COVID-19 Continues On, Vaccinations Are Strongly Urged for All Patients With Cancer

Despite all hopes, the COVID-19 pandemic persists through the end of 2021. In light of the continued risks of COVID-19, especially for immunocompromised patients and those with cancer, physicians and guidelines have recommended vaccination including booster shots as soon as possible for all patients with cancer.

“Today, there continues to be an issue with COVID-19,” said Steven Ludlow, PharmD, BCOP, BCPS, during a presentation at the 39th Annual Chemotherapy Foundation Symposium (CFS®).¹ “We [recently] crossed the very ominous line of 5 million worldwide deaths. We’re looking pretty good; things are on the mend right now. But we were saying this in June as well, just before we had our brush with [the Delta variant]. We still have a very large pool of [patients with] COVID-19 in the population, and there is also the general unvaccinated status of many undeveloped nations.”

Three COVID-19 vaccines are available in the United States: BNT162b2 (Pfizer/ BioNTech), mRNA-1273 (Moderna), and JNJ78436735 (Janssen/Johnson & Johnson). BNT162b2 and mRNA-1273 are mRNA-based vaccines, whereas JNJ-78436735 is an adenovirus vector–based product. Both mRNAbased vaccines are administered in a 2-dose series approximately 28 days apart; JNJ78436735 is a single-dose vaccine. BNT162b2 is the only vaccine that has received full FDA approval for patients who are at least 16 years or older, and the other 2 have been granted emergency use authorization by the FDA.^1,2 On November 1, the FDA also granted emergency use authorization for the Pfizer vaccine for children between the ages of 5 and 11.³

According to the most recent National Comprehensive Cancer Network (NCCN) recommendations concerning COVID-19 vaccines for patients with cancer, individuals should receive the vaccine if it is available to them, except for those with solid tumors undergoing major surgery, being treated with hematopoietic cell transplantation (HCT)/cellular therapy, and those with hematologic malignancies receiving intensive cytotoxic chemotherapy.⁴

The NCCN recommends that patients undergoing HCT or cellular therapy wait until at least 3 months after their treatment to receive a COVID-19 vaccine. Patients with hematologic malignancies undergoing intensive cytotoxic chemotherapy are recommended to delay their vaccination until absolute neutrophil count recovery. Patients with solid tumors being treated with major surgery are recommended to separate their date of surgery from vaccination by a few days, at minimum.⁴

“The only reason for [patients who have undergone major surgery to delay the vaccine] is not because of surgery itself, [this is to prevent] confusion with fevers that are an adverse effect related [to a vaccine] with one that may be a complication of a major surgery,” said Ludlow, a clinical pharmacy specialist at the H. Lee Moffi tt Cancer Center in Tampa, Florida.

In terms of vaccine booster doses, almost all patients with cancer should receive a booster dose 6 months after their second dose of an mRNA vaccine. For patients who received the JNJ-78436735 vaccine, a booster dose is recommended 2 months later. The NCCN does not recommend using antibody titers to determine if patients should receive the third dose; the decision should be made based on the underlying cancer, therapy, and other immunocompromising conditions.⁵

In patients with immunosuppression, a third dose of an mRNA is recommended by the CDC after the standard 2-dose regimen. The third shot is not considered a booster, but rather it is part of a 3-dose series. The third dose should be given 28 days after the initial primary of an mRNA vaccine.⁶

Recently, the FDA authorized a single booster dose of either the Moderna or Pfizer-BioNTech vaccines for all adults 18 years or older, after completion of primary vaccination.⁷

In the moderately to severely immunocompromised, the CDC recommends a booster dose 6-months after the third of the initial series. This primarily concerns patients with hematologic malignancies and patients who receive stem cell transplant. After the fourth dose, if these patients progress to CAR-T cell therapy or stem cell transplant, they should repeat their initial primary series, potentially with a booster dose.¹

“We cannot do direct comparisons; these vaccines were studied in different places, at different times, and with different variants,” Ludlow said. “We saw the data with the mRNA vaccines which were tested originally against the Alpha strain. We saw the South American and South African strains being tested against the Johnson & Johnson products. It’s unfair to put these [data] right next to each other. I would say that the best vaccine is the one that’s in your patient’s arm.”

_REFERENCES

_{1. Ludlow S. COVID-19 vaccine: what the medical oncologist needs to know. Presented at: 39th Annual CFS® Innovative Cancer Therapy for Tomorrow; November 3-5, 2021; New York, NY.}

_{2. FDA Approves First COVID-19 Vaccine. News release. FDA; August 23, 2021. Accessed November 30, 2021. https://bit.ly/2ZGRqix}

_{3. FDA authorizes Pfizer-BioNTech COVID-19 vaccine for emergency use in children 5 through 11 years of age. News release. October 29, 2021. Accessed November 30, 2021. https://bit.ly/3buG3MT}

_{4. Cancer and COVID-19 vaccination, version 4.0 : recommendations of the National Comprehensive Cancer Network (NCCN) COVID-19 Vaccination Advisory Committee. August 30, 2021. September 13, 2021. Accessed November 30, 2021. https://bit.ly/3oaceIB}

_{5. NCCN COVID-19 vaccination guide for people with cancer. National Comprehensive Cancer Network. Accessed November 30, 2021. https://bit.ly/31gv5sX}

_{6. COVID-19 vaccines for moderately to severely immunocompromised people. CDC. Updated October 18, 2021. Accessed November 30, 2021. https://bit.ly/3GiVdT5 7. Coronavirus (COVID-19) Update: FDA Expands Eligibility for COVID-19 Vaccine Boosters. FDA. November 19, 2021. Accessed November 30, 2021. https://bit.ly/3De4QAe}