Expert Gives Nod to COVID-19 Vaccines for Patients With Cancer

David Cohn, MD, discusses how to approach COVID-19 vaccination in patients with cancer.

Patients with cancer should strongly consider being vaccinated to prevent coronavirus disease 2019 (COVID-19), as it can reduce the risks associated with the virus, despite the potential of having a weakened immune system, according to David Cohn, MD.

“It is a really good idea for [patients with] cancer to be vaccinated,” said Cohn. “We know that patients with cancer have a higher rate of contracting COVID-19, and they also have a higher rate of severe complications or death from COVID-19 if they were to get it. To me, that is very important information on how an individual [patient with] cancer should think about protecting him or herself to minimize the chance that they're going to have a major complication from this disease.”

In December 2020, the FDA granted Emergency Use Authorizations to BNT162b2 and the Moderna COVID-19 vaccine, as the first vaccine to prevent coronavirus disease 2019 in individuals aged 16 and 18 years and older, respectively.

In an interview with OncLive, Cohn, who is chief medical officer and director of the Gynecologic Cancer Research at The Ohio State University Comprehensive Cancer Hospital, discussed how to approach COVID-19 vaccination in patients with cancer.

OncLive: From your perspective, what are the biggest misconceptions with the COVID-19 vaccines for patients with cancer that you have heard from health care providers or patients?

Cohn: The 2 biggest misconceptions is number one, about the safety of the vaccine, and number two, about the efficacy or how the vaccine works, especially in patients with cancer. First, from a safety side, certainly the vaccination process came out really quickly. To me, that's very exciting, and I think to everybody, it's a little bit curious because it's never happened as quickly before. Therefore, it's natural to be somewhat suspect about whether or not all of the appropriate processes and procedures were followed. I would harken back to the fact that this is exactly what was necessary to try to work to get us out of the pandemic.

A lot of the research that has been the basis of these vaccines has been in the works for years. Therefore, there is a massive head start to get to this point, and that's the important thing about how we can be here so quickly, yet the research has been [ongoing] for years. The FDA has been evaluating this research and has looked at the short-term safety. While we don't have long-term safety data, there is nothing that would make us believe that there is anything inherently risky about these vaccines.

The second misconception surrounds how patients would be expected to respond to the vaccines. These include patients with cancer, and those with cancer who have had treatment and therefore have a reduced immune system. Therefore, the question becomes whether you have a vaccine that a patient can have a response to, or whether their lack of immune response is going to lead them to not have any effect from that vaccine.

However, what is known is that even in individuals who had been heavily treated for cancer, they still do have the capacity to mount an immune response. Most importantly, some level of immunity to COVID-19 is better than not. Right then and there is the key that any patient who has cancer should be vaccinated, unless there's not an absolute contraindication for them to be vaccinated.

Could you share some background to the technology of this vaccine? What exactly is the research that has been in development for the past several years?

When you think about the technology behind the mRNA vaccine, the general process for any vaccine is that you introduce something, which is recognized by the body as being foreign, and then the body can mount an immune response to it. That immune response is going to then be durable, meaning it may last for months or years or more than that. That is the general principle for all vaccines. This technology is using mRNA, a small piece of the genetic material of the spike protein of COVID-19 itself.

Someone described the technology as Snapchat. In Snapchat, you send a photograph, and then that photograph is deleted from somebody's phone, for example, so that it's not durable. The mechanism is that the delivery is the Snapchat—it's there and then it's gone. However, the lasting impact of that photograph can be quite durable, and that's the hope with the immunity as well. I like that analogy because it does demonstrate that you can do something, which you can see and feel, but then it goes away very quickly. That's the technology where you have the mRNA that's wrapped in a certain type of compound, a lipid, that allows it into the body and then it's disintegrated very quickly. However, the immunity process is far longer lasting.

Are there certain criteria you're looking at when discussing vaccine eligibility for your patients with cancer?

The criteria that we use about who should or should not be vaccinated is fairly simple. There are certain contraindications to the vaccine, and those are individuals who have an anaphylaxis or severe allergic reaction to previous mRNA vaccines or to other medications. That's certainly one thing that you want to talk to your health care provider about, to ensure that there's no way that you could get a vaccine.

Beyond that, in general, patients should be vaccinated. I talk to my patients about the fact that I've been vaccinated; as someone who cares for patients with cancer, I want to make sure that I minimize my personal risk. Then, the second piece is that we know that certain chemotherapy drugs have the same polyethylene glycol, which is one of the compounds that is part of the mRNA vaccine.

Therefore, for patients with cancer, if you've had an allergic reaction to certain chemotherapy drugs, there may also be a reason to not be vaccinated with this mRNA technology. Again, you will need to speak with your health care provider to make sure that there's the appropriate scrutiny that's being taken to make sure that they're not able to be vaccinated. If that's the case, there are new technologies or other types of vaccine technology on the horizon that hopefully will be authorized for emergency use by the FDA as well that they may be eligible for, if not the mRNA vaccines.

Two vaccines are currently available from the FDA through Emergency Use Authorization, and additional companies are also working on vaccines. Will there be a point where you're having difficulty choosing which vaccine to administer, similar to how there are multiple TKIs approved to target the same oncogene-driven cancer?

As the number of vaccines hopefully come online in the very near future, it would be a dream to have the opportunity to have to choose for a patient what type of vaccine that they can get. Right now, it's just a matter of how we sequence patients, because the vaccines currently are still a relatively scarce resource. Therefore, if we're in a position to have more vaccines, we may then use certain types of allergic reactions as a determination as to what type of vaccine someone should have.

Secondly, for patients with cancer in particular, there might be an optimal time during their chemotherapy cycles that they should be vaccinated. If you have 2 vaccines that are required, which have the mRNA technology that's existing, then maybe if there's a vaccine that's authorized with 1 vaccine [dose], that could actually be optimal for patients with cancer. You would only have to plan 1 vaccine around chemotherapy and not have separate vaccinations.

What if a patient is undergoing different cancer treatment, such as a checkpoint inhibitor or one of the many TKIs that are available across solid tumors? Do any of these interfere with the vaccine?

Different kind of treatments, whether it's a small molecule inhibitor, antibody therapy, cytotoxic chemotherapy, immunotherapy, or radiation all have different effects. Any patients with cancer should speak to their oncologist about whether there's an optimal time for them to receive the vaccine, and a lot of it depends upon their history, their immune system, and the expectation for what the future holds for their treatments as well. That will determine the appropriate timing for vaccination.

What key side effects are associated with the vaccine that should also be stressed to patients?

The message about vaccine side effects is that they are most likely going to happen. That is going to be a sore arm or some redness or warmth in the vaccination site, and that's just your body providing that reaction to the mRNA, to the vaccine itself.

Severe complications are very, very rare. Although these are the ones that we read about in the newspaper or hear about it on the radio—that make the news—that is not what defines the general status of vaccination. It seems to be very safe.

It seems that the second vaccine may have more side effects than the first because that's the goal. It's priming the body, and then it's boosting the immunity with a second vaccine. You can think about timing the vaccine around your daily life so that you're not in a position of experiencing a sore arm or even a low-grade temperature at a time when you need to be maximally functional.

Do you have any advice for other health care professionals who are having these conversations about the vaccine with their patients, especially those who are apprehensive or are concerned about long-term side effects?

These conversations are very important to have. Certainly, engaging in shared decision-making with a patient is critically important because, patients are going to come in with their own conceptions about whether they want to be vaccinated or not. It's important to make sure that we're having these conversations that are directed towards their goals, as well.

There's a lot of resources out there; ASCO has great patient-facing resources that are out there. The American College of Obstetricians and Gynecologists also have patient-facing resources as it relates to breastfeeding and pregnancy with a vaccine. Make sure to leverage all of the resources that are out there, educate ourselves as much as we can as providers of cancer care, but also make sure that we have that shared decision-making with our patients so that we are achieving their goals, as well.

In general, it is in the best interests, in my mind, for patients with cancer to be vaccinated to protect themselves because they've got a higher risk for getting COVID-19, and certainly a higher risk for having major complications or dying from COVID-19, as well.