whether the reactions are vaccine-related will be indicated. 
 
 
ASSESSING IMMUNOLOGICAL RESPONSE AND VIRAL CLEARANCE 
9.3.1 
Immunological Response 
9.3.1.1 CD3 T-Cell Response to HPV 
As described above, a paired t-test for paired samples will be performed in order to compare each 
region with increased positivity index after 2 or 4 injections compared to pre-vaccination, as shown 
in Fig. 3 for the PepCan arm. An analogous analysis will be performed for the Candin® arm, and 
the number of regions with statistically significant increases will be compared between the two 
treatment arms to elucidate the additive effects of the E6 peptides. 
 
A correlation between CD3 T-cell response to HPV and clinical response will be examined by 
drawing a contingency table for a number of subjects with at least one region with statistically 
significant increase to E6 in “responders” and “non-responders” separately for the PepCan and 
Candin® groups. Fisher’s exact test will be used. 
 
9.3.1.2 Circulating Immune Cells 
The changes in percentage of circulating immune cells such as Th1, Th2, Treg, and MDSC will be 
compared after 2, 6 months after 4 vaccinations, and 12 months after 4 vaccinations with baseline 
as shown in Fig. 4. Paired t-test and one-way ANOVA will be performed to determine statistical 
significance separately for the PepCan and Candin® groups. 
 
The differences between the percentages of each circulating immune cell types will be compared 
between the “responders” and the “non-responders” at pre-vaccination, post-2 vaccination, 6 
months after post-4 vaccination, and 12 months after post-4 vaccination using Wilcoxon rank-sum 
test separately for the PepCan and Candin® groups. 
 
9.3.2 
Viral Clearance and Microbial Community 
HPV-DNA and bacterial testing will performed using Thin-Prep samples from Screening, 6-Month, 
and 12-Month Visits. 

IRB# 202790 A phase II clinical trial of PepCan 
PI: Mayumi Nakagawa, MD, PhD 
Site: UAMS OBGYN Clinics, UAMS Winthrop P. Rockefeller Cancer Institute 
Funding Source: NIH (NCI) 
Sponsor: UAMS 
Version: 19 
Date: January 19, 2023 
Page 40 
 
A correlation between clinical response and virological response (at least one HPV type becoming 
undetectable after vaccination) will be examined by drawing a contingency table for responder vs. 
non-responders and HPV persistence vs. HPV clearance separately for the PepCan and Candin® 
groups. Fisher’s exact test will be used. The presence and abundance of microbial taxa from species 
to phylum level will be correlated with clinical response and other immunological parameters. 
 
 
FACTORS CONTRIBUTING TO STUDY RECRUITMENT AND RETENTION 
Based on data provided in “Screening Visit Questionnaire”, “Early Termination Questionnaire”, 
and “12-Month Visit Questionnaire”, factors that contribute to subject recruitment and retention 
may be assessed. The Fisher’s exact test will be used to compare factors such as frequent use of 
Facebook private group, motivation for entering the study, or having young children will be 
compared between the subjects who are withdrawn from the study early and the subjects who 
completed the study. 
 

IRB# 202790 A phase II clinical trial of PepCan 
PI: Mayumi Nakagawa, MD, PhD 
Site: UAMS OBGYN Clinics, UAMS Winthrop P. Rockefeller Cancer Institute 
Funding Source: NIH (NCI) 
Sponsor: UAMS 
Version: 19 
Date: January 19, 2023 
Page 41 
 
FACTORS PREDICTING CLINICAL RESPONSE AND VIRAL CLEARANCE 
Variables for prediction of vaccine response will be analyzed, first by univariate analyses, and then 
multivariable analysis with variable selection using lasso[63] with ten-fold cross validation. 
Computations will be performed in the R and R/Bioconductor[64] environments. Variable selection 
using lasso will be implemented with the package glmmLasso, while enrichment analysis for Gene 
Ontology terms will be performed using topGO. 
 
10 
DATA AND SAFETY MONITORING PLAN 
The PI will have the overall responsibility for assuring safety and gathering the data for with 
assistance from the co-investigators, sub-investigators, and research staff, under the guidance of 
the Institutional Review Board (IRB). As the sponsor, UAMS is responsible for providing quality 
monitoring for this study. 
 
Clinical site monitoring will be conducted by the UAMS Office of Research Regulatory Affairs 
(ORRA) to ensure that the rights and well-being of human subjects are protected; the trial data are 
accurate, complete and verifiable from source documents; and the trial is conducted in compliance 
with currently approved protocol/amendment(s), ICH GCP, and applicable regulatory 
requirements. 
 
Monitoring specialists from ORRA will conduct periodic on-site, comprehensive monitoring as 
determined by a protocol-specific monitoring plan, which will be provided by the ORRA 
Monitoring Unit. 
 
 
DEFINITIONS 
10.1.1 Adverse Event 
An adverse event is any occurrence or worsening of an undesirable or unintended sign, symptom, 
or disease that is temporally associated with the use of the vaccine, and it will be graded according 
to the Common Terminology Criteria for Adverse Events (CTCAE) Version 4.03. Local and/or 
systemic adverse events may include itching, burning, pain, peeling, rash, oozing, redness, 
tenderness, scarring, fever, nausea, dizziness, and wheezing. The subjects will be allowed to use 
and provided analgesics (such as ibuprofen or naproxen) according to the appropriate dosages after 
injections to limit any adverse events that may occur. Any adverse event will be reviewed and 
considered related or not related to the vaccine. All applicable events will be reported to the IRB 
according to IRB policy 10.2 and the FDA according to 21 CFR 312.32. 
 
10.1.2 Serious Adverse Event 
A serious adverse event is any medical event that: 
 
Results in death 
 
Is an immediate threat to life 
 
Requires hospitalization or prolongation of existing hospitalization 
 
Is a congenital anomaly or birth defect, or 
 
Other important medical events that have not resulted in death, are not life-threatening, or do 
not require hospitalization, may be considered serious adverse events when, based upon the 
appropriate medical judgment, they are considered to jeopardize the subject and may require 
medical or surgical intervention to prevent one of the outcomes listed above. 
 
 

IRB# 202790 A phase II clinical trial of PepCan 
PI: Mayumi Nakagawa, MD, PhD 
Site: UAMS OBGYN Clinics, UAMS Winthrop P. Rockefeller Cancer Institute 
Funding Source: NIH (NCI) 
Sponsor: UAMS 
Version: 19 
Date: January 19, 2023 
Page 42 
 
ADVERSE EVENTS MONITORING 
10.2.1 Time Period 
Adverse events will be collected from the time of enrollment until the 12-Month Visit. 
 
10.2.2 Collecting Procedure 
Adverse events may be uncovered through any of these methods: 
 
Observing the subject 
 
Asking the subject to keep “Subject Diary” 
 
Receiving an unsolicited complaint from the subject 
 
All adverse events will be recorded in either CRF and/or Communication Note as appropriate. In 
addition, all adverse events will be recorded in AERS. 
 
10.2.3 Relationship to the Investigational Drug 
The relationship between the adverse event and the investigational drug should be assessed using 
the following categories: 
 
Definitely Related: A direct cause and effect relationship between the investigational drug and 
the adverse event exists. 
 
Possibly Related: A direct cause and effect relationship between the investigational drug and 
the adverse event has not been clearly demonstrated, but is likely or very likely. 
 
Unlikely Related: A direct cause and effect relationship between the investigational drug and 
the adverse event is improbably, but not impossible. 
 
Unrelated: The adverse event is definitely not associated with the investigational drug. 
 
REPORTING ADVERSE EVENTS 
10.3.1 Standard Reporting 
A summary of adverse events will be included in the annual IRB status report and the IND report 
to the FDA. 
 
10.3.2 Expedited Reporting 
A serious, unexpected (previously not expected in nature, severity, or degree of incidence), and 
drug-related adverse event is required to be reported to: 
 
The UAMS Research Support Center-Regulatory Affairs within 24 hours of PI being notified 
 
The FDA will be notified using the MedWatch Form 3500A within 10 days of PI being notified 
(http://www.fda.gov/medwatch/safety/FDA-500A Fillable.pdf) 
 
The UAMS IRB will be notified of events requiring expedited reporting within 10 days of PI 
being notified (see below if SAE is death) 
 
A drug-related death occurring while a subject is on the study must be reported to: 
 
The UAMS IRB immediately 
 
The FDA within 7 days of the investigator learning of the event 
 
The cause of death and the investigator’s discussion regarding whether or not the death 
was drug-related should be described in a written report. 
 
 

IRB# 202790 A phase II clinical trial of PepCan 
PI: Mayumi Nakagawa, MD, PhD 
Site: UAMS OBGYN Clinics, UAMS Winthrop P. Rockefeller Cancer Institute 
Funding Source: NIH (NCI) 
Sponsor: UAMS 
Version: 19 
Date: January 19, 2023 
Page 43 
11 
PROTOCOL DEVIATION AND PROTOCOL VIOLATION 
 
DEFINITIONS 
11.1.1 Protocol Deviation 
A study event that is not covered under the existing protocol and represents a failure to comply 
with the protocol. Most deviations are minor and involuntary. If the deviations represent a variation 
from the approved protocol that could affect the safety and welfare of the subject, it must be 
reported to the UAMS IRB immediately. 
 
Missing subject diaries will not be considered protocol deviations, as there are mechanisms in place 
to collect this information. 
 
11.1.2 Protocol Violation 
An event clearly occurring outside of the approved research activity, which also represents a failure 
to comply with the protocol, e.g., enrollment of a subject that fails to meet inclusion or exclusion 
criteria. A protocol violation refers to more serious non-compliance, which more often leads to 
exclusion of subjects from eligibility analysis or their discontinuation from the study. 
 
 
REPORTING PROTOCOL DEVIATIONS AND PROTOCOL VIOLATIONS 
11.2.1 Standard Reporting 
If the protocol deviation/protocol violation does not represent a significant alteration in the 
approved protocol and/or affect the safety or welfare of the subject, it will be reported to the UAMS 
IRB at the time of Continuing Review. 
 
11.2.2 Expedited Reporting 
If the protocol deviation or protocol violation represents a significant alteration in the approved 
protocol and/or if it affects the safety or welfare of the subject, it must be reported to the UAMS 
IRB immediately. 
 
12 
ETHICAL CONSIDERATIONS AND REGULATORY COMPLIANCE 
 
HUMAN SUBJECT PROTECTION 
This study will be conducted in compliance with the protocol and with all applicable regulatory 
requirements. 
 
 
UAMS IRB AND PROTOCOL REVIEW AND MONITORING COMMITTEE (PRMC) 
 
A copy of the protocol and informed consent documents will be approved by the UAMS IRB 
and PRMC prior to initiation of the study. 
 
The investigator must submit and obtain approval for any changes in the protocol or informed 
consent forms. The UAMS Research Support Center must also be notified and provided the 
revised documents. 
 
Annual status report will be submitted. 
 
Change of PI will be notified within 30 days. 
 
PI will sign a statement regarding the protection of human subjects and vulnerable population 
in CLARA. 
 
 

IRB# 202790 A phase II clinical trial of PepCan 
PI: Mayumi Nakagawa, MD, PhD 
Site: UAMS OBGYN Clinics, UAMS Winthrop P. Rockefeller Cancer Institute 
Funding Source: NIH (NCI) 
Sponsor: UAMS 
Version: 19 
Date: January 19, 2023 
Page 44 
 
INFORMED CONSENT 
 
Before a subject’s participation in the trial, the investigator is responsible for obtaining written 
informed consent from the subject or the subject’s legally acceptable representative. 
 
Before signing the consent, the subject must have received adequate explanation of the 
objectives, methods, anticipated benefits, and potential risks associated with the study, 
including age-specific standard of care guidelines as periodically released by the American 
Society of Colposcopy and Cervical Pathology. 
 
No study-related procedures are to be performed before the subject has given his/her written 
informed consent. 
 
The consent process must be recorded in the Informed Consent Process Note. 
 
A copy of the signed, written informed consent will be given to the subject. 
 
Original consent documents will be kept with the study record. 
 
 
STUDY DOCUMENTATION AND STORAGE 
The investigator shall maintain a list of appropriately qualified persons to whom she has delegated 
trial duties. All persons authorized to make entries and/or corrections on case report forms will be 
included on the Delegation of Authority form. 
 
The investigator and study staff are responsible for maintaining a comprehensive and centralized 
filing system of all study-related documentation. A subject’s file should include: 
 
CRFs 
 
Informed consent documentation 
 
Source documentation 
The study file should contain: 
 
The protocol and all amendments 
 
Current curriculum vitas of investigators 
 
Medical licenses of investigators 
 
The IRB statement of compliance and membership rosters 
 
Completed FDA form 1572 
 
All correspondence to and from the UAMS IRB, PRMC, and FDA. 
 
Any other study related documents 
 
Study records will be retained on-site in accordance with applicable institutional and federal 
regulatory requirements. 
 
 
STUDY REGISTRATION AND PUBLICATIONS 
This clinical trial will be registered at ClinicalTrials.gov (www.clinicaltrials.gov), and information 
will be updated in a timely manner. The findings from this study will be presented at professional 
society meetings at national and international levels, and will be published in peer-reviewed 
journals. 
 
 

IRB# 202790 A phase II clinical trial of PepCan 
PI: Mayumi Nakagawa, MD, PhD 
Site: UAMS OBGYN Clinics, UAMS Winthrop P. Rockefeller Cancer Institute 
Funding Source: NIH (NCI) 
Sponsor: UAMS 
Version: 19 
Date: January 19, 2023 
Page 45 
13 
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IRB# 202790 A phase II clinical trial of PepCan 
PI: Mayumi Nakagawa, MD, PhD 
Site: UAMS OBGYN Clinics, UAMS Winthrop P. Rockefeller Cancer Institute 
Funding Source: NIH (NCI) 
Sponsor: UAMS 
Version: 19 
Date: January 19, 2023 
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509901. J Immunother. 2006;29:95-101. 

IRB# 202790 A phase II clinical trial of PepCan 
PI: Mayumi Nakagawa, MD, PhD 
Site: UAMS OBGYN Clinics, UAMS Winthrop P. Rockefeller Cancer Institute 
Funding Source: NIH (NCI) 
Sponsor: UAMS 
Version: 19 
Date: January 19, 2023 
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Enhancement of regression of cervical intraepithelial neoplasia II (moderate dysplasia) with topically 
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IRB# 202790 A phase II clinical trial of PepCan 
PI: Mayumi Nakagawa, MD, PhD 
Site: UAMS OBGYN Clinics, UAMS Winthrop P. Rockefeller Cancer Institute 
Funding Source: NIH (NCI) 
Sponsor: UAMS 
Version: 19 
Date: January 19, 2023 
Page 48 
[58] de Villiers EM, Fauquet C, Broker TR, Bernard HU, zur Hausen H. Classification of papillomaviruses. 
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G, Smith C, Smyth G, Tierney L, Yang JY, Zhang J. Bioconductor: open software development for 
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IRB# 202790 A phase II clinical trial of PepCan 
PI: Mayumi Nakagawa, MD, PhD 
Site: UAMS OBGYN Clinics, UAMS Winthrop P. Rockefeller Cancer Institute 
Funding Source: NIH (NCI) 
Sponsor: UAMS 
Version: 19 
Date: January 19, 2023 
Page 49 
14 
APPENDIX 
 
Appendix 1. Schedule of Study Assessments 
 
Within 60 
days of Visit 1 
Visits scheduled 3 wks (± 7 days) apart 
6 months 
(± 2 wks) 
from Visit 4 
6 months 
(± 2 wks) from 
6-Month Visit 
As soon as 
possible following 
6-Month or 12-
Month Visit 
Additional 
Optional Follow-
Up Visit(s) 
 
Screening 
Visit 
Visit 1 
Visit 2 
Visit 3 
Visit 4 
6-Month Visit 
12-Month Visit 
Optional LEEP 
Visit 
 
Informed Consent 
X 
 
 
 
 
 
 
 
 
Inclusion/ Exclusion 
Review 
X 
 
 
 
 
 
 
 
 
Screening Visit 
Questionnaire 
X 
 
 
 
 
 
 
 
 
Subject Contact 
Information 
X 
 
 
 
 
 
 
 
 
History 
X 
 
 
 
 
 
 
 
 
Physical Exama 
X 
 
 
 
 
X 
X 
 
 
Colposcopybc 
X 
 
 
 
 
X 
X 
 
 
ThinPrep sampled 
X 
 
 
 
 
X 
X 
Xe 
 
Complete blood count 
(CBC)f 
X 
X 
 
X 
 
X 
X 
Xg 
Xg 
Comprehensive 
metabolic panel (CMP)h 
X 
X 
 
X 
 
X 
X 
Xg 
Xg 
Blood for 
Immunological 
Assessmentsi 
 
X 
X 
X 
X 
X 
X 
Xg 
Xg 
Urine Pregnancy Test 
 
X 
X 
X 
X 
 
 
 
 
BMI 
 
X 
 
 
 
 
 
 
 
Pre-Injection 
Vital Signs 
 
X 
X 
X 
X 
 
 
 
 
Vaccination 
 
X 
X 
X 
X 
 
 
 
 
Post-Injection 
Vital Signs 
 
X 
X 
X 
X 
 
 
 
 
Adverse Events 
 
X 
X 
X 
X 
X 
X 
X 
X 
Concomitant 
Medications 
 
X 
X 
X 
X 
X 
X 
 
 
Analgesics offered 
 
X 
X 
X 
X 
 
 
 
 
Provide Subject Diary 
 
X 
X 
X 
X 
 
 
 
 
Collect Subject Diaryj 
 
 
X 
X 
X 
X 
 
 
 
12-Month Visit 
Questionnaire 
 
 
 
 
 
 
X 
 
 
Optional LEEPjc 
 
 
 
 
 
 
 
X 
 
Hysterectomyk 
 
 
 
 
 
X 
X 
X 
X 
Visit Follow-upl,m 
X 
 
 
 
 
 
 
X 
Xn 
 
                                                                                             
a Physical Examination will include blood pressure, heart rate, respiratory rate, body temperature, and body weight. 
b Colposcopy will include punch biopsy and endocervical curettage as indicated; biopsies will be obtained from all subjects at the 12-Month visit. 
c If performed in the OR, a COVID-19 test may be required per hospital policy prior to intervention. The study will pay for the mandatory pre-
operative COVID-19 testing while institutional COVID-19 precautions are in effect. 
d Specimens will be collected for HPV-DNA and bacterial testing at Screening, 6- & 12-Month Visits. Pap smear added only at the 6-Month Visit. 
e This only needs to be collected when requested. 
f CBC will include white count, hemoglobin, hematocrit, and platelet counts. 
g  These bloods draws only need to be done when requested. 
h CMP will include aspartate transaminase, alanine transaminase, albumin, alkaline phosphatase, total bilirubin, total protein, sodium, potassium, 
chloride, CO2, blood urea nitrogen (BUN), creatinine, calcium, and glucose 
i Blood samples will be collected for ELISPOT assay, circulating immune cells, and/or other research laboratory assessments. 
j It is anticipated some participants in this population will not return completed diaries. However, there are mechanisms in place to collect this 
information. When this occurs staff, will ask subjects whether they have experienced any adverse events or changes to concomitant medications 
and document their response in Epic. Missing diaries will not be considered protocol deviations. 
k In rare instances, should a diagnosis of invasive cervical cancer be confirmed, a hysterectomy may be offered if a study physician determines it 
to be medically necessary. This should be scheduled as soon as possible following the determination of medical necessity. 
l Test results and visit outcomes will be discussed with subjects via telephone. Optional follow-up visits may be scheduled to discuss test results, 
perform clinically indicated examinations/procedures, and/or further discuss a subject’s condition. These should be scheduled as soon as possible. 
m Based on the results of the ELISPOT assay, some subjects will be furthered studied for cross-reactivity, epitope spreading, and/or defining novel 
T-cell epitopes. 
n Other reasons for additional optional follow-up visits during study participation are referenced in section 6.11.