The results were in, and Geoff Grubbs braced for the worst.
But his immunologist surprised him: After getting both doses of COVID-19 vaccine, Grubbs had acquired some immunity against the coronavirus.
It’s not the first time Grubbs, 70, has beaten the odds. After being diagnosed about 12 years ago with chronic lymphocytic leukemia, the Washington, D.C., resident watched in pain as his immune system broke down and left him exposed to the raw forces of the world. He’s faced frequent sickness, undergone chemotherapy and may soon need to start a new round of treatment.
But his care team, including his Johns Hopkins immunologist, has helped him manage the cancer. And after learning that the coronavirus vaccine worked better than expected, he knew he had been spared a devastating blow.
“I would’ve been really depressed to never get away from the anxiety totally, because there’s nothing to do,” Grubbs said. “I know plenty of people with no response at all.”
Cancer patients in Maryland and elsewhere were among the first to be prioritized for vaccinations, with clinicians and advocacy groups citing the population’s predisposition to sickness and medical complications due to their weakened immune systems as a result of the disease, the treatment or any existing conditions.
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Experts say most people with cancer or undergoing active treatment for the disease should get vaccinated against COVID-19 at the earliest opportunity, but it’s still not known how well protected they are from the virus after getting inoculated, or precisely when during the course of their treatment regimen they should get immunized.
Uncertainty looms large over this community of people and their caretakers, who now face additional hurdles as states like Maryland begin lifting their mask requirements in most public spaces.
Some, like Grubbs, are told the vaccine at least partially protected them. But it remains unknown at this time what level of protection is considered enough.
Among the additional outstanding questions are how vaccination could be supplemented, or altered, in patients who don’t generate antibodies, and why some are able to produce immune responses while others are not.
This leaves Grubbs and other cancer patients with hard choices to make about how to live life post-vaccination.
“I was specifically told, ‘We can’t tell you it’s safe, because no one knows,’” Grubbs said. “There is a risk.”
Physicians and researchers say much remains unknown about the effectiveness of the vaccines, especially among patients with cancers in the blood, where the defensive antibodies are made.
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Lee Greenberger, chief scientific officer at The Leukemia & Lymphoma Society, said preliminary analyses of cancer patients who have been vaccinated against the coronavirus have shown that as many as 40% of people with blood cancers do not generate antibodies. The numbers are better in people with solid tumor cancers, he said, but not always on par with people without the disease.
When looking at people without cancer, antibody production is widespread, he said. Still, it’s possible that the vaccine protects cancer patients in other ways, even at a blunted level.
“Immune responses are weakened for people with cancer, so all along we expected responses to the vaccine would be the same way: weaker,” said Dr. John Baddley, a professor of medicine at the University of Maryland School of Medicine and an infectious disease physician who has been working with the University of Maryland Greenebaum Comprehensive Cancer Center during the coronavirus pandemic.
“Still, they should get the vaccine,” he said. “We do expect most to respond to vaccination, and some protection is better than no protection.”
There is limited data supporting the efficacy of COVID-19 vaccines in people with cancer or patients in active treatment, according to guidance released in March from The National Comprehensive Cancer Network, a group of physicians across the country with expertise in oncology, infectious diseases and cancer research.
Because of the knowledge gap, household members, close contacts and caregivers of cancer patients are encouraged to get vaccinated at the earliest opportunity, too.
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People with cancer were included in vaccine clinical trials, according to the cancer network, but they have not been systematically evaluated. All available evidence points to the vaccine being safe to use in cancer patients, with no noticeably different side effects or reactions compared with the general population.
There’s also no evidence supporting that one vaccine works better in people with cancer than another.
People who are receiving stem cell transplants, cellular therapy, major surgeries or intensive chemotherapy should wait specified periods before getting vaccinated, the guidance says, though just how long is subject to change. And Baddley said researchers still are looking into the most optimal timing for vaccinations in the cancer community, such as when during chemotherapy a person should get vaccinated.
“The durability of vaccine protection is being investigated in the general population and is expected to be attenuated in immunocompromised patients with cancer,” the cancer network’s guidance reads.
The past 15 months have rocked the cancer community, many of whom felt consumed by the prospect of contracting COVID-19 due to its ability to overwhelm people with limited immunity. Others saw changes in their treatment regimen or how doctors delivered care as the health care system coped with surges of people needing treatment for the infectious disease in hospitals.
Ann Tull, a Westminster woman who has pancreatic cancer and is undergoing chemotherapy, said she spent the past year mostly home alone, cut off from family and friends who have helped lift her up during her journey with the disease.
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Now, after being vaccinated, she said she feels more comfortable leaving the house. She’s traveled by airplane to visit family in Massachusetts and hugged her grandkids.
“Some people have concerns about the vaccine,” Tull, 65, said. “But the risk of contracting COVID, especially for someone with serious health issues, is far more dangerous than getting the vaccine itself.”
For now, as more research becomes available and more people in her network get vaccinated, Tull said she’ll keep wearing her mask when she goes out and will avoid crowds and indoor gatherings to the best of her ability.
The U.S. Centers for Disease Control and Prevention surprised Americans last week when it gave fully vaccinated individuals the green light to stop wearing masks in most settings. It emphasized that people who remain unvaccinated should continue wearing face coverings.
Maryland Gov. Larry Hogan lifted the statewide mask mandate in response, with the exception of health care settings, airports, schools and public transit.
Dr. Arnold Baskies, past chairman of the American Cancer Society, said it’s not clear yet whether people with cancer made up a significant portion of the overall COVID-19 death toll, though they are considered more likely to get acutely ill from the coronavirus than others. Still, he said it’s important to “provide a shield” to society’s most vulnerable with widespread vaccination.
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The University of Maryland School of Medicine is one of several institutions studying the effectiveness of coronavirus vaccines in cancer patients. The Greenebaum center is seeking adult blood cancer and solid tumor patients, and organ transplant recipients, plus their household members and caregivers. It will evaluate antibody levels at various stages before and after receiving the Pfizer/BioNTech and Moderna vaccines.
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“That’s something we need to make sure we know, as physicians treating patients with cancer,” said Dr. Djordje Atanackovic, the study’s principal investigator and medical director of the Fannie Angelos Cellular Therapeutics Laboratory at the Greenebaum center.
National studies also are looking to address the unknowns. Participants in the Leukemia and Lymphoma Society National Research Registry will be invited to enroll in a 10-year study that looks at how patients with blood cancers fared with a COVID-19 diagnosis, and how they responded to vaccinations. The National Institutes of Health Clinical Center in Bethesda is assessing how people with immune system deficiencies or irregularities respond to COVID-19 vaccination.
The society’s Greenberger said it’s possible cancer patients eventually will need more than two doses of any vaccine, or will need a mix of brands. Some could stand to have regular monoclonal antibody injections, as a preventive measure, when the treatment becomes more widely available and federally approved for use.
He said more revealing data from clinical trials and other studies could start surfacing in the next three to six months. Until then, people with cancer should be cautious, he said.
As for Tull, she said she hopes people who are skeptical about getting vaccinated will consider it, as an act of service for cancer patients like her.
“It is frustrating to see some people refusing the vaccine,” she said. “The risks of getting vaccinated are far better than me getting COVID.”