‘We Can Do Better’: COVID-19 Vaccination in Cancer Patients

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Editor’s note: Find the latest COVID-19 news and guidance in Medscape’s Coronavirus Resource Center.

Every day, around 1.5 million doses of the COVID-19 vaccine are being delivered across the United States, but oncologists and patient advocates say that patients with cancer are missing out.

While official bodies recommend that patients with cancer are given priority, only 16 states currently prioritize them in the vaccine roll-out (see Table).

The other 34 states have thus far not singled out patients with cancer for earlier vaccination.

This flies in the face of recommendations from heavy hitters such as the CDC’s Advisory Committee on Immunization Practices (ACIP), the National Comprehensive Cancer Network (NCCN) and the American Association for Cancer Research (AACR).

All are in agreement: Patients on active cancer treatment should be prioritized for available vaccine due to their greater risk of death or complications from SARS-CoV-2 infection.

“All municipalities, states, cities and even individual hospitals have so far been left to their own devices to try to figure out what the best way to do this is and that often conflicts with other recommendations or guidelines,” said E. John Wherry, PhD, chair of the Department of Systems Pharmacology and Translational Therapeutics at the University of Pennsylvania, Philadelphia.

Wherry was on a panel at an AACR conference last week that discussed the failings of vaccine delivery to cancer patients.

During the meeting, lung cancer advocate Jill Feldman commented on the situation in Chicago, one of the jurisdictions that has not prioritized patients with cancer: “People don’t know what to do. ‘Do I need to sign up myself somewhere? Is my doctor’s office going to contact me?’ “

Feldman said many people have called their cancer centers, “but cancer centers aren’t really providing updates directly to us. And they aren’t because they don’t have the information [either].”

Even in the 16 states that have ushered patients with cancer to the front of the line, the process for flagging these individuals is often unclear or nonexistent.

“Everyone that registers is basically on the same playing field…because there’s no verification process. That’s very unfortunate,” said patient advocate Grace Cordovano, PhD, describing the vaccine sign-up process in New Jersey.

“It’s an easy fix,” said Cordovano. “Adding a few more fields [in the form] could really make a difference.”

COVID-19 fatality rates are twice as high in people with cancer than in people without cancer, according to a review published in December by the AACR’s COVID-19 and Cancer Task Force in the journal Cancer Discovery. Hematologic malignancies conferred an especially high risk.

“Any delay in vaccine access will result in loss of life that could be prevented with earlier access to vaccination,” AACR President Antoni Ribas, MD, told Medscape Medical News at the time.

There are also sound epidemiologic reasons to prioritize high-risk cancer patients for the COVID-19 vaccine, immunologist Wherry told Medscape Medical News. “What we do in infectious disease is to think about where your transmission and your risks are highest,” he said, citing cancer treatment centers as examples.

People with hematologic malignancies also tend to be long-term viral shedders, he said, putting caregivers and healthcare staff at increased risk. “There’s a big, big impact [in vaccinating cancer patients] and the numbers are not small”, Wherry explained.

The CDC’s January 1 recommendation is that patients with cancer should be assigned to priority group 1c, along with other “persons aged 16-64 with other high-risk medical conditions.”

However, more recent guidance from the NCCN hastened the urgency, advising that “patients with cancer should be assigned to the [CDC] priority group 1b/c.”

Out of 16 states that currently prioritize patients with cancer, three states have exceeded official advice, placing patients with cancer in priority group 1a. They opened their first batches of vaccine to everyone “deemed extremely vulnerable to COVID-19 by hospital providers” (Florida), or to “16-64 years old with a chronic health condition” (Mississippi) and to “persons aged 16-64 with high-risk conditions” (Pennsylvania, some jurisdictions).

However, despite these heroic intentions, no jurisdiction appears to have specifically tackled the thorny issue of subgroups of cancer that are more urgent than others, and this worries oncologists.  

“Not all cancer patients are the same,” said Marina Garassino, MD, a medical oncologist at the National Tumor Institute of Milan, Italy. She shared registry data with the AACR panelists indicating that COVID-19 mortality in thoracic and hematologic malignancies rises to 30%-40% compared with 13% for cancer overall.

At the AACR meeting, discussion moderator Ribas summed up his feelings on the issue: “It’s clear to me that patients with cancer should be prioritized. We have to then start defining this population and it should be the patient with an active cancer diagnosis undergoing treatment, in particular patients with lung cancers or hematological malignancies.”

Since patients with cancer as a whole have problems getting timely vaccination — let alone someone with lung cancer or leukemia — the AACR meeting panelists grappled with solutions.

Cordovano said it was a “no brainer” to start with cancer centers. “Patients there are already registered, they have an account in the electronic health record system, they have insurance information, the care team knows them,”  she said in an interview with Medscape Medical News.

Vaccination referrals sent directly from oncology centers would eliminate the need for the patient to provide verification or any additional documentation, she pointed out.

However, in New Jersey, cancer centers “have been completely excluded from the process,” she said.  

Florida and New Hampshire have somewhat adopted the mechanism suggested by Cordovano. These states require healthcare providers to verify that a patient is “especially vulnerable” (Florida) or “medically vulnerable” (New Hampshire) in order for the patient to receive priority vaccine access (see Table). In New Hampshire, patients must have at least one other medical condition in addition to cancer to get on the list.

Jia Luo, MD, a medical oncology fellow at Memorial Sloan Kettering Cancer Center in New York City, told the meeting that MSKCC has set up a proactive task force that sends “daily emails” to clinic staff highlighting patients eligible for the vaccine. “My sense is, it’s being prioritized to active cancer treatment,” said Luo. “All of our physicians are currently discussing [it] at each appointment and…all of our nurses and staff have been talking to our patients on the phone.”

Cordovano, while advocating hard for cancer patients today, retained optimism about tomorrow: “This isn’t a long-term thing. This is just until things catch up. We knew we were going to have this problem.” Her hope is that, within 6 months, COVID-19 vaccination will become a standard of care in cancer.

Wherry agreed: “It’s going to take time to catch up with how far behind we are on certain things…What we’re seeing is a healthy debate rather than something that we should be concerned about — as long as that debate leads to rapid action.”

“We have to follow the science,” concluded Cordovano. “We can do better than this.”

Table. States currently prioritizing patients with cancer for COVID-19 vaccination
States prioritizing patients with cancer Earliest eligibility Definition Restrictions/caveats
Florida Currently eligible “Persons deemed extremely vulnerable to COVID-19 by hospital providers” Only available through hospitals/healthcare providers
Maryland* Phase 1c (current) “Cancer patients who are currently in active treatment” Must be receiving active, hospital-based treatment (including outpatient)
Mississippi Currently eligible “16-64 years old with a chronic health condition” **  
Missouri Phase 1b (current)  ”Any adults with cancer”  
Montana Phase 1b (current) “Persons aged 16-69 with high-risk medical conditions” **  
Nebraska Phase 1b (current)  A “high-risk medical condition” ** “Current” cancer only; aged 18+
New Hampshire Phase 1b (current) Aged under 65 and “medically vulnerable” with two or more conditions ** Healthcare providers must register and verify “medically vulnerable” patients
New Jersey Phase 1b (current) “Individuals at high risk” aged 16-64 with medical condition on CDC list **  
New Mexico Phase 1b (current) “16 years or older with underlying medical conditions that place them at greater risk” **  
North Dakota* Phase 1b “Individuals 65-74 with two or more high-risk medical conditions” **  
Oregon When Phases 1a and 1b complete  ”People of all ages with underlying conditions that put them at moderately higher risk”  
Pennsylvania* Phase 1a (current) “Persons aged 16-64 with high-risk conditions”  
South Dakota Phase 1d (current) “Current cancer patients”  
Texas Phase 1b (current)  ”Persons aged 16+ with at least one chronic medical condition” **  
Virginia Phase 1b (current) “Persons aged 16-64 with an underlying medical condition” **  
Wyoming* Phase 1b (current) “Persons aged 16-64 with an underlying medical condition” **  

*May vary by local jurisdiction **Cancer listed as an eligible condition
Sources: List of states prioritizing high-risk adults as of February 8, 2021 from   The New York Times . All other data Medscape Medical News.

Cordovano, Feldman, and Wherry have disclosed no relevant financial relationships. Luo declared a financial relationship with Targeted Oncology. Ribas declared financial relationships with Amgen, 4C Biomed, Advaxis, Agilent, AstraZeneca, Arcus, Kite-Gilead, and Bristol-Myers Squibb.

American Association for Cancer Research (AACR) Virtual Meeting: COVID-19 and Cancer. February 3-5, 2021

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