With a limited number of COVID-19 vaccines available, the most important takeaway from the updated NCCN guidelines is that patients with cancer get a COVID-19 vaccine — no matter which one it is — according to an expert from the Seattle Cancer Care Alliance and Fred Hutchinson Cancer Research Center.
Earlier this month, the National Comprehensive Cancer Network (NCCN) released an updated set of guidelines offering treatment advice and COVID-19 vaccine guidance in patients with cancer. In an interview with CURE®, Dr. Steven Pergam, medical director of infection prevention at Seattle Cancer Care Alliance and associate professor in the Vaccine and Infectious Disease Division and Clinical Research Division at Fred Hutchinson Cancer Research Center, discussed the most important aspects of the guidelines and what patients could expect in the future regarding vaccines.
Pergam: One, that there is no preference for a particular vaccine. This was really addressing Johnson & Johnson being added to the list of vaccines that now have an emergency use authorization designation from the Food and Drug Administration (FDA). And we looked at data from Moderna; we looked at data from Pfizer-BioNTech and now we looked at Johnson & Johnson. We feel like these are all equivalent, and all effective vaccines. The concept I think that’s most important is whatever vaccine (is) made available to you, get it.
So that's one thing, I think a second was, we wanted to review an odd side effect that happens in some people who get vaccinated. There's been a few that have been getting lymph node enlargement after a vaccine, but as a cancer patient, some of those lymph nodes can be quite scary, because (patients) can think that that might be early evidence of cancer recurrence or metastatic disease. So, we wanted to have some awareness to providers that lymph node enlargement is pretty expected. It's also important for scans, because if you're getting a scan it might light up and might look a little abnormal, and so we wanted to have a warning that you should delay scans around the time that the vaccines are happening.
And then the final was two things, really, a two-part piece that we don't recommend getting antibody testing after a vaccine, because we just don't know what to do with that data yet. We know that antibody formation is one of the components of how the immune system protects against the virus but having antibodies or not having the antibodies; we're not sure how well these vaccines work beyond that. There is another component to your immune system; something that you might hear, sometimes called T-cell immunity, and T-cell immunity is kind of the cellular immunity — it's not the antibodies, but it's the cells actually attacking the virus. We're not really sure how much T-cell immunity plays a role. So, we're hoping that there's a fair amount of that as well in these vaccines, but we just don't know yet. So, not all vaccines produce a huge response in cancer patients who are quite diverse, but the thought would be that T-cell immunity could be important. So, antibodies are just going to worry people and with very limited vaccine available, even if you have no response, it's not like you can go out and get another vaccine — it's not going to be feasible.
And then, in addition to that, one of the really important things is that there’s been a lot of discussion that once you're vaccinated, you're really safe (and) you can get together with family who are also vaccinated and not worry. It's really critical for cancer patients to understand that we don't really know how well these vaccines work in immunosuppressed patients, and until we know that, we're really advocating for continued masking, social distancing and avoiding crowds as much as possible (and) to really be thoughtful about those decisions, because we really think that some of the patients who are getting vaccinated are still going to be at risk for developing COVID-19. And we want to protect them as much as we can.
The best way to approach this is to talk to their providers and say, “Hey, I just got a vaccine,” or to talk to their provider about getting a vaccine. A lot of these scans that patients got are sort of screening scans, they're sort of follow up to monitor the progress of cancer, and I think having that discussion with their provider is really important. We sort of suggested anywhere from four-to-six weeks to try to avoid that if possible. But that's not always feasible for patients, and not everybody develops lymph nodes, so I think it's really important to have that discussion with your provider about the importance of this scan, versus one that's just a routine and then maybe could be delayed a little bit.
It’s particularly important for breast cancer patients; if there's an updated look at their lymph nodes, for some reason, definitely have a discussion. And for those who have had lymph node dissections on one side, for a breast cancer patient who has had a number of lymph nodes removed, I definitely recommend getting it in the other arm where lymph nodes haven't been removed, because that probably … will increase the chances that it would be effective.
For future updates, there's going to be additional information about how effective these vaccines are. My inclination is that they're not going to be as effective as the general population, I think most of us would guess that. I think it may be really dependent on the patient, specifically, and what kind of treatment they're on. And that's going to vary quite substantially over time. I think, for them, it's going to be keeping track of what the guidelines say about timing, because that timing component may change.
There may be different recommendations for specific vaccines for different populations, that maybe one is more effective than the other. There's a lot of data we just don't know. But I would not envision any of that is going to change in the short term well enough that somebody who (is) offered a vaccine should make a differential change or should wait. I think it's really about getting a vaccine. Mostly what is going to be found in these studies is going to be for the future, because we know that there will be additional vaccines. Let’s say you got Johnson & Johnson and you didn't get a response, or you got Moderna, and you got two doses, and you didn't get a response. Well, there'll be future studies looking at booster shots, or at different dosing of the vaccines that I think will be coming (and are) maybe more effective against some of these immunosuppressed patients.
(Patients) can continue to look at the guidelines, but what I would do is go out and find places where you can get vaccinated, talk to your cancer providers about where you can get it and see if you can get it at your cancer center, specifically. And then I think the other thing that’s really important, is one of the best ways to protect yourself is to get your family and caregivers and everyone you live with in your house vaccinated. We know that transmission between person-to-person is possible, but household transmission is one of the most effective ways because we don't wear a mask; we sleep in the same bed; are often in spaces where the ventilation is not as good as it is in a hospital. So, focusing on that I think can be really important. So that's another takeaway, I would say from the guidance is we really want to make sure that people understand that getting their family members vaccinated is key.
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