Discussion
The pathophysiology of cancer and treatment modalities appear to have long-term effects on various functions of the immune system. This study focused immune memory from primary vaccines in CCS. Data revealed a loss of immunity across the vaccine series suggesting immune memory is impaired by chemotherapy. Cancers involving the immune system, i.e., hematological malignancies, resulted in a greater loss of immunity. As baseline titers were not available for all CCS subjects, the general population’s immunity rate extracted from the literature was used as the control. Therefore, all P-values listed are based upon the difference in this study cohort compared to this control.
The CDC states that protection from the measles, mumps, and rubella (MMR) vaccine is lifelong.19 One study found seropositivity rates of 95%, 74%, and 100% for measles, mumps, and rubella, respectively, 20 years after vaccination with other studies confirming these results.20,21 While the general population tends to retain their protective antibodies, the CCS cohort retained immunity to measles, mumps, and rubella in 77%, 66%, and 76.2%, respectively. This effect was more dramatic in those with hematological malignancies, with 70%, 58.4%, and 75% retaining protection to measles, mumps, and rubella, representing a significant decrease in long-term protection. Of note, mumps was the only titer that did not reach a P value <0.05 in the study likely due to the lower antibody persistence of mumps in the control group.
As not all subjects had received the full 5 dose series for tetanus, the seropositive rate of 85.2% correlating to those who received <5 doses was utilized for the control.1750% (10/20) of our cohort retained seropositive titers to tetanus. The hematological malignancy group was more pronounced with only 40% (6/15) having protective titers.
All subjects received at least one dose of the varicella vaccine. Data from 1995, prior to the 2006 booster recommendations, demonstrating 99% seropositivity 6 years after initial vaccination was used as the control.15 Across all malignancies, 43.4% of patients retained protective antibody levels with 31.25% of those treated for hematological malignancies retaining protective antibody levels.
Hepatitis B showed the greatest rates of seronegativity. In a 30-year study conducted in rural Alaskan villages, 33% of individuals had surface antibody levels below 10 mIU/ml at 15 years.1833% (6/18) of our total cohort and 23% (3/13) of the hematological malignancies group retained protective antibody.
This retrospective study has several limitations. There were no pre-treatment titers for most patients; thus, data was compared to expected vaccine seropositivity of the general population. Pediatric malignancies are rare, and the cohort was limited to CSMC patients. This small data set may not necessarily extrapolate to all CCS.
Despite limitations, these results bolster the idea that CCS likely need to be revaccinated after completing treatment. CCS, especially hematological malignancies patients, appear to have lower seropositivity rates when compared to the general population. After chemotherapy, it may take months to years for complete immune reconstitution;7,10,11 however; it is unknown how much immune recovery is essential for patients to seroconvert after revaccination.
These findings demonstrate a statistically significant loss of immunity to measles, rubella, varicella, tetanus and hepatitis B in CCS; however, no statistically significant difference in mumps antibody persistence. Future prospective studies are needed to build comprehensive guidelines for CCS who have not undergone HSCT.
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