Vaccination Guidelines for Cancer Patients

Introduction to Vaccination Recommendations

The National Comprehensive Cancer Network strongly recommends COVID-19 vaccination for all persons with cancer or who have been previously treated for cancer, and annual influenza vaccination is recommended for all patients with hematologic or solid tumor malignancies 1
The Centers for Disease Control and Prevention (CDC) recommends COVID-19 vaccination for all individuals aged 6 months and older, with particular emphasis on high-risk populations, including older adults, immunocompromised individuals, pregnant women, and those with underlying health conditions 2

There are no absolute contraindications to COVID-19 vaccines in cancer patients undergoing immunotherapy, including checkpoint inhibitors like pembrolizumab 3
Inactivated influenza vaccines are safe for patients on immunotherapy 1, 4
Vaccination helps prevent pulmonary comorbidities during respiratory virus seasons, and the T-cell response induced by vaccines remains strong enough to recommend vaccination in these patients 3, 4
The American College of Cardiology demonstrates that COVID-19 mRNA vaccines have a favorable benefit-to-risk ratio for all age and sex groups, with benefits substantially outweighing risks even in populations at highest risk for adverse events such as myocarditis 5

If starting a new course of pembrolizumab, ideally administer vaccines at least 2 weeks before initiating therapy, and for patients already on pembrolizumab, vaccines can be administered at any time during treatment 1, 3
Optimal timing for maximum efficacy is 2-4 weeks prior to initiating cancer treatment when feasible, with vaccination between chemotherapy cycles for patients already on treatment, and delayed vaccination for at least 3 months after treatment completion for patients on lymphocyte-depleting therapies, as recommended by the NCCN 6, 7, 3

Pregnant women, especially those over 35 years, with comorbidities, and of Black, Asian, or Hispanic ethnicity, are at higher risk of severe COVID-19 and should be vaccinated 8
Individuals with certain comorbidities, such as cardiovascular disorders, diabetes mellitus, obesity, and autoimmune disorders, are at increased risk of severe COVID-19 and should be vaccinated 3
Older adults (≥65 years) are considered a high-priority group due to increased risk of severe outcomes, and specific high-dose or adjuvanted formulations may be preferred for this age group 9
Immunocompromised individuals, including solid organ transplant recipients, patients on immunosuppressive medications, cancer patients, and those with HIV infection, are at higher risk of severe COVID-19 outcomes and should be vaccinated 2, 9, 3
Booster doses are recommended for high-risk populations, such as older adults and those with underlying health conditions, to maintain protection against severe COVID-19, according to the CDC and the Advisory Committee on Immunization Practices (ACIP) 10, 11

The most significant rare adverse event is myocarditis/pericarditis, particularly in young males, with approximately 39-47 cases expected per million doses of mRNA vaccine in males aged 12-29 years receiving a second dose 5
Most cases of vaccine-associated myocarditis are mild and self-limiting, with no associated thrombotic events, thrombocytopenia, or disseminated intravascular coagulation 5
Benefit-risk assessment strongly favors vaccination, with the risk of myocarditis being outweighed by the prevention of hospitalizations, ICU admissions, and deaths, as reported by the Journal of the American College of Cardiology, which is affiliated with the American College of Cardiology (ACC) 5
For every 1 million males aged 12-29 years receiving a second dose of mRNA vaccine, the risks include 39-47 cases of myocarditis, while the benefits include prevention of 560 hospitalizations, 138 ICU admissions, and 6 deaths 5

Household members and close contacts should also be vaccinated to create a "cocooning effect" to protect the cancer patient 12
Patients should continue preventive measures such as hand hygiene, masking in high-risk settings, and social distancing 3
Healthcare providers should engage patients in discussions about vaccination status and shared decision-making, and advise patients to seek medical attention if they experience symptoms of rare complications such as myocarditis (chest pain, shortness of breath, palpitations) 5, 12