1609922. Section D: Purpose and Objectives PRIMAR Y: The primary objective of the study is to determine the ef fect on 24 month progression free survival of intratumoral HPV vaccination with topical imiquimod and oral metformin for locally advanced cervical, vaginal, or vulvar carcinoma in conjunction with definitive whole pelvic radiotherapy with chemotherapy followed by brachytherapy . Although the clinical benefit of this combination of drugs has not yet been established, the intent of of fering this treatment is to provide a possible therapeutic benefit, and thus the patient will be carefully monitored for tumor response and symptom relief in addition to safety and tolerability . SECONDAR Y: Assess for unanticipated toxicity of the combination of intratumoral HPV vaccination with topical imiquimod and oral metformin when administered in conjunction with chemotherapy with whole pelvic radiotherapy for cervical or vulvar carcinoma. . Corollary Objective: Study of specific immune markers and modalities by which the combination immunotherapy boosts the immune system and works in sync with the standard of care to enhance its ef fects. Immune biomarker assays will be performed in cervical swab and blood samples at the beginning, middle, and end of the treatment to measure the ef fects of treatment on several immune markers including: CD4, CD8, NK, TNF alpha and beta, IL2, HPV viral load, TGF Beta, Ki67, IGg. W e will also do blood tests to test for IGg L1 and L2, E6 and E7 and a CBC. These markers were chosen to identify specific immune changes of the three treatment groups. Section E: Protocol Risks/Subjects E1. Risk Category Category 2: Research involving greater than minimal risk, but presenting the prospect of direct benefit to the individual subjects. E2. Subjects Gender: Female Age: Adult (18-64 yrs) Ethnicity:8/23/24, 10:39 AM Human Protocol Report https://brain.bcm.edu/esp1/reports/Human/Protocol.asp?protocol=486486 5/16 All Ethnicities Primary Language: English, Spanish Groups to be recruited will include: Asymptomatic patients with chronic conditions, healthy; Patients Which if any of the following vulnerable populations will be recruited as subjects? Vulnerable populations require special protections. How will you obtain informed consent, protect subject confidentiality , and prevent undue coercion? E3. Pregnant woman/fetus Will pregnant women and/or fetuses (as described in 45 CFR 46 Subpart B) be enrolled in the research? No E4. Neonates Will neonates of uncertain viability or nonviable neonates (as described in 45 CFR 46 Subpart B) be enrolled in the research? No E5. Children Will children be enrolled in the research? No Section F: Design/Procedure F1. Design Select one category that most adequately describes your research: u) Drug, Phase II, Single Center Discuss the research design including but not limited to such issues as: probability of group assignment, potential for subject to be randomized to placebo group, use of control subjects, etc. This window-of-opportunity study will be of fered to all eligible patients undergoing chemoradiation for cervical, vulvar , or vaginal cancer , since it is an additional treatment anticipated to enhance the response to therapy . The treatment group will be compared to a historical control. W e will evaluate the immune changes within the tumor microenvironment and validate why the combination immunotherapy study elicited such a robust immune response which led to complete resolution of the cancer , in comparison to the standard of care, chemoradiation. If the combination immunotherapy used together with chemoradiation elicits a more robust antitumor response, there is the potential that the addition of these FDA approved medications to chemoradiation could be a new standard of treatment for squamous cell carcinoma of the cervix and vulva. Inclusion Criteria: • Participants must have histologically confirmed locally advanced or metastatic cervical carcinoma (Stage IB2-IVB), vaginal, or vulvar carcinoma (Stage II-IVB), AND not be considered a primary surgical candidate. Patients of fered neoadjuvant therapy may be enrolled if they respond and receive chemoradiation. • Participants must have measurable disease, per Recist criteria. See Section 12 (Measurement of Ef fect) for the evaluation of measurable disease. Radiological evaluation shall occur within approximately 30 days prior to enrollment initiation and start of radiation. • Participants must have an Eastern Cooperative Oncology Group (ECOG) performance status of ≤ 2 • Participants must be ≥ 18 years of age • Participants must have adequate organ function within 28 days of registration, defined as follows: - Absolute neutrophil count ≥ 1,500/µL - Platelets ≥ 100,000/µL - Hemoglobin ≥ 9 g/dL - Serum creatinine ≤ 1.5 x upper limit of normal (ULN) - Total bilirubin ≤ 1.5 x ULN (≤2.0 in patients with known Gilberts syndrome) OR direct bilirubin ≤ 1 x ULN - Aspartate aminotransferase and alanine aminotransferase ≤ 2.5 x ULN unless liver metastases are present, in which case they must be ≤ 5 x ULN • Participants receiving corticosteroids may continue as long as their dose is stable for at least 4 weeks prior to initiating protocol therapy . • Participant must agree to not donate blood during the study or for 90 days after the last dose of study treatment. • Female participants of childbearing potential must have a negative serum pregnancy test within 14 days prior to registration. Females of non-childbearing potential is defined as follows (by other than medical reasons): - ≥45 years of age and has not had menses for >1 year , post-hysterectomy , post-bilateral oophorectomy , post external beam radiation of 6 Gy to the pelvis, or post-tubal ligation. • Participants must agree to not breastfeed during the study . • Participants must be able to understand the study procedures and agree to participate in the study by providing written informed consent • Participants must be eligible for chemoradiation treatment in the opinion of the treating investigator . • Participants who are HIV+ must have CD4 counts >200/dL and demonstrate documented Highly active antiretroviral therapy (HAAR T) compliance m. Participant must have CT (chest/abdomen/pelvis) or PET -CT, within 56 days of registration. • Participants must be newly diagnosed. • Standard chemoradiation using external beam radiation therapy8/23/24, 10:39 AM Human Protocol Report https://brain.bcm.edu/esp1/reports/Human/Protocol.asp?protocol=486486 6/16 (EBR T) and brachytherapy is permitted for cervical or vaginal carcinoma, and chemoradiation with EBR T for vulvar carcinoma. A lesion must be readily accessible for intratumoral tumor injection. • ECOG performance status ≤2 (Karnofsky ≥60%, see Appendix A). • For patients with evidence of chronic hepatitis B virus (HBV) infection, the HBV viral load must be undetectable on suppressive therapy , if indicated. • Patients with a history of hepatitis C virus (HCV) infection must have been treated and cured. For patients with HCV infection who are currently on treatment, they are eligible if they have an undetectable HCV viral load. • Patients with treated brain metastases are eligible if follow-up brain imaging after central nervous system (CNS)-directed therapy shows no evidence of progression. • Patients with a prior or concurrent malignancy whose natural history or treatment does not have the potential to interfere with the safety or ef ficacy assessment of the investigational regimen are eligible for this trial. Exclusion Criteria: • Patients who are receiving any other investigational agents. • Patients who have untreated, new or progressive brain metastases or leptomeningeal disease. • History of allergic reactions attributed to compounds of similar chemical or biologic composition to agents used in study . • Patients with uncontrolled intercurrent illness. • Patients with psychiatric illness/social situations that would limit compliance with study requirements. • Pregnant women are excluded from this study because cervical carcinoma or vulva carcinoma patients have undergone treatment rendering the patient infertile. Because there is an unknown but potential risk for adverse events in nursing infants secondary to treatment of the mother with cervical carcinoma or vulva carcinoma, breastfeeding should be discontinued. F2. Procedure Treatment visits will occur during the second and fourth weeks of radiation, and then during weeks 8, 10, 12, and 16, which will occur after completing radiation. At the treatment visit: A blood sample will be obtained by a research nurse (10 milliliters/ 2 teaspoons) A speculum exam will be performed and 2 small brushes (cytobrush) will be used to collect cells from the surface of the tumor . If you have a vulvar cancer , the cells will be collected from the tumor surface. HPV 9-valent recombinant vaccine (3 milliliters/approximately ½ teaspoon) will be injected into several locations on the tumor surface, using ½ half of the single dose vaccine diluted with saline solution. If you have cancer of the vulva, the vaccine will be injected without placing the speculum. Imiquimod cream will be applied to the surface of the tumor at the visit. You will then receive ½ of the vaccine dose as a subcutaneous shot. Following the visit, you will receive 6 small doses of imiquimod cream in individual packets. These are to be applied using a vaginal applicator 3 nights per week for the next 2 weeks. If you have cancer of the vulva, the imiquimod cream will be applied directly on the tumor surface. You will also receive metformin 500 mg tablets, which are to be taken by mouth twice daily for the next 2 weeks. A PET/CT test will be performed at treatment completion (week 20), then PET/CT or CT chest/abdomen/pelvis 2 years post treatment. You will have follow-up visits with a physical exam including pelvic exam every 3 months up until 2 years. Section G: Sample Size/Data Analysis G1. Sample Size How many subjects (or specimens, or charts) will be used in this study? Local: 85 W orldwide: 85 Please indicate why you chose the sample size proposed: The planned cohort size will be 77 primary cervical cancer patients, the number needed for the evaluation of improvement in time to progression-free survival, with up to 8 vulvar/vaginal cancer patients, since they are rare. Members of the protocol study team have completed a comprehensive review of local control outcomes for all women treated for a locoregionally advanced cervical cancer (bulky FIGO IB3- IV A) with chemoradiotherapy to include standard of care concurrent cisplatin at the Harris Health System. Twenty-four month progression-free survival for patients who presented with FIGO IIIA-IV A cervical cancer is 67%. Since this clinical trial is enrolling an advanced stage cohort, we estimate that PFS would be 67% with standard of care and we will consider the trial a success if PFS is better than 77% at 24 months. Employing a one-sample exponential hazard rate test, and using a survival time of at least 2 years, which is consistent with the follow up time of 2 years, a sample of 77 patients are needed (alpha=10%, one-tailed, history control PFS24 m=67% vs new PDA24m=77%). Similar results are obtained for a standard one-sample log-rank test. .8/23/24, 10:39 AM Human Protocol Report https://brain.bcm.edu/esp1/reports/Human/Protocol.asp?protocol=486486 7/16 Vulvar and vaginal carcinoma patients will be accrued while the trial is enrolling, in addition to the 77 cervical cancer patients, since these cancers are much more rare. An adequate number of patients for statistical comparison is not anticipated to accrue, but this data will be reported separately . Up to 8 vulvar or vaginal cancer patients are anticipated, for a total of 85 patients. G2. Data Analysis Provide a description of your plan for data analysis. State the types of comparisons you plan (e.g. comparison of means, comparison of proportions, regressions, analysis of variance). Which is the PRIMAR Y comparison/analysis? How will the analyses proposed relate to the primary purposes of your study? The primary objective will be addressed by looking at progression free survival at 24 months compared to a historical cohort with a Kaplan Meyer curve using a log-rank test to evaluate for significance. Section H: Potential Risks/Discomforts H1. Potential Risks/Discomforts Describe and assess any potential risks/discomforts; (physical, psychological, social, legal, or other) and assess the likelihood and seriousness of such risks: Human Papillomavirus 9-valent V accine, Recombinant: The vaccine will be given intratumorally , but this is not anticipated to change the risk compared to standard vaccination, since trial of intralesional injection of HPV vaccine in nearly 1200 women found similar side ef fects to standard HPV vaccination. There may be some minimal discomfort during vaccine administration. Because vaccines may develop syncope, sometimes resulting in falling with injury , observation for 15 minutes after administration is recommended. Syncope, sometimes associated with tonic-clonic movements and other seizure-like activity , has been reported following HPV vaccination. When syncope is associated with tonic-clonic movements, the activity is usually transient and typically responds to restoring cerebral perfusion by maintaining a supine or Trendelenburg position. ADVERSE REACTIONS The most common (≥10%) local and systemic adverse reactions reported: injection-site pain (80-90%), injection-site swelling (23-40.0%), injection-site erythema (17-34.0%) and headache (15%). Imiquimod: The cream will be applied topically per vagina using an applicator . There may be some discomfort during application, and there is some risk of local skin reaction of the vulva, similar to that noted with vulvar application, as reported in trials of approximately 500 women using imiquimod treatment for cervical lesions Local skin reactions in a study of external genital warts were reported as the following reactions, with the percentage of severe reactions noted in parentheses: erythema (4%), erosion (1%), excoriation/ flaking (0%), edema (1%), scabbing (0%), induration (0%), ulceration (3%), vesicles 0(0%). Remote site skin reactions were also reported. Other possible reactions included burning, hypopigmentation, irritation, itching, pain, rash, sensitivity , soreness, stinging, tenderness, remote bleeding, burning, itching, pain, tenderness, tinea cruris, Systemic reactions included fatigue, fever , influenza-like symptoms, headache, diarrhea, myalgia. Metformin: Common adverse reactions to metformin include GI symptoms such as diarrhea 53.2% nausea/vomiting 25.5% flatulence 12.1% indigestion 7.1% abdominal discomfort 6.4% Other symptoms such as fatigue 9.2%, headache 5.7% were reported. LACTIC ACIDOSIS is also a risk with metformin. Blood Sample Collection: Blood sample collection (~10 ml of blood) at three time points (prior to treatment, mid treatment and 6 months post treatment) will occur in the course of usual and routine prenatal care and will not require any additional sampling or added blood draws. There is potential for transient pain, bleeding, infection, and injury to the participant during routine venipuncture for blood sample collection; however , these risks are minimal and exist at baseline with obtaining of blood samples for any medical indication, regardless of participation in proposed research. Cervical swab collection: Two sterile disposable cytobrushes (Cytobrush Plus GT (Cooper Surgical, Trumbull, CT)) will be used to collect cells from the cervix by rotating the brush 360 with 3 to 4 full rotations against the tumor . This procedure is less invasive that what occurs during a routine gynecological care such as during a pap-smear and is not associated with any increased pain or discomfort. There is potential for transient pain, bleeding, infection, and injury to the participant during routine cervical sample collection; however , these risks are minimal and exist at baseline with obtaining of blood samples for any medical indication, regardless of participation in proposed research. Patient Data: The use or disclosure of protected health information involves no more than minimal risk to the individuals because the data collected will be presented without any patients' identification. Each patient will receive an identifier code. Only the study team will have access to the patients' names. Patients are assigned a study ID, which is used for data entry . Biologic samples collected from participants will be marked with the same assigned study ID. All patient information will be entered into a database via that ID. There is the potential for loss of privacy , but by careful protection of the data by keeping the data on a password protected file on the PI's computer on the hospital server , this risk will also be minimal. H2. Data and safety monitoring plan8/23/24, 10:39 AM Human Protocol Report https://brain.bcm.edu/esp1/reports/Human/Protocol.asp?protocol=486486 8/16 Do the study activities impart greater than minimal risk to subjects? Yes NOTE: The answer to the questions in H2 requires the completion of the form: 'Section H â€“ Data and Safety Monitoring Plan' as an attachment in Section S. H3. Coordination of information among sites for multi-site research Is the BCM Principal Investigator acting as the SPONSOR-INVESTIGA TOR for this multi-site research? No or Not Applicable Is BCM the COORDINA TING CENTER for this multi-site research? No or Not Applicable Section I: Potential Benefits Describe potential benefit(s) to be gained by the individual subject as a result of participating in the planned work. The potential benefit is increased likelihood of cure, if the treatment is found to be ef ficacious. Describe potential benefit(s) to society of the planned work. Worldwide approximately 300,000 women die from cervical cancer annually , with 4000 of those deaths occurring in the United States. W orldwide, women from lower and middle income countries are disproportionately af fected. In the United States, Hispanic women have the highest rates of developing cervical cancer , and Black women have the highest rates of dying from cervical cancer . HPV is thought to be responsible for more than 90% of anal and cervical cancers (Cancers Associated with Human Papillomavirus (HPV), 2023). Despite our best ef forts, persistent/recurrent disease continues to occur in 30-40% of locally advanced cervical patients in clinical trials and in our patient population. Treatment with radiation has been the mainstay for treatment of locally advanced cervical and vulvar cancer for over a century , with addition of chemotherapy as a radiation sensitizer following an NCI Clinical Announcement in 1999. Recently , immunotherapy has demonstrated benefitin patients positive for PD-L1 in advanced stage cancers. Vaginal and vulvar cancers, which are also often HPV related, are very rare. Together , they account for about 7% of all gynecologic cancers diagnosed in the U.S. There is little clinical trial data studying vulvar cancer and vaginal cancer since they are rare, but they are typically treated with chemoradiation, and pembrolizumab if PD-L1 positive, in the same manner as squamous cell cervical cancer . Given that all of these disease processes can be HPV related, inclusion of these patient populations is planned if an eligible patient is identified. Radiation is available in a number of countries worldwide, including low and middle income countries. If ef fective, this treatment can be utilized in those settings immediately , since we are utilizing medications that are approved in many countries and are somewhat readily available thus reducing the rate of HPV related cervical, vaginal and vulvar cancers annually . This treatment could also be considered for any HPV induced cancer , expanding the potential patient population further Do anticipated benefits outweigh potential risks? Discuss the risk-to-benefit ratio. There is minimal risk with these widely used medications, and there are 4-5 additional clinic visits to apply the treatment. There is the potential to improve the cure rate for dif ficult to treat cancers, a benefit to the patients if the treatment improves progression free survival Section J: Consent Procedures J1. Waiver of Consent Will any portion of this research require a waiver of consent and authorization? No J1a. Waiver of requirement for written documentation of Consent Will this research require a waiver of the requirement for written documentation of informed consent? No J2. Consent Procedures Who will recruit subjects for this study?8/23/24, 10:39 AM Human Protocol Report https://brain.bcm.edu/esp1/reports/Human/Protocol.asp?protocol=486486 9/16 PI PI's staf f Describe how research population will be identified, recruitment procedures, any waiting period between informing the prospective participant and obtaining consent, steps taken to minimize the possibility of coercion or undue influence and consent procedures in detail. All patients undergoing chemoradiation for cervical, vaginal, or vulvar carcinoma at BCM sites (Smith Clinic and Dan L Duuncan Comprehensive Cancer Center - DLDCCC) will be identified as candidates by their Gynecologic oncology (Gyn Onc) providers at their initial visit and/or at tumor board presentation. All Gyn Onc providers are listed as investigators for this study and will be able to discuss the procedure with patients. Research coordinators will then evaluate the patients for eligibility for the study . The trial will be discussed with patients in the weeks before starting radiation and of fered to them by the physician. A copy of the consent form will be provided and all ef forts will be made to provide the patient with time to decide on the trial without delaying their standard of care treatments. It will be explained that this treatment is not required to receive standard chemoradiation, and that participation is completely optional and will not otherwise af fect the standard care that they receive. W e will discuss the rationale for the study based on case reports where these experimental treatments have cured a small number of patients. It will also be explained that the medications themselves are well known and widely used, with a known safety profile that is overall well tolerated. Are foreign language consent forms required for this protocol? Yes Which of the following ways will you document informed consent in languages other than English? A full-length informed consent document J3. Privacy and Intrusiveness Will the research involve observation or intrusion in situations where the subjects would normally have an expectation of privacy? No J4. Children Will children be enrolled in the research? No J5. Neonates Will non-viable neonates or neonates of uncertain viability be involved in research? No J6. Consent Capacity - Adults who lack capacity Will Adult subjects who lack the capacity to give informed consent be enrolled in the research? No J7. Prisoners Will Prisoners be enrolled in the research? No Section K: Research Related Health Information and Confidentiality Will research data include identifiable subject information? Yes Information from health records such as diagnoses, progress notes, medications, lab or radiology findings, etc. Yes Specific information concerning alcohol abuse: No Specific information concerning drug abuse: No Specific information concerning sickle cell anemia: No Specific information concerning HIV : No8/23/24, 10:39 AM Human Protocol Report https://brain.bcm.edu/esp1/reports/Human/Protocol.asp?protocol=486486 10/16 Specific information concerning psychiatry notes: No Demographic information (name, D.O.B., age, gender , race, etc.): Yes Full Social Security #: No Partial Social Security # (Last four digits): No Billing or financial records: No Photographs, videotapes, and/or audiotapes of you: No Identifiable biospecimens Yes Other: No At what institution will the physical research data be kept? BCM How will such physical research data be secured? Secure storage At what institution will the electronic research data be kept? BCM Such electronic research data will be secured via BCM IT Services- provided secured network storage of electronic research data (Non-Portable devices only): Yes Such electronic research data will be secured via Other: No Will there be anyone besides the PI, the study staf f, the IRB and the sponsor , who will have access to identifiable research data? No Please describe the methods of transmission of any research data (including PHI, sensitive, and non-sensitive data) to sponsors and/or collaborators. A Data Safety Monitoring Committee will review data for unanticipated adverse events. There is currently no plan to share research data with non-BCM personnel. For data to be transmitted between study personnel will be transmitted via BCM's encrypted/secure email system. All personnel are BCM employees and therefore have access to the BCM secure network. Any data files with patient information will be password protected and stored on the secure BCM server to ensure patient data security . Will you obtain a Certificate of Confidentiality for this study? No Please further discuss any potential confidentiality issues related to this study . All treatments will take place at BCM af filiated facilities, so no potential confidentiality issues are anticipated. Section L: Cost/Payment Delineate clinical procedures from research procedures. Will subject's insurance (or subject) be responsible for research related costs? If so state for which items subject's insurance (or subject) will be responsible (surgery , device, drugs, etc). If appropriate, discuss the availability of financial counseling. Research procedures will be the application of 6 doses of HPV vaccine, requiring a clinic visit with the Gynecologic Oncology provider . These visits and medications will be covered by the institution/trial which is sponsored by the BCM Gynecologic Oncology division. All other visits and imaging are standard of care.8/23/24, 10:39 AM Human Protocol Report https://brain.bcm.edu/esp1/reports/Human/Protocol.asp?protocol=486486 11/16 The study medications, including HPV vaccine, metformin and imiquimod, and vaginal applicators (if needed) will be provided at no cost to the study participants. The study sponsor (BCM Division of Gyn Oncology) will be providing these items. After finishing the treatments, the patient will receive standard follow up care, which includes a PET/CT test about 3 months after treatment completion and follow up visits every 3 months for 2 years that include a physical/pelvic exam and evaluation of symptoms. They will also have a routine CT scan or PET scan (per doctor ’s preference) at 1 and 2 years after finishing treatment. Insurance will be billed for all standard of care visits and testing, and the patient will be responsible for any co-pays for these visits. If subjects will be paid (money , gift certificates, coupons, etc.) to participate in this research project, please note the total dollar amount (or dollar value amount) and distribution plan (one payment, pro-rated payment, paid upon completion, etc) of the payment. Dollar Amount: 0 Distribution Plan: Section M: Genetics How would you classify your genetic study? Discuss the potential for psychological, social, and/or physical harm subsequent to participation in this research. Please discuss, considering the following areas: risks to privacy , confidentiality , insurability , employability , immigration status, paternity status, educational opportunities, or social stigma. Will subjects be of fered any type of genetic education or counseling, and if so, who will provide the education or counseling and under what conditions will it be provided? If there is the possibility that a family's pedigree will be presented or published, please describe how you will protect family member's confidentiality? Section N: Sample Collection SAMPLE: Blood What is the purpose of the sample collection? Evaluate immune response For blood draws, specify the amount drawn, in teaspoons, at each visit and across the course of the subjects entire participation time. 10 mL (2 teaspoons) blood in EDT A-coated tubes at each of the 3 treatment visits (prior to initial treatment, mid treatment, and 6 months post treatment initiation). Peripheral blood samples will be collected in EDT A-coated tubes and peripheral blood mononuclear cells (PBMCs) will be isolated from the blood using the standard procedure with L ymphoprepTM (Stemcell technologies, Cambridge, MA) density gradient centrifugation for use in flow cytometry analysis. Is there the possibility that cell lines will be developed with this sample? No Sample will be obtained from: Clinical Labs Will the sample be stripped of identifiers? No If sample will be released outside the hospital: Will sample be released to anyone not listed as an investigator on the protocol? Will the information be identifiable, coded or de-identified? N/A Will sample material be sold or transferred to any third parties? Will the information be de-identified? N/A8/23/24, 10:39 AM Human Protocol Report https://brain.bcm.edu/esp1/reports/Human/Protocol.asp?protocol=486486 12/16 If sample will be banked for future use: Where will the sample be banked and for how long? N/A Does the banking institution have an approved policy for the distribution of samples? N/A If the entire sample will NOT be used during the course of this research study: Will the remaining tissue be discarded? If not what will be done with the remaining sample after study completion and how long will the sample be kept? Yes Will samples be made available to the research subject (or his/her medical doctor) for other testing? No If a subject withdraws from the study: Will subject have the option to get the remaining portion of their sample back? No Will samples be destroyed? If not, will they be kept anonymously? What will happen to the sample if the subject revokes authorization? Yes Will data obtained from their sample be deleted? What will happen to the sample if the subject revokes authorization? Data collected from samples will be password protected and stored on the BCM secure serve. If a subject revokes authorization their data will be deleted. Will study data or test results be recorded in the subject's medical records? No Will results of specific tests and/or results of the overall study be revealed to the research subject and or his/her doctor? Specific test results will not be released, since they are assessing immune response over time to determine the ef fect of the treatment on the immune response. Overall study results can be shared with the patients. Please identify all third parties, including the subject's physician, to receive the test results. None SAMPLE: Other 1: Tumor cytobrushing What is the purpose of the sample collection? Two sterile disposable cytobrushes (Cytobrush Plus GT (Cooper Surgical, Trumbull, CT)) will be used to collect cells from the cervix by rotating the brush 360 with 3 to 4 full rotations against the tumor . Study of specific immune markers and modalities by which the combination immunotherapy boosts the immune system and works in sync with the standard of care to enhance its ef fects. Immune biomarker assays will be taken at the beginning, middle, and end of the treatment to measure using flow cytometry . For blood draws, specify the amount drawn, in teaspoons, at each visit and across the course of the subjects entire participation time. N/A Is there the possibility that cell lines will be developed with this sample? No Sample will be obtained from: Other: Provider Will the sample be stripped of identifiers? No If sample will be released outside the hospital: Will sample be released to anyone not listed as an investigator on the protocol? Will the information be identifiable, coded or de-identified? No Will sample material be sold or transferred to any third parties? Will the information be de-identified?8/23/24, 10:39 AM Human Protocol Report https://brain.bcm.edu/esp1/reports/Human/Protocol.asp?protocol=486486 13/16 No If sample will be banked for future use: Where will the sample be banked and for how long? Sample will not be banked Does the banking institution have an approved policy for the distribution of samples? N/A If the entire sample will NOT be used during the course of this research study: Will the remaining tissue be discarded? If not what will be done with the remaining sample after study completion and how long will the sample be kept? Remaining tissue will be stored in our -80 freezer located in our laboratory . Samples will be stored with a study ID and all patient identifiers will be removed. All samples will be disposed upon study publication. Will samples be made available to the research subject (or his/her medical doctor) for other testing? No If a subject withdraws from the study: Will subject have the option to get the remaining portion of their sample back? No Will samples be destroyed? If not, will they be kept anonymously? What will happen to the sample if the subject revokes authorization? yes Will data obtained from their sample be deleted? What will happen to the sample if the subject revokes authorization? Data collected from samples will be password protected and stored on the BCM secure serve. If a subject revokes authorization their data will be deleted. Will study data or test results be recorded in the subject's medical records? No Will results of specific tests and/or results of the overall study be revealed to the research subject and or his/her doctor? Specific test results will not be released, since they are assessing immune response over time to determine the ef fect of the treatment on the immune response. Overall study results can be shared with the patients. Please identify all third parties, including the subject's physician, to receive the test results. N/A SAMPLE: Tissue What is the purpose of the sample collection? Baseline evaluation of immunity prior to initiation of treatment For blood draws, specify the amount drawn, in teaspoons, at each visit and across the course of the subjects entire participation time. N/A Is there the possibility that cell lines will be developed with this sample? No Sample will be obtained from: Pathology Will the sample be stripped of identifiers? No If sample will be released outside the hospital: Will sample be released to anyone not listed as an investigator on the protocol? Will the information be identifiable, coded or de-identified? No Will sample material be sold or transferred to any third parties? Will the information be de-identified? No8/23/24, 10:39 AM Human Protocol Report https://brain.bcm.edu/esp1/reports/Human/Protocol.asp?protocol=486486 14/16 If sample will be banked for future use: Where will the sample be banked and for how long? No Does the banking institution have an approved policy for the distribution of samples? N/A If the entire sample will NOT be used during the course of this research study: Will the remaining tissue be discarded? If not what will be done with the remaining sample after study completion and how long will the sample be kept? Stored in pathology Will samples be made available to the research subject (or his/her medical doctor) for other testing? No If a subject withdraws from the study: Will subject have the option to get the remaining portion of their sample back? No Will samples be destroyed? If not, will they be kept anonymously? What will happen to the sample if the subject revokes authorization? yes Will data obtained from their sample be deleted? What will happen to the sample if the subject revokes authorization? yes Will study data or test results be recorded in the subject's medical records? No Will results of specific tests and/or results of the overall study be revealed to the research subject and or his/her doctor? Results of the overall study will be shared with the subject Please identify all third parties, including the subject's physician, to receive the test results. N/A Section O: Drug Studies Does the research involve the use of ANY drug* or biologic? (*A drug is defined as any substance that is used to elicit a pharmacologic or physiologic response whether it is for treatment or diagnostic purposes) Yes Does the research involve the use of ANY gene transfer agent for human gene transfer research? No O1. Current Drugs Drug : Human Papillomavirus 9-valent V accine, Recombinant (Gardasil9) Drug : imiquimod 5% cream (Aldara) Drug : metformin Is this study placebo-controlled? No Will the research involve a radioactive drug? No Section P: Device Studies Does this research study involve the use of ANY device?8/23/24, 10:39 AM Human Protocol Report https://brain.bcm.edu/esp1/reports/Human/Protocol.asp?protocol=486486 15/16 No Section Q: Consent Form(s) HPV 9-valent vaccine, recombinant; imiquimod; and metformin (HPV VIM) Trial Section R: Advertisements None 8/23/24, 10:39 AM Human Protocol Report https://brain.bcm.edu/esp1/reports/Human/Protocol.asp?protocol=486486 16/16