Patients With Cancer Have Unique Considerations for Influenza Vaccination

Influenza, commonly called the flu, is an upper respiratory tract infection that can spread to the lower respiratory tract, sometimes leading to respiratory failure.¹ Although many individuals believe influenza is just a common cold with symptoms including coughing, congestion, and fever, this is not the case for all patients. Immunocompromised patients, especially those with cancer, have an additional mortality and morbidity risk when they contract influenza. The risk of hospitalization after an influenza infection is 3 to 5 times greater for patients with cancer than for the general population, and concurrent use of systemic corticosteroids is an additional risk factor.² This is why all patients with cancer need to protect themselves and receive an influenza vaccination.^3-5

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Despite the need for vaccination, recent study findings indicate that vaccination rates among individuals with cancer are suboptimal.⁶ Researchers examined the records of 283 patients newly diagnosed with cancer and found that only 1.4% had received all recommended vaccines. Regarding influenza vaccine, only 11.8% had been vaccinated.⁶

In addition to the need to increase vaccination rates, clinicians often express concern that response to the immunization may be blunted in individuals receiving cancer treatment.⁴ However, a study of more than 26,000 patients 18 years and older who were previously diagnosed with cancer found that although influenza vaccine effectiveness was lower in this cohort of patients than in the general population, it was robust enough to provide measurable protection.⁷ This creates an opportunity for pharmacists, who can assess patients’ vaccination history and ensure they receive the influenza vaccine appropriately.

Follow CDC Recommendations

The CDC recommends inactive influenza vaccination for all patients starting at the age of 6 months, and particularly for those in close contact with patients who have cancer (ie, caregivers)^.3,5,8-10 Table 1^8,11-16 lists currently available influenza vaccines.

Importantly, patients who are immunocompromised should not receive any live versions of the influenza vaccine, including the live attenuated influenza vaccine/nasal spray vaccine (LAIV). Live vaccines can cause serious infections in patients with weakened immune systems, although family members and caregivers can receive the LAIV.^5,11,17-19 Because inactive vaccinations only have an inactive version of the flu virus, they are safe for patients who are immunocompromised due to their comorbidities or treatments.³

Successful immunization depends on how well the immune system can produce antibodies and a T-cell response against exposure to outside antigens. The cancer’s severity and type of treatment can determine the state of the patient’s immune system.¹ The ideal time to receive the flu vaccine is 2 to 4 weeks prior to cancer treatment,³ although, if necessary, inactive vaccines may be administered during or after chemotherapy, immunotherapy, hormonal treatment, radiation, or surgery. Because patients with a cancer diagnosis are considered immunocompromised, the vaccination should be administered during the highest peak of the patient’s immunity as described in Table 2.^3,4,17 If the therapy can cause immunosuppression, the vaccine must be administered either a few weeks ahead of therapy or after therapy to give the immune system time to create a response.^6,7,8

Influenza circulates every year, with its peak occurrence usually in December through February in the northern hemisphere.¹⁹ Patients with cancer can benefit by receiving vaccinations as soon as the annual vaccine is released to develop a proper immune response before the peak of influenza season.²⁰

Conclusion

Patients with cancer are at a greater risk of severe influenza infection that can become life threatening. Patients need to receive the annual flu vaccine to protect themselves, and pharmacists should also encourage their caregivers to be vaccinated.³ Although this patient population may have weaker immune responses than others, the vaccine will still give them a necessary layer of protection. Proper timing of the vaccination will ensure these patients have the best possible immune response from the vaccine.^1,3,17

References

1. Pedrazzoli P, Baldanti F, Donatelli I, et al; Italian Society of Medical Oncology. Vaccination for seasonal influenza in patients with cancer: recommendations of the Italian Society of Medical Oncology (AIOM). Ann Oncol. 2014;25(6):1243-1247. doi:10.1093/annonc/mdu114

2. Rijk MH, Platteel TN, van den Berg TMC, et al. Prognostic factors and prediction models for hospitalisation and all-cause mortality in adults presenting to primary care with a lower respiratory tract infection: a systematic review. BMJ Open. 2024;14(3):e075475. doi:10.1136/bmjopen-2023-075475

3. Vaccinations and flu shots for people with cancer. American Cancer Society. Updated September 14, 2023. Accessed March 25, 2024. https://www.cancer.org/cancer/managing-cancer/side-effects/low-blood-counts/infections/vaccination-during-cancer-treatment.html

4. Einarsson J, Wilkinson AN. Vaccination considerations for patients receiving cancer therapy. Can Fam Physician. 2022;68(10):751-752. doi:10.46747/cfp.6810751

5. Survivorship care for healthy living. National Comprehensive Cancer Network. 2024. Accessed March 26, 2024. https://www.nccn.org/patients/guidelines/content/PDF/survivorship-hl-patient.pdf

6. Sabatino DC, Campbell P, Santamala J. Assessment of adherence to routine vaccination schedules in oncology patients. J Oncol Pharm Pract. Published online October 17, 2023. doi:10.1177/10781552231208434

7. Blanchette PS, Chung H, Pritchard KI, et al. Influenza vaccine effectiveness among patients with cancer: a population-based study using health administrative and laboratory testing data from Ontario, Canada. J Clin Oncol. 2019;37(30):2795-2804. doi:10.1200/JCO.19.00354

8. Immunization schedules. CDC. Updated February 10, 2023. Accessed March 25, 2024. https://www.cdc.gov/vaccines/schedules/index.html

9. Kamboj M, Bohlke K, Baptiste DM, et al. Vaccination of adults with cancer: ASCO guideline. J Clin Oncol. Published online March 18, 2024. doi:10.1200/JCO.24.00032

10. Seasonal flu vaccines. CDC. Updated March 12, 2024. Accessed March 25, 2024. https://www.cdc.gov/flu/prevent/flushot.htm

11. Grohskopf LA, Blanton LH, Ferdinands JM, Chung JR, Broder KR, Talbot HK. Prevention and control of seasonal influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices — United States, 2023-24 Influenza Season. MMWR Morb Mortal Wkly Rep. 2023;72(RR-2):1-25. doi:10.15585/mmwr.rr7202a1

12. Adjuvanted flu vaccine. CDC. Updated August 25, 2022. Accessed March 25, 2024. https://www.cdc.gov/flu/prevent/adjuvant.htm

13. Influenza vaccine options: 2023-2024 Season. National Foundation for Infectious Diseases. Updated September 2023. Accessed March 25, 2024. https://www.nfid.org/resource/influenza-vaccine-options-2023-2024-season/

14. Influenza vaccination: a summary for clinicians. CDC. Updated March 21, 2024. Accessed March 25, 2024. https://www.cdc.gov/flu/professionals/vaccination/vax-summary.htm#

15. Fluzone high-dose seasonal influenza vaccine. CDC. Updated May 30, 2023. Accessed March 25, 2024. https://www.cdc.gov/flu/prevent/qa_fluzone.htm

16. Recombinant influenza (flu) vaccine. CDC. Updated August 25, 2023. Accessed March 25, 2024. https://www.cdc.gov/flu/prevent/qa_flublok-vaccine.htm

17. Influenza vaccination. Oncology Nursing Society. Accessed March 25, 2024. https://www.ons.org/node/2426?display=pepnavigator&sort_by=created&items_per_page=50

18. Immunizations. Canadian Cancer Society. Accessed March 25, 2024. https://cancer.ca/en/treatments/tests-and-procedures/immunizations

19. Flu season. CDC. Updated September 20, 2022. Accessed March 25, 2024. https://www.cdc.gov/flu/about/season/index.html#

20. Flu vaccine and cancer treatment. Cancer Research UK. Updated July 6, 2023. Accessed March 25, 2024. https://www.cancerresearchuk.org/about-cancer/treatment/cancer-drugs/flu-vaccine