Steven Pergam, MD, MPH, director of infection prevention at Seattle Cancer Care Alliance and infectious disease physician at Fred Hutchinson Cancer Research Center, describes the shifts in COVID-19 recommendations for patients with cancer and those receiving CAR T-cell therapy.
Steven Pergam, MD, MPH, director of infection prevention at Seattle Cancer Care Alliance and infectious disease physician at Fred Hutchinson Cancer Research Center, describes the evolution in COVID-19 recommendations for patients with cancer and those receiving CAR T-cell therapy. The National Comprehensive Cancer Network (NCCN) updated its recommendations for COVID-19 vaccines and prevention for patients with cancer.
In Seattle, you’ve seen the trajectory of COVID-19 and cancer from the very start of the pandemic. Have any major recommendations evolved or shifted since the beginning?
Being on the forefront of this was kind of challenging at the beginning. I think what you've seen is you've seen people really work together to try to protect patients as best as possible. We've gone from little masking in the community to masking in the community and masking in health care institutions. We've seen a shift from having no therapies available to now therapies being available. We've had a shift from no vaccines to vaccines. I think the biggest shift right now is just the number of people that are getting infected; Omicron’s ability to transmit is quite a big shift.
Despite being early engaged in this, I think we didn't have the number of patients that we're seeing that are coming up positive as we are now just because it's so much more prevalent. We are in a different situation, though, because we do have some treatments available and we have people that are vaccinated. So I think, in general, patients are a little more protected than they were during the initial phase. I think people are also being more cautious. I think they've learned a lot through the process and patients know to wear masks in public; they're more cautious when they go out in group activities. I think our cancer patients are more aware, as are our providers about providing that advice.
Just before the Pfizer vaccine received its EUA [Emergency Use Authorization], Dr Anthony Fauci recommended at the ASH meeting that patients with blood cancers get vaccinated, because even if the vaccine was not fully effective, some protection was better than none. Is that advice still basically true?
Understanding exactly how vaccines work in an immunosuppressed population, cancer patients being one of those, is still really complex. We know that we use antibody levels and antibody responses to vaccine as a surrogate marker for protection. But there are other aspects of the immune system that are harder to assess—things like T-cell immunity—that also probably play important roles, so even people that don't have fully antibody responses may have some level of protection. Really what you want with these vaccines is, I try to explain to patients, you don't want to meet COVID on the street unless you've been vaccinated first. Because that's going to give you some protection. Even if it's a small percent—if it's 10% that it gives you protection—it's better than going into that meeting unprotected at all. So, vaccines are important. And I think what's shifted is now we're doing more aggressive vaccines. Instead of doing 2 doses, we're doing 3 doses as the primary with a boost about 6 months later. I think that boost is important and can provide additional protection as well. Immunosuppressed patients have a lot of opportunities to get additional benefits from vaccines. They're not perfect, and you still need to think about other things that you can do to protect yourself, but I absolutely agree that vaccine remains the most important prevention method we have as a primary and then those others are just as critical—the masking, social distancing, etc.
Can you discuss the NCCN recommendations for patients receiving CAR T-cell therapy?
People who are getting CAR T-cell therapy or BMT therapy, even if they've been previously vaccinated with a full series, you're sort of replacing or really updating their immune system and they need to be revaccinated post. Because, with an allogeneic transplant, you're providing a whole new immune system, and a lot of those memory cells are gone so you need to re-educate the system against that. Similar with CAR T-cells, we're revaccinating all those patients post those events because of the way the therapy affects the immune system in general. So that has been a big update, I think, in this time frame. Then we're waiting typically about 3 months post therapy, because we want that cellular recovery to be back and then vaccinate them at that time.