publication date: Jan. 29, 2021

Clinical Roundup

NCCN shares guidance for vaccinating cancer patients against COVID-19

The National Comprehensive Cancer Network issued a guidance for COVID-19 vaccinations in people with cancer.

The NCCN COVID-19 Committee’s recommendations state that all people currently in active cancer treatment should get the vaccine, with some advice to consider regarding immunosuppression and timing. The full document can be found here.

The NCCN COVID-19 Vaccine Committee includes hematology and oncology experts with particular expertise in infectious diseases, vaccine development and delivery, medical ethics, and health information technology.

These recommendations can help cancer care providers make informed decisions on how to protect their patients from the ongoing COVID-19 pandemic, based on available evidence plus expert consensus.

“Our number one goal is helping to get the vaccine to as many people as we can,” NCCN COVID-19 Vaccine Committee Co-leader Steve Pergam said in a statement. “That means following existing national and regional directions for prioritizing people who are more likely to face death or severe illness from COVID 19. The evidence we have shows that people receiving active cancer treatment are at greater risk for worse outcomes from COVID-19, particularly if they are older and have additional comorbidities, like immunosuppression.”

Pergam is also associate professor of the Vaccine and Infectious Disease Division at Fred Hutchinson Cancer Research Center and Infection Prevention Director at Seattle Cancer Care Alliance.

“Too many caveats can lead to confusion,” committee co-leader Lindsey Baden, associate professor of medicine, infectious disease of Brigham and Women’s Hospital and Dana-Farber Cancer Institute, said in a statement. “If strong new evidence comes out to support prioritizing certain groups over others, we can always adjust. This is intended to be a living document that is constantly evolving—it will be updated rapidly whenever new data comes out, as well as any potential new vaccines that may get approved in the future.”

The guidance statement from NCCN builds off of existing understanding and guidelines for the flu vaccine during active cancer treatment—such as those in the NCCN Clinical Practice Guidelines in Oncology for Prevention and Treatment of Cancer-Related Infections.

“One of our primary goals is reducing morbidity and mortality,” Sirisha Narayana, associate professor of medicine and chair of the UCSF Ethics Committee at UCSF Health, said in a statement. “We also have to take social determinants of health into account and make special efforts for people in high-risk communities.”

The guidance acknowledges that although these vaccines have been shown to be safe in general populations, their effectiveness among cancer and transplant patients is not precisely known at present.

Available data from vaccine trials have demonstrated that vaccines decrease the incidence of COVID-19 disease and complications, but it is unclear if these vaccines prevent infection and subsequent transmission.

Therefore, everyone should continue to wear masks, avoid large gatherings, and follow other recommendations for preventing COVID-19 acquisition and transmission, even after vaccination. The committee feels strongly that caregivers and other members of the same household should also be encouraged to get the vaccine as soon they are considered eligible where they live.

The committee also addressed:

  • How to prioritize patients in the event of limited supplies and staff capacity.

  • How to recommend appropriate scheduling based around immunosuppressive therapy.

  • How to prepare for possible medication interactions or adverse events.

  • How to account for societal inequities and prioritize at-risk communities.

  • How to communicate with patients and caregivers, particularly non-English speakers.

  • The balance of vaccination efforts between the cancer center and community settings.

The panel will continue to meet regularly in order to refine the recommendations for these and other issues, as they come up. Any open questions can also serve as a guide for areas where new research is most needed.


First mammography screening guidelines issued for older survivors of breast cancer

A nationwide panel of experts has developed the first mammography guidelines for older survivors of breast cancer, providing a framework for discussions between survivors and their physicians on the pros and cons of screening in survivors’ later years.

The guidelines, published in JAMA Oncology, recommend discontinuing routine mammograms for survivors with a life expectancy under five years; considering stopping screening for those with a 5-10-year life expectancy; and continuing mammography for those whose life expectancy is greater than 10 years.

The guidelines will be complemented by printed materials to help survivors gauge their risk of cancer recurring in the breast and weigh the potential benefits and drawbacks of mammography with their health care team.

“The standard recommendation for mammography in breast cancer survivors of all ages has been annual screening,” first author Rachel A. Freedman, of Dana-Farber Cancer Institute, said in a statement. “There has been little guidance on how to tailor screening for older survivors—what role life expectancy, risk of recurrence, patient preferences, or the tradeoffs associated with mammography should play.”

“The result is that the use of mammography for older survivors has been highly inconsistent. With the number of older women who will be diagnosed with breast cancer expected to increase in the coming years, it’s important that we find ways to individualize decisions for each patient’s circumstances and preferences,” Freedman said.

Freedman recruited an 18-member panel of patients and experts from breast cancer primary care, geriatrics, radiology, survivorship, and nursing to review the scientific literature on the risk of in-breast cancer among older breast cancer survivors.

The group conducted a parallel review of research on the benefits and downsides of mammography.

Reassuringly, the literature review confirmed that most older breast cancer survivors had a low risk for breast cancer in either breast—particularly for those who had been treated with hormone-blocking therapy for hormone receptor-positive tumors. The panel estimated older survivors’ risk of developing cancer in the breast over a 10-year period and organized their results by cancer type and treatment.

The review of mammography studies found that although the benefits of screening in older women are not well defined, research suggests mammography offers little to modest clinical benefit for many older women. The main downsides of mammography were false-positives (detection of growths that appear cancerous but turn out not to be), anxiety associated with diagnostic testing, and overtreatment.

Combining the results of these reviews, the panel formulated a series of mammography guidelines for survivors of breast cancer. The guidelines were considered by a group of clinicians and patient advocates and by five clinician focus groups, resulting in several revisions. After further review by the International Society for Geriatric Oncology, the guidelines were refined and finalized.

Because of the low risk that older survivors will develop a cancer in their breast, the lengthy time needed for the small benefits of mammography to be realized, and the persistence of the negative effects of mammography, the new guidelines recommend discontinuing mammography for breast cancer survivors age 75 or older whose life expectancy is under five years.

This holds even for those with a history of higher-risk tumors such as triple-negative or ERBB2-positive. (Life expectancy is estimated by factors such as an individual’s medical history, their degree of functional independence, whether they smoke cigarettes, had a fall in the previous year, and whether they were recently hospitalized).

The guidelines call for consideration of stopping mammography when life expectancy is five to 10 years and continuing annual or biennial mammography when life expectancy exceeds 10 years. For women age 85 and older, whose life expectancy is often under five years, the guidelines recommend ceasing mammography unless an individual is in extraordinary health and has a strong preference to continue testing.

“The purpose of the guidelines is to offer clinicians support for having these conversations with patients and to make a shared, individualized decision for each woman,” Freedman said.


Variation in tax rates and tobacco control measures produces variation in cancer  deaths in 152 U.S. metropolitan and micropolitan areas

A study published in Cancer Causes & Control demonstrates that four in 10 cancer deaths are attributable to cigarette smoking in parts of the South region and Appalachia.

For the study, Farhad Islami and colleagues at the American Cancer Society examined the proportion of cancer deaths from 2013 to 2017 attributed to cigarette smoking in 152 metropolitan and micropolitan statistical areas (MMSAs).

Data show the proportion of cancer deaths attributable to cigarette smoking was greater in men than in women in all evaluated MMSAs. In both sexes combined, the proportion of smoking-related cancer deaths ranged from 8.8% in Logan (Utah-Idaho) to 35.7% in Lexington-Fayette (Kentucky).

Despite this wide variation, at least 20% of all cancer deaths were attributable to cigarette smoking in 147 out of 152 evaluated MMSAs. Most MMSAs with the highest proportions were in the South region and Appalachia.

“This information is important to inform and help evaluate state and local-level tobacco control policies such as state, city- or county-level tobacco taxes and smoke-free air laws, investments in tobacco prevention and increasing access to smoking cessation resources,” Islami said in a statement.

Data also indicate the variations in total cigarette tax rates and other tobacco control initiatives are likely to have contributed to variations in smoking-related cancer deaths within the same regions. For example, the high total excise tax in New York City ($1.50 per pack in addition to the New York state tax of $4.35 per pack) may have contributed to the lower proportion of smoking-related cancer deaths in New York-Jersey City-White Plains metropolitan division compared to other evaluated MMSAs in New York state and the Northeast region.

“Broad and equitable implementation and enforcement of proven tobacco control intervention at all government levels could avert many cancer deaths across the United States,” the authors conclude.


Older minority cancer patients experience worse surgical outcomes compared to white patients with similar socioeconomic factors

Older minority cancer patients with poor social determinants of health are significantly more likely to experience negative surgical outcomes compared to white patients with similar risk factors, according to a study published by researchers at The Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital and Richard J. Solove Research Institute (OSUCCC – James).

A retrospective analysis of more than 200,000 patients conducted by researchers with the OSUCCC – James suggests that minority patients living in high socially vulnerable neighborhoods had a 40% increased risk of a complication and 23% increased risk of 90-day mortality compared with white patients for neighborhoods with low social vulnerability.

The U.S. Centers for Disease Control defines social vulnerability as “potential negative effects on communities caused by external stresses on human health.”

Study results were published in the Journal of the American College of Surgeons Jan. 25, and were highlighted in the 2020 Southern Surgical Association Program.

“This study speaks to how health care and health outcomes extend beyond the doors of the hospital and even beyond the specifics of the disease the patient may have. Ultimately, the resources in the patient’s community may be as important to a patient’s health as what goes on in the hospital,” senior author Timothy Pawlik, Urban Meyer III and Shelley Meyer Chair for Cancer Research at the OSUCCC – James, said in a statement.

Pawlik is also surgeon-in-chief at the Ohio State Wexner Medical Center and chair of the Department of Surgery in the Ohio State College of Medicine.

“This issue is not new, but the data strongly suggests we could significantly improve surgical outcomes by intentionally integrating vulnerability assessments into our national standard of care models. By doing so, we could help identify the most vulnerable among us—upfront—and provide additional supports as patients move through treatment and recovery,” Pawlik said. “The data emphasize how efforts to improve outcomes for cancer patients need to extend beyond the hospital and address systemic health-related disparities within the communities in which patients live.”

For this retrospective study, researchers used a novel risk stratification tool called the social vulnerability index (SVI), a composite measure of 15 social and economic factors. Although the CDC created the SVI using census data to identify communities needing greater support during disasters, researchers recently have applied it to medical studies.

Researchers identified 203,800 patients ages 65 or older from the 2016-2017 Medicare inpatient claims files who underwent an operation for one of three common cancers—lung, colon and rectal—or for cancer of the esophagus between 2013-2017.

The investigators merged the Medicare information with the CDC’s SVI for each patient’s county of residence. The SVI includes county-level data such as unemployment rates, racial distribution, prevalence of people with disabilities, vehicle access and overcrowded community living. A high SVI score indicates greater social vulnerability.

Researchers found that minority patients with high SVI scores had a 47% increased chance of an extended length-of-stay, 40% increased odds of a surgical complication and 23% increased odds of 90-day mortality. When comparing white to non-white patients with a similar social vulnerability risk factor score, non-white patients fared worse in overall recovery.

Additionally, researchers noted that older patients who underwent a cancer operation and resided in areas with high social vulnerability were less likely to achieve a “textbook outcome” as a result of their procedures. A “textbook outcome” means that these patients did not have in-hospital complications, an extended hospitalization or a readmission within three months, and that they were alive 90 days after surgery.

As social vulnerability increased, the outcomes differences by race became more pronounced, Pawlik said.

“Especially for Black and Hispanic individuals, the impact of residing in a socially vulnerable community was much more pronounced,” he added. “They had much greater risk of having adverse outcomes than white patients.”

Even when the researchers matched patients’ characteristics, such as age and cancer type, they found that Blacks and Hispanic patients from high-SVI counties had 26% lower odds of receiving a textbook outcome compared to whites from a low-SVI county.

In general, the differences in textbook outcomes were driven by complications and prolonged hospitalization, according to Pawlik.

“Patients from socially vulnerable communities had the most difficulty achieving a postoperative course without a complication, and they were the most likely to have an extended length of stay. These patients are in double and triple jeopardy,” Pawlik said. “Our data clearly showed a disparity in health, as defined by textbook outcome, with poorer outcomes if a patient was a minority, or from a highly socially vulnerable community or, in particular, both.”

Pawlik cautioned that, because the SVI is population-based, it is not a useful tool to calculate risk at the individual level. Instead, he says, health care providers should ask about patients’ home situations and address their potential lack of resources/support as a routine step in standard of care across all health care systems.

Copyright (c) 2021 The Cancer Letter Inc.