Dr Harish P, Consultant – Medical Oncology, with Cytecare Cancer Hospitals, Bengaluru
To say that the COVID-19 pandemic challenged mankind in more ways than one would be an understatement. Yet we must acknowledge that the challenge was more intense for some communities, including cancer patients, particularly those amid treatment, living with fragile immunities.
The delay in access to surgeries, procedures, and therapies owing to lockdowns and fear of contracting the virus saw close to 40 per cent rise in the number of patients in advanced stages of cancer. The impact would be even greater if we consider those dependent on India’s public healthcare system.
While the peak seems to be behind us and critical care resumes its regular pace as we progress further into 2021, the community remains vulnerable owing to its co-morbidities as well as low immunity levels, especially while undergoing treatments and during the recovery phase.
As India looks to start vaccinating its population over the age of 50 beginning March 2021, countless questions demand answers. Should cancer patients be first in line for their shot, or last? If they’re in treatment, can the vaccine be injurious to health? Are cancer survivors the same as the general public?
Decoding infection risk & recovery ratio
Studies show that the risk for serious COVID-19 complications increases considerably in those with progressing cancer, the elderly and those with additional medical conditions. However, we must be prudent not to apply data based on one category of cancer patients to another. For instance, there are reports which state that lung and blood cancer patients are a lot more vulnerable than other cancer patients. Currently, though, we do not have adequate data to make informed judgments about such differences.
The fact remains that cancer patients fall under the high-risk category for contracting any infections, including COVID-19, as these patients are known to be immunosuppressed or have low immunity. However, our experience over the last year has shown that cancer patients largely respond well to the treatment for coronavirus infection and recover similarly as compared to the general population.
Yet, if we are to err on the side of caution and do our best in controlling the Covid-19 pandemic, we must prioritise the protection of this susceptible community. Cancer patients make up for a significant percentage of the overall population. As per a WHO report, one out of ten Indians will develop cancer in their lifetime.
Understanding vaccine efficacy among patients
It is a matter of great hope and pride that India has two indigenous vaccines against COVID-19 – the Serum Institute’s Covishield and Covaxin developed by Bharat Biotech. And this hope is rooted in data and proven impact.
Before we consider COVID-19 vaccines and their effectiveness, it is important to note that past evidence proves that cancer patients and survivors can generate an adequate amount of immune response to influenza with anti-SARS-CoV-2. Of course, the level of this immunity depends on a range of factors, including the nature of cancer, medium and time of therapy and other administration, as well as immunity owing to other health-related factors.
As far as COVID-19 vaccines are concerned, data suggests that lung and breast cancer patients build an adequate immunity post the vaccination. In the case of patients with malignant tumours too, the response to vaccination falls within an effective range.
There are certain exceptions, though, such as patients undergoing chemotherapy or those suffering from lymphoma. The vaccine efficacy would, as expected, be low in patients with hematologic malignancies, wherein the immune system is destroyed, for instance. However, even in such cases, as per the limited data available so far, once the patients are out of the immunosuppression phase, vaccination is successful in offering immunity against COVID-19. Further, in patients opting for immunotherapy too, efficacy rates fall within the adequate range.
The prospect of winning the battle against the global contagion kindles true hope, particularly for the community fighting cancer, along with its myriad physical, mental and emotional challenges. However, it’s important to remember that there’s no conclusive evidence whether the vaccines can prevent a person from spreading the coronavirus. It’s vital to continue to wear a mask and practice social distancing until we reach herd immunity through the vaccine.
Administering it right
There are a host of factors that will determine the success of the inoculation exercise in the case of cancer patients and survivors. First of all, the timing is critical. Patients in treatment should work with their oncologists to time the two-shot vaccine.
It would be ideal to complete the vaccination process before a patient opts for chemotherapy, if that has been prescribed as part of the overall treatment. In the case of patients who have already begun their chemotherapy sessions, it may be prudent to wait for three-four months after the completion of the treatment before going in for vaccination. The decision has to be made in consultation with the oncologist.
Dosage and timing are two important factors that will have to be part of the consideration. It is quite likely that a defective lymphocyte function among cancer patients may demand unique dosage and booster schedules. Additionally, the relationship between active therapy and immune response is another aspect we will have to study. This will define how we time vaccines with therapy and treatment.
Next, the make of the vaccine itself can make a huge difference. For instance, the UK has gained access to around 400 million doses of multiple vaccine candidates. These include, BioNTech/Pfizer, Oxford/AstraZeneca, Moderna, Janssen, GSK/Sanofi, Valneva. Of these, the latter vaccines, particularly those that are attenuated live virus vaccines, may not be the most ideal vaccines for cancer patients. This would be even truer in the case of those witnessing a rapid cancer progression or those on chemotherapy. These attenuated live virus vaccines could result in a low-grade infection and hence, further complications.
On the other hand, the technology leveraged to create the Pfizer-BioNTech and Moderna vaccines were initially designed to fight cancer. We have studies and data to prove that these genetic or mRNA vaccines do generate adequate immune responses to cancer-related proteins with such vaccines.
Therefore, quite likely that these genetic vaccines could be the most effective in offering immunity against COVID-19 among cancer patients, especially those with solid tumours. Of course, our understanding is limited at this point since neither Pfizer-BioNTech nor Moderna has data around cancer patients’ vaccine response.
The journey ahead
We don’t know whether the so-called second or third wave is bound to occur or not. Perhaps, it will remain at a low level with periodic increases, especially in winters, among elderly and among immunosuppressed patients, like those living with cancer.
While we will have to figure out a few details along the way, one thing is clear: Patients with cancer are vulnerable to COVID-19 because of the immunocompromising nature of cancer treatments as well as progressing cancer itself, which depletes the immune system and leaves patients susceptible to infection.
At Cytecare Cancer Hospitals, our approach is to screen patients and suggest inoculation accordingly. One size cannot fit all. We need to take special precautions around other co-morbidities, current medications, and the overall condition of the patient before suggesting vaccination.
The pro-vaccination approach isn’t limited to patients, but it is for all us who are at high risk due to various factors. To cite our example, all the doctors at Cytecare have opted for the vaccine.
In context of addressing the dilemma and scepticism about the vaccines’ safety and efficacy, as a fraternity, we need to reassure people based on available data and honest exchange of information. We also need to talk about the care and due diligence followed while administering the vaccine and India’s robust vaccination ecosystem, which has helped us roll-out the programme at a globally unprecedented speed.
As the general population looks at us and our turnout for the vaccination, we need to remind ourselves of our duties towards contributing to a safe and healthy populace. Our confidence in the vaccines, a methodical approach to recommending them on a case-to-case basis in the case of patients with immunity concerns, and our openness in sharing the impact of both, the virus and the vaccine, is the need of the hour.
This is not just crucial to put a lid on the pandemic, but also to help people focus on the equally big or bigger health risks that need urgent attention. Without this, we may be silently denying access to critical healthcare for hundreds of thousands of patients who may be reluctant to spend time in high-risk environments – hospitals.