key: cord-1010342-zwudeafk authors: Webber, Tania Buttiron; Provinciali, Nicoletta; Musso, Marco; Ugolini, Martina; Boitano, Monica; Clavarezza, Matteo; D’Amico, Mauro; Defferrari, Carlotta; Gozza, Alberto; Briata, Irene Maria; Magnani, Monica; Paciolla, Fortuna; Menghini, Nadia; Marcenaro, Emanuela; De Palma, Raffaele; Sacchi, Nicoletta; Innocenti, Leonello; Siri, Giacomo; D'ecclesiis, Oriana; Cevasco, Isabella; Gandini, Sara; DeCensi, Andrea title: Predictors of poor seroconversion and adverse events to SARS-CoV-2 mRNA BNT162b2 vaccine in cancer patients on active treatment date: 2021-10-11 journal: Eur J Cancer DOI: 10.1016/j.ejca.2021.09.030 sha: 6878ae8adedcb91c3bc9a3330906c28b7b671f6d doc_id: 1010342 cord_uid: zwudeafk PURPOSE: Initial findings in patients with cancer suggest a lower seroconversion to SARS-COV-2 vaccination possibly related to myelo-immunosuppressive therapies. We conducted a prospective study to assess factors predicting poor seroconversion and adverse events following immunization (AEFI) to the BNT162b2 vaccine in patients on active treatment. PATIENTS AND METHODS: Cancer patients candidate to two doses of BNT162b2 SARS-COV-2 vaccination were enrolled. Patients on active surveillance served as controls. The primary endpoint was poor seroconversion (anti S1/S2 IgG<25 AU/mL) after 21 days from second dose. RESULTS: Between March and July 2021, 320 subjects were recruited and 291 were assessable. The lack of seroconversion at 21 days from the second dose was 1.6% (95% CI, 0.4-8.7) on active surveillance, 13.9% (8.2-21.6) on chemotherapy, 11.4% (5.1-21.3) on hormone therapy, 21.7% (7.5-43.7) on targeted therapy and 4.8% (0.12-23.8) on immune-checkpoint-inhibitors (ICI). Compared to controls, the risk of no IgG response was greater for chemotherapy (P=0.033), targeted therapy (0.005) and hormonotherapy (P=0.051). Lymphocyte count<1x10(9)/L (P=0.04) and older age (P=0.03) also significantly predicted poor seroconversion. Overall, 43 patients (14.8%) complained of AEFI, mostly of mild grade. Risk of AEFI was greater in females (P=0.001) and younger patients (P=0.009). CONCLUSION: Chemotherapy, targeted therapy, hormone therapy, lymphocyte count< 1x10(9)/L, and increasing age predict poor seroconversion after two doses of BNT162b2 in up to 20% of patients, indicating the need for a third dose and long-term serological testing in non-responders. AEFI occur much more frequently in women and younger subjects who may benefit from preventive medications. SARS-COV-2 has been associated with increased morbidity and mortality in cancer patients [1] [2] , indicating the need for a prompt preventive intervention in this myelo-immunosuppressed population. However, vaccines trials mostly excluded cancer patients [3] . Initial observational studies on seroconversion in cancer patients with SARS-COV-2 demonstrated that some subgroups of patients, especially those with hematologic malignancies, have lower rates of seroconversion [4] [5] [6] . Cancer patients have been identified as a high-priority subgroup for SARS-COV-2 vaccinations [7] [8] [9] [10] . However there remain many uncertainties, including their seroconversion ability leading to a safe immunization and their best timing for patients undergoing cancer treatment [11] . Vaccine safety and immunogenicity information is also incomplete in patients on immune checkpoint inhibitors (ICI) with a few studies suggesting general safety and heightened immunity [12] , but others leading to opposite conclusions [13] . Moreover, there is insufficient data on seroconversion under targeted therapies as well as under hormone therapy for breast and prostate cancer patients which is generally deemed not to be immunosuppressive [14] . Similar uncertainties remain for the rate of adverse events following immunization (AEFI) in this frail population, particularly in light of the risk of hemorrhagic events in young females in the general population [15] . To shed light into this knowledge gap, we conducted an observational study to determine the immunogenicity of vaccines in cancer patients undergoing different treatments through evaluation of rates of anti-spike immunoglobulin G (IgG) antibody positivity following vaccination with the BNT162b2 SARS-COV-2. Specifically, our cohort study aims at assessing which factors predict a poor seroconversion (a proxy of lack of vaccine efficacy) and AEFI in order to plan better prevention strategies in this frail population. We conducted a prospective, observational cohort study in order to assess the antibody titer reactogenicity to BNT162b2 SARS-COV-2 vaccine (Pfizer-BioNTech) in cancer patients on active treatment. Inclusion criteria were patients with malignancy aged ≥ 18 years, cancer treatment ongoing or ended within the last 6 months and lymphocytes count ≥ 0.5x10 9 /L (500/uL) based on risk of infections in subjects on chronic immunosuppressive therapy with lymphopenia< 0.6x10 9 /L [16] . The patients with the last treatment > 6 months on active surveillance served as control group. Participants underwent a clinical visit and blood sample collection: 1) at baseline before the first vaccine dose (visit 1), 2) 21 days after the first vaccine dose (visit 2), 3) 42 days after visit 1 (visit 3), and 4) 6 months after visit 1 (visit 4). The trial (ClinicalTrials.gov ID: NCT04932863) was approved by the National Institute for Infectious Diseases, Rome, and the local Ethical Committee. Participants were recruited at Galliera Hospital, Genoa, from March J o u r n a l P r e -p r o o f Procedures Vaccine treatment consisted of 30 μg of BNT162b2 (0.3 ml volume per dose) delivered in the deltoid muscle in 2 doses, 21 days apart. Current treatment groups consisted of different combinations, including chemotherapy alone (23.4%), chemotherapy with hormone therapy (4.4%), or targeted therapy (9.6%), or ICI (4.1%); hormone therapy alone, including LHRH analogs, novel antiandrogens and aromatase inhibitors or tamoxifen (17.2%) or with targeted therapy (CDK 4/6 inhibitors, 6.9%); targeted therapy alone, including tyrosine kinase inhibitors, PARP inhibitors, CDK 4-6 inhibitors, and monoclonal antibodies (7.9%); ICI alone (6.9%) or combined with biological (0.3%). We pooled treatments in five groups to facilitate comparisons: active surveillance (no treatment), chemotherapy, hormone therapy, targeted therapy and ICI. The antibody titer was measured by the LIAISON® SARS-CoV-2 S1/S2 IgG, a chemiluminescent immunoassay (CLIA) for the quantitative detection of IgG antibodies against the S1/S2 domains of the SARS-CoV-2 spike protein in the human serum [17, 18] . The analyser calculates SARS-CoV-2 S1/S2 IgG antibody concentrations as arbitrary units (AU/mL; assay range 3.8-400 AU/ml) and grades the results. The diagnostic specificity of the test is 98.9% and sensitivity 96.2% [18] , with a positive IgG cut-off >15.0 AU/mL. However, the threshold of seroconversion was increased to ≥25 AU/mL according to our lab procedures due to previous preliminary study of correlation between level of antibodies and concomitant T cell response that further proved immunization. The main findings are presented using 25 AU/mL threshold, but supplementary tables using 15 AU/mL are also provided. The primary objective was to assess which factors predicted a poor antibody titer reactogenicity (<25 AU/mL) to BNT162b2 vaccine at 42 days (primary endpoint) and 6 months (co-primary endpoint). The rate of seroconversion at 21 days from the first dose was a secondary endpoint. The factors predicting the onset of Adverse Events Following Immunization (AEFI) in cancer patients were also evaluated [19] . The onset of AEFI was evaluated at visit 2, 3 and 4 and was graded as mild, moderate or severe. The sample size was calculated with a test of precision assuming a standard error ≤5% in the lack of seroconversion rate (i.e., S1/S2 IgG<25 AU/mL). Assuming a rate of poor seroconversion at 42 days of 15% [20] , with 300 assessable subjects, the rate of poor seroconversion should have an error of ± 4%. Median and interquartile range (IQR) for continuous variables and absolute and relative frequencies as summary measures of categorical variables were calculated. Fishers-Exact tests, Wilcoxon Rank tests or the Kruskal-Wallis rank sum test were performed to investigate association of seroconversion and AEFI with clinical characteristics and biomarkers. Multivariable logistic and Poisson models were applied to identify independent factors associated with AEFI and seroconversion, respectively. Relative J o u r n a l P r e -p r o o f Page 5 of 17 risk (RR) and percentages of IgG non-responders and AEFI are presented with 95% CI. All analyses were carried considering two cut-off points for responders at 25 or 15 AU/mL. All p-values were two-sided with 5% significance level. Analyses were carried out using the R studio (R version 4.0.0) and STATA (version 14.2) softwares. From March 15, 2021 to July 21, 2021, 407 patients were screened for vaccination and offered to participate in the study of whom 320 agreed to participate and 291 were assessable for the primary endpoint at 42 days ( Figure 1 ). The main subject and tumor characteristics of the 291 patients are summarized in Table 1 surveillance) and by type of therapy, with chemotherapy, targeted therapy and hormone therapy, but not ICI, being significantly associated with a poor IgG response compared with no treatment (Table 2) . There was no difference on seroconversion between breast and prostate cancer among hormone therapy users (P=0.38), nor was there a low response in CDK4/6 inhibitors users (18/20 responders). There was no effect of corticosteroids on poor seroconversion (16% in corticosteroid users vs 10% in non-users, P=0.32). Increasing age (above the median age) significantly predicted poor seroconversion, whereas higher disease stage and sex did not (Table 2 ). Patients with urological or gynecological cancers had a higher rate of seroconversion than other tumor sites ( Table 2) . Patients with baseline lymphocyte count <1x10 9 /L had a rate of no immunization of 18.5% versus 8.9% in those with lymphocytes ≥1x10 9 /L (p=0.04). Figure 2 ). There was a trend for a higher risk of poor seroconversion in patients with breast cancer and patients with miscellaneous (other) tumors compared with genitourinary and gynecologic cancers and no association with tumor stage (Figure 2 ). Patients with baseline lymphocyte count <1x10 9 /L had a two-fold risk of no seroconversion compared with lymphocytes ≥1x10 9 /L (OR=2.17, 1.03-4.56). Cancer patients develop severe COVID 19 infection with higher mortality [1, 2] and were therefore considered a highly frail population by Health Authorities requiring priority in accessing vaccination [10]. The immunogenicity of cancer patients is also lower than the general population after contracting SARS-CoV-2 infection [4] [5] [6] so that the ability to develop a response to the vaccine was also expected to be different in cancer patients compared to healthy subjects, who attained a 95% efficacy with BNT162b2 vaccine [3] . Patients with solid tumors exhibited a higher seroconversion compared with those with hematologic malignancies after a first dose of vaccine [4] . Our study was designed to identify factors predicting a poor seroconversion to BNT162b2 vaccine in patients under treatment for solid cancers in an attempt to guide strategies in non-responders. Moreover, we aimed at identifying predictors of higher risk of AEFI to manage their occurrence and prevent them in future subjects. Our findings indicate that up to 20% of patients under current treatment with chemotherapy, targeted therapy and hormone therapy show no seroconversion after two doses of BNT162b2 vaccine, whereas patients on ICI or patients on clinical surveillance had J o u r n a l P r e -p r o o f a >95% IgG response. Importantly, patients with G3 lymphopenia (<1x10 9 /L or 1000/uL) had a nearly 20% prevalence and a 2-fold risk of poor seroconversion compared with lymphocyte count ≥1000/uL. Poor seroconversion to COVID 19 infection has been shown in patients with low lymphocyte count [21] , and lymphopenia is predictive of infection in patients on chronic immunosuppressive therapy [16] and is associated with severe COVID-19 disease [22] . Increasing age and, to a lesser extent, advanced stage were also predictors of poor seroconversion. It is plausible that patients on those anticancer treatments who develop lymphopenia as well as older patients have a lower antibody response to the vaccine due to immunosenescence [23] [24] . Our findings strongly indicate the need for long-term serological testing and a third dose or other approaches in this important fraction of non-responding cancer patients [25] . While the immunosuppressive effects of chemotherapy and targeted therapy are plausible, the effect of hormone therapy was quite surprising and in contrast with recent findings [14] . These results appear to be related to a general immunosuppressive mechanism of hormone deprivation as there were no differences between breast and prostate cancer, nor was there an additive effect of CDK 4/6 inhibitors. Female hormones are known to potentiate the immune system [26] , and sex steroids have been associated with differences in immune response to SARS-COV-2 [27] . Hence, a hormone deprivation therapy may also induce immunosenescence in this population [28] . We noted a low response rate (nearly 60% of poor seroconversion) to the first vaccine dose in line with previous studies [4, 29] . Therefore, despite considerations to extend the interval between the two vaccine doses for the healthy population, cancer patients should respect the 21-day distance between the two doses, including subjects receiving ICI who showed a slow seroconversion [4, 29] . Lowering the IgG positivity cut-off from 25 to the manufacturer threshold of 15 AU/ml did not affect the pattern of predictors of poor seroconversion, with higher risk for patients undergoing chemotherapy or targeted therapy, as well as patients with older age and advanced stage. Notably, patients undergoing corticosteroids did not exhibit a higher risk of poor seroconversion, thus supporting recommendations to offer the SARS-COV-2 vaccination to patients taking chronic steroid therapy [30] , although a recent study showed a lower immunization in patients with cancer under corticosteroid therapy [31] . Younger age, female sex and non-smoking status were significant predictors of higher risk of AEFI. Overall, the vaccine was found to be safe, since mainly mild AEFI were reported. These observations are consistent with Polack et al. in which AEFI were observed more frequently in young subjects [3] . The reason why women are at higher risk of AEFI is unclear but again points to immune-endocrine interactions. This is important given the known risk of hemorrhagic events in young females in the general population following vaccines [15] . Differences in the response to vaccines between males and females are already known, as women seem to develop a greater antibody response after antiviral and antibacterial vaccines, suggesting that effective doses for women may be lower [32] . This could also J o u r n a l P r e -p r o o f Page 12 of 17 explain the greater occurrence of adverse events in women, perhaps linked to a sort of "overdose" of the vaccination. Interestingly, current and former smokers, who are at higher risk for severe SARS-COV-2 infection, seem to be protected from developing AEFI, possibly related to the immunosuppressive effect of smoking [33] [34] . Preventive medications to minimize AEFI onset such as paracetamol and antihistamines should be discussed in these subgroups to minimize adverse events. The strength of our study is the large sample size obtained in a single center, with minimal variability in clinical and laboratory parameters. A limitation is the use of antibody titration alone as a method for testing the immune response to the vaccine, since the association between antibody binding titers and antibody effector function is still poorly understood, but is also dependent upon the activation of other specific immune cells, such as T lymphocytes and the generated inflammatory response. In conclusion, our study has important clinical and public health implications as it shows that except for ICI, there is a lack of seroconversion after two doses of BNT162b2 vaccine in up to 20% of cancer patients under active treatment or patients with lymphocyte count <1000/uL, strongly indicating the need for long-term serological testing and a third vaccine dose or passive immunization in vaccine non-responders. Adverse events occur more significantly in women, younger subjects and non-smokers who may benefit from preventive medications such as paracetamol and antihistamines. Clinical impact of COVID-19 on patients with cancer (CCC19): a cohort study COVID-19 prevalence and mortality in patients with cancer and the effect of primary tumour subtype and patient demographics: a prospective cohort study Safety and Efficacy of the BNT162b2 mRNA Covid-19 Vaccine Safety and immunogenicity of one versus two doses of the COVID-19 vaccine BNT162b2 for patients with cancer: interim analysis of a prospective observational study Weak immunogenicity after a single dose of SARS-CoV-2 mRNA vaccine in treated cancer patients Impaired immunogenicity of BNT162b2 anti-SARS-CoV-2 vaccine in patients treated for solid tumors The ESMO Call to Action on COVID-19 vaccinations and patients with cancer: Vaccinate. Monitor. Educate COVID-19 Commission of Accademia Nazionale dei Lincei, Rome. COVID-19 vaccines: where we stand and challenges ahead COVID-19 vaccination: the VOICE for patients with cancer COVID-19 vaccine guidance for patients with cancer participating in oncology clinical trials Short-term safety of the BNT162b2 mRNA COVID-19 vaccine in patients with cancer treated with immune checkpoint inhibitors Low titers of SARS-CoV-2 neutralizing antibodies after first vaccination dose in cancer patients receiving checkpoint inhibitors Seroconversion rates following COVID-19 vaccination among patients with cancer Blood clots and bleeding events following BNT162b2 and ChAdOx1 nCoV-19 vaccine: An analysis of European data Immune status and risk for infection in patients receiving chronic immunosuppressive therapy Clinical and Analytical Performance of an Automated Serological Test That Identifies S1/S2-Neutralizing IgG in COVID-19 Patients Semiquantitatively Performance characteristics of five immunoassays for SARS-CoV-2: a head-to-head benchmark comparison Patterns of seroconversion for SARS-CoV-2 IgG in patients with malignant disease and association with anticancer therapy Lymphocyte as A Predictive Marker for Seronegativity of COVID-19 Lymphopenia is associated with severe coronavirus disease 2019 (COVID-19) infections: A systemic review and meta-analysis Safety and Immunogenicity of Two RNA-Based Covid-19 Vaccine Candidates Age-related immune response heterogeneity to SARS-CoV-2 vaccine BNT162b2 Current perspectives for SARS-CoV-2 vaccination efficacy improvement in patients with active treatment against cancer Progesterone, Immunomodulation What's Sex Got to Do With COVID-19? Gender-Based Differences in the Host Immune Response to Coronaviruses. Front Immunol Cytokines and hormones as possible links between endocrinosenescence and immunosenescence Weak immunogenicity after a single dose of SARS-CoV-2 mRNA vaccine in treated cancer patients Recommendations and Guidance for Steroid Injection Therapy and COVID-19 Vaccine Administration from the American Society of Pain and Neuroscience (ASPN) Efficacy of SARS-CoV-2 vaccine in thoracic cancer patients: a prospective study supporting a third dose in patients with minimal serologic response after two vaccine doses Sex differences in immune responses Impacts of cigarette smoking on immune responsiveness: Up and down or upside down? Oncotarget Effects of cigarette smoke on the immune system