Patients with cancer who are infected with COVID-19 coronavirus have an overall 21.2% increased mortality rate, compared to 8.7% for those without cancer—and for those with a smoking history, mortality increases to 31.1%. With statistics like those, should patients with cancer get COVID-19 vaccination as soon as possible?
COVID-19 Vaccine Eligibility and Rollout
Vaccination prioritization and allocation requires careful review of availability, potential risks and benefits, and ethical principles of equity and beneficence. In October 2020, a National Academies of Science, Engineering, and Medicine committee, formed under the direction of the National Institutes of Health and Centers for Disease Control and Prevention (CDC), released the Framework for Equitable Allocation of Vaccine for the Novel Coronavirus consensus study. to guide national and state policymakers to plan and distribute COVID-19 vaccines in a phased approach. In December 2020, CDC’s Advisory Committee on Immunization Practices released a series of reports based on the framework to guide the United States and healthcare providers in allocating the vaccine among specific and general populations.
In the first phase (phase 1a), healthcare workers and first responders were offered the vaccination. In phase 1b, people at high risk for serious outcomes from COVID-19 infection are prioritized, although eligibility may vary by state. Phase 1b may include people with cancer or other high-risk diagnoses and older adults. Those working in correctional facilities, group homes, or skilled nursing facilities are generally also eligible for phase 1b. People who have had COVID-19 or received monoclonal antibodies for treatment of COVID-19 in the previous 90 days should wait to get the vaccine.
Are the Vaccines Safe for Patients With Cancer?
In a review of clinical trials, the U.S. Food and Drug Administration reported that the vaccines have been shown to be safe and effective for the general population. However, people with cancer and those receiving immunosuppressive and cytotoxic treatments were mostly excluded from participation in the vaccine trials to date, so we have little to no data on their safety and efficacy in patients with cancer.
Should Patients With Cancer Get Priority?
National organizations have advocated for prioritization of COVID-19 vaccinations for people with cancer given the risks from the diagnosis, decreased immune function resulting from some antineoplastic treatments, and presence of other comorbidities. The American Society for Clinical Oncology, Infectious Disease Society of America, American Association for Cancer Research, and European Society for Medical Oncology have all issued conclusions or recommendations that although people with cancer were mostly excluded from the vaccines’ clinical trials, vaccination provides more benefit than risk and should be offered to patients as long as any of the vaccine’s components are not contraindicated.
Experts suggest that although some immunosuppressed patients may experience decreased response to the vaccine, it may still confer some benefit and is important to reduce the risk or severity of COVID-19 infection. Healthcare providers must counsel patients about the unknown safety profile and effectiveness in immunocompromised populations as well as the potential for reduced immune responses.
Guidelines for Vaccination in Patients With Cancer
Given the risk of serious outcomes or even death from COVID-19 infection, people with cancer need to be prioritized for vaccination. In January 2021, the National Comprehensive Cancer Network released preliminary recommendation guidelines on COVID-19 vaccination for people with cancer:
- Patients with cancer should be prioritized for vaccination (CDC priority group 1b or 1c).
- All patients receiving active therapy should be immunized, understanding the limitations of the safety and efficacy data.
- Delay vaccination according to guidelines for the general public (e.g., recent exposure to COVID-19, COVID-19 infection or treatment within previous 90 days) and for at least three months following stem or engineered cellular therapy (e.g., CAR T cells) to maximize vaccine efficacy.
- Caregivers and those living in the same household or close contacts should be immunized when possible.
Strategies such as providing the vaccine between treatment cycles and after appropriate waiting periods for patients receiving immunoglobulin or cellular therapies (e.g., two weeks before or six weeks after cytotoxic chemotherapy or immunotherapy) can reduce risks while maintaining vaccination efficacy. The Society of Breast Imaging recommended that people who have had axillary lymph node dissection or removal should be vaccinated in the opposite arm.
After vaccination, patients must continue to follow all current guidelines to protect themselves and others against COVID-19 (e.g., wearing face masks, social distancing, handwashing) because vaccinated people, although asymptomatic, may still transmit the virus. Additionally, new COVID-19 variants are emerging and the vaccine has not yet been tested to prevent infection against them.
Patients with cancer must discuss their desire to get the vaccine with their oncology team before making their appointment to get vaccinated in their state-run program. Oncology nurses have a significant role in educating patients with cancer about the COVID-19 vaccine, its appropriateness for them, and what to expect with their state’s requirements and availability.