Plymouth Meeting, PA—Immunocompromised cancer patients should receive a total of five shots of the COVID-19 vaccine to be considered up-to-date on immunization, according to new guidance from the National Comprehensive Cancer Network (NCCN).

In its latest recommendations, the alliance of leading cancer centers emphasized that the primary mRNA vaccination series for immunocompromised patients is considered three shots. That includes most patients with active cancer or a recent history of cancer, according to the group, which adds that the primary series remains two shots for those who are not immunocompromised.

"This guidance is intended to let cancer care providers know not only what they can do, but also what they should do, according to experts across the United States," stated Brahm Segal, MD, Roswell Park Comprehensive Cancer Center, and co-leader of the NCCN Advisory Committee on COVID-19 Vaccination and Pre-exposure Prophylaxis.

The latest update includes the following:

• Recommendations for two booster doses for people who are immunocompromised; the three primary mRNA doses plus the two booster doses add up to five total doses.

• Detailed information on how the primary series and booster definition and number differ for patients who initially received the JNJ-78436735 [Janssen/Johnson & Johnson (J&J)] vaccine.

• Updated dosing recommendations for preexposure prevention with monoclonal antibodies (tixagevimab plus cilgavimab) for cancer patients. The guidance underscores that the treatment should not be considered as a substitute for vaccination.

• Updated data on mixing mRNA vaccine types, which is now considered to have similar effectiveness compared with using the same vaccine type.

In terms of the Janssen/J&J vaccines, the panel says that in "most situations, the mRNA vaccines (Pfizer-BioNTech or Moderna) are preferred over the JNJ-78436735 (Janssen/Johnson & Johnson) vaccine after reports of thrombosis with thrombocytopenia syndrome among Johnson & Johnson vaccine recipients. All people ages 12 years and older should receive 1 booster dose of a COVID-19 vaccine, preferably an mRNA vaccine, at least 2 months after the primary JNJ78436735 (Janssen/Johnson & Johnson) vaccine. People who are 50 years or older may choose to receive a second booster dose at least 4 months after the first booster. For immunocompromised patients who receive an initial JNJ-78436735 (Janssen/Johnson & Johnson) dose, the primary series should include a second dose of an mRNA vaccine one month later."

The NCCN added that heterologous prime-boost strategies, in which the booster is a different formulation than the vaccine used in the primary series, could be beneficial by extending immune protection and could simplify the logistics of vaccination for those who prefer it.

The group also strongly urged that household members and other close contacts of cancer patients should get vaccinated, according to their CDC-determined eligibility.

Other general recommendations from the NCCN include:

• Most cancer patients can receive a COVID-19 vaccination as soon as possible, regardless of their cancer treatment, with some exceptions detailed in the guidance.

• Vaccine delays in patients with cancer should also include those recommended by the CDC for the general public (e.g., recent exposure to COVID-19).

• COVID-19 vaccinations can be given without regard to the timing of other vaccines.

• Revaccination (of the 3-dose primary series and boosters) is recommended 3 months following hematopoietic cell transplantation or chimeric antigen receptor T-cell therapy if a patient was vaccinated prior to such therapy.

• Preexposure prevention with tixagevimab plus cilgavimab is recommended for specified immunocompromised individuals (including anyone undergoing active cancer therapy), although it is not a substitution for vaccination.

• COVID-19 vaccination does not need to be delayed following receipt of monoclonal antibodies, including prophylactic tixagevimab plus cilgavimab.

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