Guideline: COVID vaccines for people with cancer

Contents

GUIDELINES AT A GLANCE

What are these guidelines about?

This review reports on recommendations from two major medical expert panels about COVID vaccine for people with cancer. In January 2021, the National Comprehensive Cancer Network (NCCN) and the American Society of Clinical Oncology (ASCO) released new vaccine guidelines.

Why are these guidelines important?

People with cancer are susceptible to COVID infection just like people without cancer. Cancer patients are at increased risk of complications from COVID. People who recover from a COVID infection face potential long-term health problems, including impacts on lung, heart and brain function.

What are the guidelines?

NCCN guidelines and ASCO guidelines are similar. With a few exceptions, they advise cancer patients to get vaccinated when the vaccine is available. The NCCN notes that data about vaccines in cancer patients is limited, so recommendations are based on the expert opinion of the committee and will be updated as more data becomes available.

NCCN guidelines

• If you have been diagnosed with cancer, it is recommended that you get a COVID vaccine when it is available to you even if you are in active therapy.
  • No known safety concerns are linked to COVID vaccines for cancer patients.
    • Data on the safety and efficacy of COVID vaccine in cancer patients is limited.
  • If you have a solid tumor cancer (e.g., brain, breast, colorectal, endometrial, ovarian, pancreas or prostate cancer), it is recommended that you get the vaccine when it is available. If you are about to have major surgery, you should delay getting vaccinated for a few days after your operation.
  • If you are a Black/African American, Hispanic/Latino and/or Native American patient with cancer, you may be at increased risk of developing COVID-19.
     
• As a cancer patient, you may want to delay getting a COVID vaccine for the same reasons as people without cancer.
  • If you have been recently exposed to COVID-19 or you have a COVID-19 infection, you should delay vaccination until you are well (i.e., no longer showing symptoms of illness).
  • If you have received blood cells or engineered cells (e.g., CAR-T cells) you should wait at least three months to maximize vaccine efficacy (these treatments may decrease immune system function).
  • If you have major surgery, you may want to delay your vaccination for a few days. This allows you and your doctor to distinguish a fever that may occur due to surgery from a fever that develops from vaccination.
  • If you have blood cancer (e.g., leukemia) and you are on intensive chemotherapy, you should delay getting the vaccine until your white blood cell counts stabilize. (White blood cells are part of your immune system.)
• Your caregivers and household/close contacts should be vaccinated when possible.
  • People around cancer patients (e.g., spouses, household members) are the most likely sources of transmission and should be considered for early vaccination.
• Even if you are vaccinated, your close contacts should continue to wear masks, maintain social distancing, and follow other recommendations for preventing COVID-19.

ASCO guidelines

If you are a cancer patient, a COVID vaccination is recommended as long as you do not have a history of allergy to specific components of the vaccine. (Note: Unlike many traditional vaccines, the Moderna and Pfizer mRNA vaccines do not contain egg components.)

This recommendation includes the following circumstances:

• If you are a patient in active cancer treatment, you should get the vaccine when it is available.
  You may want to talk to your doctor about strategies, such as getting the vaccine between cycles of therapy or waiting after receiving stem cell transplants and immune globulin treatment.
• If you are a cancer survivor, you should get the vaccine when it is available.
• If you have a compromised immune system, you should get the vaccine when it is available.
  Importantly, the safety and effectiveness of vaccines in immunocompromised patients are unknown because the vaccine clinical trials did not include immunocompromised patients. If your immune system is compromised, you may have a lower response to the vaccine, but you may benefit to some degree. If you do become infected with COVID, getting vaccinated beforehand may reduce the severity and impact of the infection.

Contraindications

• Do not get the vaccine if you are allergic to any of its components.

• Ingredients in the Moderna and Pfizer vaccines include mRNA, lipids, salts and sucrose (a type of sugar).
• The complete list of ingredients for the Moderna vaccine is listed here.
• Ingredients for the Pfizer vaccine include:
  • Polyethylene glycol (PEG) or a PEG-related ingredient is a component of both mRNA vaccines. PEG is a common additive in foods, cosmetics and medicines (e.g., skin creams, laxatives, personal lubricants and toothpaste). Allergy to PEG is rare, however, people who have a known allergy to PEG should not get either mRNA vaccine.
  • If you are allergic to polysorbate, you should not get an mRNA COVID-19 vaccine. Polysorbate is not an ingredient in either mRNA COVID-19 vaccine but it is closely related to PEG, which is in both vaccines.
• If you had a severe allergic reaction after getting the first dose of an mRNA COVID-19 vaccine, the CDC recommends that you should not get the second dose. 

Do the vaccines work?

The vaccines currently approved in the U.S. from Moderna and Pfizer are 94 to 95 percent effective, respectively. This data is based on clinical trials that showed these vaccines provide substantial protection. People who have been vaccinated may still transmit the COVID virus but the vast majority will not have symptoms or become ill.

How do the mRNA vaccines work?

The COVID vaccine from Moderna and Pfizer are mRNA vaccines. mRNAs are the directions a cell uses to make proteins. The COVID virus has 29 proteins. The vaccine delivers a portion of one virus mRNA that encodes just one of these proteins. When the vaccine mRNA enters a cell, the cell uses its normal  machinery to translate the mRNA for the COVID spike protein. The other proteins of the virus are not made so there is no complete virus present. mRNAs are used to make proteins and do NOT alter the cell's DNA. The presence of the spike protein prompts the immune system to make antibodies that will recognize and attack the virus if it enters the body. The mRNA from the vaccine is degraded by normal cell processes in a short time. Once a person is vaccinated, their immune system remembers what the virus looks like.

What are the potential side effects of the COVID vaccine?

Most side effects associated with the COVID vaccine are mild.
Many people report mild side effects in one to three days after getting the vaccine, particularly after the second vaccination. Most of these side effects are thought to be indications that the immune system is responding appropriately to the vaccine.

More common side effects within one to three days after vaccination include reaction at the site of the injection and several flu-like symptoms:

• soreness, redness or swelling in the arm where the vaccine is injected
• feeling tired
• headache
•  chills
• low-grade fever
• muscle soreness
• joint pain
• occasional nausea or vomiting
• swollen lymph nodes

Adverse events are rare.

• Among the 1.9 million people who were vaccinated with the Pfizer vaccine of December 23, 2020, 4,393 (0.2%) had severe adverse events. Signs of a severe allergic reaction may include:
  • difficulty breathing
  • swelling of your face and throat
  • a fast heartbeat
  • a bad rash over your entire body
  • dizziness and weakness

• Anaphylaxis  is a severe, life-threatening allergic reaction.
  • 21 people (of 1.9 million people) vaccinated with the Pfizer vaccine had a severe allergic reaction.
    • Most (17 of 21) had a prior documented history of allergic reactions and/or anaphylaxsis.
    • Most (15 of 21) reacted within 15 minutes of getting vaccinated.
    • All people who had available follow-up information (20 of 21) recovered or were discharged home.  
  • 1 person (of 224,00 people) vaccinated with the Moderna vaccine had a severe allergic reaction.
     
• Some people have experienced non-severe allergic reactions within four hours after being vaccinated (known as immediate allergic reactions), including hives, swelling and wheezing (respiratory distress).

Among those vaccinated with the Pfizer vaccine:

• • 83 cases (of 1.9 million people vaccinated) had severe allergic reactions that were not life-threatening including hives, itching, rash, scratchy throat and mild respiratory symptoms (wheezing).
  • 72 (87%) were classified as not serious.
  • Most people who had a reaction (56%) had a prior history of allergic reactions.
  • Most reactions (85%) occurred within 30 minutes.
     
• No deaths have been associated with the COVID vaccine.

Individuals with inherited mutations that increase cancer risk do not have a greater risk of side effects or harm from COVID vaccines.

• See video statements by FORCE scientific advisory board members Dr. Alison Kurian of Stanford University and Dr. Matt Yurgelun of Dana-Farber Cancer Institute about the safety of COVID vaccines for those with inherited mutations that increase cancer risk.

A recent vaccine may affect breast imaging results

You may experience swollen lymph nodes as your immune system responds to the vaccine. If you are a breast cancer patient, swollen lymph nodes from vaccination may be confused with swollen lymph nodes associated with your breast cancer or swelling near surgery sites. Swollen lymph nodes in the armpit have been reported in mammograms or ultrasound of patients after vaccination. If you have been vaccinated, you may want to inform the healthcare staff performing your mammogram. You may want to consult with your doctor to distinguish whether swollen lymph nodes require further monitoring.

What does this mean for me?

Vaccination is recommended for most cancer patients. Data indicates that it is a safe and effective way to prevent a COVID infection. You may want to consult with your doctor about whether they recommend the COVID vaccine considering your cancer and personal medical history. If you recently had surgery, you may want to discuss with your doctor whether you should delay vaccination for a few days. If you are currently undergoing chemotherapy, you may want to talk with your doctor about the best time to get the vaccine during your chemotherapy cycle.

If you are vaccinated, you can still be infected with the COVID virus but your immune system will be better able to fight it. However, you can still transmit the COVID virus to others so continued social distancing and mask-wearing is recommended until more people have been vaccinated.

If you are vaccinated, you may experience mild symptoms for one to three days after your shot, including pain at the injection site, fatigue and sore muscles.

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Posted 2/1/21

Reference

• American Society of Clinical Oncology (ASCO): COVID vaccine and patients with cancer. Update as of 1/15/21
• NCCN: Cancer and COVID-19 Vaccination. Version 1.0. posted online 1/22/2021

Disclosure

FORCE receives funding from industry sponsors, including companies that manufacture cancer drugs, tests and devices. All XRAYS articles are written independently of any sponsor and are reviewed by members of our Scientific Advisory Board before publication to assure scientific integrity.