“My doctor has not told me to get the vaccine.” That was the number one reason patients with cancer gave in a survey at an outpatient infusion therapy clinic for not having received at least one dose of the COVID-19 vaccine. Rivalling that reason were concerns about safety and fear of vaccine side effects.
The survey was a collaborative effort between The University of Texas Mays Cancer Center (home to the UT Health Center San Antonio MD Anderson Cancer Center) and the nearby University Health Systems, a large academic county hospital that serves a high-risk patient population with a high representation of minority and uninsured patients. Patients participating in the survey received treatment at both institutions, but their infusion therapy was administered at the county hospital.
Although the study was relatively small, involving 194 patients, and limited to a single infusion clinic, it focused on “a predominately underserved Hispanic group of patients, which is generally a group that has been difficult to reach,” Kate I. Lathrop, MD, lead author of the survey research project, said in an interview with The ASCO Post. “We were really trying to look at what is going on in that group, which we know has socioeconomic factors that in general influence poor outcomes from COVID.” Dr. Lathrop is Associate Professor, Breast Medical Oncology, Mays Cancer Center.
We were a little surprised to find out that often patients were saying they hadn’t been advised by their physicians to receive COVID-19 vaccination.— Kate I. Lathrop, MD
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The survey results were presented at the 2021 San Antonio Breast Cancer Symposium1 and were reported by range of media, including the NBC television affiliate in San Antonio, CBS Austin, and U.S. News & World Report.
Gap Revealed
The surveys were conducted from May through July 2021. The 194 patients surveyed “were all undergoing active treatments for their cancer, either active chemotherapy or immunotherapy,” Dr. Lathrop said.
Patients had temperature checks before entering the infusion clinic and were required to wear masks and social distance. “We had decreased our capacity in the infusion clinic and were limiting the number of patients we were infusing,” Dr. Lathrop noted.
Patients were asked whether they had received at least one dose of a COVID-19 vaccine, and 56% replied yes. At the time, the community vaccination rate for Bexar County, where San Antonio is located, was 76%.
“In our minds as oncologists, the treating physicians, we were thinking we need to make sure all these patients were getting vaccinated,” Dr. Lathrop said. The survey revealed a “gap between what we as medical oncologists were thinking was happening and what was actually happening in our clinic.”
Reasons for Reluctance
Patients who reported not receiving at least one dose of the COVID-19 vaccine were asked to choose from a list of six reasons for not doing so. Not being told to do so by their doctor was chosen by 30%. Closely trailing were concern about safety, chosen by 28%, and fear of side effects, chosen by 23%. “Access to the vaccine was not a common reason, with only 10% of patients reporting this reason,” Dr. Lathrop said.
“We were a little surprised to find out that often patients were saying they hadn’t been advised by their physicians to receive COVID-19 vaccination. I would have really expected that our patients with cancer would have a higher rate of vaccination based on their risk,” Dr. Lathrop said.
Safety vs Efficacy
“There was a question about safety vs efficacy,” Dr. Lathrop explained. Concurrent with the survey research project, she was also involved in a trial looking at antibody response rates among patients with cancer after one and two doses of mRNA COVID-19 vaccines. “Patients with cancer had not been included in the early vaccine trials,” Dr. Lathrop pointed out. “It was kind of a ‘data-free zone.’”
Dr. Lathrop continued: “Very quickly, the scientific and medical community felt the benefits were certainly outweighing the risks of any safety signal, but efficacy was certainly a question. We didn’t know how protective this vaccine is in this group. I was telling my patients, ‘You should get it. How well it works for you is not certain yet. We are doing a trial to help figure that out.’”
We now know that patients receiving anything that limited their anti-CD20 cells— such as rituximab—weren’t mounting an antibody response [to COVID-19 vaccination].— Kate I. Lathrop, MD
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In addition, Dr. Lathrop advised her patients receiving vaccinations to continue to wear masks and social distance. “At that point in time, there was this feeling that if you were vaccinated, you didn’t have to be as careful, and that was not always productive in our patients with cancer before we knew how effective the vaccines were for them.”
The antibody response trial, subsequently published in Cancer Cell,2 found that “patients with cancer have excellent antibody response at 3 weeks after two doses with mRNA COVID-19 vaccines,” except for a subset of immunocompromised patients. “We now know that patients receiving anything that limited their anti-CD20 cells—such as rituximab—weren’t mounting an antibody response,” Dr. Lathrop said. “We now know that the efficacy is different, but we didn’t know it then.”
Adding to the safety concerns about vaccines is a misunderstanding about how vaccines work. Some patients “have a sense that they can get the virus from the vaccine. It is still a very commonly held belief,” Dr. Lathrop said. “In communities where sometimes the health literacy is lower, it is common for many patients to think the vaccine can be harmful if their immune system is weak.”
On-Site Interventions
Concerns about safety and side effects are addressed in two flyers developed by University Health Systems and distributed at the outpatient infusion clinic and other locations. The flyers were not specifically targeted at patients with cancer, but they were used “system-wide, in all clinics and lobby areas,” and offered “to unvaccinated patients as well as people who accompanied patients to the hospital,” Eva Y. Prieto, MSN, RN, AMB-BC, a coauthor of the research project, told The ASCO Post. Ms. Prieto is Manager of Clinical Outcomes, Quality Improvement Department, at University Health Systems.
Eva Y. Prieto, MSN, RN, AMB-BC
Ms. Prieto continued: “COVID-19 Vaccine Quick Facts assured patients that “mRNA vaccine technology is not new” and advised that “a full list of ingredients is publicly available on the FDA and CDC websites. We know there is a lot of conflicting information out there,” she added, and patients were encouraged to ask questions and were given listed locations and hours for free walk-in COVID-19 vaccinations.
These flyers were used “to create awareness,” Ms. Prieto said, and to encourage patients to talk to their doctors about vaccination. “The flyers are available in Spanish and English because that is primarily our population.” Ms. Prieto said.
Survey participants who responded that they had not received at least one dose of COVID-19 vaccine could receive their first dose at the vaccination clinic in the hospital lobby. Ms. Prieto noted that University Health Systems is both a teaching hospital and the county hospital, and many of those served struggle with transportation issues. Locating a vaccination clinic in the lobby makes it easier for patients who come in for treatment to receive vaccination during the same trip to the hospital. Free on-site vaccinations are also offered to family, friends, or others who provided transportation to patients. “It is open to anybody who comes into the hospital, but specifically for patients with cancer,” Ms. Prieto said.
The clinic in the lobby is still up and running. “We will do the first shot, the second, and the third,” stated Ms. Prieto. “We will do whichever is wanted—Moderna or Pfizer.”
System-Wide Interventions
Pop-up reminders about COVID-19 vaccinations were added to the electronic medical records system at Mays Cancer Center to increase “awareness for our faculty that this patient population falls behind the average vaccination rate,” Dr. Lathrop reported. “We were definitely looking at ways to improve our vaccination rate, and having this knowledge from the infusion clinic informed that, too.”
Mays Cancer Center and University Health Systems use the same medical records system software, Dr. Lathrop noted. So, the systems have the capability to communicate with each other.
A second survey was conducted in October and November 2021 among a smaller cohort of just 24 patients at the infusion therapy clinic. It revealed that the percentage of patients with cancer who had received at least one dose of COVID-19 vaccine had increased to 77%. Dr. Lathrop commented that the interventions “probably helped get our vaccination rate up. But there are lots of things going on simultaneously. There was a lot of community push in San Antonio, obviously like everywhere else. It is difficult to know exactly what intervention pushed the needle, but it did get better.”
DISCLOSURE: Dr. Lathrop has served as a consultant for GE Health, Pfizer, and Encore Educational Services; has served on a speakers bureau for Biotheranostics; and has received educational grants from Pfizer. Ms. Prieto reported no conflicts of interest.
REFERENCES
1. Lathrop KI, Prieto E, Viveros S, et al: Declining the COVID-19 vaccination: An evaluation of why some high-risk cancer patients decline vaccination. 2021 San Antonio Breast Cancer Symposium. Poster. Presented December 7, 2021.
2. Addeo A, Shah PK, Bordry N, et al: Immunogenicity of SARS-CoV-2 messenger RNA vaccines in patients with cancer. Cancer Cell 39:1091-1098, 2021.
