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COVID vaccination for immunocompromised cancer patients


Eva Segelov


19/01/2022 5:48:54 PM

Oncologist Professor Eva Segelov details important clinical information specific to this vulnerable cohort.

Cancer patient receiving COVID vaccine.
ATAGI has recommended a third primary dose for adults and children aged five years and older who are severely immunocompromised.

Information current as of 19 January 2022.
 
The concept of impaired response to COVID-19 vaccines for people with immunosuppression due to cancer is well recognised.
 
This group is heterogenous, with varying immunosuppressive states and treatments. Much more nuanced data on humoral (antibody) and T-cell responses that are likely to be important for long-term immunity against SARS-CoV-2 are emerging through studies, including the large Australian study SerOzNET, supported by Cancer Australia.
 
In no other disease in our lifetimes has so much data emerged and been updated so quickly. For both patients and health professionals, Cancer Australia’s Frequently Asked Questions about COVID-19 vaccines for people affected by cancer has been a reliable and regularly updated source of information, including primary source references.
 
Quick facts about COVID-19 vaccination and cancer patients
Patients with cancer increasingly have an excellent prognosis for cure or long-term control of their disease, with many new therapies available.
 
Protection from COVID-19 and the ability to participate in societal activities means vaccination is an important strategy for this group. If in doubt, check the prognosis of individual patients with their treating team, as many outcomes from COVID-19 infection, particularly severe outcomes, are worse for cancer patients, even after vaccination.
 
Patients with suppressed immunity may also experience more persistent COVID-19 infection and viral shedding. Data suggests this predisposes them to accelerated viral evolution or increased risk of developing new SARS-CoV-2 variants.
 
Patients with cancer, particularly patients on chemotherapy, those with blood cancers or following transplant or specialised T-cell therapies (such as CAR-T therapy), are documented to have a poorer antibody and/or T-cell response to COVID-19 vaccines, and protection appears to wane earlier.
 
Patients on immune checkpoint therapy (now commonly used to treat melanoma, lung cancer and many other cancers) also appear to have altered response to vaccination.
 
It is important to remember that even after two doses of COVID-19 vaccination, patients on chemotherapy and with other causes of immunosuppression still remain at higher risk of hospitalisation and death from COVID-19. The Australian Technical Advisory Group on Immunisation (ATAGI) has therefore recommended a third primary dose for adults and children aged five years and older who are severely immunocompromised as part of their primary COVID-19 vaccination regimen.
 
ATAGI and other bodies have used the term ‘severely immunocompromised’, while guidelines issued by the US Centers for Disease Control (CDC) refer to patients with moderate and severe immunocompromise.
 
There are no standard definitions with respect to the use of the term ‘severely immunocompromised’ in the context of COVID-19. The ATAGI document lists various conditions and also allows physician discretion for those who may not fit the criteria. For cancer patients, the criteria include the following:

  • People with active haematological cancer
  • People with non-haematological cancers, on current active treatment including chemotherapy, radiotherapy, and/or targeted therapies anticipated to reduce the immune response to COVID-19 vaccine, but not including people treated only with immunotherapy with immune checkpoint inhibitors
  • People who have had a solid organ transplant with immunosuppressive therapy
  • People who have had a stem cell transplant or chimeric antigen receptor T-cell (CAR-T) therapy, within two years of transplantation
The current advice is that immunocompromised people will require three priming doses, with the third dose timed 2–6 months after the second dose; in the SerOzNET study we are organising it at two months if possible.
 
Immunocompromised people aged 18 years or older who have received a three-dose primary course are now recommended to have a booster (fourth) dose at four months after their third dose. This is expected to improve protection against symptomatic infection and serious illness from COVID-19 caused by the Omicron variant.
 
This is compared with the vaccination schedule for the general population, with a two-dose priming schedule followed by a booster four months after their second dose. ATAGI recommends providing boosters to all eligible adults from three months after the second dose as soon as practical.
 
In the US, people who are severely immunocompromised represent less than 3% of the adult population but constituted up to 44% of breakthrough infections admitted to ICU, even after double dose vaccination.
 
Fortunately, there are no additional safety signals seen with COVID-19 vaccination for cancer patients or patients who are immunosuppressed.
 
However, despite being allocated to a priority group for vaccination in the Australian vaccine rollout, some patients with cancer and likely immunosuppression remain unvaccinated, due to concerns from patients and some clinicians about how the vaccine may interact with their illness or its treatment.
 
Detailed guidelines for clinicians and information for patients with various immunosuppressive states have been developed by specialised societies for solid tumour, transplant and cellular therapies and haematology patients.
 
The SerOzNET study
This is a prospective Australian multicentre trial of vaccine response in patients with various malignancies.
 
Differences from international studies include the very low proportion of patients who have had COVID-19 infection, the collection of blood and data prior to the first vaccine dose, and the collection of data on quality of life, impact on cancer care, and patient- as well as physician-reported toxicity.
 
The SerOzNET study is currently recruiting adults and children with cancer aged five years and older. To date, more than 430 patients have been enrolled.
 
Rapid protocol adjustment has recently been made to accommodate measuring response to the third priming dose, as well as to allow children aged 5–11 to join once vaccination was approved for this age group.
 
This valuable cohort with highly annotated clinical data and linked biospecimens will inform our understanding about the safety and efficacy of the COVID-19 vaccines for patients with cancer in Australia. 
 
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Dr Christopher Charles Newall   20/01/2022 11:04:52 AM

Will the advised gap between 3rd dose and booster of 4 months for pts on chemo etc change after 31st Jan 2022 when the general population will be advised to have a booster after 3 months?


Dr Christopher Charles Newall   21/01/2022 9:13:38 AM

Will the advised gap between 3rd dose and booster of 4 months for pts on chemo etc change after 31st Jan 2022 when the general population will be advised to have a booster after 3 months?