NCCN Recommends Third COVID-19 Dose for Patients With Cancer

Roxanne Nelson, RN, BSN

August 30, 2021

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

Experts at the National Comprehensive Cancer Network (NCCN) have now issued an updated recommendation for COVID-19 vaccination in people with cancer. The panel calls for these patients to be among the highest priority group to be vaccinated against COVID-19 and to receive the newly approved third dose of vaccine.

The NCCN has recommended in February that all patients receiving active cancer treatment should receive a COVID-19 vaccine and should be prioritized for vaccination. Two weeks ago, the FDA authorized a third dose of either the Pfizer or Moderna COVID-19 vaccines for people with compromised immune systems. Those eligible for a third dose include solid organ transplant recipients, those undergoing cancer treatments, and people with autoimmune diseases that suppress their immune systems

The new NCCN recommendations state that the following groups should be considered eligible for a third dose of the mRNA COVID-19 vaccine immediately, based on the latest decisions from the Food and Drug Administration and the Centers for Disease Control and Prevention:

  • Patients with solid tumors (either new or recurring) receiving treatment within 1 year of their initial vaccine dose, regardless of their type of cancer therapy

  • Patients with active hematologic malignancies regardless of whether they are currently receiving cancer therapy

  • Anyone who received a stem cell transplant (SCT) or engineered cellular therapy (e.g. CAR T-cells), especially within the past 2 years

  • Any recipients of allogeneic SCT on immunosuppressive therapy or with a history of graft-versus-host disease regardless of the time of transplant

  • Anyone with an additional immunosuppressive condition (eg, HIV) or being treated with immunosuppressive agents unrelated to their cancer therapy

Cancer Patients at High Risk of Complications

As previously reported by Medscape Medical News, infection with COVID-19 in people with cancer can severely impact survival. One study published last year found that patients with both COVID-19 infection and progressing cancer had a fivefold increase in the risk of 30-day mortality, compared with COVID-19–positive cancer patients who were in remission or had no evidence of cancer.

Another study found that cancer type, stage, and recent treatment could affect outcomes of COVID-19 in patients with cancer. Patients with hematologic malignancies and metastatic cancers had higher risks of developing severe or critical COVID-19 symptoms, being admitted to the intensive care unit, requiring ventilation, and dying. Conversely, those with nonmetastatic disease had outcomes that were comparable with persons without cancer and a COVID-19 infection. This study also found that having undergone recent surgery or receiving immunotherapy also put patients at a higher risk of poor outcomes, although patients with cancer who were treated with radiotherapy had outcomes similar to those of noncancer COVID-19 patients.

"COVID-19 can be very dangerous, especially for people living with cancer, which is why we're so grateful for safe and effective vaccines that are saving lives," said Robert W. Carlson, MD, chief executive officer of NCCN, in a statement.

Right Timing and Location

The current NCCN update also recommends that individuals wait at least 4 weeks between the second and third doses, and those who are infected with  COVID-19 after being vaccinated should wait until they have documented clearance of the virus before receiving a third dose.

It also recommends that people who live in the same household with immunocompromised individuals should also get a third dose once it becomes available, and that it is best to have a third dose of the same type of vaccine as the first two doses. However, a different mRNA vaccine is also acceptable.

Immunocompromised individuals should try to receive their third dose in a healthcare delivery setting, as opposed to a pharmacy or public vaccination clinic if possible, as it would limit their risk of exposure to the general population.

Steve Pergam, MD, MPH, associate professor, Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, commented that it is still necessary to take precautions, even after getting the booster dose.

"That means even after a third dose of vaccine, we still recommend immunocompromised people, such as those undergoing cancer treatment, continue to be cautious, wear masks, and avoid large group gatherings, particularly around those who are unvaccinated," said Pergam, who is also co-leader of the NCCN COVID-19 Vaccination Advisory Committee. "All of us should do our part to reduce the spread of COVID-19 and get vaccinated to protect those around us from preventable suffering."

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