COVID-19 vaccination in cancer patients: Yes or no?

Now that COVID-19 vaccinations are being gradually rolled out globally, a frequently asked question pertains to the allocation of vaccination – ie, who should be first in line to be vaccinated.

The current focus is to get the vaccines out to healthcare workers, frontline essential staff, and the elderly as they are considered high-risk populations. [https://www.cancer.org/treatment/treatments-and-side-effects/physical-side-effects/low-blood-counts/infections/covid-19-vaccines-in-people-with-cancer.html] However, individuals with certain comorbidities – such as cancer – are also at an increased risk of developing severe COVID-19, though patients with active or a history of cancer are not in the CDC* first priority group for vaccination. [https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html; https://www.cancer.org/treatment/treatments-and-side-effects/physical-side-effects/low-blood-counts/infections/covid-19-vaccines-in-people-with-cancer.html]

As such, the question remains as to whether these individuals should be vaccinated, and if yes, what is the appropriate timing of vaccinations?

 

NCCN COVID-19 vaccination recommendations: Who and when?

Data show that individuals who are most at risk of developing COVID-19 complications should get the vaccine and patients with cancer are considered a high-risk group, said Dr Steven Pergam from the Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, US, and co-leader of the NCCN** COVID-19 Vaccination Advisory Committee. [https://www.cancer.gov/news-events/cancer-currents-blog/2021/people-with-cancer-coronavirus-vaccine]

The NCCN COVID-19 Vaccination Advisory Committee – which included experts in haematology and oncology with expertise in infectious diseases, vaccination development, medical ethics, and health information technology – has preliminarily recommended*** that patients with cancer be prioritized for COVID-19 vaccination and should be vaccinated upon vaccine availability. This recommendation pertains to patients currently undergoing treatment despite there being limited efficacy and safety data of vaccination in this population. [https://www.nccn.org/covid-19/pdf/COVID-19_Vaccination_Guidance_V1.0.pdf]

However, there are certain subpopulations for whom vaccination may need to be delayed. These includes patients with a recent exposure to COVID-19, as well as patients who received haematopoietic cell transplantation (HCT) or engineered cellular therapy (eg, chimeric antigen receptor [CAR] T-cell therapy). As patients who have recently received HCT or CAR T-cell therapy will most likely be on immunosuppressive therapy, the NCCN recommendation is that COVID-19 vaccination be delayed for ≥3 months following completion of these treatments to maximize efficacy.

“That’s based on data that [other] vaccines have had limited efficacy during periods when these patients are their most immunosuppressed,” noted Pergam.

The NCCN recommends that vaccination be prioritized for patients with active cancer on treatment (including those receiving haematopoietic or cellular therapy), those who plan to start treatment, and those <6 months post-treatment, except for patients who are receiving hormonal therapy only.

This recommendation was echoed by the American Society of Clinical Oncology (ASCO) which advocated for vaccination in cancer patients receiving active treatment so long as none of the vaccine components were contraindicated. [https://www.asco.org/asco-coronavirus-resources/covid-19-patient-care-information/covid-19-vaccine-patients-cancer] ASCO suggested several strategies to maintain the efficacy of the vaccine while reducing potential risks in cancer patients. These included vaccinating patients between therapy cycles and vaccinating after an appropriate waiting period in patients who are receiving certain therapies (eg, stem cell transplant).

According to Pergam, cancer patients scheduled to undergo surgery should probably wait about a week post-surgery to get their vaccinations. This is primarily to avoid potential vaccine side effects (eg, fever) that may delay surgery. Furthermore, avoidance of vaccination in the perioperative period will allow symptoms to be correctly attributed to surgery or vaccination.

As patients with cancer are immunocompromised, the extent to which they develop immunity to COVID-19 following vaccination is yet undetermined. As such, it is imperative that standard COVID-19 prevention measures such as social distancing and mask wearing should be continued even after vaccination.

 

Any protection is better than no protection

Based on data from other vaccines, cancer patients or survivors may not reap the highest protection from the COVID-19 vaccine as seen with the general population, said Pergam. “But even if it’s 50 percent, it’s still going to be a major benefit,” he said. Furthermore, the purpose of the vaccine is not just to prevent infection but also its complications, and the hope is that vaccination will prevent COVID-19 symptoms and hospitalization in cancer patients.

The NCCN Committee also advocates for the vaccination of household contacts and caregivers of cancer patients upon eligibility for vaccination, while ASCO encourages cancer survivors to receive the vaccine as long as none of the vaccine components are contraindicated. 

“[I]f we assume that people with cancer aren’t going to respond as well to the COVID-19 vaccine, one of the best ways to protect them is to give the vaccine to people who will respond well. And that means anybody who they spend time with,” noted Pergam.

 

Get the vaccine when you can

“The approach we discussed in the NCCN Committee is that we really don’t want to create guidance that will prevent cancer patients from getting vaccinated. So, the best approach is to get the vaccine when you can,” said Pergam.

Ultimately, allocations of vaccines must be made according to local guidelines.

 

Singapore recommendations

At time of print, the Expert Committee on COVID-19 Vaccination set up by the Ministry of Health, Singapore, discourages COVID-19 vaccination with the mRNA-based vaccines in patients with cancer on chemotherapy, radiation therapy, or immunotherapy. [https://www.singaporeoncology.org.sg/, accessed 17 March 2021]

In a statement previously published on the Singapore Society of Oncology website, the reason for current avoidance of vaccination is the exclusion of immunocompromised individuals in COVID-19 vaccine trials, leading to a lack of information on the safety of COVID-19 vaccination in this population. [https://www.singaporeoncology.org.sg/, accessed 10 March 2021]

However, patients with active cancer not on the above-mentioned treatments can be vaccinated, as can those on hormonal therapy, and those currently in remission. The Society also encourages vaccination among family members of unvaccinated cancer patients living in the same household.