NCCN Recommends Fifth COVID-19 Shot for Patients with Cancer

Lindsey R. Baden, MD

The National Comprehensive Cancer Network (NCCN) is advising individuals who are immunocompromised, including those with cancer, to receive a fifth COVID-19 vaccination. The NCCN Advisory Committee on COVID-19 Vaccination and Pre-exposure Prophylaxis recommends mRNA vaccines for the primary 3-shot series and 2 subsequent booster shots.¹

In terms of the timeline for administration, the committee recommends that patients with weakened immune systems get a third vaccine dose administered approximately 4 weeks after getting the second dose of primary vaccine to complete their initial series. After approximately 3 months, individuals should receive a booster shot.

Patients who do not have weakened immune systems should get a booster at least 5 months after receiving their first 2 shots of the BNT162b2 (Pfizer/BioNTech) or mRNA1273 (Moderna) vaccines, or 2 months after receiving the Ad26.COV2.S (Janssen/Johnson & Johnson) vaccine.

The committee stressed that the third dose for immunocompromised patients is different from the booster dose given to the general public. The third full dose of the mRNA vaccines is 100 μg and 30 μg for the mRNA-1273 and BNT162b2 vaccines, respectively. The dose of the booster vaccine is 50 μg for mRNA-1273 and 30 μg for BNT162b2. Among patients with a history of cancer, those who do not meet the criteria for the third vaccine dose given to immunocompromised patients should be offered a booster similar to the general population at 6 months after completion of their primary vaccine series.

The NCCN notes that patients with cancer are at elevated risk for serious illness, hospitalization and/or death from COVID-19.

“Bottom line, we want to share COVID-19 recommendations that are simple and useful,” committee coleader Lindsey R. Baden, MD, a professor of medicine at Harvard Medical School and an infectious diseases specialist at Brigham and Women’s Hospital and Dana-Farber Cancer Institute, said in a news release.² “We know a lot more about COVID-19 and the vaccines now, and we can use that knowledge to minimize the confusion and enhance the protection we can offer to our immunocompromised patients.”

The NCCN is also urging most patients with cancer, as well as their caregivers and close contacts, to get vaccinated as soon as possible. Those who have received hematopoietic stem cell transplant (HCT) or chimeric antigen receptor (CAR) T-cell therapy should wait at least 3 months before undergoing vaccination. Patients who were previously vaccinated should begin a full vaccination series 3 months following HCT or CAR T-cell therapy.

Patients who have undergone major surgery for solid tumors are advised to wait a few days before vaccination so that physicians can accurately determine if symptoms such as fever are a result of surgery or vaccination. Further, the NCCN recommends delaying vaccination for approximately 2 weeks following complex surgeries such as splenectomy.

Patients receiving intensive cytotoxic therapy should wait until absolute neutrophil count (ANC) recovery. Those who are not expected to achieve ANC recovery and all other patients with hematologic malignancies should be vaccinated as soon as possible.

The NCCN says that mixing and matching of vaccines with boosters is acceptable. 

Preliminary study results suggest that vaccines are not as effective in people cancer compared with the general population, particularly in patients undergoing active treatment. In data from a study published in January 2022, 50% of had no detectable immunity to COVID-19 after receiving the 2-shot vaccination.³ Therefore, the NCCN says that individuals with cancer should continue wearing masks and taking precautions such as social distancing, avoiding crowds, and minimizing travel.⁴

References

1. Recommendations of the National Comprehensive Cancer Network advisory committee on COVID-19 vaccination and pre-exposure prophylaxis. The National Comprehensive Cancer Network. April 27, 2022. Accessed April 28, 2022. bit.ly/3Lrdu3x
2. Updated cuidance for COVID-19 vaccination from NCCN recommends fifth mRNA Shot (second booster dose) for immunocompromised people. News release. The National Comprehensive Cancer Network. April 27, 2022. Accessed April 28, 2022. bit.ly/3kp93dE
3. Shapiro LC, Thakkar A, Campbell ST, et al. Efficacy of booster doses in augmenting waning immune responses to COVID-19 vaccine in patients with cancer. Cancer Cell. 2022;40(1):3-5. doi:10.1016/j.ccell.2021.11.006
4. NCCN COVID-19 vaccination guide for people with cancer. The National Comprehensive Cancer Network. February 24, 2022. Accessed April 28, 2022. bit.ly/3OINEtG