Patients with cancer are at high risk of COVID-19-associated complications and, accordingly, the preliminary recommendations issued by the National Comprehensive Cancer Network (NCCN) COVID-19 Vaccination Advisory Committee state that all cancer patients should be prioritized for COVID-19 vaccination, and caregivers and household/close contacts should also be considered for early immunization.¹

Due to limited prospective data on vaccination in patients with active malignancies, the preliminary recommendations summarized here are based on expert opinion from the NCCN COVID-19 Vaccination Advisory Committee. The guidance will be updated regularly when new data becomes available.

Key points

Local guidelines should be used to decide when to vaccinate cancer patients, alongside guidelines laid out by the US National Academies of Sciences, Engineering, and Medicine (NASEM) Framework for Equitable Allocation of COVID-19 Vaccine. The key principles are as follows:

Cancer patients are at high risk of COVID-19 complications and therefore treatment centers should take measures to control the spread of infection
The vaccination process should be simple and rapid
Equity of vaccine distribution should be ensured, inclusive of socially underrepresented groups such as patients with disabilities, ethnic minorities, and non-English-speaking patients
Carers and close contacts should be considered for early vaccination as they can be a potential source of transmission
There are no known safety concerns linked to COVID-19 vaccines in patients being treated for cancer

Vaccine timing

Recommendations for vaccination timing for patients with hematologic malignancies according to treatment type are laid out in Table 1.

Table 1. A summary of the recommendations for vaccine timing for patients with hematologic malignancies, including those receiving cellular therapies¹

Treatment type	Timing*
Allo-HCT	At least 3 months post-HCT/cellular therapy**
Auto-HCT
Cellular therapy
Intensive cytotoxic chemotherapy	Delay until absolute neutrophil count recovery
Marrow failure from disease and/or therapy expected to have limited or no recovery	When vaccine available
Long-term maintenance therapy	When vaccine available
allo-HCT, allogeneic hematopoietic cell transplantation; auto-HCT, autologous hematopoietic cell transplantation. Due to the lack of data on dual vaccination, COVID-19 vaccines should be prioritized over other needed vaccines, with a 14-day delay between vaccines. Graft-versus*-host disease (GvHD) and immunosuppressive GvHD treatment regimens could hinder the COVID-19 vaccine response. Therefore, vaccine administration should be delayed until there is evidence of T-cell and B-cell immunity from immune phenotyping and/or there is a reduction in immunosuppressive therapy.

Priority criteria

In the case of limited availability of COVID-19 vaccines, prioritization among cancer patients should be evidence- and values-based. The following criteria may help with the development of local guidance on vaccine prioritization:

All cancer patients undergoing active treatment, scheduled to start treatment, and <6 months posttreatment should be given priority (excluding those receiving only hormonal therapy)
Additional risk factors for COVID-19 complications that should be considered for patient prioritization include:
1. Advanced age, i.e., ≥65 years
2. Comorbidities, such as chronic pulmonary, cardiovascular, or renal disease
3. Social and demographic factors, such as poverty, limited access to healthcare, and underrepresented ethnic groups

Efficacy and safety

Current vaccines are considered safe and effective in the general population. However, due to the lack of data for immunocompromised patients, cancer patients should be made aware of the importance of following current prevention guidance, postvaccination.

Summary

This article summarizes the guidance for COVID-19 vaccination for patients with cancer, including those with hematologic malignancies. Patients with cancer should be prioritized for vaccination, and those of older age, with underlying health conditions, and undergoing treatment should be given further priority. Vaccine timing should be considered in the context of treatment regime. Due to limited postvaccination information, cancer patients and their close contacts should continue to follow the recommendations for COVID-19 prevention, even after receiving the vaccine.

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