March 15 brought welcome news from the California Department of Public Health (CDPH): People over the age of 16 with health conditions that place them at the highest risk for severe illness from COVID-19 — including certain cancer patients — are now eligible for vaccination.
These guidelines still leave some important questions to be answered. Which cancer patients will qualify to receive the vaccine? Who among them should get the vaccine and who shouldn’t? And is it safe for patients currently undergoing treatment to be vaccinated?
To learn the answers, we spoke with Tyler Seto, M.D., vice president of Enterprise Quality and Patient Safety and COVID-19 incident commander at City of Hope.
Which Cancer Patients Are Eligible for the Vaccine?
“According to these new CDPH guidelines, the vaccine will be available only to current cancer patients who are debilitated by the disease or have a weakened immune system,” Seto said. “So, for example, if you have a basal cell skin cancer or had cancer many years ago and are now cancer-free, you probably would not meet the requirements.”
“All of this comes down to resources,” he added. “If there was an unlimited amount of vaccine, we would be able to vaccinate everyone.”
Should You Get the Vaccine — and If So, When?
City of Hope follows guidelines set out by the National Cancer Care Network, clarifying them where necessary.
In general, patients should not be vaccinated if they have had treatments within the last three months that severely compromise the immune system. These include therapies that deplete B cells, such as cytarabine or rituximab; autologous or allogenic stem cell transplantation; more than 1mg/kg or higher of prednisone; T cell-depleting therapies such as infliximab and basiliximab; or a CAR T cell infusion.
“The reason for this is not that the vaccine is dangerous,” said Seto. “But when treatments suppress your immune system, the vaccine — which relies on your natural immune response — will not be effective.”
Here are some guidelines for specific types of cancer and treatments:
• Solid tumors: If you’re about to begin chemotherapy, the vaccine should be given at least one week before treatment begins. If you are currently receiving chemotherapy, the optimal time for vaccination — when your blood counts will be highest — is one to three days before your next treatment.
“You have to understand, though, that there is a lot of variability from patient to patient in this gap between chemotherapy cycles,” said Seto. “So what’s probably more important than the number of days is looking at how high or low your white blood cell count is or will be.”
If you’re being treated with chemotherapy, there’s another reason timing is important.
“A common side effect of the vaccine is fever, and it’s nothing to be concerned about. On the other hand, if you have fever from chemotherapy, that could be a harbinger of something more serious, like a systemic infection,” said Seto. “We want to make sure that we separate the two, so there’s no confusion about what's causing the fever.”
• Lymphoid malignancies: As mentioned above, wait three months after a B cell-depleting treatment before being vaccinated. If you are on a maintenance therapy, you can vaccinate between cycles — but there is a strong likelihood that you will not respond to vaccination.
• Acute myeloid leukemia (AML) and myelodysplastic syndromes: If you are being treated with a hypomethylating agent or induction chemotherapy, avoid vaccination until your absolute neutrophil count (ANC) is above 500. For AML patients planning postremission chemotherapy, get your vaccination at least seven days prior to its start.
• Acute lymphocytic leukemia: Wait until you complete your induction therapy, and if you’re on maintenance therapy, vaccinate between cycles.
• Multiple myeloma: You can vaccinate between chemotherapy cycles. However, vaccination results with this type of cancer are typically below par — but the potential benefit outweighs that risk.
• Patients on immunotherapies: You can be vaccinated, but should consult the provider administering the immunotherapies first.
• Patients having major surgery: To ensure the potential side effects of the COVID-19 vaccine aren’t confused with potential postoperative symptoms, it is recommend that you space your surgery and CCOVID-19 vaccination at by least 14 days.
If you have questions or concerns about whether you should receive a vaccine, you should consult your physician.
What If You’re in a Clinical Trial?
A large percentage of City of Hope patients are enrolled in clinical trials, and there are some special considerations for those patients — though not because of a concern about negative interaction between the vaccine and trial drug.
“The issue is that trials have very strict protocols. Some have windows for when it is optimal to receive a vaccine, and may even have specific criteria about whether a patient can continue to participate if they have received a vaccine,” Seto said. “So imagine the trial drug was working for you, and because you had a COVID-19 vaccination, you couldn’t get that drug anymore.”
If you’re in a clinical trial, it is very important to check with your research team before getting the vaccine. There is also a nurse at the City of Hope COVID19 vaccination clinic who can check trial protocols and explain the considerations so that patients can make an informed decision for themselves.
Overcoming Common Fears
The Pfizer and Moderna vaccines use mRNA, and Johnson & Johnson DNA technology — and since cancer is caused by DNA mutations, a big question for cancer patients is whether the vaccine can cause cancer growth or recurrence.
“The answer is, it cannot,” said Seto. “These vaccines do not modify your DNA. There is no risk of that happening.”
The vaccines use this advanced technology to show your immune system what it has to fight, without exposing it to the virus itself.
“It’s like giving a bloodhound a piece of clothing with scent on it so they can find a missing person,” he explained. “It’s essentially teaching your body the ‘scent’ of that virus, so the next time it appears, your immune system can attack it.”
And, of course, many cancer patients share the same concerns as the rest of the population — the speed with which the vaccines were approved, questions about efficacy and long-term side effects and, for some racial groups, fears grounded in historical medical abuses as well as lack of diversity in clinical trials.
Two excellent ways to allay concerns about the COVID-19 vaccines are to speak with a health care professional you trust or check out the excellent information available from the Centers for Disease Control and Prevention.
Are Side Effects and Efficacy Different for Cancer Patients?
Both side effects and efficacy will vary among cancer patients, as they do for everyone who receives the vaccine.
Many people do have side effects that generally last for a day or two. Some common ones include a sore arm, aches, fever and chills, which simply indicate that your immune system has sprung into action.
While most patients require a 15-minute observation time after receiving the vaccination, those with a history of anaphylactic shock will be observed for longer.
The efficacy of the vaccine depends on the strength of your immune system — and this varies among the general population as well as among cancer patients. And, as we detailed above, certain types of cancers and treatments have an impact on immunity,
Be sure to consult your physician to find out what’s best for you.
Which Vaccine Should You Get, and Where?
At the moment, there are three vaccines available — Pfizer, Moderna and Jannsen (Johnson & Johnson) — and they are all considered effective. And as you’ve undoubtedly heard on the news, take the first vaccine that’s available to you.
While there are many sites providing the vaccine, from megasites like Dodger Stadium and the Pomona Fairplex to a local pharmacy, City of Hope patients have another option.
“Probably the best thing to do if you want a vaccine is to sign up for a patient portal account at MyCityofHope,” Seto said. “We send eligible patients invitations to the clinic via the patient portal — vaccine supply allowing. And when your turn comes up, you want to have an active portal account to receive it. Once you get an invitation, you can self-schedule your appointment with the click of a button.”
As part of its own research, City of Hope is also working on a COVID-19 vaccine using a platform (MVA) different than the vaccines currently available. Previous MVA vaccines have been shown to be safe and effective in immunocompromised patients, such as cancer and transplant patients, and can produce an immune response in less than 14 days with long-lasting T cell immunity. The City of Hope COVID-19 vaccine is now in Phase 1 trials. If you’d like more information, you can visit CityofHope.org/covid-vaccine-trial.