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Jan 14, 2021

In today’s episode, we hear from the internationally renowned medical oncologist and health economist, Dr. Gary Lyman of the Fred Hutchinson Cancer Research Center, about the issue of vaccine hesitancy amid the COVID-19 pandemic and how to engage with patients who are wary of a vaccine that will ultimately pave the way back to normal life.


ASCO Daily News: Welcome to the ASCO Daily News podcast. I'm Geraldine Carroll, a reporter for the ASCO Daily News. Joining me today is the internationally renowned medical oncologist and health economist Dr. Gary Lyman, who serves as co-director of the Hutchinson Institute for Cancer Outcomes Research at the Fred Hutchinson Cancer Research Center.

Today, we're discussing the issue of vaccine hesitancy amid the COVID-19 pandemic and how to engage with patients who are wary of a vaccine that will ultimately pave the way back to normal life. Dr. Lyman reports no conflicts of interest relating to our topic today. And full disclosures relating to all episodes of the ASCO Daily News podcast are available at Dr. Lyman, welcome back to the ASCO Daily News podcast.

Dr. Gary Lyman: Thank you very much. It's a pleasure to be here again.

ASCO Daily News: Well, as you know, vaccine hesitancy is a threat to public health and has been blamed by the World Health Organization, for example, for the alarming worldwide surge in measles cases. In the United States, vaccination rates are low. Only 43% of adults get an annual flu shot. What are your concerns about potential confusion and anxiety among patients with cancer about the COVID-19 vaccines?

Dr. Gary Lyman: It's an extremely important question. Both I and, of course, many of my colleagues are very concerned about this for a couple reasons. One is vaccine hesitancy could lead to lower rates of vaccination across the country and in certain regions of the country and mean it will take us longer to get to that proportion of the population vaccinated or with available antibodies in order to achieve what's often called herd immunity that will bring down the rates of infection throughout the country.

I'm also concerned about--and we can get into this a little bit later--about hesitancy within the clinical community. We're all humans. We are subjected to the same information and sometimes misinformation about cancer, treatments, and vaccines.

So obviously, hesitancy can be a very broad issue. But the major impact is if it slows up, delays, or reduces that proportion of the population being vaccinated and gaining immunity, it's just going to prolong the entire pandemic.

ASCO Daily News: Well, public perception of the two FDA-approved COVID-19 vaccines is complex. The fast development of these vaccines has raised concerns among some people about their efficacy and side effects. And there's the optics among the general public surrounding the name, quote, "Operation Warp Speed." Surely, these things pose a challenge for oncologists and other clinicians.

Dr. Gary Lyman: Yeah. I think these are very important questions. And frankly, they didn't ask me about the name of Operation Warp Speed. I would have advised them otherwise because one could easily anticipate there would be some concerns about that. Again, I have looked at all the data and some of my colleagues who were actually on the U.S. Food and Drug Administration (FDA) advisory committee that looked at these vaccines in detail, both the efficacy, the effectiveness, and the safety.

There were no shortcuts. There was nothing that was not looked at that is normally looked at in the data we have. The speed was driven by the scientific community, their innovation developing new techniques that allow for more rapid development of vaccines. We are benefiting from such tremendous advances in science over the last 2 decades. And that includes vaccine development and investigation.

And then on top of all that, everyone, my colleagues in the laboratories, my colleagues in the clinics, have felt such an urgency to get information quickly. And I think patients who have participated in these trials--and I can only really give such praise and respect to those that were willing--before we knew whether they would work.

And many of these were just healthy individuals, healthy volunteers, who agreed to participate in these trials not knowing exactly what the result would be. But they felt such an urgency for themselves and for their family and the general population that they participated in these studies. So everything went, yes, at warp speed. But no corners were cut.

So I reassure not only patients but my colleagues. Because, of course, we're susceptible to misinformation and social media and so forth just like the general population is. And there has been a few that have questioned whether they want to do this. But the data is so compelling, so overwhelming, that the benefits far outweigh the harm, particularly in patients with cancer, but probably in just about everybody given what's happening with mutated forms of the virus appearing, the rates going up, [and] mortality now over 4,000 in a day.

This is an urgent situation. And I think what we have here is science benefiting from the urgency of the scientific community as well as the patients they're serving to get this information quickly. So I don't have a bit of concern about any issues that were related to how rapidly this was developed. Everything that should be done, that should be looked at, has been done, and has been looked at.

ASCO Daily News: Where do you think patients with cancer and survivors will be in line to receive one of the two FDA-approved vaccines, COVID-19 vaccines?

Dr. Gary Lyman: Yeah. This is a moving target, of course. And there may be some regional variation. The CDC guidelines--and I'd emphasize these are just guidelines. They're not laws. They're not rules. It's up to the states and local regions to decide how they want to proceed in terms of prioritization. I agree with what most places are doing, what the CDC recommends, getting the health care providers and frontline worker staff that are exposed on a daily basis very high-risk, get them vaccinated first, I think that's being done and in many places has been completed.

And then the next step is looking at the more vulnerable populations, whether it's by age, patients over 65, 70, 75 years of age, and those with comorbidities. And of course, again, very much so, patients with cancer represent a vulnerable and a large vulnerable segment of the population. So my personal feeling--course, I'm biased because I'm an oncologist, and I want to see my patients protected--is to have them prioritized very high on the list to get vaccinated.

But patients with other serious chronic medical conditions that may not be cancer, but are just as vulnerable, should also be in that high priority group. And we know that age is a very strong driver of risk of COVID-19 complications. So if you have cancer, and you're in an older age group, you should be really asking your provider, how soon can I get vaccinated? Because I feel very vulnerable. And I want to move forward with this.

ASCO Daily News: Well, let's focus on social media for a moment. Combating disinformation that is spread on social media channels about COVID-19 and a vaccine itself is a huge challenge. You're on Twitter. You've, I'm sure, seen a lot of disinformation over the past year. What are your thoughts about this? And how should oncologists engage with those patients and family members who may believe myths and conspiracy theories?

Dr. Gary Lyman: Well, this week if not in many weeks preceding this, have just told us what influence social media and misinformation, disinformation, and outright lies can--the toll they may take on the population and on our country. So yes, a lot of this is through the impact of social media. Of course, it's revolutionized so many areas and helped us in so many ways. But it's also presented enormous challenges that we've seen so blatantly displayed.

I tell my patients and my colleagues--again, we're all susceptible to this disinformation--to don't automatically dismiss concerns that are raised. Talk to the patient. Listen to them to begin with. Listen to these concerns. Because we may think they're nonsense or unreal. But they're very real to the patient or the family member who has raised them.

So listen to them, and then discuss with them why many of these ideas just do not hold up to scientific scrutiny, that they are perhaps misleading or again outright false. But it starts with listening and trying to put yourself in their shoes and their background. Because there is a distrust of the medical community in many parts of our society, particularly minorities, but many other segments and a mistrust of science. We're living in an age when science is being questioned in many corners of the country.

So you start with listening, and then you try to explain what's correct here and what is not correct. And then within reason, tell them your understanding of the data, all the work that's been done in terms of showing that these vaccines are safe and efficacious, and try to restore their confidence in the science and the clinical community and the efforts to bring safety to them and their families.

Yes, it is true as you pointed out that the data is not as robust as we hope it will be soon for patients with cancer. But that should not in any way impact on the safety of the vaccines. So even if you don't think the vaccines are going to protect you very much--and I do think they will. But even if you don't believe that that they'll protect you, there's no reason to believe they're unsafe or will cause any more problems because you're a patient with cancer or a cancer survivor than they would someone in the general population as those that were on the trials.

And then I try to steer them finally to reliable sources. Again, some of these are on social media. Some are in certain websites of professional organizations. Each of the major institutions, cancer centers, have their sources of information generally on their website.

I certainly encourage folks to turn to and find out as much information about COVID-19 and about the vaccinations. We've, of course, as you know, done webcasts and discussed this with our colleagues at ASCO and with the Infectious Disease Society of America and other international organizations ( 

So there are sources you can direct patients to that are reliable, that are up to date, and that are truly trustworthy that they should be referred to. And if they have another site that they've looked at, ask them to send it to you or to explain where they came with that so that you can investigate and see if it's entirely a bogus source of information of false information or might be potentially a worthwhile site.

So again, I think it's, again, listening, discussing, referring them to the appropriate social media and web sources that are reliable, and then explain the whole process of actually getting vaccinated, often institution specific or stage specific. But explain the process because there's this unknown. Maybe they've had flu vaccines, many of them, in the past. But this is somewhat different. They'll have to go to a different location. They'll have to wait around afterwards to make sure they're not having any allergic reaction whatsoever, although that's very rare.

And then tell them that you'd like to hear how they do. Many institutions have a process for doing routine follow-up in the patients who do get vaccinated. Again, I'm hopeful as an investigator and an oncologist that we'll be tracking these patients. We'll be keeping our eye on them. We'll follow up with them. Because we need to learn while we're actually changing the landscape of the COVID-19 pandemic.

ASCO Daily News: Well, I'd like to ask you about the distribution of the vaccines. Top FDA officials say that two doses of COVID-19 vaccines are a must. But there have been discussions among health officials globally about mixing and matching vaccines in order to immunize more people against COVID-19. What are your thoughts about this?

Dr. Gary Lyman: Yeah. I think this gets pretty complicated and in a situation where things are already pretty complicated. And I'll just tell you my personal feeling. Others may disagree. And you certainly should talk to your provider, your oncologist, and get their take. And this may change over time. But my sense is--and we all had this unease that things are going kind of slowly right now. And I share that unease.

We were promised 20 million injections by the end of 2020. That didn't happen, of course. We're nowhere near that even now. So there have been some holdups and glitches along the way. And maybe I would call them more serious than just glitches. Because, again, the pandemic continues to expand. But having said that, I don't see the limitation or the reason that things have gone slow a shortage of vaccine yet.

Now, that could come in certain regions. And if there was truly a shortage of vaccine, then I think you need to look at these other strategies, like getting just the first dose to a broader population or perhaps mixing and matching like you described between vaccines as one becomes more prevalent than the other.

But I don't see we're there right now. Right now I see the real holdup is on the implementation side, is on the giving of the injections, getting patients invited for vaccines, getting them in, making sure we have their health care personnel prepared and trained to give the vaccines.

And that's where I think we need warp speed. We need, again, without cutting corners, we need experienced, trained professionals vaccinating as many patients safely and effectively as possible in as many places, health care facilities, as possible. And again, until we have a true shortage of vaccine--and I don't think that's going to happen any time soon--I would stick with the dosing and schedule used in the clinical trials, which is our major source of evidence about efficacy and safety here, which involves two injections, at least of the Pfizer and Moderna vaccine, either 21 days or 28 days apart, and ideally probably giving them the same vaccine in both.

Although, these are both messenger RNA vaccines, again, this new technology we've talked about. It probably would not be any real issue if you got the Pfizer to start with and then the Moderna for the second shot. But of course, you never know. So I would only do that if you truly had to.

There are other vaccines coming from AstraZeneca. The Oxford vaccine, which has been approved in the UK but not here, ran into some glitches in their trials, the Johnson & Johnson and many others that are coming along. Many of these use other technologies, more traditional technology, not this messenger RNA technology. And I guess I have a little bit more concern about mixing and matching across platforms, across vaccine development platforms, and whether that would be the optimal thing to do.

So for now, I don't see any compelling reason to not give everybody the two injections in the schedule recommended. I think the real challenge now is making sure we move as expeditiously and effectively and prioritizing those at greatest risk and getting the dosage schedule recommended by the FDA into as many patients over the next 30, 60, 90 days.

I think it will happen. I know the President-elect and the incoming administration are determined to vaccinate a large proportion of the population in the first 100 days of the next administration. And we'll get there. But the sooner, the better when so many people are getting infected every day. And so many people are dying every day. So we just need to ramp up at the local level, at the state, regional, institution level, the ability to vaccinate as many people as possible safely and effectively.

ASCO Daily News: I'd like to follow up on something you said a little earlier. There's very little research on the impact of the COVID-19 vaccine on patients with cancer. So surely, this is a gap that needs to be filled.

Dr. Gary Lyman: Absolutely. And we and others have written and talked about this at some length. You're absolutely right. The pivotal trials--and this is pretty much true of vaccine trials in general either for other infections and for new therapies- are often done in a population where they're trying to prove that a treatment or a vaccine can work.

And so the companies avoid patients who may not be quite as reactive or responsive to a treatment. So they often will exclude patients with cancer or in this case patients with immunosuppressive conditions, underlying conditions, or receiving immunosuppressive therapy such as chemotherapy and other cancer therapies.

So they were not--while patients with cancer were not specifically excluded from these trials, if you're a patient with cancer and have been recently treated or still have active disease, you were probably not included in the trial. So there are some patients certainly in the Pfizer vaccine trial that had a history of cancer. This may have totaled as many as 1,400 patients out of the 40,000 or so in that trial.

But these were largely patients not on active treatment, not in serious condition from their cancer. They probably had a history of cancer maybe many months or even years previously. And they did get vaccinated. The response rate was a little bit less in those. But the numbers are very small. So I don't think we can draw any conclusions.

But certainly, vaccination of patients with cancer with other vaccines like the previous inactivated influenza vaccines going back historically. There was not as--they were not as effective although still partially effective at reducing the risk of infection. But what seemed to be the major factor was the timing of vaccination in relationship to their cancer treatment. If they received the vaccine at the same time on the same day as their cancer treatment, the protection was only about half of what it is if the patient was not on treatment.

And so it will be important with further studies, ongoing studies. And we hope to track this large real-world experience now as more and more people in different states are getting vaccinated that we will track them and find out how they do, what the protection rate is, any side effects that might be encountered. It would be extremely important.

And eventually, we'll have dedicated trials. I'm very confident of that that now that we know the vaccines do work and in fact are highly protective in the general population and the noncancer population, the burden is now on industry and the FDA to go back and say, OK, we need to look at some of these more vulnerable patients who really were not duly represented in the pivotal trials and see how the vaccine is going to work in them.

And again, as more and more of the population gets vaccinated, well over four million individuals now and globally far more than that, we'll soon be having information on reported effects, reported infections. And we'll be able to get a better and better handle on how patients with cancer fare and how well they're protected with the vaccines.

So yes, we do need more information. But this was not a fault of the studies. They were designed pretty much in the classical fashion to see whether these vaccines even worked. Of course, we didn't know until these studies were done that they--this is new technology--whether they would. But now that we know they do work, now by and large, we need to look at these more vulnerable populations to see how well they work and how safe they are in total.

ASCO Daily News: I'd like to follow up on something you said earlier about health care professionals. Are you surprised by the refusal of some health care workers in the United States to get vaccinated? Is this a fringe segment of the health workforce? Or is it potentially more pervasive than we know?

Dr. Gary Lyman: Yes, well, of course, I don't think we know for sure. I do think you might call it a fringe. It's a subset of health care workers who have raised concerns. The early reports of this I think have gone down at least that I've seen.

I think as the epidemic has grown, as the death rate has grown almost exponentially, many people who had initial concerns, didn't want to be the first one to get vaccinated, they're kind of changing their tune. And they're more accepting and are most anxious to get vaccinated now. So I think that's going to change.

As I said very early on, health care workers are humans too. And we see the same programs, the same social media. We get bombarded with the same false information as the general public. One would hope because of our training and background and/or scientific orientation and understanding of how these things are done and what the urgency and need is that there would be less of it. And I presume that there probably is. But we're not immune from these kind of hesitancies or concerns. And that's led some to just refuse.

My own feeling-- and again, this is personal. I don't think it--certainly doesn't represent ASCO or my own institution. I'm [in] support of requiring health care providers who have direct frontline contact with patients mandating vaccination, requiring vaccination health care workers who work with susceptible patients.

I wouldn't fire those that still disagree. I would reassign them, put them in other duties. But I think it's a disservice to patients, their families, all of us, if you're taking people who could be vaccinated but have refused to be vaccinated and putting them in contact with susceptible patients.

So that's my personal view. The hesitancy will still exist. But I think it's, as I said, I think it's going down. I think it's diminishing. There probably will be some regional geographic differences, so many other issues related to misinformation or disinformation, a lot of it embedded in politics these days.

But the same things that have impacted on the population in general unavoidable impact on the health care community and health care providers. My only hope is in very fast order and now with a mutant virus that seems to be much more contagious--it certainly doesn't appear to be more deadly but more contagious right now--the more people get infected, the more people who will die with COVID-19.

As things just continue to escalate and further impact on our health care delivery, people with other conditions not being able to get into the hospital, get surgery, get emergency care, with all of this happening, we just need to really educate each other and get vaccinated and protect both ourselves, our family, and our patients.

ASCO Daily News: So when we are vaccinated, is that the end of it?

Dr. Gary Lyman: Even after you are vaccinated or while you're waiting to get vaccinated, keep up with the recommended public health precautions, protections, that we've been talking about for almost a year now--frequent handwashing, wearing masks under any situation where you're in contact with people that you haven't been living with, and then social distancing. If you're outside or any kind of closed space, you need to social distance. And you need to be wearing a mask.

And just because you're vaccinated, we don't know for sure that that means that you can't still be infected asymptomatically and spread the virus or that you can't pick up the virus itself. Just it's not likely to be as serious or lethal as if you are not vaccinated.

So good public health protections for now and for the coming months still needs to be enforced and taken very seriously even after vaccination until we get to that point where 80%, 85%, 90% of the population are protected and we see the rates of infection and lethal consequences dramatically reduced. Only then will we begin to open things up and return to some sense of normalcy.

ASCO Daily News: Well, thank you as always, Dr. Lyman, for sharing your insight with us on the ASCO Daily News podcast. I wish you all the best for a healthy year ahead.

Dr. Gary Lyman: And to you as well and to everyone out there. Thank you so much.

ASCO Daily News: And thank you to our listeners for joining us today. If you enjoyed this episode of the podcast, please take a moment to rate, review, and subscribe wherever you get your podcasts.


Disclosures: Dr. Gary Lyman

Consulting or Advisory Role: G1 Therapeutics, Partners Healthcare, Spectrum Pharmaceuticals, invitae, Sandoz-Novartis, Samsung Bioepis, BeyondSpring Pharmaceuticals

Institution Research Funding: Amgen

 Travel, Accommodations, Expenses: Bayer

Disclaimer: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.