Hematologic malignancy patients should receive a COVID-19 vaccine whenever possible. That's the consensus of experts who discussed which patients with hematologic malignancies should or should not get the COVID-19 vaccine and will it work for them at the 2021 Great Debates & Updates in Hematologic Malignancies virtual meeting.

vaccine. vaccine

At times, oncologists need to provide urgent cancer care. Delaying therapy for certain hematologic malignancies to provide a COVID-19 vaccine may allow diseases to progress quickly. On the other hand, a patient with an indolent disease may be able receive the vaccine and wait for therapy. At the moment, no definitive data exists on whether heavily immunocompromised patients can receive the vaccine safely.

"Most patients with hematologic diseases should get a COVID-19 vaccine. The efficacy is 95 percent with the mRNA vaccines. Even if they are only half as effective, they will have the same efficacy as the flu vaccine. It could be a lifesaver," said Michael Satlin, MD, Instructor in Medicine at Weill Cornell Medical College.

For patients with acute myeloid leukemia (AML) in crisis or those with aggressive lymphomas, start them on induction chemotherapy. "There may be good reason to hold anti-CD20 antibodies while you give the COVID-19 vaccine," said Satlin. Patients receiving intensive induction chemotherapy for leukemia can wait and become vaccinated. "CD20 antibodies show reasonable efficacy if you give the vaccine in the first 6 months of therapy. Three months after transplant is a reasonable time to give the COVID-19 vaccine," he said.

Michael Satlin, MD. Michael Satlin, MD

Oncologists using a "watch and wait" approach for indolent lymphomas can presume the COVID-19 vaccine will not cause any problems with immune response. However, if the patient needs treatment, then go full steam ahead with therapy first.

"I have seen several people with newly diagnosed mantle cell lymphoma who have delayed therapy for 4-6 weeks to become vaccinated," said John Leonard, MD, Richard T. Silver Distinguished Professor of Hematology and Medical Oncology and Professor of Medicine at Weill Cornell Medical College. "In an ideal world, I would wait for weeks after the second COVID-19 vaccine dose, and watch the patient closely before starting therapy. If the patient recently received therapy, there is little downside in giving the COVID-19 vaccine."

For a patient on rituximab therapy, if B cells return, "I will probably revaccinate later. We need to be careful to not count on the vaccine for full protection of these patients. Also, make sure the patient's family has been vaccinated as well," said Leonard.

John Leonard, MD. John Leonard, MD

Patients with chronic myelogenous leukemia or myeloproliferative neoplasms on stable therapy and reasonable blood counts should also be immunized. "For those with aggressive disease, such as acute leukemias, wait until after they receive induction chemotherapy. Those taking hypomethylating agents who constantly receive therapy and have cytopenias, immunize when you can. Maybe wait to vaccinate when they recover cell counts between cycles," said Jessica Altman, MD, Professor of Medicine in the Hematology Oncology Division at the Feinberg School of Medicine.

Oncologists working up a patient for transplant should err on the side of vaccinating post-transplant. "The vaccine is more likely to take effect after a transplant than before. With more doses available now, this will be easier to accomplish," said Alexander Perl, MD, MS, Associate Professor of Medicine at the Hospital of the University of Pennsylvania. "COVID-19 vaccines are more likely to benefit myeloid than lymphoid patients. CAR-T cells can be pooled, but patients may not clear COVID after they receive CARs."

Jessica Altman, MD. Jessica Altman, MD

A more liberal policy on vaccinating hematologic malignancy patients may be called for. "These patients may not have seen their grandchildren in 1 year. I feel patients can't indefinitely isolate. This is cruel. Many patients won't have many more holidays with their family. We can offer some protection with a COVID-19 vaccine," said Leonard.

Alexander Perl, MD, MS. Alexander Perl, MD, MS

COVID-19 vaccination may also be safe for multiple myeloma patients. "Most multiple myeloma patients stay on treatment for a long time. My approach is there's no reason not to give them the vaccine," said Joseph Mikhael, MD, Professor in the Applied Cancer Research and Drug Discovery Division at the Translational Genomics Research Institute, an affiliate of City of Hope Cancer Center. "The risk is not that high. When we have more vaccine, we may revaccinate many of these patients. Unfortunately, patients at greatest risk are those with the most active disease. For raging myeloma, treat the myeloma first."

Satlin agrees that as COVID-19 vaccines become more available hematologic malignancy patients will be revaccinated more than the general population.

Joseph Mikhael, MD. Joseph Mikhael, MD

Patients with immune thrombocytopenia and low platelet counts should also receive a COVID-19 vaccine. "We are generally able to vaccinate these patients for COVID-19. If need be, do a platelet transfusion to be safe before vaccinating," said Satlin.

Should a patient who has recovered from COVID-19 receive the vaccine? "It appears the antibody response to vaccines is at least as vigorous in a COVID-19 patient as someone without infection. We don't know the antibody response for hematologic malignancy patients. I recommend hematologic malignancy patients who have had COVID-19 get 2 doses of the vaccine," Satlin concluded.

Mark L. Fuerst is a contributing writer.