Oncologists can allay COVID-19 vaccination concerns of patients with cancer, survivors
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Oncologists are in a critical position to provide potentially life-saving information about the COVID-19 vaccine to their patients with cancer, experts said.
To aid oncologists and their patients, National Comprehensive Cancer Network and American Society of Radiation Oncology released clinical guidance on the safety and efficacy of the COVID-19 vaccine for people with and recovering from cancer.
Although timing and immunosuppression are factors to keep in mind — NCCN recommends patients undergoing major surgery wait 1 to 2 weeks, those receiving intensive chemotherapy wait until absolute neutrophil count recovery, and those undergoing stem cell transplant or receiving chimeric antigen receptor T-cell therapy wait 3 months — most patients with cancer should be prioritized for vaccination, according to the guidance.
“We really want to be giving vaccines to these high-risk patients because we know [patients with cancer] are at risk for COVID-19 complications,” Steven Pergam, MD, MPH, medical director of infection prevention at Seattle Cancer Care Alliance, associate professor in the vaccine and infectious disease division at Fred Hutch, and co-leader of NCCN’s COVID-19 vaccine committee, told Healio. “The cancer community feels very strongly that [patients with cancer] and those who are immune-suppressed should be as early as possible in the allocation strata because of their risks for complications. Data have shown that somewhere between 13% and 15% of patients who develop cancer can die of COVID-19.”
Yet, Pergam said he imagines it must be “really hard” for the average patient with cancer to chase down the somewhat elusive vaccine.
“They’re dealing with chemotherapy, they have pain issues, they’ve got a lot on their plate,” he said. “They’re waking up in the middle of the night to take medicines. They have nausea and vomiting. ... And then, somehow, they’re supposed to go on these websites and refresh them all the time to make sure they get their vaccine. It seems untenable.”
Basis for vaccination priority
Both sets of recommendations from NCCN and ASTRO recommend that patients with cancer actively receiving treatment be immunized, after giving consideration to timing, and that these patients be prioritized in the case of limited vaccine supply.
“To be very clear,” Pergam said, “there is no information that vaccination is going to have any effect on their cancer treatment, or going to cause cancer, or anything crazy.”
That recommendation is based on data that suggest patients with active and inactive cancer are at risk for poorer COVID-19 outcomes.
In an observational study, published in JNCI Cancer Spectrum, Sun and colleagues analyzed records of 328 individuals who tested positive for COVID-19, 67 of whom had cancer. Most of these patients (80.6%) had a solid tumor, and 26.9% had active disease.
Results showed patients with cancer and COVID-19 had higher rates of hospitalization (55.2% vs. 29%), ICU admission (25.7% vs. 11.7%) and 30-day mortality (13.4% vs. 1.6%) than those without cancer.
Adjusted models showed greater risk for these outcomes among patients with active cancer, but patients in remission also remained at risk.
Thus, providers should also encourage patients with inactive cancer and those not currently undergoing treatment to get vaccinated, according to the guidance.
Specifically, ASTRO’s guidance states, “individuals with a prior history of cancer who are not in active treatment are encouraged to seek vaccination whenever it is made available to them.”
More than half (56.4%) of cancer survivors in the U.S. reported having additional underlying medical conditions associated with higher risk for severe COVID-19 illness, according to an observational study published in Journal of the National Cancer Institute.
Jiang and colleagues found that the prevalence of these conditions — which included chronic obstructive pulmonary disease, heart diseases, diabetes, chronic kidney disease and obesity — was nearly 40% higher in cancer survivors than in the general population. Cancer survivors also reported having more than one of the conditions, with nearly one-quarter of them reporting more than two conditions.
Pergam said “it’s hard to make clear lines in the sand” about priority for patients with active vs. inactive cancer, because the treatments they may have undergone and their respective risks range widely.
“Cancer survivors, many of whom may have ongoing effects of their cancer, should absolutely be a group that gets vaccinated,” Pergam said. “Patients with active, ongoing treatment should be prioritized because they are the highest-risk group. Within that group, other factors like age and comorbidities should be given consideration.”
Questions to expect
Experts with whom Healio spoke said oncologists should discuss the importance of vaccination among their patients with and survivors of cancer, which means they should be able to address common questions, including whether it will be effective.
“Most of these patients have a compromised immune system,” ASTRO chair Thomas Eichler, MD, told Healio. “Is the [body’s response to vaccination] in my patient with prostate cancer going to be as good as my own? The answer is probably not. But [National Institute of Allergy and Infectious Diseases Director Anthony S. Fauci, MD,] said at one of the medical meetings, ‘If you’re immuno-suppressed, history tells us that you won’t have as big of a protective response. But some is better than none.’ And I totally agree with him. Having a 70% response might not be as good as a 95% response, but it’s a lot better than zero response.”
Oncologists should also be ready to be asked about adverse effects.
Eichler said patients may ask, “Is this going to make me feel worse than I feel right now?”
“It’s interesting. The most common side effect is pain at the injection site,” he said. “I had colleagues with more severe side effects — body aches, fever, headaches. [But with my second vaccine shot] I had absolutely no issues at all. I was pleasantly surprised.”
It is also important for providers to remind patients that they should continue to take precautions after vaccination, Pergam said.
“We need to remind patients and their families that a vaccine is not sort of a concert ticket to go out in the community and start doing your normal stuff,” he said. “We really want people to still remember that, although vaccination is another layer of protection, the standard approaches to prevention are still really important — masks, social distancing, washing your hands, and avoiding large crowds and closed spaces remain super important. The vaccine may protect you, but you’re still at risk. And we really want our patients to be protected wherever possible.”
Until the country reaches herd immunity, many of the pre-vaccination COVID-19 precautions apply.
“You’re probably going to need to wear a mask for the next year-plus,” Eichler said.
Increasing access
For the at-risk community of people with cancer, the first step is getting the vaccine.
Last month, the board of directors of Community Oncology Alliance wrote a letter to the National Governors Association, then-President-elect Joseph R. Biden Jr.’s COVID-19 Task Force, and other government officials in an attempt to get priority approval for local independent oncology practices to administer the COVID-19 vaccine to immunocompromised patients with cancer and blood disorders. The association stated that vaccine availability at cancer centers would both ramp up nationwide efforts and help reach a vulnerable community.
Pergam wholeheartedly agreed, but because such centers are not getting enough supply, he knows practitioners must help guide their patients to places they can receive the vaccine.
“Some communities are opening more large vaccination sites than others; I’m always a little bit cautious,” Pergam said. “[Patients should] talk to their providers about where is the best place to get vaccinated, when is the best time to get vaccinated, what their risks would be with this particular type of treatment, etc. Those are all conversations you can have.”
When speaking with their patients, providers also should loop in household members caring for patients regularly, Pergam said. Because caregivers are in direct contact with someone with cancer, they, too, should be immunized.
“The primary caregiver is critical to helping the patient with cancer,” Pergam said. “If you protect those around the individual from getting COVID-19, it might protect the patient, as well.”
References:
American Society for Radiation Oncology. COVID-19 clinical guidance. Available at: https://www.astro.org/Daily-Practice/COVID-19-Recommendations-and-Information/Clinical-Guidance. Accessed Feb. 4, 2021.
Community Oncology Alliance. Oncologists request approval to administer COVID-19 vaccinations. Available at: https://communityoncology.org/coa-comments-on-oncologists-request-approval-to-administer-covid-19-vaccinations/. Accessed Feb. 5, 2021.
Jiang C, et al. J Natl Cancer Inst. 2021;doi:10.1093/jnci/djab012.
National Comprehensive Cancer Network. NCCN: Cancer and COVID-19 vaccination. Available at: www.nccn.org/covid-19/pdf/COVID-19_Vaccination_Guidance_V1.0.pdf. Accessed Feb. 4, 2021.
Sun L, et al. JNCI Cancer Spectr. 2021;doi:10.1093/jncics/pkaa120.
For more information:
Thomas Eichler, MD, can be reached at ndmd1974@gmail.com.
Steven Pergam, MD, MPH, can be reached at spergam@fredhutch.org.
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National Comprehensive Cancer Network. NCCN: Cancer and COVID-19 vaccination. Available at: www.nccn.org/covid-19/pdf/COVID-19_Vaccination_Guidance_V1.0.pdf. Accessed Feb. 4, 2021.
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