As COVID-19 variants continue to emerge, vaccination crucial for patients with cancer
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COVID-19 remains a significant global burden, with 5 million worldwide deaths recorded as of October, according to a speaker at Chemotherapy Foundation Symposium.
“We continue to struggle with COVID-19 and given the very basis of the virus, it will continue to mutate every step of the way,” Steven Ludlow, PharmD, BCOP, BCPS, clinical pharmacy specialist in internal and hospital medicine and medical oncology at Moffitt Cancer Center, said during a presentation. “ There have been countless mutations, most of which have not been worth mentioning, but we will see continued variants emerge.”
The most dominant strain in the U.S. is the delta variant, which has a reported 1,260-times higher viral load and is nearly twice as contagious as previous strains.
“We still have a very large pool of COVID-19 in the population, and we will continue to see these emergent variants,” Ludlow said. “Mutations often associated with past and present variants of concern include N501Y, the E484K escape mutation that has been unrecognized by some of the first-wave antibodies, and the P681R furin cleavage site mutation, which increases efficiency of the virus.”
Ludlow said vaccination remains the most hopeful measure for combatting the pandemic and protecting individuals from hospitalization and severe disease.
“However, what is also concerning for patients with cancer are the adverse event profiles associated with vaccination,” Ludlow said. “With the messenger RNA [mRNA] vaccines, myocarditis remains an issue. It has been mostly observed in male patients aged 12 to 39 years and more often occurs after the second vaccine dose, usually within several days after vaccination. Of note, the myocarditis that we see with these vaccines is not the same myocarditis we have been accustomed to. Individuals do not get as sick and there have been no deaths associated with it.”
Thrombosis and thrombocytopenia syndrome, as well as cerebral venous sinus thrombosis, are adverse events associated with the Johnson & Johnson vaccine.
“These events have been rare, but there have been three deaths in the United States. It is important to note that if a blood clot is detected after vaccination that we avoid heparin at all costs,” Ludlow said. “Also, we cannot do direct comparisons of the vaccines, as testing occurred at different times and at different places with different variants. The best vaccine is the one that is in your patient’s arm. Patients who have been infected with COVID-19 should still receive the vaccine once they have achieved viral clearance and symptom relief.”
National Comprehensive Cancer Network recommendations state that everyone should receive the vaccine — the only exception being patients who are undergoing stem cell transplant or receiving induction chemotherapy for hematologic malignancies.
“Everyone else is a candidate for the vaccine and the only other outliers are those who may have undergone major surgery so that there is no confusion with fever as a major complication from the surgery vs. a side effect from the vaccine,” Ludlow said.
An FDA update recommends a booster dose 6 months after the initial two-dose series for mRNA vaccines — a full dose of the BNT162b2 vaccine (Pfizer/BioNTech) and a 50% dose of mRNA-1273 [Moderna].
“Johnson & Johnson has also been given the nod for a booster 2 months after the completion of the single-dose primary regimen to those aged 18 years and older,” Ludlow said. “Additionally, the CDC recommends a third dose of an mRNA vaccine be administered at least 4 weeks after a second dose among individuals who are immunosuppressed — basically hematology patients.
“The same mRNA vaccine should be used if possible and it is important to note that the three-dose series is not a booster,” Ludlow continued, “and antibody titers should not be used to determine if a third dose should be given. Optimal timing of vaccination in relation to chemotherapy is unknown and it is not yet known whether vaccination will be more effective if administered at the time of chemotherapy or mid-cycle.”
Ludlow added that the CDC recommends a fourth dose be given 6 months after dose three to patients who are moderately to severely immunocompromised, including those receiving active cancer therapy for tumors or cancers of the blood, as well as those who have undergone organ transplant and are taking medicine to suppress the immune system.
“Moreover, patients who have undergone transplant or CAR T-cell therapy who received the fourth dose of the vaccine before undergoing either of these treatments should be revaccinated with their primary vaccine series at least 3 months after transplant or CAR T-cell therapy,” he said.
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Ludlow S. COVID-19 vaccine: What the medical oncologist needs to know. Presented at: 39th Annual Chemotherapy Foundation Symposium: Innovative Cancer Therapy for Tomorrow; Nov. 3-5, 2021.
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