• To assess duration of response and ratio of participants that are hospitalized because of adverse events attributed to disease progression. • To evaluate the safety of the combination at a reduced dose level in patients with cervical cancer with prior pelvic radiation and boost brachytherapy where a potential higher risk of grade 3 hematuria may exist with the full starting doses of both M7824 and NHS-IL12. 1.1.3 Exploratory Objectives • To conduct exploratory immunologic studies to understand and improve the administered treatment, including: o peripheral immune subset analysis before and on treatment; 8 Abbreviated Title: Combo Immunotx in HPV Cancers Version Date: 05.12.2023 o soluble factors circulation (e.g., sCD27 and sCD40 ligand) before and on treatment ; o tumor tissue immune infiltration before and after treatment. • To assess responses to therapy using iRECIST. • To assess responses to therapy by HPV serotype or PD -L1 expression. • To assess correlation between circulating tumor DNA and response to therapy • To assess response to therapy in checkpoint refractory disease • To assess response to therapy by HLA type • To assess response using reduced doses of NHS-IL12 or M7824 1.2 BACKGROUND AND RATIONALE 1.2.1 HPV Associated Malignancies In the United States, there are more than 30,000 cases of HPV associated cancer annually [ 1] (Table 1). Met astatic HPV associated malignancies (cervical, anal, oropharyngeal cancers etc.) are often incurable and poorly palliated by standard therapies . Responses to chemotherapy are variable but generally short -lived with median PFS around 3 to 7 months [ 2-5]. In a Gynecologic Oncology Group randomized trial comparing four cisplatin -based doublets as first line therapy for cervical cancer the response rates were 22 -29% and median PFS was 4 to 6 months with m edian OS 10 to 13 months [6]. The addition of bevacizumab to combination chemotherapy has been reported to increase OS by 3.7 months, but virtually all patients die of their disease within 2 years [7]. Randomized trials of second line therapy are lacking but response rates for single agents are generally reported to be less than 20% [ 8]. Early evidence suggests that immune checkpoint therapy also has a low response rate in this disease with a phase 1b trial (KEYSTONE 028) showing a 12.5% response rate (3/24 patients) and a phase II study showing a response rate of 13.3% (13/98 patients) to pembrolizumab in patients with recurrent or met astatic cervical cancer [9]. Table 1: Estimated annual incidence of HPV associated cancers in the U S Site Incidence of HPV associated cancers Cases attributed to HPV (%) Oropharyngeal 15,738 11,000 (70.1%) Cervix 11,771 10,700 (90.6%) Vulvar 3554 2400 (68.8%) Vaginal 802 600 (75%) Penis 1168 700 (63.3%) 9 Abbreviated Title: Combo Immunotx in HPV Cancers Version Date: 05.12.2023 Site Incidence of HPV associated cancers Cases attributed to HPV (%) Rectal (squamous cell) 750 700 (91.1%) Anus 5,010 4,600 (91.1%) Total 38,793 30,700 (79.1%) For oropharyngeal cancer, the best estimates of the chemotherapy responsiveness are inferred from looking at the oropharyngeal site in subset analyses from clinical trials for head and neck cancer s. In a pivotal clinical trial that established platinum, 5 -fluorouracil (5-FU), plus cetuximab as first line therapy in head and neck cancer, patients with oropharyngeal tumors experienced PFS of 4 to 6 months and OS of 8 to 11 months [3]. Immune checkpoint therapy has become the standard second line therapy for metastatic oropharyngeal cancer but response rates are still low with this therapy. As an example, the phase 1b trial (KEYNOTE -012) of pembrolizumab which led to its FDA approval for recurrent or metastatic head and neck squamous cell carcinoma (HNSCC) as second line therapy had a 17.7% response rate (34/192 patients). Response rates were slightly better in HPV positive HNSCC (21.9%) [ 10], but still occurred in only a minority of the patients. In regard to metastatic anal cancer, only a handful of randomized trials have been performed in the last 30 years. In the metastatic setting, most of the evidence is limited to small phase II trials, retrospective series, and case reports. A recent retrospective series looking at 77 patients, 44 (55%) of whom received 5- FU in combination with cisplatin, 24 (31%) of whom received carboplatin + paclitaxel, and 11 (14%) of whom received another regimen showed a median PFS of 7 months and median OS of 22 months [ 5]. As with HNSCC, recent early phase trials evaluating immune checkpoint therapy in this disease have shown that responses here too are limited to around 20% of patients treated. A recent phase II trial of nivolumab for metastatic squamous cell anal cancer showed a 21% response rate (7/33 patients) and a recent phase IB trial (KEYNOTE -028) of pembrolizumab showed a 20% response rate (5/25 patients) [11]. In a recent ly publ ished phase II trial, Massarelli et al . evaluated the combination of a therapeutic HPV vaccine and Nivolumab [12]. In contrast to previous single therapy immune checkpoint inhibitor trials, they found an overall response rate of 33% showing the potential benefit of Immuno- Oncology ( I/O) combination therapy for these diseases. 10 Abbreviated Title: Combo Immunotx in HPV Cancers Version Date: 05.12.2023 Table 2 Response in patients treated with ISA101 and Nivolumab (Massarelli JAMA Oncol Sept 27, 2018) Unfortunately, little data exists evaluating immunotherapy for rarer HPV associated malignancies including metastatic vulvar, vaginal, penile, squamous cell rectal or neuroendocrine cervical cancer. 1.2.2 Rationale for Combination of I/O Agents Pre clinical studies are now revealing that an effective immuno -oncology strategy for enhancing anti-tumor responses is the use of multiple immune -mediating agents, each targeting different components of the immune system. These include: (a) induction of an immune response via vaccination directed against tumor -associated antigens, (b) reduction of immunosuppressive entities in the TME by the use of anti -PD1/PDL1 MAb checkpoint inhibitors, and/or reduction of immunosuppressive cytokines such as TGF -β with th e use of a bifunctional anti -PDL1/TGF -β2 “Trap” designated M7824, and (c) potentiation of the immune response in the TME by the use of the tumor targeting NHS-IL12 immunocytokine. The LTIB, in collaboration with the GMB, has been able to develop and/or co- develop these agents via a series of CRADAs.