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CME / ABIM MOC / CE

What Is the Effect of COVID-19 Boosters for Patients With Cancer Undergoing Therapy?

  • Authors: News Author: Megan Brooks; CME Author: Charles P. Vega, MD
  • CME / ABIM MOC / CE Released: 6/10/2022
  • Valid for credit through: 6/10/2023
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  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

    Nurses - 0.25 ANCC Contact Hour(s) (0.25 contact hours are in the area of pharmacology)

    Pharmacists - 0.25 Knowledge-based ACPE (0.025 CEUs)

    Physician Assistant - 0.25 AAPA hour(s) of Category I credit

    IPCE - 0.25 Interprofessional Continuing Education (IPCE) credit

    You Are Eligible For

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    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for primary care physicians, nurses, nurse practitioners, physician assistants, pharmacists, oncologists, infectious disease specialists, and other physicians who care for patients with cancer.

The goal of this activity is for learners to be better able to assess the immune response after COVID-19 vaccination among patients receiving treatment for cancer.

Upon completion of this activity, participants will:

  • Evaluate the efficacy of a fourth dose of a COVID-19 vaccine
  • Analyze the immune response to COVID-19 vaccination among patients receiving treatment for cancer
  • Outline implications for the healthcare team


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All relevant financial relationships for anyone with the ability to control the content of this educational activity are listed below and have been mitigated according to Medscape policies. Others involved in the planning of this activity have no relevant financial relationships.


News Author

  • Megan Brooks

    Freelance writer, Medscape

    Disclosures

    Megan Brooks has no relevant financial relationships.

CME Author

  • Charles P. Vega, MD

    Health Sciences Clinical Professor of Family Medicine
    University of California, Irvine School of Medicine

    Disclosures

    Charles P. Vega, MD, has the following relevant financial relationships:
    Advisor or consultant for: GlaxoSmithKline; Johnson & Johnson Pharmaceutical Research & Development, L.L.C.

Editor/Nurse Planner

  • Stephanie Corder, ND, RN, CHCP

    Associate Director, Accreditation and Compliance
    Medscape, LLC

    Disclosures

    Stephanie Corder, ND, RN, CHCP, has no relevant financial relationships.

Compliance Reviewer

  • Lisa Simani, APRN, MS, ACNP

    Associate Director, Accreditation and Compliance
    Medscape, LLC

    Disclosures

    Lisa Simani, APRN, MS, ACNP, has no relevant financial relationships.

Peer Reviewer

This activity has been peer reviewed and the reviewer has no relevant financial relationships.


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This activity was planned by and for the healthcare team, and learners will receive 0.25 Interprofessional Continuing Education (IPCE) credit for learning and change.

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CME / ABIM MOC / CE

What Is the Effect of COVID-19 Boosters for Patients With Cancer Undergoing Therapy?

Authors: News Author: Megan Brooks; CME Author: Charles P. Vega, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 6/10/2022

Valid for credit through: 6/10/2023

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Note: The information on the coronavirus outbreak is continually evolving. The content within this activity serves as a historical reference to the information that was available at the time of this publication. We continue to add to the collection of activities on this subject as new information becomes available. It is the policy of Medscape Education to avoid the mention of brand names or specific manufacturers in accredited educational activities. However, manufacturer names related to COVID-19 vaccines may be provided in this activity to promote clarity. The use of manufacturer names should not be viewed as an endorsement by Medscape of any specific product or manufacturer.

Clinical Context

The data regarding COVID-19 vaccination are constantly evolving, and one of the most salient questions now focuses on the application of a fourth dose of messenger RNA (mRNA)-based vaccination among middle-aged and older adults. Magen and colleagues addressed this issue in a study published in the April 28, 2022 issue of the New England Journal of Medicine.[1]

Researchers compared the clinical efficacy of a fourth dose of BNT162b2 (Pfizer-BioNTech) with a course of 3 doses, with the third dose provided at least 4 months previously. All study patients were aged at least 60 years. The study period extended from January 3 to February 18.

Relative vaccine effectiveness of the fourth dose in days 7 to 30 after vaccination was 45% against lab-confirmed infection with SARS-CoV-2; 55% against symptomatic COVID-19; 68% against COVID-19--related hospitalization; 62% against severe COVID-19; and 74% against death related to COVID-19. The absolute risk reduction associated with the fourth dose were 180.1 cases per 100,000 persons for COVID-19--related hospitalization and 68.8 cases per 100,000 persons for severe COVID-19.

One important group of patients for vaccination includes those undergoing active treatment for cancer or with a history of stem cell transplant. The current study by Khan and colleagues addresses COVID-19 vaccine efficacy in this population.

Study Synopsis and Perspective

New data shed light on the durability of antibody responses to SARS-CoV-2 vaccines and the impact of booster doses for patients with cancer undergoing systemic therapy or who have received a stem cell transplant (SCT).

In a cross-sectional study of 453 such patients, anti-SARS-CoV-2 spike protein receptor binding domain (anti-RBD) antibodies peaked 1 month after the second dose of an mRNA vaccine and remained stable over the next 6 months.

Notably, compared with the primary vaccine course, patients experienced a 20-fold increase in anti-RBD antibodies after the third vaccine dose, "indicative of a brisk anamnestic response from memory B cells," Qamar Khan, MD, a medical oncologist at the University of Kansas Medical Center, Kansas City, Missouri, and colleagues reported.

The study appeared online April 21 in JAMA Oncology.[2]

Given the risk for poor outcomes among patients with cancer and recipients of SCTs who get COVID-19, Khan and colleagues wanted to understand the durability of the antibody response to COVID-19 vaccines in this population.

Among the 453 patients enrolled in the study, 70% had solid tumors, and 30% had hematologic malignancies. About 40% were receiving chemotherapy, 17% were receiving immunotherapy, 14% were receiving a targeted oral agent, 5% were receiving chemoimmunotherapy, and 25% had received an SCT.

Regarding vaccine type, 61% received the Pfizer-BioNTech mRNA vaccine, 35% received the Moderna mRNA vaccine, and 4% got the Janssen/Johnson & Johnson vaccine. The mean age of the cohort was 60.4 years; 56% were women.

Before vaccination, the geometric mean titer (GMT) of anti-RBD antibodies for all patients was 1.7; it increased to 18.65 two weeks after the first dose.

At one month after the second mRNA dose (or 2 months after the Johnson & Johnson vaccine), GMTs of anti-RBD antibodies reached 470.38 and then decreased to 425.8 at 3 months after the second dose (or 4 months after the Johnson & Johnson vaccine). Patients who were male, older than 65 years, and who had been diagnosed with a hematologic malignant tumor were more likely to have lower anti-RBD GMT 3 months after the second vaccine dose.

GMTs subsequently increased to 447.23 six months after the second dose (7 months for Johnson & Johnson).

One month after the third dose, GMTs of anti-RBD antibodies rose to 9224.85 -- more than 20 times the previous GMT value.

According to the investigators, approximately 80% of these patients remained above the threshold of an anti-RBD level of ≥ 100 U/mL at 6 months.

"While still an arbitrary cutoff, an anti-RBD level of 100 U/mL or higher has been associated with protection and has been used to evaluate the effectiveness of a third dose of an mRNA vaccine in a randomized clinical trial of patients who received a solid organ transplant," Khan and colleagues wrote.

"Although more data are needed to confirm this level as protective, if established, anti-RBD can potentially be used to prioritize additional vaccine doses, especially in regions of the world with limited vaccine resources," the authors concluded.

The study was supported in part by the University of Kansas Cancer Center and the Investigator Initiated Steering Committee, by a grant from the National Institute of General Medical Sciences, and a University of Kansas Cancer Center Support Grant from the National Cancer Institute. Khan reported no relevant financial relationships. A complete list of author disclosures is available with the original article.

Study Highlights

  • Study patients were aged ≥ 18 years and were either receiving systemic anticancer treatment or had received an allogenic SCT or chimeric antigen receptor T-cell therapy.
  • The main study outcomes were levels of anti--SARS-CoV-2 spike protein receptor binding domain antibodies (anti-RBD) and neutralizing antibodies (nAb). These outcomes were assessed as follows:
    • mRNA-based vaccines (BNT162b2 and mRNA-1273: 2 week after the first dose; 1, 3, and 6 months after the second dose; 1 month after third dose
    • Adenovirus-based vaccine (JNJ-7846735): 1, 2, 4, and 7 months after the first dose; 1 to 2 months following a booster dose, depending on the vaccine used in the booster
  • 453 patients provided data for the study. 80% of patients were aged ≥ 50 years, and 56% were female. 70% had solid tumors, and 30% had hematologic cancer.
  • 40% of patients were being treated with chemotherapy, and 25% had a history of SCT. Other patients were taking a variety of immunomodulators.
  • 61% of patients received BNT162b2, and 35% received mRNA-1273. 4% received JNJ-7846735.
  • Before vaccination, the average anti-RBD geometric mean titer levels for all patients was 1.7. These increased to 18.65, 470.38, 425.8, and 447.23 at time measurement points 1 to 4 after vaccination, and anti-RBD levels increased to a mean of 9224.85 one month after vaccination.
  • A level of anti-RBD ≥ 100 U/mL is considered protective against SARS-CoV-2. The percentages of patients who achieved this minimal level were 12% at time 0, 29% at time 1, 75% at time 2, 80% at time 3, and 79% at time 4.
  • The anti-RBD titers were lower than similar assays involving patients without cancer in previous studies; however, the rate of seropositivity at time points 0 through 4 were 26%, 68%, 93%, 95%, and 95%, respectively.
  • Patients older than 65 years and male persons had a weaker immune response to vaccination. Patients with a history of hematologic vs solid malignancy also had a lower immune response.
  • The rate of threshold neutralization for nAb at time points 0 through 3 were 15%, 39%, 80%, and 81%, respectively.

Clinical Implications

  • In a recent population-based study by Magen and colleagues of adults aged at least 60 years, the relative vaccine effectiveness of a fourth dose of BNT162b2 in days 7 to 30 after vaccination vs 3 doses of the vaccine was 45% against lab-confirmed infection with SARS-CoV-2; 55% against symptomatic COVID-19; 68% against COVID-19-related hospitalization; 62% against severe COVID-19; and 74% against death related to COVID-19.
  • The current study by Khan and colleagues demonstrates a weaker immune response to the COVID-19 vaccines among patients with cancer compared with previous research of adults without cancer, but most patients with cancer still achieved a protective immune response. Men and patients with a history of hematologic cancer had a weaker response to the vaccine.
  • Implications for the healthcare team: The current study by Khan and colleagues reinforces the need for the healthcare team to strongly recommend the COVID-19 vaccine to patients being treated for cancer.

 

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