Updated ASCO Guideline Issues Vaccine Recommendations in Cancer Populations

“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,” according to guideline cochair and author Elise C. Kohn, MD.

Optimizing vaccination status should be considered a key element in achieving early vaccination of patients with cancer, according to an updated guideline published by the American Society Clinical of Oncology (ASCO) in the Journal of Clinical Oncology.¹

Authors of an updated clinical practice guideline sought to answer 4 overarching questions associated with the use of vaccines among a target population of adult patients with solid tumors or hematologic malignancies receiving treatment with stem cell transplantation, CAR T-cell therapy, and B-cell–depleting therapies, as well as long-term cancer survivors. These questions included:

• What are the recommended routine preventative vaccinations for adults with cancer?
• What additional vaccinations and revaccinations are recommended for adults undergoing hematopoietic stem cell transplantation (HSCT), CAR T-cell therapy, or B-cell–depleting therapy?
• What additional vaccinations are recommended for adults with cancer who are traveling outside the United States?
• What are vaccination recommendations for household and close contacts of adults with cancer?

Authors answered these questions by conducting a systemic literature review of 102 systemic publications—including 24 systemic reviews, 14 randomized clinical trials, and 64 nonrandomized studies—that evaluated the safety and efficacy of vaccines in adult patients with cancer or their household contacts. Most publications addressed the use of COVID-19 vaccines.

“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,” guideline cochair and author Elise C. Kohn, MD, of the Cancer Therapy Evaluation Program at the National Cancer Institute, said in a press release on the publication of the updated guideline.² “These vaccinations have very limited if no potential harm, but the potential benefits are significant.”

Preventative Vaccination

The guideline authors issued a strong recommendation that clinicians should determine vaccination status and ensure that adult patients with newly diagnosed cancer should be up to date on seasonal vaccines and age- and risk-based vaccines based on moderate evidence. Additionally, the guideline contains a strong recommendation for vaccination before any planned cancer treatment by 2 to 4 weeks based on moderate evidence.

Specifically, authors highlighted serologic responses to COVID-19 vaccines in patients with cancer. In one study assessing 1610 patients with cancer and a positive COVID-19 test result, vaccinated patients had a significantly lower probability of undergoing hospitalization for COVID-19 or death within 30 days compared with those who did not receive a vaccination (odds ratio [OR], 0.44; 95% CI, 0.28-0.77).³

Regarding the use of influenza vaccines, one pilot randomized clinical trial assessed the use of a high-dose trivalent influenza vaccine compared with a standard-dose vaccine among 100 adult patients under 65 years old with cancer who received chemotherapy.⁴ Findings highlighted that local site pain was more common and that seroconversion rates were higher in the high-dose group.

COVID-19 vaccination is recommended for patients of any age based on the latest Centers for Disease Control and Prevention (CDC) schedule for individuals who are immunocompromised. Additionally, the guideline recommends annual influenza vaccines for patients of all ages. Other recommended immunizations include recombinant zoster vaccines for patients 19 years and older at 2 doses at least 4 weeks apart as well as pneumococcal vaccines for those 19 years and older with one dose of pneumococcal conjugate vaccine (PCV)–15 followed by 23 valent Pneumococcal polysaccharide vaccine (PPSV23) 8 weeks later or one dose of PCV20.

Additional Vaccination

The guideline authors issued strong recommendations backed by moderate evidence for revaccination of patients who receive HSCT, those who receive B-cell–depleting therapies, and long-term survivors of hematologic malignancies. However, a weak recommendation was issued for revaccinating patients who receive CAR T-cell therapy based on very low–quality evidence.

Regarding recipients of HSCT, primary mRNA vaccines appeared to yield immune responses, although overall humoral responses were less frequent compared with those observed in other groups. Findings from a multicenter prospective study of allo-HSCT supported the use of COVID-19 vaccines before 4 months and showed similar humoral and cellular responses for those starting vaccination between 4 and 12 months.⁵

Those who were receiving B-cell–depleting therapies tended to have worse outcomes related to COVID-19 and ineffective humoral responses to COVID-19 vaccines in the first 6 to 12 months following treatment, although a substantial portion of patients had cellular immune responses. Based on available data, authors recommended that COVID-19 revaccination may be considered at 6 to 12 months after patients complete B-cell–depleting therapy.

Vaccination for Travelling Populations

Based on moderate evidence, the guideline authors issued a strong recommendation that adult patients with solid and hematologic malignancies should follow CDC standard recommendations when travelling to an area of risk.

A guideline from the Infectious Disease Society of America (IDSA) published in 2013 stated that adults and children who are immunosuppressed may be eligible to receive nonlive vaccines while travelling outside of the United States; it was generally not recommended to administer live vaccines to immunosuppressed populations.⁶ Literature review for the updated guideline did not identify any new publications that would modify the recommendations. According to findings from the 2024 CDC Yellow Book: Health Information for International Travel, patients who receive HSCT should ideally delay travel for at least 2 years after this treatment and undergo complete revaccination.⁷

Household and Close Contacts

The authors strongly recommended that all household members and close contact individuals of adults with cancer should stay up to date on vaccinations based on moderate evidence.

Individuals who are immunocompetent and live in a household with those who are immunocompromised can safely receive all recommended live and nonlive vaccines based on the 2013 IDSA guideline, although oral polio vaccines for household contacts of patients who are immunocompromised are not recommended.⁶ Additionally, household contacts of patients with graft-versus-host disease or those who have recently undergone HSCT are recommended not to receive live-attenuated influenza vaccines.

References

1. Kamboj M, Bohlke K, Baptiste DM, et al. Vaccination of adults with cancer: ASCO guideline. J Clin Oncol. Published online March 18, 2024. doi:10.1200/JCO.24.00032.
2. New ASCO guideline recommendations answer key questions about vaccinating adults with cancer. News release. ASCO in Action. March 26, 2024. Accessed March 27, 2024. https://tinyurl.com/hvwp76j5
3. Best AF, Bowman M, Li J, et al: COVID-19 severity by vaccination status in the NCI COVID-19 and cancer patients study (NCCAPS). J Natl Cancer Inst. 2023;115(5):597-600. doi:10.1093/jnci/djad015.
4. Jamshed S, Walsh EE, Dimitroff LJ, Santelli JS, Falsey AR. Improved immunogenicity of high-dose influenza vaccine compared to standard-dose influenza vaccine in adult oncology patients younger than 65 years receiving chemotherapy: a pilot randomized clinical trial. Vaccine. 2016;34(5):630-635. doi:10.1016/j.vaccine.2015.12.037
5. Hill JA, Martens MJ, Young JH, et al: SARS-CoV-2 vaccination in the first year after allogeneic hematopoietic cell transplant: A prospective, multicentre, observational study. EClinicalMedicine. 2023;59:101983. doi:10.1016/j.eclinm.2023.101983.
6. Rubin LG, Levin MJ, Ljungman P, et al: 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin Infect Dis. 2014;58(3):309-318. doi:10.1093/cid/cit816.
7. CDC Yellow Book 2024: Health Information for International Travel. Centers for Disease Control and Prevention. 2023. New York, NY, Oxford University Press.