This page was last updated on 04/16/2021. Please check back frequently for updates.
On December 17, 2020, the American Society of Clinical Oncology and Infectious Diseases Society of America held a “COVID-19 Vaccine & Patients with Cancer” webinar to discuss the importance of COVID-19 vaccination and to provide expert opinion on its use for cancer patients. At the time of the webinar, there was only one vaccine authorized for use against COVID-19, the Pfizer/BioNTech vaccine, although the expert panel discussion focused on mRNA vaccines and addressed vaccines in general. The panel of oncology and infectious disease experts agreed that the Pfizer, and now Moderna, vaccines have been shown to be safe and effective for the general population and there was no evidence that they would not be safe for most cancer patients, although it should be noted that patients receiving immunosuppressive and cytotoxic treatments were excluded from participation in the vaccine trials to date so there is little to no data on the safety and efficacy of the Pfizer and Moderna vaccines in cancer patients.
At this writing, the FDA has also approved another vaccine: a single-dose vaccine from Johnson & Johnson. On April 13, 2021, the CDC issued a Health Alert through the Health Alert Network (HAN): “Cases of Cerebral Venous Sinus Thrombosis with Thrombocytopenia after Receipt of the Johnson & Johnson COVID-19 Vaccine” about the identification of 6 cases of CVST, a rare and severe thrombotic event. The details of this health alert are available on the CDC website. As of April 16, 2021, the CDC makes the following recommendations:
- Pause the use of the J&J COVID-19 vaccine until the ACIP is able to further review these CVST cases in the context of thrombocytopenia and assess their potential significance.
- Maintain a high index of suspicion for symptoms that might represent serious thrombotic events or thrombocytopenia in patients who have recently received the J&J COVID-19 vaccine, including severe headache, backache, new neurologic symptoms, severe abdominal pain, shortness of breath, leg swelling, petechiae (tiny red spots on the skin), or new or easy bruising. Obtain platelet counts and screen for evidence of immune thrombotic thrombocytopenia.
- In patients with a thrombotic event and thrombocytopenia after the J&J COVID-19 vaccine, evaluate initially with a screening PF4 enzyme-linked immunosorbent (ELISA) assay as would be performed for autoimmune HIT. Consultation with a hematologist is strongly recommended.
- Do not treat patients with thrombotic events and thrombocytopenia following receipt of J&J COVID-19 vaccine with heparin, unless HIT testing is negative.
- If HIT testing is positive or unable to be performed in a patient with thrombotic events and thrombocytopenia following receipt of J&J COVID-19 vaccine, non-heparin anticoagulants and high-dose intravenous immune globulin should be strongly considered.
- Report adverse events to VAERS, including serious and life-threatening adverse events and deaths in patients following receipt of COVID-19 vaccines as required under the Emergency Use Authorizations for COVID-19 vaccines.
As this is a rapidly developing situation, please refer to the CDC’s alert link above for more recent information.
The American Society of Hematology (ASH) has also released relevant information in “Immune Thrombotic Thrombocytopenia: Frequently Asked Questions.”
Memorial Sloan Kettering Cancer Center has made available an interim guideline on vaccination for cancer patients. The National Comprehensive Cancer Network (NCCN) has made available preliminary recommendations as well. The recommendations in these documents are based on opinion and extrapolation from other vaccine studies and may change rapidly as new information becomes available.
Should people with cancer be vaccinated against COVID-19?
At this time, patients with cancer may be offered vaccination against COVID-19 as long as components of that vaccine are not contraindicated. The current Centers for Disease Control and Prevention (CDC) interim clinical guidance discusses immunocompromised individuals. It states: “Immunocompromised individuals may still receive COVID-19 vaccination if they have no contraindications to vaccination. However, they should be counseled about the unknown vaccine safety profile and effectiveness in immunocompromised populations, as well as the potential for reduced immune responses and the need to continue to follow all current guidance to protect themselves against COVID-19.” The expert panel noted that while some immunocompromised patients may experience decreased response to the vaccine, it may still confer some benefit and is important to reduce the risk or severity of COVID-19 to cancer patients, especially given recent evidence of higher rates of severe infection.
Should people undergoing active treatment for cancer be vaccinated against COVID-19?
At this time, patients undergoing treatment may be offered vaccination against COVID-19 as long as any components of the vaccine are not contraindicated. Oncologists have experience providing other types of vaccines to patients receiving treatment for cancer, including chemotherapy, immunotherapy, radiation therapy or stem cell transplantation. Strategies such as providing the vaccine in between cycles of therapy and after appropriate waiting periods for patients receiving stem cell transplants and immune globulin treatment can be used to reduce the risks while maintaining the efficacy of vaccination. ASCO is only aware of one study published to date, Wassengrin et al, Lancet Oncol, that has specifically reported on vaccine safety outcomes in patients with cancer receiving treatment (immune checkpoint inhibitors).
Should cancer survivors be vaccinated against COVID-19?
Cancer survivors may be offered vaccination against COVID-19 as long as any components of the vaccine are not contraindicated.
Are there people who should not be vaccinated?
At this time, only those with contraindications to a specific vaccine component should not be offered vaccination with that specific product. These contraindications are described in detail in CDC interim clinical guidance.
What other concerns are there for people with cancer who are vaccinated?
As there is still uncertainty around the extent to which immunocompromised patients with cancer will develop immunity in response to vaccination, vaccinated patients should continue to follow current guidance to protect themselves from exposure to COVID-19. The expert panel underscored the message that while providing the vaccine to cancer patients and their caregivers will reduce risk for infection or clinical COVID-19 disease, they emphasized the importance of continuing practices of wearing masks, social distancing, and maintaining good hand hygiene even after vaccination.
There is some evidence that vaccination with mRNA vaccines prior to imaging may cause difficulties in interpretation of the resulting images. Two multidisciplinary groups have published information on imaging in general in the context of COVID-19 vaccination: Lehman et al, J Am Coll Radiol; Becker et al, Radiology. The Society for Breast Imaging has published guidance on how these potential difficulties should be managed in patients with breast cancer.
The COVID-19 and Cancer Clinical Trials Working Group has published information on vaccination of patients who are seeking to participate in or enrolled in clinical trials (Desai et al, Nat Rev Clin Oncol).
CDC Advisory Committee on Immunization Practices
CDC’s Advisory Committee on Immunization Practices (ACIP) has approved several recommendations regarding the prioritization of COVID-19 vaccination. Once approved by the CDC, these recommendations are intended to help state and local jurisdictions maximize the distribution of the vaccines while they are still in scarce supply. These recommendations are not binding mandates, nor do they relate to the allocation of the vaccine itself which is being managed separately within HHS. To date, they have recommended the following priority groupings:
Phase 1a: The Advisory Committee on Immunization Practices (ACIP) recommended, as interim guidance, that both (1) health care personnel and (2) residents of long-term care facilities be offered COVID-19 vaccine in the initial phase of the vaccination program.
Phase 1b: persons aged ≥75 years and frontline essential workers. For purposes of this recommendation, the following essential workers are considered frontline: firefighters, police officers, corrections officers, food and agricultural workers, Postal Service workers, manufacturing workers, grocery store workers, public transit workers, those who work in the education sector (teachers, and support staff), and daycare workers.
Phase 1c: persons aged 65–74 years, persons aged 16–64 years with high-risk medical conditions, and other essential workers. Cancer has been identified as one of the high-risk medical conditions for Phase 1c.
CDC is regularly updating the number of vaccines distributed and administered on their COVID-19 page. ACIP continues to convene emergency meetings as new information, evidence and clinical trial results are available. Materials from previous meetings and suggested dates and agendas for future meetings can be found on the CDC website.
HHS Expands Pool of Professionals Eligible to Administer COVID-19 Vaccines
On January 28, 2021, HHS added additional categories of qualified persons authorized to prescribe, dispense, and administer COVID-19 vaccines authorized by the FDA. This action authorizes any healthcare provider who is licensed or certified in a state to prescribe, dispense, and/or administer COVID-19 vaccines in any other state or US territory. It also authorizes any physician, registered nurse, or practical nurse whose license or certification expired within the past five years to prescribe, dispense and/or administer COVID-19 vaccines in any state or US territory so long as the license or certification was active and in good standing prior to the date it went inactive.
Please see this announcement for additional information, including training requirements and details on liability protections.
Resources from the American Medical Association
The American Medical Association (AMA) has produced several resources with helpful advice for clinicians regarding the COVID-19 vaccines. Please visit the links below for concise information on the vaccines as well as tips for how to discuss them with patients.
- Physician Frequently Asked Questions
- Patient Frequently Asked Questions
- Tips on How to Talk to Patients about the Vaccine (video with transcript)
Resources from CDC
CDC has developed toolkits to assist clinicians providing or advising patients on the COVID-19 vaccine. Please visit the links below for additional resources:
- Clinical Resources on COVID-19 Vaccination
- Vaccination Communication Toolkit
- Vaccine Recipient Education Toolkit
Resources from the Centers for Medicare and Medicaid Services
The Centers for Medicare and Medicaid Services (CMS) COVID-19 page includes valuable information on coverage and reimbursement for vaccine administration. CMS’ Office of Minority Health (CMS OMH) has also developed a COVID-19 Vaccine Resources website of federal resources and organized them for health care professionals, partners, consumers, and for assistance in additional languages.