National Immunization Awareness Month With Richa Thakur, MD, and Waqas Haque, MD

Richa Thakur, MD: Hi, I'm Dr. Richa Thakur. I'm a second-year Oncology Fellow at Northwell, and I'm here with one of my colleagues, also on the OncData Forum, Dr. Haque, and we really have a great video planned for you today.

Waqas Haque, MD: Hello, thanks so much for the introduction, Richa. I'm Waqas. I'm a third-year Medicine Resident at New York University (NYU) on a clinical investigator track, and I'm looking forward to having a really important discussion with you about National Immunization Awareness Month.

Dr. Thakur: If you guys didn't know, August is the National Awareness for Immunization Month, and we thought it'd be really great to talk about a few different topics on vaccines and what would be important to our cancer patients too. Hopefully you all like this, and we really want to increase awareness to get vaccinated. Whatever the vaccine series is, please share this video so that they're also motivated to go get their vaccines.

Dr. Haque: Dr. Thakur, why don't you tell us a little bit about the importance of the month for you and how it's significant in your practice?

Dr. Thakur: Of course, I mean, growing up I always wanted to be a physician, and one of the stories that would always capture me was listening to my grandparents and parents talk about what the world was like before polio and watching the smallpox vaccine eradicate. I was just always mesmerized by these. In 2020, especially as a resident in New York, I saw how terrible COVID could be, and that was the world without just one vaccine. And after December when it first came out, it completely changed the landscape for treatment for our patients.

So, that's really what has made me so passionate about vaccines, and especially with our cancer patients, these vaccines are huge. They may not do as much for someone that's 20 and gets the flu, for example—younger, healthier patients are less likely to end up in a hospital—but for our cancer patients, that's huge. For a patient in the hospital having delays in treatment, that can take someone from a curative intent treatment and cause significant delays in their treatment, not only their overall quality of life, but their chances of responding to the treatment. Dr. Haque, why are you so passionate about immunizations?

Dr. Haque: Yes, it's really interesting that you mentioned that you were in New York during the height of the pandemic. I think I started residency a year after you, so I was a little bit after the class of residents that were the COVID interns, but I was actually at Baltimore doing my Master's in Public Health (MPH) at the time, at Johns Hopkins. I was taking all these classes on immunizations, epidemiology, and health management, and then seeing the pandemic start in the middle of my MPH, I just put all the classes and all the theory I was learning into practice. That really cemented the importance of vaccinations for me.

And even though I haven't started my fellowship yet, I have rotated in several inpatient and outpatient oncology clinics, and it's really surprising to see, a lot of times when I ask patients about their immunizations, especially for immunosuppressed patients, how often many of them may not have their flu vaccine up to date or aren't vaccinated against invasive pneumococcal disease. So, I think this month is really important for both providers and patients to reflect on the role of immunizations, and hopefully we can have a good discussion about this today.

So, the first thing I wanted to ask you about is, there are sort of a handful of vaccines that we know can help prevent cancer, of course for hepatitis and also for human papillomavirus (HPV). So, I want to first talk about the importance of the Gardasil^® vaccine—the HPV vaccine. There's obviously a lot of stigma around it, and we both come from South Asian backgrounds, and there can be different perceptions on it in different communities. I was hoping you could talk a little bit about your experience of the vaccine?

Dr. Thakur: Absolutely, I think that's a really good point. Usually, a lot of times when I was in medical school and we talked about vaccine hesitancy, the focus of the conversations, I felt, was always around minority populations—people that were stigmatized by the general literature in publications, but also patients with low socioeconomic backgrounds and low health literacy.

One thing that really bothers me a lot about the hesitancy with Gardasil is there's so much stigma, especially in well-educated communities, and it's really around the association with HPV being a sexually transmitted infection. And the thing is, there are not that many vaccines and things that can prevent cancer. There are really two big ones, hepatitis B and any one of the HPV series. So, it breaks my heart seeing patients, especially in our clinic, that are suffering from head and neck cancers, anal cancers, or cervical cancers that are so preventable, and it's three shots and they wouldn't have had to go through a lifetime sequela of treatment and the complications from their treatment had they just gotten the vaccine. Unfortunately for some of the patients I have, they weren't lucky enough to have this before they were exposed to HPV, but nowadays we have this vaccine and it's just so miraculous, more people should go out and get it.

In terms of the vaccines, there are three really big buckets. I think we were probably in middle school when the original vaccine came out, which was the Gardasil, and that was the quadrivalent that protected against HPV-16 and -18. Then there's also Cervarix^®, which is three shots. Now there's another series too called Gardasil-9 that has nine different series of strains of HPV. So, being able to get this is huge because 70% of head and neck cancers, or upwards of 80% of cervical cancers, are associated with HPV. Being able to get this really prevents a lot of unnecessary treatments that these patients would have to get had they developed cancer.

The other thing we should also probably talk about is when this vaccine first came out, the inclusion criteria were pretty limited. It was mostly teenage women, I think, and then they started adding men. And probably for most of our training, even in medical school, the literature recommended the HPV vaccine, any one of the series, for patients that were nine to 26. And even the 21 was expanded to 26, probably when I was in college or medical school. But I think one thing people don't realize now is that there's also an increased expansion for people from 26 to 45. So, the Centers for Disease Control and Prevention (CDC) recommends it for everyone under 26, but between 27 and 45, they do recommend it for patients and recommend it as a risk-benefit discussion with your physician. So I feel like the stigma with HPV is pretty huge, but I'm sure, Dr. Haque, you also experience a lot of stigma in the clinics too, with not just Gardasil, but a lot of other vaccines too. What's your experience been like?

Dr. Haque: Yes, definitely. So, I think one of the cool things about being at NYU is that I'm in the three-hospital system. You have a private hospital that I'm working at, and then you have the Bellevue, which is one of the country's oldest public hospitals, and I'm also at the Veteran's Affairs (VA). So, it's really three different patient populations, and I've seen vaccine hesitancy wrapped up in different buckets in all the hospitals and different patient populations. I've definitely seen my fair share of patients, even ones who are immunosuppressed who might be hesitant about keeping up with vaccines or who might have some doubts about the efficacy of them, especially if they still have cancer or if they still have some kind of complication or infection even after getting immunized.

I think the first thing that's been really helpful for me is using plain language when I talk about vaccine safety. And I'm sure a lot of other trainees and physicians know about this, but really just using the SHARE approach, that when you're speaking about vaccines, it's not like you're talking down to a patient, but you're trying to make a decision with them so you get a sense of what their values are, what their preferences are, and also getting a sense of where they're coming from. Do they have any family members, cousins, siblings, or parents who did or didn't have a vaccine? Do they have any traumatic experiences with them or is there any mistrust with the medical community or medical system? So, it's getting a sense of where they're coming from and just trying to empathize with them, and then informing them of the pros and cons of vaccination after that and usually trying to reach a decision with them. Personally, I've found a lot of benefit with this approach, and it makes things a lot less tense, especially when there is a patient who's pretty contemplative about a vaccine. That's been my experience in the outpatient clinic setting.

Dr. Thakur: Good. The SHARE approach isn't something I really was taught in residency or medical school as much. I'm familiar with it a little bit, but would you mind going over it a little bit more? I think that would really help a lot of physicians have another tool to talk about vaccine hesitancy.

Dr. Haque: Yes, for sure. The SHARE approach was developed by the Agency of Healthcare Research and Quality (AHRQ), and it's basically a five-step approach to approach decision-making with the patient.

Step one is S, where you're seeking your patients' participation. So, you're really just trying to bring up a topic with them and get a sense of where they're coming from when it comes to discussing the vaccine.

H is helping your patient explore and compare treatment options. So, you're talking to your patient about getting vaccinated now versus vaccinated later versus not getting vaccinated at all. Once again, just trying to get a sense of where they're at in terms of knowing the pros and cons of each of those options.

And then you go on to A, which is where you assess your patient's values and preferences. This is where you have really the best shot to empathize with your patient. You ask if they've had any family members who have gotten the vaccine, if they've had any bad experiences with vaccines, and what they know about vaccines from the TV or media.

R is where you reach a decision with your patient. So, you've gone up with the pros and cons of the different options and now you're making a choice with them.

And then E is where you evaluate the patient's decision. So, obviously, we're not always going to get the answer we want, but hopefully they decide that they want to get vaccinated, and you say that this is a great choice, you're going to hopefully, potentially add years to your life by preventing something down the road. So, that's sort of the approach that I've used as a resident, and it's been very helpful.

Dr. Thakur: I really like that framework. I'm definitely going to take that away and try to use it more often, not just with vaccines but with other treatments that I think patients are very hesitant to pursue.

Dr. Haque: Oh yeah, it is very helpful not just for immunizations, but for other things as well. And just to build on that, I know that you're in the middle of a fellowship and you're having to probably help administer chemotherapy or different cancer treatments. So, I'm kind of curious on how you talk to patients about immunization scheduling around chemotherapies and your experience with that?

Dr. Thakur: Right. So, fortunately for us, a lot of our patients do have really good primary care doctors that are on top of most of the vaccine series. As an Oncology Fellow, I focus more on ones that are affected with their treatment, or the annual ones that they really do need to make sure they get. Flu and COVID vaccines are usually the ones I bring up most often with patients.

There are also, depending on the treatments, some special considerations with a few. For example, when patients have some sort of treatment, like a CD20 inhibitor like rituximab, they may not always have a good response to the vaccine. So, counsel patients on getting them before you start treatment or if the vaccine can be delayed until several months after they finished treatment to time it so that they would have a better response.

The other approach sometimes is there are some treatments like eculizumab which affect certain pathways in the immune system, like the complement-mediated pathway, and making sure these patients have the meningococcal vaccine that's timed relative to the dose of the treatment is also really important.

But I think one of the biggest patient populations that a lot of patients or primary care physicians don't know about is our transplant patients. So, for patients that have some sort of blood cancer, usually leukemia or myeloma, that are often undergoing curative-intent treatment—not in myeloma, but at least in leukemias—these patients have to get an entire bone marrow stem cell transplant. They undergo high-intensive chemotherapy and then they're given their stem cells back or a donor stem cell back. But because of that high-intensive chemotherapy, they literally have wiped out every immune cell they have in their body. So, for the first year, you really can't vaccinate a lot of these patients, and depending on complications from the transplant, we would start the flu vaccine and the COVID vaccine maybe six months out, but that's also assuming they don't have complications from the transplant itself. Even some of the other vaccines, you have to delay significantly.

Transplant patients have to get the entire primary series—so, all of the vaccines you and I got as a kid— again, after transplant. Even some of the live attenuated ones like varicella (chickenpox) or measles, mumps, and rubella (MMR), they're not able to get until two years after transplant, minimum. Because these patients are such high-risk, it's really hard for our transplant patients, and a lot of our cancer patients, to be protected from these infections. So, we really do rely on a lot of healthy people getting these vaccines to help protect the crowd.

Dr. Haque: Yes, definitely. One of the interesting things is that when you think about understanding the efficacy of vaccines or understanding the disease prevention, a lot of the trials that are done to understand these vaccines aren't really going to include cancer patients in the first place. So, that's why there's lack of some hard data if the patient ever asks you about, "What's my chance of not getting a complication if I do have cancer with the vaccines." Interestingly, there have been some studies that have tried to, at least, expose dissociation, and I do know that the inactivated varicella-zoster vaccine has been shown to reduce zoster severity in adults who have a stem cell transplant. Also, the inactivated influenza vaccine has been shown to reduce severity in cancer patients who get the flu. So, there is some evidence, but unfortunately trials just aren't powered to explore this relationship, but it's definitely very important that we have these guidelines that you're talking about.

Dr. Thakur: So, what other resources have you found that you think would help other physicians, trainees, or even patients with getting vaccines and keeping an eye on what they need?

Dr. Haque: The first thing for me that's really helpful is the CDC does have guidelines on vaccinations, the Infectious Diseases Society of America (IDSA) as well. They have guidelines that have been updated as early as this month actually. They have a special section for patients with altered immuno-incompetence. So, that's really the best way for me to keep up with these things because every year there are going to be some changes here and there in patients.

Also, the National Immunization Awareness Month website has really good resources for both care providers, patients, and patients' family members. For patients, they have some apps where you can check if you need to get a vaccine or not and help you keep up with that, and just some general counseling. For providers as well, it has some links to the different schedules that you should be following for patients. That's a really nice website that I really like.

Dr. Thakur: Dr. Haque, I really love the resources that you gave, and I also found another one online on the CDC website too, which we can definitely put out in the show notes of this podcast. It has a couple of quizzes for children and adults; very simple questions, and it'll tell you what vaccines you need and if you're missing.

For anyone that's listening, if you know anyone that's not vaccinated, please send them this video, and encourage them to go out and get vaccinated because it's so important to keep our community healthy.

Dr. Haque: Thank you so much, Dr. Thakur, for sharing that resource. And not just for patients to get vaccines, but also if you're a family member or if you have a loved one who has cancer, then definitely stay with the vaccines as well. We know that vaccinated close contacts and family members of patients can create a cocooning effect where hopefully you're able to block out the effect of that disease or virus in the patient's household. So, definitely it could be for everybody, not just for cancer patients.

About Dr. Thakur & Dr. Haque

Richa Thakur, MD, is both a Palliative Care Physician and a Hematology/Oncology Fellow at Zucker School of Medicine at Hofstra/Northwell Health. She graduated from Washington University in St. Louis with a bachelor's in chemistry, medical school at Texas A&M, residency in Internal Medicine, and a fellowship in Palliative Care at Zucker School of Medicine. Her research interests include improving quality of life in patients diagnosed with hematologic malignancies.

Waqas Haque, MD, MPH, is a third-year Internal Medicine Resident at New York University in a Clinical Investigator Track. As a Clinical Investigator Track Resident, Dr. Haque has balanced his patient care work with a variety of research projects. He hopes to begin fellowship training next year in Medical Hematology/Oncology at an academic program with opportunities to further his work in innovative clinical trial design, value-based care delivery to cancer patients, and becoming an early-stage clinical investigator.

Resources

Transcript edited for clarity. Any views expressed above are the speakers' own and do not necessarily reflect those of Oncology Data Advisor.