Routine vaccinations during EBRT

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I do not allow any vaccinations from the first through last day of radiation, nor do I allow the patient contact with any new first exposures to any bacteria or viruses (or immunogenic proteins) in the environment because this could effectively vaccinate via immune system response against those agents as well. (Also, it's superfluous that some vaccines, e.g. Pneumovax, are just the "shell" of the infectious agent and can't actually cause any infection themselves, but I digress.) Also, I don't allow breast RT patients to wear deodorant/antiperspirant. Of course, this makes more bacteria grow under their armpit... Hmm.
 
I allow vaccinations, never encountered any issues.

@Scarbtj: no reason to troll... 🙂
 
seper said:
Sorry if it's been discussed already, but do you defer vaccines during fractionated radiotherapy?
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Radiation does not matter. Chemo might though. It counts are low nothing bad will happen but the vaccine might not work. Early into treat you can vaccinate. Later on, probably best to wait to make sure the vaccine works.
 
Ongoing fractionated radiotherapy induces a mildly immunosuppressive state. Studies have been done to show RT-induced lymphopenia which takes weeks to recover. I tend to discourage vaccines during RT, but just was not sure how widespread the practice is. Thank you for sharing.
 
seper said:
Ongoing fractionated radiotherapy induces a mildly immunosuppressive state. Studies have been done to show RT-induced lymphopenia which takes weeks to recover. I tend to discourage vaccines during RT, but just was not sure how widespread the practice is. Thank you for sharing.
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Probably a function of where you are treating.... More of an issue with pelvic or long bone treatment and not such a big deal on breast, h&n or skin treatment
 
Agree. Some people do talk about adverse effects of "irradiating peripheral blood", but I'm not well versed in data on the subject.

medgator said:
Probably a function of where you are treating.... More of an issue with pelvic or long bone treatment and not such a big deal on breast, h&n or skin treatment
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seper said:
Ongoing fractionated radiotherapy induces a mildly immunosuppressive state. Studies have been done to show RT-induced lymphopenia which takes weeks to recover. I tend to discourage vaccines during RT, but just was not sure how widespread the practice is. Thank you for sharing.
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Just some doctor-y observations, from a stupid radiation oncologist:
1) Getting old induces more immunosuppression than getting standard external beam RT. If you were getting really large field XRT, XRT might cause more immunosuppression than getting old. However, old people routinely get vaccines.
2) People with HIV routinely are offered and get vaccines. Having HIV causes more immunosuppression than XRT. Supposedly (again I'm just a stupid rad onc) HIV patients need the vaccines because they are immunosuppressed. Weirdly over in here in rad onc we're holding vaccines because of really mild almost immeasurable immunosuppression?
3) If your worry is that the vaccine might not "take," why not offer the vaccine during XRT and sometime after as well just to make sure you're covered? Since when in medicine do we not offer a preventative measure because the odds of it working vary from an expected baseline? Seat belts are less likely to save you at 100mph vs 50mph, but I still prefer them in either situation.
4) If you're profoundly immunosuppressed, an attenuated live-virus vaccine might not be a good idea, but almost no XRT patients get profoundly immunosuppressed from XRT. Flu vaccine is an attenuated vaccine. It's about the only live virus vaccine I can think of that a cancer patient might want/get. But if an XRT patient wants a flu vaccine, wouldn't it make more sense to offer them the flu vaccine versus offering them exposure to flu out in the wild so to speak?
5) The way the human immune system works, you don't need high or normal or even low normal white counts to get immunogenic memory from an immunogenic agent.
6) In general, severe vaccine side effects are really, really rare. Probably more rare than radiation myelitis.
 
I wish I could offer a poll on this; IMHO it should be 100% yes.
"Hey doc, as you know I run a rusty nail removal business here in town. Last week one of my workers stepped on a rusty nail and his foot got infected and that fella died of tetanus last night. Pretty scary. I know all us adults are supposed to get a tetanus booster every 10 years but none of us do; I can't really remember if I ever did even in the first place. I hear it's pretty safe. Now if you look here on my foot, I stepped on a nail this morning and got a nasty cut. Seems OK but I gashed it pretty good huh. Should I go get the vaccine just to be safe? I know you said while I was getting my prostate radiated I should not take any vaccines... I just wanna be sure I do what you say. Yes or no?"
 
Why are we deferring vaccines? I don't see the rationale.

Always a bad look to have a patient's daughter say, "Mom died of the flu after Dr. X said she couldn't get the flu vaccine during her breast radiation for DCIS."
 
scarbrtj said:
Just some doctor-y observations, from a stupid radiation oncologist:
1) Getting old induces more immunosuppression than getting standard external beam RT. If you were getting really large field XRT, XRT might cause more immunosuppression than getting old. However, old people routinely get vaccines.
2) People with HIV routinely are offered and get vaccines. Having HIV causes more immunosuppression than XRT. Supposedly (again I'm just a stupid rad onc) HIV patients need the vaccines because they are immunosuppressed. Weirdly over in here in rad onc we're holding vaccines because of really mild almost immeasurable immunosuppression?
3) If your worry is that the vaccine might not "take," why not offer the vaccine during XRT and sometime after as well just to make sure you're covered? Since when in medicine do we not offer a preventative measure because the odds of it working vary from an expected baseline? Seat belts are less likely to save you at 100mph vs 50mph, but I still prefer them in either situation.
4) If you're profoundly immunosuppressed, an attenuated live-virus vaccine might not be a good idea, but almost no XRT patients get profoundly immunosuppressed from XRT. Flu vaccine is an attenuated vaccine. It's about the only live virus vaccine I can think of that a cancer patient might want/get. But if an XRT patient wants a flu vaccine, wouldn't it make more sense to offer them the flu vaccine versus offering them exposure to flu out in the wild so to speak?
5) The way the human immune system works, you don't need high or normal or even low normal white counts to get immunogenic memory from an immunogenic agent.
6) In general, severe vaccine side effects are really, really rare. Probably more rare than radiation myelitis.
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I agree with everything here, this is all true! Especially #5 is really important. Recommend all indicated vaccines even during treatment.

The only contraindications should be the standard ones listed for vaccines, ie prior anaphlactic reaction to the vaccine, no Live vaccine if immunosuppressed and hold on vaccination if there is a severe acute illness. If patient has a mild or moderate illness like a cold you can still vaccinate. The main ones that come up are going to be flu and pneumoccocus vaccine, both flu and pneumonia can kill a patient, so by delaying a recommended vaccine for no valid reason you take alot of liability on yourself.

I think for pediatric patient though during treatment I would defer to pediatrician, because they know how any delay could fit into the approved schedules and windows for childhood vaccinations...
 
The big question is if getting a vaccine and radiation at the same time will induce an abscopal effect that may allow you to skip other vaccines...
:heckyeah::heckyeah::heckyeah:
 
Delaying Pnemovax for 6 weeks constitutes a liability? That's an extreme example of defensive medicine type of thinking.
 
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Tetanus boost is not a routine vaccine. I like your vignette. It would have been even more fun if you changed the case to rabies.

scarbrtj said:
I wish I could offer a poll on this; IMHO it should be 100% yes.
"Hey doc, as you know I run a rusty nail removal business here in town. Last week one of my workers stepped on a rusty nail and his foot got infected and that fella died of tetanus last night. Pretty scary. I know all us adults are supposed to get a tetanus booster every 10 years but none of us do; I can't really remember if I ever did even in the first place. I hear it's pretty safe. Now if you look here on my foot, I stepped on a nail this morning and got a nasty cut. Seems OK but I gashed it pretty good huh. Should I go get the vaccine just to be safe? I know you said while I was getting my prostate radiated I should not take any vaccines... I just wanna be sure I do what you say. Yes or no?"
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seper said:
Delaying Pnemovax for 6 weeks constitutes a liability? That's an extreme example of defensive medicine type of thinking.
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I guess if in week 6 your patient dies of pneumonia, you probably do have some liability there. You're giving bad medical advice with no rationale to a patient under your care and they sustain a harm. Pretty much the definition of malpractice.
 
Deferring ANY vaccine during RT is f*$%ing idiotic. Telling people not to get them is similarly stupid. There is no data, and no scientifically plausible rationale to do. It only serves to delay and increase the opportunity of missing vaccines in a population more vulnerable to the illnesses for which the vaccinations are intended.

If anything, seeing a patient weekly for several weeks is a great opportunity to get them updated on their vaccines. Especially, when many of them may be subsequently undergoing a course of immunotherapy, which is a situation in which we may actually want to be judicious about vaccinating.
 
I had a patient who died from the flu during rt.
 
nkmiami said:
I had a patient who died from the flu during rt.
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Interesting discussion guys. I honestly never had any hesitation and if anything go out of my way to discuss things like this during OTV's since I have their attention.

I also had a gentleman die of the flu while undergoing radiation for intermediate risk prostate cancer last year so I actually go out of my way to ask during OTV's if the patient is up to date on vaccines. I've had more than a few patients say "oh, I thought since I was getting radiation (for non-imminently life threatening prostate cancer) I couldn't get the flu vaccine this year."
 
Vaccinations for cancer patients: What to know

emt409 said:
Deferring ANY vaccine during RT is f*$%ing idiotic. Telling people not to get them is similarly stupid. There is no data, and no scientifically plausible rationale to do. It only serves to delay and increase the opportunity of missing vaccines in a population more vulnerable to the illnesses for which the vaccinations are intended.

If anything, seeing a patient weekly for several weeks is a great opportunity to get them updated on their vaccines. Especially, when many of them may be subsequently undergoing a course of immunotherapy, which is a situation in which we may actually want to be judicious about vaccinating.
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emt409 said:
Deferring ANY vaccine during RT is f*$%ing idiotic. Telling people not to get them is similarly stupid.
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MD Anderson disagrees in link posted by seper.

“In general, vaccines aren’t recommended during chemotherapy or radiation therapy.”
 
Here is another way to look a this. A patient dies of pneumonia 2 years after breast RT. A law firm looks for Pneumovax records and identifies its receipt during the 3d week of irradiation. Do they max out radiation oncologist's malpractice insurance or also take his/her vacation home?
 
Defensive medicine goes both ways. If you give a neutropenic patient in week 4 of CRT (lets say we are talking whole pelvic RT + Xeloda after 12 cycles of FOLFOX) a flu vaccine and for some reason you forget to re-vaccinate and they die of the flu a couple months later, they could theoretically come at you for not following up for ensuring they received proper treatment.

Just do what you think is right for the patient. Everyone agrees nothing bad will happen if you give routine vaccines during treatment. If they are profoundly immunosuppressed (not just a low white count) you can give it but will probably want to consider a booster (which not all insurance companies will pay for by the way) or maybe just waiting a couple weeks (they don't have to recover to normal). For the other 95% of patients just vaccinate. This frankly shouldn't be an on-treatment discussion. Oncologists and PCPs should be making sure these things are taken care of before starting immune-compromising treatments (which the vast majority of radiation treatments are not). We could do likewise (though admittedly I don't do this with any regularity).
 
seper said:
Here is another way to look a this. A patient dies of pneumonia 2 years after breast RT. A law firm looks for Pneumovax records and identifies its receipt during the 3d week of irradiation. Do they max out radiation oncologist's malpractice insurance or also take his/her vacation home?
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Depends on the state.... Most malpractice cases are settled within policy limits.. . I've never personally heard of a case where significant assets were seized from someone personally, have you?

Some states won't even let them look at any assets co-owned or owned by your spouse. Also the statutes of limitation to file the suit is typically 2-3 years later

But I digress. I am amazed at how much discussion this thread has generated
 
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medgator said:
But I digress. I am amazed at how much discussion this thread has generated
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Nice to hear about everybody's collective experiences and input and various viewpoints on something like this that makes me thinks . . . or anything other than the job market/residency expansion and how the residents got screwed on the physics/radio-biology exam.

On that note and since malpractice was mentioned (not sure if this should be a separate thread) but how do you guys answer when patients or their family ask if they can drive after having been treated for brain mets? I'm obviously not handing my car keys to a frail/elderly patient with uncontrolled systemic disease and multiple brain mets (who probably should have stopped driving years ago anyway) but what about a 60 year old man with small cell who had a complete response to therapy, opted for surveillance MRI vs PCI, remains asymptomatic, but MRI now shows minimal burden of brain mets that I treated with 3 Gy x 10.

I don't know what justification I could have to restrict his driving but at the same time could easily imagine getting in a mess if he gets in a car crash and a lawyer finds out that the patient was just treated for "brain cancer" and the doctor said he is ok to drive.
 
oldking said:
Nice to hear about everybody's collective experiences and input and various viewpoints on something like this that makes me thinks . . . or anything other than the job market/residency expansion and how the residents got screwed on the physics/radio-biology exam.

On that note and since malpractice was mentioned (not sure if this should be a separate thread) but how do you guys answer when patients or their family ask if they can drive after having been treated for brain mets? I'm obviously not handing my car keys to a frail/elderly patient with uncontrolled systemic disease and multiple brain mets (who probably should have stopped driving years ago anyway) but what about a 60 year old man with small cell who had a complete response to therapy, opted for surveillance MRI vs PCI, remains asymptomatic, but MRI now shows minimal burden of brain mets that I treated with 3 Gy x 10.

I don't know what justification I could have to restrict his driving but at the same time could easily imagine getting in a mess if he gets in a car crash and a lawyer finds out that the patient was just treated for "brain cancer" and the doctor said he is ok to drive.
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I try to punt and ask them to speak with the neurosurgeon or neurologist.
 
I don't get my nose involved with safe or unsafe to drive. If there's any question generally send back to med-onc/NSG. If symptomatic from any brain tumor (seizures, neuro deficits, etc.) I'd lean towards 'it is not safe for you to drive'. If asymptomatic (and no concerns for impending symptoms like significant mass effect, etc.) then wouldn't restrict.
 
Gfunk6 said:
MD Anderson disagrees in link posted by seper.

“In general, vaccines aren’t recommended during chemotherapy or radiation therapy.”
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Notice it also says, "talk to your doctor" for every one of them. Info provided to patients should always be cautiously presented, but as physicians it's our duty to understand why or why not a course of action should be taken.

I steadfastly stand by my comment. If someone can provide an example of a patient developing shingles as a result of a vaccine during RT, I'll eat my Eclipse workstation.
 
RickyScott said:
I try to punt and ask them to speak with the neurosurgeon or neurologist.
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To be honest that's what I normally do but in this unique case (small cell with asymptomatic brain mets that I discovered on survellience MRI since he declined PCI) he has never seen a neurosurgeon/neurologist and it's a stretch to send him for a new patient consultation just to assess suitability to drive, especially since he has always been and remains asymptomatic.

I didn't restrict his driving but I'm not too thrilled about telling him "no restrictions" since his risk of new brain mets at some point is still relatively high (but then again so is any patient with stage IIIB NSCLC or other locally advanced disease but it would be crazy to tell such a patient who feels well "don't drive ever again in case you develop a brain met that suddenly causes a seizure or becomes symptomatic while you are driving").

It doesn't help that this gentleman is literally a construction worker and wants to get back to work operating cranes and heavy machinery soon!
 
There are state laws. Last time I checked them, any degree of cognitive impairment disqualified you from driving. Seizures disorders do also. That's a lot of brain RT patients. I've never actually called state to take away a patient's driving license, but I do discuss these issues and document. Think about your own safety on the road, not malpractice.
 
emt409 said:
Notice it also says, "talk to your doctor" for every one of them. Info provided to patients should always be cautiously presented, but as physicians it's our duty to understand why or why not a course of action should be taken.

I steadfastly stand by my comment. If someone can provide an example of a patient developing shingles as a result of a vaccine during RT, I'll eat my Eclipse workstation.
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Yes, it is not simple. Like many things in medicine we are dealing with highly complex issues with multiple moving parts which requires nuanced decision making. Based on this thread I think that we can safely say that vaccine administration during cancer therapy is one of them. People have differing views as it is a "data free" zone.

Which is why I don't think it is particularly appropriate to call out people who choose differently than you to be ****ing idiotic or stupid.
 
1) Asymptomatic brain met or brain tumor patients are legally allowed to drive; that is to say, if there is no neurological deficit in a person, whether you "medically prescribe" no driving to a person, they still may drive, legally. To cover myself, I tell asymptomatic patients that they are legally allowed to drive if they have had no blackouts, seizures, etc. (And just because a brain met patient is on anti-seizure meds, it doesn't mean they've had a seizure... they just might have encountered a bad doctor). Some states have laws. In my state, if you've had a seizure in the last 6 months, you aren't legally allowed to drive. I make sure to tell patients that too. The U.S. hasn't spent as much time on this as other countries have.
2) Vaccines are the most effective medical intervention in the history of medicine. As doctors, we ought to encourage vs discourage them, seek ways to offer them vs withhold them.
3) Emdeeandersonians notwithstanding, other oncologists like Dr Larry Solin have seen the issue differently.
4) We are radiation experts. We should be smart enough to figure out who will and who won't get unsafe-to-vaccinate-immunosuppressed from RT. If we aren't smart enough, we can always get a CBC.
5) If your radiation patient gets a shingles vaccine and gets the shingles, just give them more radiation. Radiation is one of the most effective treatments of shingles around!
 
Gfunk6 said:
Yes, it is not simple. Like many things in medicine we are dealing with highly complex issues with multiple moving parts which requires nuanced decision making. Based on this thread I think that we can safely say that vaccine administration during cancer therapy is one of them. People have differing views as it is a "data free" zone.

Which is why I don't think it is particularly appropriate to call out people who choose differently than you to be ****ing idiotic or stupid.
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I concede my response could have been more measured, and I agree that there are many nuanced issues in our field. However, I strongly disagree that this is one of them. Seeding unnecessary and unfounded doubt about the clinical propriety of vaccinations is bad for patients and bad for medicine as a whole. It only fuels the noxious anti-vaxxer sentiments we are constantly affronted with.
 
Come on, there’s not a small part of you that thinks the mandatory flu shot requirement is a way for the government to control your mind or use microbots to infect your body?

I take the flu shot and yes I’m one of those who always gets sick for 2 weeks right after. I know it’s not a live vaccine but it’s been my experience every year!

I’m all for vaccines but why does the waiver have to say “I’m an evil doctor who wants to kill my patients.” I don’t see that same waiver used for parents who elect not to have their children vaccinated.
 
RadOncDoc21 said:
I take the flu shot and yes I’m one of those who always gets sick for 2 weeks right after. I know it’s not a live vaccine but it’s been my experience every year!
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This reminds me of the etymology for the word "disaster." It comes from the Greek "dis-" meaning bad and "-aster" (ironically, also "-astro") meaning star; literally "bad star." When people in medieval times and prior would see a comet or shooting star in the sky, and then have crops fail a couple months later, or a famine or plague would hit, the two events would be associated. The frightening, mysterious vision in the heavens was felt surely to herald bad events yet to take place here on earth.

And when I get vaccinated, I always get sick too 🙂
 
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