Patients With Cancer a 'High Priority' for COVID-19 Vaccine

Roxanne Nelson, RN, BSN

December 29, 2020

Updated December 31, 2020 // Editor's note: This story was updated with comments from AACR president Dr Antoni Ribas.

Now that COVID-19 vaccines are being distributed, the American Association for Cancer Research (AACR) has called for people with cancer to be considered as a high priority group.

"The available evidence supports the conclusion that patients with cancer, in particular with hematological malignancies, should be considered among the high-risk groups for priority COVID-19 vaccination," says the AACR's COVID-19 and Cancer Task Force.

A review of literature suggests that COVID-19 fatality rates for patients with cancer were double that of individuals without cancer, the team notes. The higher mortality rates still trended upward, even after adjusting for confounders including age, sex, and comorbidities, indicating that there is a greater risk for severe disease and COVID-19 related mortality.

The new AACR position paper was published online December 19 in Cancer Discovery.

"We conclude that patients with an active cancer should be considered for priority access to COVID-19 vaccination, along other particularly vulnerable populations with risk factors for adverse outcomes with COVID-19," the team writes.

However, the authors note that "it is unclear whether this recommendation should be applicable to patients with a past diagnosis of cancer, as cancer survivors can be considered having the same risk as other persons with matched age and other risk factors. 

"Given that there are nearly 17 million people living with a history of cancer in the United States alone, it is critical to understand whether these individuals are at a higher risk to contract SARS-COV-2 and to experience severe outcomes from COVID-19," they add.

Allocation of Initial Doses

There has already been much discussion on the allocation of the initial doses of COVID-19 vaccines that have become available in the US. The Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) recommended that the first wave of vaccinations, described as Phase 1a, should be administered to US healthcare workers (about 21 million people) and residents of long-term care facilities (about 3 million).

The next priority group, Phase 1b, should consist of front-line essential workers, a group of about 30 million, and adults aged 75 years or older, a group of about 21 million. When overlap between the groups is taken into account, Phase 1b covers about 49 million people, according to the CDC.

Finally, Phase 1c, the third priority group, would include adults aged 65-74 years (a group of about 32 million), adults aged 16-64 years with high-risk medical conditions (a group of about 110 million), and essential workers who did not qualify for inclusion in Phase 1b (a group of about 57 million). With the overlap, Phase 1c would cover about 129 million people.

"Cancer is one of the categories of individuals at high risk," said Antoni Ribas, MD, PhD, AACR president and chair of the AACR COVID-19 and Cancer Task Force. "At the ACIP vote on December 20, the priority access was assigned to Phase 1c, but this results in a potential significant delay in vaccination for the particularly vulnerable population of patients with cancer at this time of highest risk, with the winter worsening of the COVID-19 pandemic."

"Any delay in vaccine access will result in loss of life that could be prevented with earlier access to vaccination," Ribas told Medscape Medical News.

He noted that the task force agrees that people whose work is essential to run society should receive priority vaccination, but consideration should be given to first vaccinating patients with cancer who are at increased risk of dying if they get COVID-19.

"This would include the 2 or 3 million people in the US who currently are receiving treatments for cancer, in particular if they have blood cancers or lung cancer, as they are at a particularly higher risk of dying based on the studies we reviewed," he said. "Moreover, a subset of cancer patients appears to have prolonged viral shedding, placing their healthcare providers and caregivers at higher risk."

The best scenario, Ribas emphasized, "would be that with two approved COVID-19 vaccines there is enough stock in the next few weeks to vaccinate all individuals assigned to Phase 1b and 1c."

Questions Remain

Approached for independent comment, Cardinale Smith, MD, PhD, chief quality officer for cancer services for the Mount Sinai Health System in New York City, agreed with the AACR task force. "I share that they should be high priority," she said, "But we don't know that the efficacy will the same."

Smith noted that the impact of cancer therapy on patient immune systems is more related to the type of treatment they're receiving, and B and T cell responses. "But regardless, they should be getting the vaccine, and we just need to follow the guidelines," she said.

The AACR task force notes that information thus far is quite limited as to the effects of COVID-19 vaccination in patients with cancer. In the Pfizer-BioNTech BNT162b2 COVID vaccine trial, of 43,540 participants, only 3.7% were reported to have cancer.

"It is clear that we need more data and specific studies in patients with cancer, but this should not delay access to priority vaccination," said Ribas. "There is considerable experience with other vaccines, such as the yearly flu vaccine, in cancer patients with very good safety records."

Other large COVID-19 vaccine trials will provide further follow-up information on the effectiveness of the vaccines in patients receiving different cancer treatments, they write, but for now, there is "currently not enough data to evaluate the interactions between active oncologic therapy with the ability to induce protective immunity" to COVID-19 with vaccination.

Ribas pointed out that studies of natural immune response to COVID-19 have documented that patients with hematologic malignancies have a suboptimal ability to mount an immune response to the virus. This results in these patients having a "remarkably" high risk of fatality compared with other patient populations with COVID-19 infection.

"The fact that the antibody and T-cell responses to the COVID-19 vaccines are higher than in many individuals with natural COVID-19 infection provides an even stronger rationale to offer vaccination to persons with lower immune responses to the virus," he said. "Although ongoing studies will provide more information about how to best protect cancer patients with vaccines, at present, there is no evidence that the vaccine should be delayed in cancer patients.

"Of course, patients with cancer should consult with their healthcare providers about their potential risks and benefits to decide whether getting vaccinated is right for them," he added.

In a recent interview with Medscape Medical News, Nora Disis, MD, a medical oncologist and director of both the Institute of Translational Health Sciences and the Cancer Vaccine Institute, University of Washington, Seattle, also discussed vaccinating cancer patients.

She pointed out that even though there are data suggesting that cancer patients are at higher risk, "they are a bit murky, in part because cancer patients are a heterogeneous group."

"For example, there are data suggesting that lung and blood cancer patients fare worse," said Disis, who is also editor-in-chief of JAMA Oncology. "There is also a suggestion that, like in the general population, COVID risk in cancer patients remains driven by comorbidities."

She also pointed out the likelihood that individualized risk factors including the type of cancer therapy, site of disease, and comorbidities "will shape individual choices about vaccination among cancer patients."

It is also reasonable to expect that patients with cancer will respond to the vaccines, even though historically some believed that they would be unable to mount an immune response. "Data on other viral vaccines have shown otherwise," said Disis. "For example, there has been a long history of studies of flu vaccination in cancer patients, and in general, those vaccines confer protection."

Several of the authors of the AACR position paper, including Ribas, report relationships with industry as detailed in the paper. Smith has disclosed no relevant financial relationships.

Cancer Discov. Published online December 19, 2020. Position paper

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