The Cruelest Month
Mikkael A. Sekeres, MD, MS
Chief, Division of Hematology,
Sylvester Comprehensive Cancer Center, University of Miami
As we wrap up the “cruelest month” of April, we are at a funny time in the Covid-19 pandemic. The prevailing message from the U.S. government’s Centers for Disease Control is that we are finally emerging from the long, cold, and isolating winter of our viral discontent, and that we should celebrate both our dogged grit in staying safe, and the soon to be future of our return to normalcy! But we shouldn’t celebrate too soon, or change any of the precautions that kept us alive to this point, and that we really don’t have any idea when that future will arrive.
So our patients turn to their doctors – us – to help make sense of this message, and to advise them about the safety and efficacy of the available vaccines. These are challenging issues for anyone to address, never mind for people with medical conditions that affect the blood and bone marrow – and, frequently, the very immune system that is supposed to combat the virus, and be educated by the vaccines. After all, the patients I see who have these diagnoses weren’t eligible to be enrolled in the studies that led to the vaccines’ approval.
Adding to the cruelty.
In people eligible for the studies leading to the Emergency Use Authorization of the vaccines, vaccine efficacy (as measured by clinical Covid-19 infection during the brief follow-up period) was north of 90%, and appears to last at least 6 months. Side effects were typical of other vaccines, and on the whole not devastating, with the exception of the one-in-a-million rare, rare complication of cerebral sinus venous thromboses seen with the J&J and Astra-Zeneca vaccines.
Whether this complication will increase vaccine hesitancy, or will be used as an excuse for those already hesitant to receive a vaccine, remains to be seen.
Recent studies in patients with chronic lymphocytic leukemia or multiple myeloma – cancers of the arm of the immune system that combats viral infections, and is educated by vaccines – have shown that their ability to mount an immune response to the vaccine plummets to no more than 40% overall, cratering at less than 20% for those receiving chemotherapy or immunotherapy.
Begging the question, should we encourage our patients to receive the vaccine at all?
The answer is an unequivocal “Yes.” Any efficacy against a viral scourge that leads to particularly high mortality rates in this same patient population is better than no efficacy from vaccine avoidance, particularly given the favorable side effect profile of the vaccines. It is inevitable that we all will need booster shots probably later this year, and these patients can be included in THAT public health campaign. If possible, vaccines should be given prior to the start of chemotherapy or immunotherapy, or after their completion.
And yes, the CDC’s paradoxical message notwithstanding, patients should also be cautioned that they must continue to mask and social distance given the greater than odds chance that the vaccine may not be effective, as we all should.
T.S. Eliot wrote that April was the cruelest month, but that summer surprised us, and that we went on in the sunlight. Perhaps fall will bring a loss of masks, and winter a return to normalcy, and we will re-emerge next spring like the hyacinths Eliot celebrates, to bloom virus-free.
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