COVID-19 Vaccine: A Q&A for Health-care Providers

In December 2020, the U.S. Food and Drug Administration (FDA) issued emergency use authorizations (EUAs) for two COVID-19 vaccines, one developed by Pfizer-BioNTech and the other by Moderna. As vaccinations have begun across the U.S., questions have arisen as to whether cancer patients should receive either vaccine.

We strongly recommend that patients discuss risks and benefits of the vaccine with their oncologist.

This advisory and the information below represents a compilation of current opinions of physicians and other experts at Washington University School of Medicine in St. Louis, Siteman Cancer Center and BJC HealthCare related to COVID-19 vaccines for cancer patients. Additional information included in this document is from the Centers for Disease Control and Prevention (CDC), American Medical Association, American Society of Clinical Oncology (ASCO), American Society of Hematology and Infectious Diseases Society of America.

What should we know about the new COVID-19 vaccines?

The two vaccines are defined as mRNA vaccines, which use a synthetic version of messenger RNA to produce an immune response. While mRNA vaccines are a new class of vaccines, they have been rigorously studied for more than a decade. The vaccines do not contain a live virus and do not interact with a person’s DNA.

Both vaccines were tested in large clinical trials. Results of these trials found the vaccines are safe and effective for the general population. Pfizer’s vaccine is authorized for individuals ages 16 and older, and Moderna’s for those ages 18 and older.

Are there concerns with cancer patients receiving the vaccine?

Cancer patients or immunocompromised individuals were not included in the large clinical trials evaluating the effectiveness of the two vaccines.

We do know, however, that recent studies already have demonstrated that if cancer patients get COVID-19, they are at higher risk for complications, hospitalizations and death compared with healthy people. Cancer patients currently receiving, or recently completing, cytotoxic chemotherapy also are at higher risk, as are patients being treated for blood cancers compared with solid tumor cancers.

RECOMMENDATION: We recommend that cancer patients talk with their oncologist about the risks and benefits of receiving a COVID-19 vaccine because, in many cases, the benefits will outweigh the risks of getting vaccinated. For oncology patients in active treatment, we do recommend that they receive the vaccine when offered.

Should cancer patients avoid getting any vaccine? 

In general, anyone with a weak immune system should not get any vaccine that contains live virus. However, there is no live virus in the COVID-19 vaccine. Vaccines that contain live virus include MMR (measles-mumps-rubella), varicella (chickenpox) and meningococcal vaccines, as well as the nasal mist version of the flu vaccine. The flu shot does not contain live virus and is safe.

What is recommended for patients in active treatment for cancer?

We do not have data yet on cancer patients getting the COVID-19 vaccines, but there are data published that demonstrate adequate responses to influenza and pneumonia vaccines in patients receiving chemotherapy. Although we do not expect an increased risk of serious side effects in patients who are immunosuppressed due to cancer chemotherapy, we know they may have a blunted response to vaccines in general.

  • Oncology patients actively receiving anti-neoplastic therapy. Delay vaccination until two weeks after chemotherapy, and delay subsequent chemotherapy until one week post booster vaccination. If unable to delay chemotherapy, defer vaccination until completion of chemotherapy and encourage earliest possible vaccination of household contacts and continued strict adherence to infection control guidelines. These guidelines include wearing a mask in public, washing hands, sanitizing touched surfaces and trying to maintain a small “bubble” of family members with whom the patient comes in contact.
  • Patients receiving checkpoint inhibition therapy. Despite theoretical concern regarding stimulation of a deleterious hyperimmune response to vaccination in conjunction with concurrent checkpoint inhibitor therapy, there has been no evidence reported of increased adverse reactions in these patients receiving flu vaccination. These patients should be monitored closely, however, for evidence of immune-mediated complications post-vaccination.
  • Patients who are receiving maintenance therapies that are not as cytotoxic. For these patients it is reasonable to consider proceeding with vaccination.
  • Patients receiving radiation therapy. These patient should be able to receive a COVID-19 vaccine during treatment but should confirm this in consultation with their treating radiation oncologist.

What about bone marrow/stem cell transplant patients or those on immunosuppressive medications? 

Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine is using the following guidelines on COVID-19 vaccination, based in part on published guidelines and published data for other vaccinations, as well as current clinical practice:

  • Allogeneic stem cell transplant patients. Defer vaccination until three months post-transplant to maximize the likelihood of response. Consider a brief delay in vaccine administration if significant taper of immunosuppression (i.e., steroids) is anticipated over the near term. Encourage earliest possible vaccination of household contacts and continued strict adherence to infection control guidelines. These guidelines include wearing a mask in public, washing hands, sanitizing touched surfaces and trying to maintain a small “bubble” of family members with whom the patient comes in contact.
  • Autologous stem cell transplant patients. Delay vaccination until one month post-transplant to maximize the likelihood of response. Encourage earliest possible vaccination of household contacts and their and the patient’s continued strict adherence to infection control guidelines, such as those outlined above.
  • Oncology patients not on active treatment but receiving chronic oral immunosuppressive medications. No restrictions. Administer vaccination when available.

If a patient is diagnosed with cancer, but hasn’t started treatment, should he or she receive the vaccine prior to treatment getting underway?

The decision should be made in consultation with the patient’s oncologist. The answer will be guided by when and how fast treatment needs to start.

If a patient is finished with treatment or is not on active treatment, how long should he or she wait to receive the COVID-19 vaccine?

This also should be discussed with the patient’s oncologist. The time frame will likely depend upon whether the patient received chemotherapy, radiation, a bone marrow or stem cell transplant or non-cytotoxic therapy. In general, we recommend that oncology patients not undergoing active treatment receive the vaccine when available. For patients who are undergoing treatment, please refer to the aforementioned recommendations regarding specific types of treatment.

Should cancer patients who have recovered from COVID-19 receive the vaccine?

The vaccine is recommended in this setting once patients have recovered. For patients who have received convalescent plasma or monoclonal antibodies, we recommend they wait for three months after receiving convalescent plasma or monoclonal antibodies before they receive the vaccination. This is because COVID-19 antibodies are likely to impair vaccine response.

Should a patient’s family members get the COVID-19 vaccine?

Yes. We do recommend that family members in good health get the vaccine. This will better protect cancer patients while they are in treatment.

Can pediatric cancer patients get the COVID-19 vaccine?

At this time, no vaccine against COVID-19 has been approved for anyone younger than 16.

What steps should cancer patients take to reduce their risk of COVID-19?

No vaccine is 100 percent effective. Therefore, it’s important for patients to remain vigilant in minimizing the risk of getting COVID-19. We strongly recommend that cancer patients as well as the general population continue safety protocols. These include wearing a mask in public, washing hands, sanitizing touched surfaces, changing clothes after going to appointments and trying to maintain a small “bubble” of family members they see. All can help to minimize the risk of exposure to COVID-19.

Again, we do advocate for the vaccine for patients who have completed cancer treatment.

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The answers above are a compilation of opinions from and/or have been reviewed by:

  • John DiPersio, MD, PhD, the Virginia E. and Samuel J. Golman Endowed Professor of Oncology and chief of the Division of Oncology at Washington University School of Medicine in St. Louis and deputy director of Siteman Cancer Center
  • Peter Westervelt, MD, PhD, a professor of medicine and chief of the Section of Bone Marrow Transplantation at the School of Medicine and a bone marrow transplant specialist at Siteman Cancer Center
  • Keith Stockerl-Goldstein, MD; a professor of medicine at the School of Medicine and bone marrow transplant specialist at Siteman Cancer Center
  • Rachel Presti, MD, PhD, an associate professor of medicine and medical director of the Infectious Diseases Clinical Research Unit at the School of Medicine

Revised Dec. 23, 2020