A new ASCO Clinical Practice Guideline recommends several vaccinations (eg, seasonal, herpes zoster, human papillomavirus [HPV], and others) for adults with solid or hematologic malignancies because of heightened infection risks from vaccine-preventable illnesses.1 The guideline covers the essential questions of which vaccines to give, to whom, when, and which ones to avoid because of potential risks.
“We want to document vaccination status at the first patient visit and provide recommended vaccines that might be needed as quickly as possible within the parameters of optimal oncology care … recognizing that we do not want to impede or impinge upon care,” said Guideline Co-Chair Elise C. Kohn, MD, of the Cancer Therapy Evaluation Program at the National Cancer Institute. “These vaccinations have very limited if no potential harm, but the potential benefits are significant.”
Guideline Recommendations
• Types of Vaccines Patients With Cancer Should Receive: Guideline Co-Chair Mini Kamboj, MD, of Memorial Sloan Kettering Cancer Center, noted the questions addressed in the guideline are those “that providers will perhaps find most useful in the day-to-day assessment and evaluation of vaccine eligibility for their patients.” Vaccines discussed in the guideline are seasonal vaccines such as influenza, COVID-19 infection, and respiratory syncytial virus, as well as vaccines against pneumococcal infection, herpes zoster, hepatitis B, tetanus-diphtheria-pertussis, and HPV infection.
Specifically regarding COVID-19 vaccination, Dr. Kamboj advised patients to continue to receive the most current COVID-19 vaccines per the most recent Centers for Disease Control and Prevention guidance.2 On the topic of live vaccines, the guideline notes they can provide heightened risk and should be avoided, if possible, in people with cancer.
• Vaccination in Patients Who Receive Allogeneic or Autologous Hematopoietic Stem Cell Transplants: The guideline also addresses vaccines for patients who have received allogeneic or autologous hematopoietic stem cell transplants, since transplant recipients gradually lose immunity to previous immunizations. Per the new guideline, revaccination should occur in the first year after transplantation, depending on the type of transplant, and some vaccines can be given as early as 3 months; however, others such as the live virus vaccines—if needed—are given much later once a patient’s immune system has reconstituted.
• Travel-Related Vaccines: Another key topic the guideline covers centers on travel-related vaccines. This includes counseling patients about the safety of travel, destination-specific immunization requirements, and risks associated with live travel vaccines.
• Caregiver Guidance: An additional important topic featured in the guideline is vaccination of household members, close contacts, or primary caregivers of the patient and the safety of using the commonly recommended live virus vaccine: measles, mumps, and rubella vaccine; varicella vaccine; and the live attenuated influenza vaccine. Experience shows that these vaccines are safe for household contacts and do not pose a significant transmission risk.
“In fact, keeping the family members protected to prevent the introduction of contagious illnesses within the household, I think, is very important,” Dr. Kamboj said. The one exception is that close contacts of patients who have received stem cell transplants should receive nonlive or inactivated flu vaccine rather than the live attenuated influenza vaccine, which is given as a nasal spray. The high-dose flu vaccine is normally for people aged 65 and older.
“Studies show that a high-dose vaccine produces better immune response in transplant recipients, which means better protection. We are now recommending the high-dose influenza vaccine in adult transplant patients regardless of age,” Dr. Kamboj said. “[However,] for adults with cancer who have not undergone transplant, we still ask them to follow the age-based criteria.” She said the recommendations overall apply exclusively to adults aged 19 and older.
• Additional Recommendations: Vaccination recommendations for patients receiving chimeric antigen receptor (CAR) T-cell treatments or B-cell–depleting therapies are separately outlined in the guideline. The new recommendations also address the needs of long-term cancer survivors.
It is important that any vaccinations for patients with cancer are coordinated with the entire care team. “We want this to be a collaborative optimization of care for our patients,” with interaction and coordination among health-care providers, including oncologists, primary care practitioners, pharmacists, and nursing team members, Dr. Kohn noted. “Now that some vaccinations can be received at the local pharmacy, the weight of communication about receipt of those vaccines falls on the patients’ shoulders to make sure [they] communicate that with their primary care physician and oncologist,” she said. If patients use a retail pharmacy, written instructions from the oncologist are advisable based on the new guidance.
Vaccination Trials Needed
Although the new guideline recommendations are based on an analysis of 102 publications derived from a systematic literature review, there is a paucity of evidence specifically involving patients with cancer for some vaccines (eg, COVID-19). Therefore, those recommendations are based on good medical care consensus.
Dr. Kohn said the guideline therefore addresses the need for vaccination trials in patients with cancer and, specifically, in different areas of need, such as transplantation, CAR T-cell therapy, and B-cell–depleting therapies.
REFERENCES
1. Kamboj M, et al: Vaccination of adults with cancer: ASCO guideline. J Clin Oncol. March 18, 2024 (early release online).
2. Centers for Disease Control and Prevention: COVID-19: How to protect yourself and others. Updated April 4, 2024. Available at www.cdc.gov. Accessed April 22, 2024.
Originally published in ASCO Daily News. © American Society of Clinical Oncology. ASCO Daily News, March 19, 2024. All rights reserved.
