Every day, around 1.5 million doses of the COVID-19 vaccine are being delivered across the United States, but oncologists and patient advocates say that patients with cancer are missing out.
While official bodies recommend that patients with cancer are given priority, only 16 states currently prioritize them in the vaccine rollout. The other 34 states have thus far not singled out patients with cancer for earlier vaccination.
This flies in the face of recommendations from heavy hitters such as the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices, the National Comprehensive Cancer Network, and the American Association for Cancer Research.
All are in agreement: Patients on active cancer treatment should be prioritized for available vaccine because of their greater risk of death or complications from SARS-CoV-2 infection.
“All municipalities, states, cities, and even individual hospitals have so far been left to their own devices to try to figure out what the best way to do this is and that often conflicts with other recommendations or guidelines,” said E. John Wherry, PhD, chair of the department of systems pharmacology and translational therapeutics at the University of Pennsylvania, Philadelphia.
Dr. Wherry was on a panel at an AACR conference last week that discussed the failings of vaccine delivery to cancer patients.
During the meeting, lung cancer advocate Jill Feldman commented on the situation in Chicago, one of the jurisdictions that has not prioritized patients with cancer: “People don’t know what to do. ‘Do I need to sign up myself somewhere? Is my doctor’s office going to contact me?’ ”
Ms. Feldman said many people have called their cancer centers, “but cancer centers aren’t really providing updates directly to us. And they aren’t because they don’t have the information [either].”
Even in the 16 states that have ushered patients with cancer to the front of the line, the process for flagging these individuals is often unclear or nonexistent.
“Everyone that registers is basically on the same playing field ... because there’s no verification process. That’s very unfortunate,” said patient advocate Grace Cordovano, PhD, describing the vaccine sign-up process in New Jersey.
“It’s an easy fix,” said Dr. Cordovano. “Adding a few more fields [in the form] could really make a difference.”
COVID-19 fatality rates are twice as high in people with cancer than in people without cancer, according to a review published in December 2020 by the AACR’s COVID-19 and Cancer Task Force in the journal Cancer Discovery. Hematologic malignancies conferred an especially high risk.
“Any delay in vaccine access will result in loss of life that could be prevented with earlier access to vaccination,” AACR President Antoni Ribas, MD, told this news organization at the time.
There are also sound epidemiologic reasons to prioritize high-risk cancer patients for the COVID-19 vaccine, Dr. Wherry said in an interview. “What we do in infectious disease is to think about where your transmission and your risks are highest,” he said, citing cancer treatment centers as examples.
People with hematologic malignancies also tend to be long-term viral shedders, he said, putting caregivers and health care staff at increased risk. “There’s a big, big impact [in vaccinating cancer patients] and the numbers are not small.”
The CDC’s Jan. 1 recommendation is that patients with cancer should be assigned to priority group 1c, along with other “persons aged 16-64 with other high-risk medical conditions.”
However, more recent guidance from the NCCN hastened the urgency, advising that “patients with cancer should be assigned to the [CDC] priority group 1b/c.”
Out of 16 states that currently prioritize patients with cancer, 3 states have exceeded official advice, placing patients with cancer in priority group 1a. They opened their first batches of vaccine to everyone “deemed extremely vulnerable to COVID-19 by hospital providers” (Florida), or to “16-64 years old with a chronic health condition” (Mississippi) and to “persons aged 16-64 with high-risk conditions” (Pennsylvania, some jurisdictions).
However, despite these heroic intentions, no jurisdiction appears to have specifically tackled the thorny issue of subgroups of cancer that are more urgent than others, and this worries oncologists.
“Not all cancer patients are the same,” said Marina Garassino, MD, a medical oncologist at the National Tumor Institute of Milan. She shared registry data with the AACR panelists indicating that COVID-19 mortality in thoracic and hematologic malignancies rises to 30%-40%, compared with 13% for cancer overall.
At the AACR meeting, Dr. Ribas summed up his feelings on the issue: “It’s clear to me that patients with cancer should be prioritized. We have to then start defining this population and it should be the patient with an active cancer diagnosis undergoing treatment, in particular patients with lung cancers or hematologic malignancies.”
Since patients with cancer as a whole have problems getting timely vaccination – let alone someone with lung cancer or leukemia – the AACR meeting panelists grappled with solutions.
Dr. Cordovano said it was a “no brainer” to start with cancer centers. “Patients there are already registered, they have an account in the electronic health record system, they have insurance information, the care team knows them.”
Vaccination referrals sent directly from oncology centers would eliminate the need for the patient to provide verification or any additional documentation, she pointed out.
However, in New Jersey, cancer centers “have been completely excluded from the process,” she said.
Florida and New Hampshire have somewhat adopted the mechanism suggested by Dr. Cordovano. These states require health care providers to verify that a patient is “especially vulnerable” (Florida) or “medically vulnerable” (New Hampshire) in order for the patient to receive priority vaccine access. In New Hampshire, patients must have at least one other medical condition in addition to cancer to get on the list.
Jia Luo, MD, a medical oncology fellow at Memorial Sloan Kettering Cancer Center, New York, told the meeting that MSKCC has set up a proactive task force that sends “daily emails” to clinic staff highlighting patients eligible for the vaccine. “My sense is, it’s being prioritized to active cancer treatment,” said Dr. Luo. “All of our physicians are currently discussing [it] at each appointment and ... all of our nurses and staff have been talking to our patients on the phone.”
Dr. Cordovano, while advocating hard for cancer patients today, retained optimism about tomorrow: “This isn’t a long-term thing. This is just until things catch up. We knew we were going to have this problem.” Her hope is that, within 6 months, COVID-19 vaccination will become a standard of care in cancer.
Dr. Wherry agreed: “It’s going to take time to catch up with how far behind we are on certain things. ... What we’re seeing is a healthy debate rather than something that we should be concerned about – as long as that debate leads to rapid action.”
“We have to follow the science,” concluded Cordovano. “We can do better than this.”
Dr. Cordovano, Ms. Feldman, and Dr. Wherry have disclosed no relevant financial relationships. Dr. Luo declared a financial relationship with Targeted Oncology. Dr. Ribas declared financial relationships with 4C Biomed, Advaxis, Agilent, Amgen, AstraZeneca, Arcus, Bristol-Myers Squibb, and Kite-Gilead.
A version of this article first appeared on Medscape.com.