- Email: [email protected]
Serum antibody response to influenza virus vaccination during chemotherapy treatment in adult patients with solid tumours
Vaccine 31 (2013) 6177–6184
Contents lists available at ScienceDirect
Vaccine journal homepage: www.elsevier.com/locate/vaccine
Serum antibody response to influenza virus vaccination during chemotherapy treatment in adult patients with solid tumours M.L. Wumkes a,∗ , A.M.T. van der Velden a , M. Los b , M.B.L. Leys c , A. Beeker d , M.R. Nijziel e , A.W.G. van der Velden f , M. Westerman g , A. Meerveld-Eggink b , G.F. Rimmelzwaan h , G.T. Rijkers i , D.H. Biesma b,j a
Department of Internal Medicine, Tergooi Hilversum/Blaricum,Tergooi Hilversum, PO Box 10016, 1201 DA Hilversum, The Netherlands Department of Internal Medicine, St. Antonius Hospital Nieuwegein, Nieuwegein; St. Antonius Hospital, PO Box 2500, 3430 EM Nieuwegein, The Netherlands c Department of Internal Medicine, Maasstad Hospital Rotterdam, Rotterdam, Maasstad Hospital, PO Box 9100, 3007 AC Rotterdam, The Netherlands d Department of Internal Medicine, Spaarne Hospital Hoofddorp, Hoofddorp, Spaarne Hospital, PO Box 770, 2130 AT Hoofddorp, The Netherlands e Department of Internal Medicine, Maxima Medical Centre Eindhoven, Eindhoven, Maxima Medical Centre Eindhoven, PO Box 90052, 5600 PD Eindhoven, The Netherlands f Department of Internal Medicine, Martini Hospital Groningen, Groningen, Martini Hospital Groningen, PO Box 30033, 9700 RM Groningen, The Netherlands g Department of Internal Medicine, Medical Centre Alkmaar, Alkmaar, Medical Centre Alkmaar, PO Box 501, 1800 AM Alkmaar, The Netherlands h Department of Virology, Erasmus Medical Center, Rotterdam; Erasmus Medical Center, PO Box 2040, 3000 CA Rotterdam, The Netherlands i Department of Medical Microbiology and Immunology, St. Antonius Hospital Nieuwegein, Nieuwegein; St. Antonius Hospital, PO Box 2500, 3430 EM Nieuwegein, The Netherlands j Department of Internal Medicine, University Medical Centre Utrecht, Utrecht, the Netherlands University Medical Centre Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands b
a r t i c l e
i n f o
Article history: Received 2 July 2013 Received in revised form 27 September 2013 Accepted 16 October 2013 Available online 29 October 2013 Keywords: Chemotherapy Influenza virus vaccination Solid tumours
a b s t r a c t Background: Higher rates of hospitalization and mortality are described in oncology patients with influenza virus infection compared to the general population. Yearly influenza vaccination is recommended for patients treated with chemotherapy. The optimal moment to administer the vaccine during a treatment cycle has not been studied extensively. Patients and methods: During the influenza season 2011–2012 we conducted a multicenter randomized controlled trial (OFLUVAC, NTR2858, no sponsoring) in the Netherlands. Patients receiving adjuvant chemotherapy for breast or colorectal cancer were randomized between early (day 5 after chemotherapy) and late (day 16 after chemotherapy) vaccination with the influenza virus vaccine (Influvac® 2011/2012—Vaxigrip® 2011/2012). Influenza virus-specific antibody titres were determined before, 3 and 12 weeks after vaccination by haemagglutination inhibition. Results: Thirty-eight breast cancer patients (early = 21; late = 17) and 18 colorectal cancer patients (early = 8; late = 10) were analyzed. In breast cancer patients overall serologic responses were adequate. A statistically significant higher response in patients who received early compared to late vaccination in the chemotherapy cycle was observed. Geometric mean titres post vaccination on day 5 versus day 16 were 69.3 versus 27.4 (H3N2), 76.4 versus 17.5 (H1N1) and 34.4 versus 26.0 (B/Brisbane), respectively. In colorectal cancer patients overall serologic responses were adequate, no significant difference was found between early and late vaccination. Geometric mean titres post vaccination on day 5 versus day 16 were 170.1 versus 192.4 (H3N2), 233.0 versus 280.8 (H1N1) and 62.6 versus 75.9 (B/Brisbane), respectively. Conclusion: Overall antibody response to the influenza virus vaccine in patients treated with chemotherapy for breast or colorectal cancer patients is adequate. Breast cancer patients seem to mount the best antibody response when vaccinated early after a chemotherapy cycle (≤day 5). No difference was found between early and late vaccination in colorectal cancer patients. © 2013 Elsevier Ltd. All rights reserved.
∗ Corresponding author. Tel.: +31 88 7531753; fax: +31 35 5391235. E-mail addresses: [email protected] (M.L. Wumkes), [email protected] (A.M.T. van der Velden), [email protected] (M. Los), [email protected] (M.B.L. Leys), [email protected] (A. Beeker), [email protected] (M.R. Nijziel), [email protected] (A.W.G. van der Velden), [email protected] (M. Westerman), [email protected] (A. Meerveld-Eggink), [email protected] (G.F. Rimmelzwaan), [email protected] (G.T. Rijkers), [email protected] (D.H. Biesma). 0264-410X/$ – see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.vaccine.2013.10.053
6178
M.L. Wumkes et al. / Vaccine 31 (2013) 6177–6184
1. Introduction Higher rates of hospitalization and mortality are described in oncology patients with influenza virus infection compared to the general population [1]. Because of immunosuppressive factors influencing the response to viral infections, patients with cancer are at risk for serious post-influenza complications including secondary bacterial pneumonia, otitis media, sinusitis or deterioration of chronic respiratory or cardiac conditions [2]. Therefore, yearly influenza vaccination is strongly recommended for patients treated with chemotherapy or other immunosuppressive drugs [3], although their immune response may be suboptimal [4]. Two factors influence the immune status and the response to immunization in patients with cancer. First, their disease state can be directly immunosuppressive, this is of particular importance in haematological malignancies. Second, most treatment modalities for cancer have (severe) immunosuppressive effects. Chemotherapy is designed to destroy rapidly growing tumour cells, but will inevitably also impair haematopoiesis. Moreover, full functional capacity of cells of the immune system depends on clonal expansion of antigen specific lymphocytes and is therefore adversely affected [5]. Despite the recommendations and availability of effective influenza vaccines, vaccination coverage is low in cancer patients with chemotherapy treatment [6]. This may be due to conflicting conclusions on the efficacy and optimal moment of administering the vaccine as well as the lack of (inter)national guidelines. Indeed, limited data are available on the utility of influenza vaccination during ongoing chemotherapy regimens. Several studies of patients with lung and breast cancer, with or without receiving treatment, showed these patients have the ability to mount protective antibody titres to influenza vaccination ([5,7–9] reviewed by [10]). In general, it is recommended to vaccinate before start of chemotherapy treatment [10,11]. However, many patients are vaccinated while on chemotherapy because the seasonal influenza vaccination campaign is restricted to the months October and November and because of the duration of the treatment course. The optimal moment to administer the vaccine during a treatment cycle remains unclear [8]. Current recommendations, to vaccinate on the furthest time point from chemotherapy, are based on a single study from 1977 which included only a very limited number of patients (n = 11) [12]. During the influenza vaccination period in 2009, we have conducted a pilot study in patients with breast cancer. Breast cancer patients receiving chemotherapy, were randomized for early (day 4 of the chemotherapy cycle) or late (day 16 of the chemotherapy cycle) influenza vaccination. In this study, patients vaccinated at day 4 tended to reach higher antibody levels compared to patients vaccinated at day 16 [9]. To confirm this observed effect we designed a study in which we evaluate the antibody response to influenza vaccination during chemotherapy and assess the effect of timing of influenza vaccination during chemotherapy in breast cancer and colorectal cancer patients.
2. Patients and methods 2.1. Study design In this multicenter trial, patients receiving adjuvant chemotherapy for breast cancer or colorectal cancer were randomized between early (day 5 after chemotherapy: at least 48 h after the last gift of steroids) and late (day 16 after chemotherapy)
vaccination with influenza virus vaccine. The study has been carried out in accordance with the Declaration of Helsinki. 2.2. Patients We included adult patients (age ≥18 years) who received adjuvant chemotherapy (non- metastatic disease) because of breast cancer or colorectal cancer. Patients with breast cancer were treated with three weekly regimens containing FEC (5-fluorouracil 500 mg/m2 , epirubicin 100 mg/m2 and cyclophosphamide 500 mg/m2 ) six cycles, FEC three cycles followed by docetaxel (100 mg/m2 ) three cycles, TAC (docetaxel 50 mg/m2 , doxorubicin 75 mg/m2 and cyclophosphamide 500 mg/m2 ) six cycles or AC (doxorubicin 60 mg/m2 , cyclophosphamide 600 mg/m2 ) four cycles (followed by paclitaxel and trastuzumab). All breast cancer patients were her −2/neu negative. Patients with colorectal cancer were treated with oxaliplatincontaining regimens: Capox (oxaliplatin 130 mg/m2 and capecitebine 1000 mg/m2 [28 dosages]) given in eight cycles of three weeks. Exclusion criteria were fever at time of vaccination (defined as a temperature of ≥38.5 ◦ C), previous allergic reaction to any of the components of the vaccines given (for example hypersensitivity to egg protein) and thrombocytopenia (defined as <50 × 109 /L) at moment of vaccination. This study was approved by the united committee on research involving human subjects (VCMO—Verenigde Commissies Mensgebonden Onderzoek) at Nieuwegein, the Netherlands. All patients signed informed consent. The study was registered at the trial register of the Netherlands (NTR) with ID number NTR-2858. This multicenter randomized trial was carried out in seven hospitals in the Netherlands. Eligible patients were randomized for early (day 5) or late (day 16) vaccination during a three weekly chemotherapy cycle. A randomization schedule was used in which patients were randomized 1:1 in blocks of 10 patients. Patients were allocated to either group in order of notification of the principal investigator. 2.3. Vaccination In the period October–December 2011, patients received one of the two available seasonal influenza virus vaccines Influvac® 2011/2012, Abbott Biologicals B.V, Weesp, the Netherlands and Vaxigrip® 2011/2012, Sanofi Pasteur MSD, Brussels, Belgium, (one dose of 0.5 mL, subcutaneous or intramuscular injection in upper arm), dependent on which vaccine was used in the respective participating hospitals. The available vaccines each contain 15 g haemagglutinin of the following influenza strains: A/California/7/2009 (H1N1)-like strain, A/Perth/16/2009 (H3N2)-like strain, B/Brisbane/60/2008like strain, according to the WHO-recommendations and EUdecision for the influenza season 2011–2012. 2.4. Laboratory investigations Serum samples were collected before, three weeks after and twelve weeks after vaccination and stored at −70 ◦ C until use. Before vaccination, differential blood cell counts were carried out. Antibodies to the haemagglutinin of all three vaccine strains were measured by the haemagglutination inhibition (HI) test according to standard procedures using four haemagglutinating units of each virus and turkey erythrocytes [13,14]. Two-fold serial dilutions of patient sera were tested with a starting dilution of 1:20. Sera were pre-treated with receptor-destroying enzyme (Vibrio cholera filtrate) to remove non-specific inhibitors and subsequently tested for HI antibodies specific for the viruses: A/California/7/2009
M.L. Wumkes et al. / Vaccine 31 (2013) 6177–6184
(H1N1, A/Perth/16/2009 (H3N2) and B/Brisbane/60/2008. The antibody titre is expressed as the reciprocal value of the highest dilution that still inhibits agglutination. Data are expressed as geometric mean HI titre (HI GMT), seroprotection rate (SPR; i.e. the percentage of vaccine recipients with a serum HI titre ≥40 post vaccination) and seroconversion rate (SCR; i.e. the percentage of vaccine recipients with a fourfold increase or more in post vaccination titre) [15,16]. According to the criteria of the EMEA (European Agency for the Evaluation of Medicinal Products) in healthy adults ≤60 years of age, an adequate response to vaccination includes one of the following three requirements of the serological assessments: SPR >70%, SCR ≥40% and mean increase in GMT >2.5. For healthy adults >60 years of age, the criteria for an adequate response include one of the following requirements: SPR >60%, SCR >30% and GMT >2.0 [17]. 2.5. Statistical analysis IBM® SPSS® version 19.0 has been used for statistical analyses. Descriptive statistics, such as the mean, median, counts and proportion, were used to characterize the patient populations. Comparisons of GMT before and after vaccination (paired samples) were carried out using the Wilcoxin signed rank test. Fisher’s exact test was used to compare groups. A P-value of <0.05 was considered statistically significant. 3. Results A total of one hundred and fifty patients with breast cancer or colorectal cancer were assessed for eligibility. Fourteen patients did not meet the inclusion criteria; reasons for exclusion were language barrier (n = 1), allergies (n = 1) and having received the influenza vaccine 2011–2012 (n = 12) before assessment. Sixtyseven patients declined to participate; 27 patients did not want to participate in a study, 40 patients refused influenza vaccination and therefore declined to participate in the study. Sixty-nine patients were randomized, 50 breast cancer patients and 19 colorectal cancer patients. Twenty-eight breast cancer patients were randomized to early vaccination, 22 to late vaccination. Nine colorectal cancer patients were randomized to early vaccination and 10 to late vaccination. After randomization a total of 12 patients (11 breast cancer patients, 1 colorectal cancer patient) decided to withdraw from the study because the burden was to high (vaccination and three times vena punction). One breast cancer patient discontinued the study after vaccination for unknown reasons and could not be analyzed. The 12 weeks post vaccination sera of three patients and the 3 weeks post vaccination serum of one patient were not available and therefore excluded from analysis (Fig. 1). The serum antibody response to vaccination was compared between 21 early vaccinated breast cancer patients and 17 late vaccinated breast cancer patients. The serologic response of colorectal cancer patients were analyzed in a similar manner with 8 patients vaccinated on day 5 and 10 patients vaccinated on day 16. In Table 1, baseline characteristics of the breast cancer and colorectal cancer patients are given. The groups did not significantly differ in age, type of chemotherapy, previous vaccination or comorbidity such as hypertension, coronary heart disease or thyroid disease. One colorectal cancer patient was treated with Folfox (oxaliplatin 85 mg/m2 /day, 5-fluorouracil 400 mg/m2 day 1–2, 5fluorouracil 600 mg/m2 , folic acid 200 mg/m2 ) in a three-weekly regimen due to side effects in the original two-weekly regimen. Haemagglutination inhibition titres were measured prevaccination and three and 12 weeks post vaccination. Antibody
6179
titres were determined separately for each influenza strain in the vaccine (Figs. 2 and 3). 3.1. Antibody response in breast cancer patients In the early breast cancer patient group, GMT three weeks post vaccination increased statistically significant for all three virus strains. Twelve weeks after vaccination the GMTincrease remained statistically significant. In the late breast cancer patient group an increase in GMT post vaccination found for all virus strains, but was only statistically significant after 12 weeks for the A/H1N1 and B/Brisbane virus strains. The decrease in GMT twelve weeks after vaccination compared to the response after three weeks, is statistically significant (P = 0.015). After three weeks the early group met all three criteria of the EMEA for defining an adequate response for the H3N2 and H1N1virus strains. (Table 2) It met only two criteria for B/Brisbane; SCR and mean increase in GMT .In the late patient group, SPR, SCR and mean increase in GMT criteria are not met for any virus strain. No significant differences were found between the pre-vaccination titres in the early and late patient group. Three weeks after vaccination early vaccinated breast cancer patients had a statistically significant better response to the H3N2 virus strain in terms of seroprotection, seroconversion and mean increase in GMT when compared to the late patient group. The percentage of patients with seroprotection against H1N1 was also significantly higher in comparison to late vaccinated breast cancer patients. After twelve weeks the early patient group still met all criteria for the H1N1 strain. Two criteria, SCR and mean increase in GMT, were met for B/Brisbane and the H3N2 virus strain only met the criteria for mean increase in GMT. The late group did not meet any of the criteria for an adequate response. After twelve weeks the seroconversion rate was significantly higher in the early vaccinated patient group. These data therefore confirmed our previous findings that influenza vaccination early during chemotherapy leads to a better antibody response. The chemotherapy regimen itself had no statistically significant influence on the post vaccination antibody titers. Comparison of the GMT response between the patients on FEC or FEC-docetaxel revealed no significant differences in any of the 3 influenza strains (GMT for H3N2 was 50 and 68.8 in the FEC and the FEC-docetaxel group, respectively (P = 0.605; for H1N1 48.3 and 79.9 (P = 0.571) and for B/Brisbane 12.5 and 53 (P = 0.067)). Our data therefore do not indicate an additional immunosuppressive effect of docetaxel when given in addition to an FEC regimen. 3.2. Antibody response in colorectal cancer patients In both colorectal cancer patient groups, early and late vaccination, GMT three weeks post vaccination increased statistically significant for the H3N2 and H1N1 virus strains. In the late patient group there was also a significant increase for B/Brisbane (P = 0.01). After twelve weeks the increase in GMT remains statistically significant for the virus strains H3N2 and H1N1. In the early patient group, the increase in GMT for B/Brisbane is significant (P = 0.027). No significant difference was found between the prevaccination titres in the early and late patient group. In colorectal cancer patients there is no statistically significant difference in the serological response to the influenza virus vaccine of the early and late group. After three weeks the early group met all three criteria for an adequate response for the H3N2 and H1N1 virus strains, for B/Brisbane only SCR >40% was not met. The late patient group met all criteria for all three virus strains.
6180
M.L. Wumkes et al. / Vaccine 31 (2013) 6177–6184
Fig. 1. Consolidated standards of reporting trials diagram. B: Breast cancer patients C: colorectal cancer patients.
After twelve weeks the response of the early patient group remained adequate, with exception of the seroconversion rate for B/Brisbane. In the late group all criteria were met for the H3N2 and H1N1 virus strains. For B/Brisbane only SCR and mean increase in GMT met the criteria (Table 2). It can be concluded that in patients with colorectal cancer, influenza vaccination either early or late during chemotherapy induces an adequate antibody response. 3.3. Previous influenza vaccination Eight colorectal cancer patients and 13 breast cancer patients had been previously vaccinated (during 1 − >10 influenza seasons
but most patients only once or twice). Seven colorectal cancer patients did not have previous vaccination, as well as 15 breast cancer patients. For the other patients, the vaccination status was unknown. Not all patients aged above 60 years received prior influenza vaccination (56%) but substantially more often than younger patients (29%). In colorectal cancer patients prevaccination titers of H3N2 were significantly higher in previously vaccinated patients than in patients who were influenza vaccine naïve (GMT 73.9 versus 6, P = 0.036). No significant differences were found in post vaccination titers. In previously vaccinated colorectal cancer patients post vaccination GMT’s for H3N2, H1N1 and B/Brisbane were 210.6, 329.5 and 29.8, respectively, versus
Table 1 Baseline characteristics of breast and colorectal cancer patients. Characteristics
Day 5 breast
Day 16 breast
Day 5 colorectal
Day 16 colorectal
Patients (n) Gender M/F Mean age (range), years Patients >60 years, n (%) Chemotherapy, n (%) FEC FEC/docetaxel TAC AC Capox Folfox Previous vaccination, n (%) Comorbidity, n (%) Diabetes COPD/Astma
21 0/21 50.7 (35–65) 4 (19)
17 0/17 50.7 (33–71) 2 (12)
8 8/0 60.9 (43–77) 5 (63)
10 8/2 62.4 (53–67) 7 (70)
6 (29) 8 (38) 6 (29) 1 (5)
2 (12) 5 (29) 9 (53) 1 (6) 8 (100)
9 (90) 1(10) 4 (40)
8 (38)
1 (6)
2 (25) 2 (25) 2 (25)
1 (10)
FEC, 5-fluorouracil, epirubicin and cyclophosphamide. TAC, docetaxel, doxorubicin and cyclophosphamide. AC, doxorubicin and cyclophosphamide. Capox, capecitabine and oxaliplatin. Folfox, fluorouracil, oxaliplatin and folinacid. COPD, chronic obstructive pulmonary disease.
M.L. Wumkes et al. / Vaccine 31 (2013) 6177–6184
6181
Fig. 2. Haemagglutination inhibition (HI) antibody titres in breast cancer patients. Open bars show pre-vaccination GMT, horizontally striped bars show GMT 3 weeks post vaccination, vertically striped bars show 12 weeks post vaccination GMT. GMT, geometric mean titre. In the early vaccinated group vaccination induced a significant increase in GMT in all cases. Statistical significance is indicated as * P < 0.05, ** P < 0.01.
Table 2 Fraction of patients and healthy controls reaching the protective threshold of ≥40 HI antibody titres or reaching seroconversion, and mean increase in GMT. All Patients
All Breast
HI antibodies ≥40, n (%), pre-vaccination 22 (39) 15 (40) H3N2 23 (41) 15 (40) H1N1 B/Brisbane 13 (23) 6 (16) HI antibodies ≥40, n (%), 3 weeks post vaccination 43 (77) 26 (70) H3N2 40 (71) 22 (60) H1N1 35 (63) 21 (55) B/Brisbane Seroconversion, n (%) 24 (40) 12 (32) H3N2 30 (50) 14 (38) H1N1 25 (42) 17 (46) B/Brisbane Mean increase in GMT H3N2 4.5 3.5 4.0 2.4 H1N1 3.4 3.5 B/Brisbane HI antibodies ≥40, n (%), 12 weeks post vaccination 36 (64) 20 (56) H3N2 39 (70) 22 (61) H1N1 29 (52) 17 (47) B/Brisbane Seroconversion, n (%) 20 (35) 8 (22) H3N2 26 (45) 13 (36) H1N1 21 (36) 14 (39) B/Brisbane Mean increase in GMT 3.7 2.7 H3N2 3.7 2.4 H1N1 2.9 2.8 B/Brisbane
All Colorectal
Early Breast
Late Breast
Early Colorectal
7 (39) 8 (44) 7 (39)
8 (38) 10 (48) 2 (10)
7 (41) 5 (29) 4 (24)
3 (38) 4 (50) 4 (50)
4 (40) 4 (40) 3 (30)
17 (94) 18 (100) 14 (78)
18 (86) 17 (81) 12 (57)
8 (50)* 5 (31)* 9 (53)
7 (88) 8 (100) 6 (75)
10 (100) 10 (100) 8 (80)
11 (61) 15 (83) 8 (44)
10 (48) 10 (48) 11 (52)
2 (13)* 4 (25) 6 (38)
4 (50) 6 (75) 2 (25)
7 (70) 9 (90) 6 (60)
1.8* 1.4 2.4
8.0 9.3 2.6
12 (63) 15 (79) 9 (47)
8 (47) 7 (41) 8 (47)
8 (100) 8 (100) 6 (75)
8 (89) 9 (100) 6 (67)
7 (37) 8 (42) 9 (47)
1 (6)* 5 (29) 5 (29)
6 (75) 5 (63) 3 (38)
6 (67) 8 (89) 4 (44)
4.5 3.0 3.7
1.4 1.9 2.0
8.9 8.8 2.9
5.9 9.9 3.3
7.9 10.7 4.1 16 (94) 17 (100) 12 (71) 12 (71) 13 (77) 7 (41) 7.1 9.4 3.2
5.8 3.7 4.6
Late Colorectal
7.8 12.7 5.9
* Significantly different from the early vaccinated patients in the same category (breast or colorectal cancer) (P < 0.05) HI, haemagglutination inhibition; GMT, geometric mean titre.
6182
M.L. Wumkes et al. / Vaccine 31 (2013) 6177–6184
Fig. 3. Haemagglutination inhibition (HI) antibody titres in colorectal cancer patients. Open bars show pre-vaccination GMT, horizontally striped bars show GMT 3 weeks post vaccination, vertically striped bars show 12 weeks post vaccination GMT. GMT, geometric mean titre. In all cases vaccination induced a significant increase in GMT. Statistical significance is indicated as * P < 0.05, ** P < 0.01.
141.4 (P = 0.1), 245.9 (P = 0.8) and 190.4 (P = 0.2) in colorectal cancer patients not previously vaccinated. In breast cancer patients previously vaccinated GMT’s for H3N2, H1N1 and B/Brisbane were 92.9, 70.3 and 35.5, respectively, versus 57.2 (P = 0.2), 32.9 (P = 0.1) and 39.9 (P = 0.6) in breast cancer patients with no previous influenza vaccination. 3.4. Age In our total patient group (n = 56) patients older than 60 years of age had higher pre-vaccination HI titres for the H3N2 and H1N1 strains than younger patients (respectively GMT 54.4 versus 11.4, P < 0.01, GMT 41.2 versus 16.3, P = 0.02). There was however no difference in response between patients aged ≤60 years and aged >60 years in both breast cancer (P = 0.407) and colorectal cancer patients (P = 0.342). 3.5. Number of chemotherapy cycles The cycle number of the chemotherapy had no statistically significant influence on the post-vaccination HI titres. The number of chemotherapy cycles received at the moment of vaccination in our patient groups ranged from 1 to 6. The magnitude of the serum antibody response measured 3 weeks after influenza vaccination was not influenced by the number of chemotherapy cycles, neither in patients with breast cancer (H3N2, P = 0.3, H1N1, P = 0.5, B/Brisbane, P = 0.5) nor in patients with colorectal cancer (H3N2, P = 0.3, H1N1, P = 0.6, B/Brisbane, P = 0.3).
4. Discussion We studied the virus-specific serum antibody response to the influenza virus vaccine 2011/2012 in patients receiving adjuvant chemotherapy for either breast cancer or colorectal cancer. In breast cancer patients, we observed a statistically significant higher response in patients who received early compared to late vaccination in the chemotherapy cycle, a finding which confirmed our earlier preliminary data. In colorectal cancer patients overall virus-specific antibody responses were adequate and no significant difference was found between early and late vaccination with the influenza virus vaccine. In our cohort of colorectal cancer patients treated with adjuvant chemotherapy the serum antibody response to influenza vaccination appears to be intact. These finding might indicate that these patients not fully meet the criteria for risk group of influenza infection. Larger studies need to be carried out to confirm this hypothesis. We decided to study the serologic response in breast and colorectal cancer patients because these are the most common types of cancer treated with adjuvant chemotherapy (non metastatic disease). These tumours occur in patients of a relatively wide range of age which allows obtaining information about for example the effect of previous vaccination. The EMEA criteria were used to determine whether our patients showed an adequate antibody response to influenza vaccination. For that reason, no comparison was made with a healthy control group. Our 2009 pilot study already showed a significantly lower
M.L. Wumkes et al. / Vaccine 31 (2013) 6177–6184
antibody response in breast cancer patients receiving chemotherapy compared to healthy controls [11]. In case of a good antigenetic match between the vaccine strains and epidemic viruses, an efficacy of inactivated influenza virus vaccine in preventing influenza of 70–90% has been described in healthy adults [18,19]. Seroprotection (HI ≥40) is associated with at least a 50% reduction in risk for influenza infection [20–22]. This underlines the importance of influenza vaccination in risk groups. After twelve weeks the vaccine induced antibody levels persisted at protective levels in both groups which means that after influenza vaccination patients remain protected during at least 3 months and that subsequent chemotherapy cycles do not diminish the antibody titres. Three months protection does not cover the complete influenza season, which in the Netherlands is considered to last from week 48 to week 20. The antibody titers of the responder patients were however of a magnitude which would be expected to remain at the protective level for at least 2 additional months. The 3 month post vaccination time point was chosen to address two issues; first, whether chemotherapyinduced immunosuppression would cause a delay in the antibody response, second, whether chemotherapy would negatively influence the duration of protection (i.e. antibody levels above threshold for protection). Indeed, in the late breast cancer group, the antibody titers at month 3 for all 3 influenza strains are comparable in magnitude with that at 3 weeks. This finding could be compatible with a delay in the response. In none of the patient groups the antibody titers at 3 months had dropped below protective levels.
6183
cancer; therefore also patients with metastatic disease were included, also treatment with biotherapies (trastuzumab or bevazicumab) was permitted; both could have had an influence on the immune response. Loulergue et al. vaccinated their patients at day one of the chemotherapy; our patients were vaccinated at day 5. Ortbals et al. [12], showed a low response rate at the day of chemotherapy. Two issues require further discussion with regard to the comparison of early versus late vaccination during chemotherapy in breast cancer patients. First, a higher fraction of the early vaccinated breast cancer patients was vaccinated in the past, which potentially could result to a better antibody response. Pre-vaccination antibody titres were, however, not significantly different between the early patient group and the late group. Second, the TAC regimen was more frequently given in the late vaccinated patient group. TAC could lead to more myelosuppression compared to FEC. In the Netherlands patients treated with TAC-containing regimens are also treated with pegfilgrastim within 24–48 h after the chemotherapy. TAC is known to reduce numbers of white blood cells for relative long periods. Pegfilgrastim is a granulocyte colonystimulating factor (G-CSF), and is used to stimulate the growth of myeloid cells in the bone marrow and therefore to prevent infection. It is unknown how this would influence the response to vaccination. The patient groups were too small to investigate the effect of pegfilgrastim on the serum antibody immune response after influenza vaccination. 4.3. Antibody response in colorectal cancer patients
4.1. Limitations of the study The main limitation of the study is the small sample size. The total number of patients included and therefore the number of patients which completed this study is less than anticipated. This may have been due to the fact that at the beginning of the influenza vaccination campaign, a public debate was started on lack of effectiveness of influenza vaccination in general, and especially in risk-groups. Another factor was that for this patient category the study burden appeared to be too demanding. In our study, age and previous influenza vaccination have no statistically significant effect on the serum antibody response post influenza vaccination. However, both can have an important impact on the responsiveness to the vaccine. The lack of correlation is probably due to the relatively small patient groups. The hormone receptor status of the breast cancer patients has not been obtained; therefore a potential effect on the immune response could not be analyzed in our study. 4.2. Antibody response in breast cancer patients Previously, treatment with docetaxel has been associated with a lower antibody response to influenza vaccination [23]. However this study included a mixed population of patients with either breast cancer (n = 13) or prostate cancer treated with docetaxel as monotherapy has been studied. The overall response to influenza vaccination was found to be low, with seroconversion rates below 30%. Based on the low level of responsiveness they propose to more immunogenic influenza vaccines. In our patient cohort, docetaxel was not used as monotherapy but in combination with FEC. Comparison of the GMT response between the patients on FEC or FEC-docetaxel revealed no significant differences in any of the 3 influenza strains. Our data therefore do not indicate an additional immunosuppressive effect of docetaxel when given in addition to an FEC regimen. There are a few other possible explanations for the differences in antibody response between our study compared to the study of Loulergue et al. Breast cancer patients included in the study of Loulergue et al. were enrolled at any stage of breast
In colorectal cancer patients no difference in response to early or late vaccination was found. A possible explanation may be that oxaliplatin induces less myelosuppression than the chemotherapy regimens in breast cancer patients. It should be mentioned that our 2 patient groups not only differ in type of disease (breast or colorectal cancer) and chemotherapy regimen but also in sex distribution. Therefore, the differences in response to influenza vaccination could be due (at least in part) to a gender bias. Data in literature indicate that women show a higher antibody response to vaccination than men [24]. The better antibody response in the predominant male colorectal cancer group therefore is unlikely to be caused by a gender bias. In a recent study of Puthillath et al. [25] colorectal cancer patients show a low response to influenza vaccination irrespective of their chemotherapy regimen or timing. We find an adequate antibody response to all three influenza strains (according to EMEAcriteria). It should be noted that in the Puthillath paper, antibody responses were measured (only) at 3 months after vaccination. From their paper it cannot be concluded whether the patients on chemotherapy would have responded better at 3 weeks after vaccination. In our patient cohort it is clear that in the so-called late group, GMTs at 3 months are significantly lower than at 3 weeks (Fig. 3). Another possible explanation for the difference in outcome are that in the study of Puthillath the majority of the patients had stage IV colorectal cancer (metastatic disease) and our patients did not have metastases. Finally, Puthillath included patients with different chemotherapy regimens in their study, while we included only oxaliplatin-containing regimens. 4.4. Optimal timing of vaccination As indicated above, current guidelines on the optimal timing of vaccination in oncology patients treated with chemotherapy are mainly based on one small study, conducted in 1977, in which the response to influenza vaccination at the day of chemotherapy or at time of the white blood cell count nadir were compared. Those results showed that vaccines should not be administered at the
6184
M.L. Wumkes et al. / Vaccine 31 (2013) 6177–6184
day of chemotherapy [12]. Changes and development in vaccine formulations as well as chemotherapy regimens may explain the difference in response rates found by us compared to the 1977 study. Moreover, in our study influenza vaccination was not administered at the day of chemotherapy, but at day 5 of the cycle. Our pilot study in 2009 showed a trend towards better response after early vaccination (i.e. 4 days) in breast cancer patients. In the current study this trend is confirmed and even showed a significantly higher response after early vaccination of breast cancer patients. In most, including our own, studies patients are vaccinated with a single dose of influenza vaccine. However, it has been shown that a significant improvement in seroconversion rates can be obtained with two doses influenza vaccine in patients with hematological malignancies or solide tumors [26,27]. In the study of van der Velden et al. no great value of single and booster vaccinations with influenza virus vaccine in patients with hematological malignancies was found [28]. Whether patients on chemotherapy would benefit from an additional dose of (adjuvanted) vaccine therefore is an issue which still is open for study. In conclusion, influenza virus vaccination relatively early after the start of a cycle of chemotherapy (day 5) induces a significantly better serum antibody response when compared to vaccination at later time point (day 16) in patients with breast cancer treated with chemotherapy. In colorectal cancer patients this difference was not observed and adequate antibody responses that meet the EMEA criteria for vaccine licensure were seen in both groups. Follow up studies with larger patient numbers have to be conducted to determine the effect of the individual chemotherapy regimens, cycle number and the effect of pegfilgrastim on the influenza vaccine induced antibody response. Conflict of interest statement None declared. References [1] Cooksley CD, Hayney MS. Immunization recommendations for adults with cancer. Ann Pharmacother 2002;36:1219–29. [2] Thompson WWW, Shay DK, Weintraub E, et al. Mortality associated with influenza and respiratory synctial virus in the united states. JAMA 2003;289:179–86. [3] Health Council of the Netherlands. Influenza vaccination: revision of the indication. The Netherlands: The Hague: Health Council of the Netherlands, Publication no. 2007/09E; 2007, ISBN 978-90-5549-712-6. [4] Arrowood JR, Hayney MS. Immunization recommendations for adults with cancer. Ann Pharmacother 2002;36:1219–29. [5] Brydak LB, Guzy J, Starzyk J, et al. Humoral immune response after vaccination against influenza in patients with breast cancer. Support Care Cancer 2001;9:65–8. [6] Loulergue P, Mir O, Alexandre J, et al. Low influenza vaccination rate among patients receiving chemotherapy for cancer. Ann Oncol 2008;19:1658.
[7] Anderson H, Petrie K, Berrisford C, et al. Seroconversion after influenza vaccination in patients with lung cancer. Br J Cancer 1999;80:219–20. [8] Vilar-Compte D, Cornejo P, Valle-Salinas A, et al. Influenza vaccination in patients with breast cancer: a case-series analysis. Med Sci Monit 2006;12:CR332–6. [9] Meerveld-Eggink A, de Weerdt O, van der Velden AMT, et al. Response to influenza virus vaccination during chemotherapy in patients with breast cancer. Ann Oncol 2011;22:20131–2035. [10] Pollyea D, Brown J, Horning S. Utility of influenza vaccination for oncology patients. J Clin Oncol 2010;14:2481–90. [11] Sommer AL, Wachel BK, Smith JA. Evaluation of vaccine dosing in patients with solid tumors receiving myelosuppressive chemotherapy. J Oncol Pharm Pract 2006;12:143–54. [12] Ortbals DW, Liebhaber H, Presant CA, et al. Influenza immunization of adult patients with malignant diseases. Ann Intern Med 1977;87:552–7. [13] Masurel N, Ophof P, de Jong P. Antibody response to immunization with influenza A/USSR/77 (H1N1) virus in young individuals primed or unprimed for A/New Jersey/76 (H1N1) virus. J Hyg (Lond) 1981;87:201–9. [14] Gelinck LB, van den Bemt BJ, Marijt WA, et al. Intradermal influenza vaccination in immunocompromized patients is immunogenic and feasible. Vaccine 2009;27:2469–74. [15] Schmidt-O.T.T R, Schwarz T, Haase R, et al. Immunogenicity and reactogenicity of a trivalent influenza split vaccine in previously unvaccinated children aged 6–9 and 10–13 years. Vaccine 2007;26:32–40. [16] Damen JE. Harmonization of requirements for influenza virus vaccines: the first year’s experience with the EEC guideline. Biologicals 1993;21: 179–82. [17] Committee for Proprietary Medicinal Products (CPMP). Note for guidance on harmonisation of requirements for influenza vaccines (CPMP/BWP/214/96); 1997. [18] Fiore AE, Shay DK, Broder K, et al. Prevention and control of influenza: recommendations of the advisory committee on immunization practices (ACIP). MMWR Recomm Rep 2008;57:1–60. [19] Hicks KL, Chemaly RF, Kontoyiannis DP. Common community respiratory viruses in patients with cancer:more than just “common colds”. Cancer 2003;97:2576–87. [20] Eastwood LM, Jennings R, Milner RD, et al. Reactogenicity and immunogenicity of a surface-antigen-adsorbed influenza virus vaccine in children. J Clin Pathol 1979;32:534–7. [21] Potter CW, Oxford JS. Determinants of immunity to influenza infection in man. Br Med Bull 1979;35:69–75. [22] Centers for Disease Control and Prevention (CDC). Serum cross-reactive antibody response to a novel influenza A (H1N1) virus after vaccination with seasonal influenza vaccine MMWR Morb Mortal Wkly Rep, 58; 2009. p. 521–4. [23] Loulergue P, Alexandre J, Iurisci I, et al. Low immunogenicity of seasonal trivalent influenza vaccine among patients receiving docetaxel for a solid tumour: results of a prospective pilot study. Br J Cancer 2011;104:1670–4. [24] World Health Organization. Sex, gender and influenza. http://whqlibdoc. who.int/publications/2010/9789241500111 eng.pdf [25] Puthillath A, Trump DL, Andrews C, et al. Serological immune responses to influenza vaccine in patients with colorectal cancer. Cancer Chemother Pharmacol 2011;67:111–5. [26] Hottinger AF, George AC, Bel M, Favet L, Combescure C, Meier S, Grillet S, PosfayBarbe K, Kaiser L, Siegrist CA, Dietrich PY. H1N1 study group a prospective study of the factors shaping antibody responses to the AS03-adjuvanted influenza A/H1N1 vaccine in cancer outpatients. Oncologist 2012;17:436–45. [27] Lo W, Whimbey E, Elting L, Couch R, Cabanillas F, Bodey G. Antibody response to a two-dose influenza vaccine regimen in adult lymphoma patients on chemotherapy. Eur J Clin Microbiol Infect Dis 1993;12:778–82. [28] van der Velden AM, Mulder AH, Hartkamp A, Diepersloot RJ, van Velzen-Blad H. Biesma DH. Influenza virus vaccination and booster in B-cell chronic lymphocytic leukaemia patients. Eur J Intern Med 2001;12:420–4.
Contents lists available at ScienceDirect
Vaccine journal homepage: www.elsevier.com/locate/vaccine
Serum antibody response to influenza virus vaccination during chemotherapy treatment in adult patients with solid tumours M.L. Wumkes a,∗ , A.M.T. van der Velden a , M. Los b , M.B.L. Leys c , A. Beeker d , M.R. Nijziel e , A.W.G. van der Velden f , M. Westerman g , A. Meerveld-Eggink b , G.F. Rimmelzwaan h , G.T. Rijkers i , D.H. Biesma b,j a
Department of Internal Medicine, Tergooi Hilversum/Blaricum,Tergooi Hilversum, PO Box 10016, 1201 DA Hilversum, The Netherlands Department of Internal Medicine, St. Antonius Hospital Nieuwegein, Nieuwegein; St. Antonius Hospital, PO Box 2500, 3430 EM Nieuwegein, The Netherlands c Department of Internal Medicine, Maasstad Hospital Rotterdam, Rotterdam, Maasstad Hospital, PO Box 9100, 3007 AC Rotterdam, The Netherlands d Department of Internal Medicine, Spaarne Hospital Hoofddorp, Hoofddorp, Spaarne Hospital, PO Box 770, 2130 AT Hoofddorp, The Netherlands e Department of Internal Medicine, Maxima Medical Centre Eindhoven, Eindhoven, Maxima Medical Centre Eindhoven, PO Box 90052, 5600 PD Eindhoven, The Netherlands f Department of Internal Medicine, Martini Hospital Groningen, Groningen, Martini Hospital Groningen, PO Box 30033, 9700 RM Groningen, The Netherlands g Department of Internal Medicine, Medical Centre Alkmaar, Alkmaar, Medical Centre Alkmaar, PO Box 501, 1800 AM Alkmaar, The Netherlands h Department of Virology, Erasmus Medical Center, Rotterdam; Erasmus Medical Center, PO Box 2040, 3000 CA Rotterdam, The Netherlands i Department of Medical Microbiology and Immunology, St. Antonius Hospital Nieuwegein, Nieuwegein; St. Antonius Hospital, PO Box 2500, 3430 EM Nieuwegein, The Netherlands j Department of Internal Medicine, University Medical Centre Utrecht, Utrecht, the Netherlands University Medical Centre Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands b
a r t i c l e
i n f o
Article history: Received 2 July 2013 Received in revised form 27 September 2013 Accepted 16 October 2013 Available online 29 October 2013 Keywords: Chemotherapy Influenza virus vaccination Solid tumours
a b s t r a c t Background: Higher rates of hospitalization and mortality are described in oncology patients with influenza virus infection compared to the general population. Yearly influenza vaccination is recommended for patients treated with chemotherapy. The optimal moment to administer the vaccine during a treatment cycle has not been studied extensively. Patients and methods: During the influenza season 2011–2012 we conducted a multicenter randomized controlled trial (OFLUVAC, NTR2858, no sponsoring) in the Netherlands. Patients receiving adjuvant chemotherapy for breast or colorectal cancer were randomized between early (day 5 after chemotherapy) and late (day 16 after chemotherapy) vaccination with the influenza virus vaccine (Influvac® 2011/2012—Vaxigrip® 2011/2012). Influenza virus-specific antibody titres were determined before, 3 and 12 weeks after vaccination by haemagglutination inhibition. Results: Thirty-eight breast cancer patients (early = 21; late = 17) and 18 colorectal cancer patients (early = 8; late = 10) were analyzed. In breast cancer patients overall serologic responses were adequate. A statistically significant higher response in patients who received early compared to late vaccination in the chemotherapy cycle was observed. Geometric mean titres post vaccination on day 5 versus day 16 were 69.3 versus 27.4 (H3N2), 76.4 versus 17.5 (H1N1) and 34.4 versus 26.0 (B/Brisbane), respectively. In colorectal cancer patients overall serologic responses were adequate, no significant difference was found between early and late vaccination. Geometric mean titres post vaccination on day 5 versus day 16 were 170.1 versus 192.4 (H3N2), 233.0 versus 280.8 (H1N1) and 62.6 versus 75.9 (B/Brisbane), respectively. Conclusion: Overall antibody response to the influenza virus vaccine in patients treated with chemotherapy for breast or colorectal cancer patients is adequate. Breast cancer patients seem to mount the best antibody response when vaccinated early after a chemotherapy cycle (≤day 5). No difference was found between early and late vaccination in colorectal cancer patients. © 2013 Elsevier Ltd. All rights reserved.
∗ Corresponding author. Tel.: +31 88 7531753; fax: +31 35 5391235. E-mail addresses: [email protected] (M.L. Wumkes), [email protected] (A.M.T. van der Velden), [email protected] (M. Los), [email protected] (M.B.L. Leys), [email protected] (A. Beeker), [email protected] (M.R. Nijziel), [email protected] (A.W.G. van der Velden), [email protected] (M. Westerman), [email protected] (A. Meerveld-Eggink), [email protected] (G.F. Rimmelzwaan), [email protected] (G.T. Rijkers), [email protected] (D.H. Biesma). 0264-410X/$ – see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.vaccine.2013.10.053
6178
M.L. Wumkes et al. / Vaccine 31 (2013) 6177–6184
1. Introduction Higher rates of hospitalization and mortality are described in oncology patients with influenza virus infection compared to the general population [1]. Because of immunosuppressive factors influencing the response to viral infections, patients with cancer are at risk for serious post-influenza complications including secondary bacterial pneumonia, otitis media, sinusitis or deterioration of chronic respiratory or cardiac conditions [2]. Therefore, yearly influenza vaccination is strongly recommended for patients treated with chemotherapy or other immunosuppressive drugs [3], although their immune response may be suboptimal [4]. Two factors influence the immune status and the response to immunization in patients with cancer. First, their disease state can be directly immunosuppressive, this is of particular importance in haematological malignancies. Second, most treatment modalities for cancer have (severe) immunosuppressive effects. Chemotherapy is designed to destroy rapidly growing tumour cells, but will inevitably also impair haematopoiesis. Moreover, full functional capacity of cells of the immune system depends on clonal expansion of antigen specific lymphocytes and is therefore adversely affected [5]. Despite the recommendations and availability of effective influenza vaccines, vaccination coverage is low in cancer patients with chemotherapy treatment [6]. This may be due to conflicting conclusions on the efficacy and optimal moment of administering the vaccine as well as the lack of (inter)national guidelines. Indeed, limited data are available on the utility of influenza vaccination during ongoing chemotherapy regimens. Several studies of patients with lung and breast cancer, with or without receiving treatment, showed these patients have the ability to mount protective antibody titres to influenza vaccination ([5,7–9] reviewed by [10]). In general, it is recommended to vaccinate before start of chemotherapy treatment [10,11]. However, many patients are vaccinated while on chemotherapy because the seasonal influenza vaccination campaign is restricted to the months October and November and because of the duration of the treatment course. The optimal moment to administer the vaccine during a treatment cycle remains unclear [8]. Current recommendations, to vaccinate on the furthest time point from chemotherapy, are based on a single study from 1977 which included only a very limited number of patients (n = 11) [12]. During the influenza vaccination period in 2009, we have conducted a pilot study in patients with breast cancer. Breast cancer patients receiving chemotherapy, were randomized for early (day 4 of the chemotherapy cycle) or late (day 16 of the chemotherapy cycle) influenza vaccination. In this study, patients vaccinated at day 4 tended to reach higher antibody levels compared to patients vaccinated at day 16 [9]. To confirm this observed effect we designed a study in which we evaluate the antibody response to influenza vaccination during chemotherapy and assess the effect of timing of influenza vaccination during chemotherapy in breast cancer and colorectal cancer patients.
2. Patients and methods 2.1. Study design In this multicenter trial, patients receiving adjuvant chemotherapy for breast cancer or colorectal cancer were randomized between early (day 5 after chemotherapy: at least 48 h after the last gift of steroids) and late (day 16 after chemotherapy)
vaccination with influenza virus vaccine. The study has been carried out in accordance with the Declaration of Helsinki. 2.2. Patients We included adult patients (age ≥18 years) who received adjuvant chemotherapy (non- metastatic disease) because of breast cancer or colorectal cancer. Patients with breast cancer were treated with three weekly regimens containing FEC (5-fluorouracil 500 mg/m2 , epirubicin 100 mg/m2 and cyclophosphamide 500 mg/m2 ) six cycles, FEC three cycles followed by docetaxel (100 mg/m2 ) three cycles, TAC (docetaxel 50 mg/m2 , doxorubicin 75 mg/m2 and cyclophosphamide 500 mg/m2 ) six cycles or AC (doxorubicin 60 mg/m2 , cyclophosphamide 600 mg/m2 ) four cycles (followed by paclitaxel and trastuzumab). All breast cancer patients were her −2/neu negative. Patients with colorectal cancer were treated with oxaliplatincontaining regimens: Capox (oxaliplatin 130 mg/m2 and capecitebine 1000 mg/m2 [28 dosages]) given in eight cycles of three weeks. Exclusion criteria were fever at time of vaccination (defined as a temperature of ≥38.5 ◦ C), previous allergic reaction to any of the components of the vaccines given (for example hypersensitivity to egg protein) and thrombocytopenia (defined as <50 × 109 /L) at moment of vaccination. This study was approved by the united committee on research involving human subjects (VCMO—Verenigde Commissies Mensgebonden Onderzoek) at Nieuwegein, the Netherlands. All patients signed informed consent. The study was registered at the trial register of the Netherlands (NTR) with ID number NTR-2858. This multicenter randomized trial was carried out in seven hospitals in the Netherlands. Eligible patients were randomized for early (day 5) or late (day 16) vaccination during a three weekly chemotherapy cycle. A randomization schedule was used in which patients were randomized 1:1 in blocks of 10 patients. Patients were allocated to either group in order of notification of the principal investigator. 2.3. Vaccination In the period October–December 2011, patients received one of the two available seasonal influenza virus vaccines Influvac® 2011/2012, Abbott Biologicals B.V, Weesp, the Netherlands and Vaxigrip® 2011/2012, Sanofi Pasteur MSD, Brussels, Belgium, (one dose of 0.5 mL, subcutaneous or intramuscular injection in upper arm), dependent on which vaccine was used in the respective participating hospitals. The available vaccines each contain 15 g haemagglutinin of the following influenza strains: A/California/7/2009 (H1N1)-like strain, A/Perth/16/2009 (H3N2)-like strain, B/Brisbane/60/2008like strain, according to the WHO-recommendations and EUdecision for the influenza season 2011–2012. 2.4. Laboratory investigations Serum samples were collected before, three weeks after and twelve weeks after vaccination and stored at −70 ◦ C until use. Before vaccination, differential blood cell counts were carried out. Antibodies to the haemagglutinin of all three vaccine strains were measured by the haemagglutination inhibition (HI) test according to standard procedures using four haemagglutinating units of each virus and turkey erythrocytes [13,14]. Two-fold serial dilutions of patient sera were tested with a starting dilution of 1:20. Sera were pre-treated with receptor-destroying enzyme (Vibrio cholera filtrate) to remove non-specific inhibitors and subsequently tested for HI antibodies specific for the viruses: A/California/7/2009
M.L. Wumkes et al. / Vaccine 31 (2013) 6177–6184
(H1N1, A/Perth/16/2009 (H3N2) and B/Brisbane/60/2008. The antibody titre is expressed as the reciprocal value of the highest dilution that still inhibits agglutination. Data are expressed as geometric mean HI titre (HI GMT), seroprotection rate (SPR; i.e. the percentage of vaccine recipients with a serum HI titre ≥40 post vaccination) and seroconversion rate (SCR; i.e. the percentage of vaccine recipients with a fourfold increase or more in post vaccination titre) [15,16]. According to the criteria of the EMEA (European Agency for the Evaluation of Medicinal Products) in healthy adults ≤60 years of age, an adequate response to vaccination includes one of the following three requirements of the serological assessments: SPR >70%, SCR ≥40% and mean increase in GMT >2.5. For healthy adults >60 years of age, the criteria for an adequate response include one of the following requirements: SPR >60%, SCR >30% and GMT >2.0 [17]. 2.5. Statistical analysis IBM® SPSS® version 19.0 has been used for statistical analyses. Descriptive statistics, such as the mean, median, counts and proportion, were used to characterize the patient populations. Comparisons of GMT before and after vaccination (paired samples) were carried out using the Wilcoxin signed rank test. Fisher’s exact test was used to compare groups. A P-value of <0.05 was considered statistically significant. 3. Results A total of one hundred and fifty patients with breast cancer or colorectal cancer were assessed for eligibility. Fourteen patients did not meet the inclusion criteria; reasons for exclusion were language barrier (n = 1), allergies (n = 1) and having received the influenza vaccine 2011–2012 (n = 12) before assessment. Sixtyseven patients declined to participate; 27 patients did not want to participate in a study, 40 patients refused influenza vaccination and therefore declined to participate in the study. Sixty-nine patients were randomized, 50 breast cancer patients and 19 colorectal cancer patients. Twenty-eight breast cancer patients were randomized to early vaccination, 22 to late vaccination. Nine colorectal cancer patients were randomized to early vaccination and 10 to late vaccination. After randomization a total of 12 patients (11 breast cancer patients, 1 colorectal cancer patient) decided to withdraw from the study because the burden was to high (vaccination and three times vena punction). One breast cancer patient discontinued the study after vaccination for unknown reasons and could not be analyzed. The 12 weeks post vaccination sera of three patients and the 3 weeks post vaccination serum of one patient were not available and therefore excluded from analysis (Fig. 1). The serum antibody response to vaccination was compared between 21 early vaccinated breast cancer patients and 17 late vaccinated breast cancer patients. The serologic response of colorectal cancer patients were analyzed in a similar manner with 8 patients vaccinated on day 5 and 10 patients vaccinated on day 16. In Table 1, baseline characteristics of the breast cancer and colorectal cancer patients are given. The groups did not significantly differ in age, type of chemotherapy, previous vaccination or comorbidity such as hypertension, coronary heart disease or thyroid disease. One colorectal cancer patient was treated with Folfox (oxaliplatin 85 mg/m2 /day, 5-fluorouracil 400 mg/m2 day 1–2, 5fluorouracil 600 mg/m2 , folic acid 200 mg/m2 ) in a three-weekly regimen due to side effects in the original two-weekly regimen. Haemagglutination inhibition titres were measured prevaccination and three and 12 weeks post vaccination. Antibody
6179
titres were determined separately for each influenza strain in the vaccine (Figs. 2 and 3). 3.1. Antibody response in breast cancer patients In the early breast cancer patient group, GMT three weeks post vaccination increased statistically significant for all three virus strains. Twelve weeks after vaccination the GMTincrease remained statistically significant. In the late breast cancer patient group an increase in GMT post vaccination found for all virus strains, but was only statistically significant after 12 weeks for the A/H1N1 and B/Brisbane virus strains. The decrease in GMT twelve weeks after vaccination compared to the response after three weeks, is statistically significant (P = 0.015). After three weeks the early group met all three criteria of the EMEA for defining an adequate response for the H3N2 and H1N1virus strains. (Table 2) It met only two criteria for B/Brisbane; SCR and mean increase in GMT .In the late patient group, SPR, SCR and mean increase in GMT criteria are not met for any virus strain. No significant differences were found between the pre-vaccination titres in the early and late patient group. Three weeks after vaccination early vaccinated breast cancer patients had a statistically significant better response to the H3N2 virus strain in terms of seroprotection, seroconversion and mean increase in GMT when compared to the late patient group. The percentage of patients with seroprotection against H1N1 was also significantly higher in comparison to late vaccinated breast cancer patients. After twelve weeks the early patient group still met all criteria for the H1N1 strain. Two criteria, SCR and mean increase in GMT, were met for B/Brisbane and the H3N2 virus strain only met the criteria for mean increase in GMT. The late group did not meet any of the criteria for an adequate response. After twelve weeks the seroconversion rate was significantly higher in the early vaccinated patient group. These data therefore confirmed our previous findings that influenza vaccination early during chemotherapy leads to a better antibody response. The chemotherapy regimen itself had no statistically significant influence on the post vaccination antibody titers. Comparison of the GMT response between the patients on FEC or FEC-docetaxel revealed no significant differences in any of the 3 influenza strains (GMT for H3N2 was 50 and 68.8 in the FEC and the FEC-docetaxel group, respectively (P = 0.605; for H1N1 48.3 and 79.9 (P = 0.571) and for B/Brisbane 12.5 and 53 (P = 0.067)). Our data therefore do not indicate an additional immunosuppressive effect of docetaxel when given in addition to an FEC regimen. 3.2. Antibody response in colorectal cancer patients In both colorectal cancer patient groups, early and late vaccination, GMT three weeks post vaccination increased statistically significant for the H3N2 and H1N1 virus strains. In the late patient group there was also a significant increase for B/Brisbane (P = 0.01). After twelve weeks the increase in GMT remains statistically significant for the virus strains H3N2 and H1N1. In the early patient group, the increase in GMT for B/Brisbane is significant (P = 0.027). No significant difference was found between the prevaccination titres in the early and late patient group. In colorectal cancer patients there is no statistically significant difference in the serological response to the influenza virus vaccine of the early and late group. After three weeks the early group met all three criteria for an adequate response for the H3N2 and H1N1 virus strains, for B/Brisbane only SCR >40% was not met. The late patient group met all criteria for all three virus strains.
6180
M.L. Wumkes et al. / Vaccine 31 (2013) 6177–6184
Fig. 1. Consolidated standards of reporting trials diagram. B: Breast cancer patients C: colorectal cancer patients.
After twelve weeks the response of the early patient group remained adequate, with exception of the seroconversion rate for B/Brisbane. In the late group all criteria were met for the H3N2 and H1N1 virus strains. For B/Brisbane only SCR and mean increase in GMT met the criteria (Table 2). It can be concluded that in patients with colorectal cancer, influenza vaccination either early or late during chemotherapy induces an adequate antibody response. 3.3. Previous influenza vaccination Eight colorectal cancer patients and 13 breast cancer patients had been previously vaccinated (during 1 − >10 influenza seasons
but most patients only once or twice). Seven colorectal cancer patients did not have previous vaccination, as well as 15 breast cancer patients. For the other patients, the vaccination status was unknown. Not all patients aged above 60 years received prior influenza vaccination (56%) but substantially more often than younger patients (29%). In colorectal cancer patients prevaccination titers of H3N2 were significantly higher in previously vaccinated patients than in patients who were influenza vaccine naïve (GMT 73.9 versus 6, P = 0.036). No significant differences were found in post vaccination titers. In previously vaccinated colorectal cancer patients post vaccination GMT’s for H3N2, H1N1 and B/Brisbane were 210.6, 329.5 and 29.8, respectively, versus
Table 1 Baseline characteristics of breast and colorectal cancer patients. Characteristics
Day 5 breast
Day 16 breast
Day 5 colorectal
Day 16 colorectal
Patients (n) Gender M/F Mean age (range), years Patients >60 years, n (%) Chemotherapy, n (%) FEC FEC/docetaxel TAC AC Capox Folfox Previous vaccination, n (%) Comorbidity, n (%) Diabetes COPD/Astma
21 0/21 50.7 (35–65) 4 (19)
17 0/17 50.7 (33–71) 2 (12)
8 8/0 60.9 (43–77) 5 (63)
10 8/2 62.4 (53–67) 7 (70)
6 (29) 8 (38) 6 (29) 1 (5)
2 (12) 5 (29) 9 (53) 1 (6) 8 (100)
9 (90) 1(10) 4 (40)
8 (38)
1 (6)
2 (25) 2 (25) 2 (25)
1 (10)
FEC, 5-fluorouracil, epirubicin and cyclophosphamide. TAC, docetaxel, doxorubicin and cyclophosphamide. AC, doxorubicin and cyclophosphamide. Capox, capecitabine and oxaliplatin. Folfox, fluorouracil, oxaliplatin and folinacid. COPD, chronic obstructive pulmonary disease.
M.L. Wumkes et al. / Vaccine 31 (2013) 6177–6184
6181
Fig. 2. Haemagglutination inhibition (HI) antibody titres in breast cancer patients. Open bars show pre-vaccination GMT, horizontally striped bars show GMT 3 weeks post vaccination, vertically striped bars show 12 weeks post vaccination GMT. GMT, geometric mean titre. In the early vaccinated group vaccination induced a significant increase in GMT in all cases. Statistical significance is indicated as * P < 0.05, ** P < 0.01.
Table 2 Fraction of patients and healthy controls reaching the protective threshold of ≥40 HI antibody titres or reaching seroconversion, and mean increase in GMT. All Patients
All Breast
HI antibodies ≥40, n (%), pre-vaccination 22 (39) 15 (40) H3N2 23 (41) 15 (40) H1N1 B/Brisbane 13 (23) 6 (16) HI antibodies ≥40, n (%), 3 weeks post vaccination 43 (77) 26 (70) H3N2 40 (71) 22 (60) H1N1 35 (63) 21 (55) B/Brisbane Seroconversion, n (%) 24 (40) 12 (32) H3N2 30 (50) 14 (38) H1N1 25 (42) 17 (46) B/Brisbane Mean increase in GMT H3N2 4.5 3.5 4.0 2.4 H1N1 3.4 3.5 B/Brisbane HI antibodies ≥40, n (%), 12 weeks post vaccination 36 (64) 20 (56) H3N2 39 (70) 22 (61) H1N1 29 (52) 17 (47) B/Brisbane Seroconversion, n (%) 20 (35) 8 (22) H3N2 26 (45) 13 (36) H1N1 21 (36) 14 (39) B/Brisbane Mean increase in GMT 3.7 2.7 H3N2 3.7 2.4 H1N1 2.9 2.8 B/Brisbane
All Colorectal
Early Breast
Late Breast
Early Colorectal
7 (39) 8 (44) 7 (39)
8 (38) 10 (48) 2 (10)
7 (41) 5 (29) 4 (24)
3 (38) 4 (50) 4 (50)
4 (40) 4 (40) 3 (30)
17 (94) 18 (100) 14 (78)
18 (86) 17 (81) 12 (57)
8 (50)* 5 (31)* 9 (53)
7 (88) 8 (100) 6 (75)
10 (100) 10 (100) 8 (80)
11 (61) 15 (83) 8 (44)
10 (48) 10 (48) 11 (52)
2 (13)* 4 (25) 6 (38)
4 (50) 6 (75) 2 (25)
7 (70) 9 (90) 6 (60)
1.8* 1.4 2.4
8.0 9.3 2.6
12 (63) 15 (79) 9 (47)
8 (47) 7 (41) 8 (47)
8 (100) 8 (100) 6 (75)
8 (89) 9 (100) 6 (67)
7 (37) 8 (42) 9 (47)
1 (6)* 5 (29) 5 (29)
6 (75) 5 (63) 3 (38)
6 (67) 8 (89) 4 (44)
4.5 3.0 3.7
1.4 1.9 2.0
8.9 8.8 2.9
5.9 9.9 3.3
7.9 10.7 4.1 16 (94) 17 (100) 12 (71) 12 (71) 13 (77) 7 (41) 7.1 9.4 3.2
5.8 3.7 4.6
Late Colorectal
7.8 12.7 5.9
* Significantly different from the early vaccinated patients in the same category (breast or colorectal cancer) (P < 0.05) HI, haemagglutination inhibition; GMT, geometric mean titre.
6182
M.L. Wumkes et al. / Vaccine 31 (2013) 6177–6184
Fig. 3. Haemagglutination inhibition (HI) antibody titres in colorectal cancer patients. Open bars show pre-vaccination GMT, horizontally striped bars show GMT 3 weeks post vaccination, vertically striped bars show 12 weeks post vaccination GMT. GMT, geometric mean titre. In all cases vaccination induced a significant increase in GMT. Statistical significance is indicated as * P < 0.05, ** P < 0.01.
141.4 (P = 0.1), 245.9 (P = 0.8) and 190.4 (P = 0.2) in colorectal cancer patients not previously vaccinated. In breast cancer patients previously vaccinated GMT’s for H3N2, H1N1 and B/Brisbane were 92.9, 70.3 and 35.5, respectively, versus 57.2 (P = 0.2), 32.9 (P = 0.1) and 39.9 (P = 0.6) in breast cancer patients with no previous influenza vaccination. 3.4. Age In our total patient group (n = 56) patients older than 60 years of age had higher pre-vaccination HI titres for the H3N2 and H1N1 strains than younger patients (respectively GMT 54.4 versus 11.4, P < 0.01, GMT 41.2 versus 16.3, P = 0.02). There was however no difference in response between patients aged ≤60 years and aged >60 years in both breast cancer (P = 0.407) and colorectal cancer patients (P = 0.342). 3.5. Number of chemotherapy cycles The cycle number of the chemotherapy had no statistically significant influence on the post-vaccination HI titres. The number of chemotherapy cycles received at the moment of vaccination in our patient groups ranged from 1 to 6. The magnitude of the serum antibody response measured 3 weeks after influenza vaccination was not influenced by the number of chemotherapy cycles, neither in patients with breast cancer (H3N2, P = 0.3, H1N1, P = 0.5, B/Brisbane, P = 0.5) nor in patients with colorectal cancer (H3N2, P = 0.3, H1N1, P = 0.6, B/Brisbane, P = 0.3).
4. Discussion We studied the virus-specific serum antibody response to the influenza virus vaccine 2011/2012 in patients receiving adjuvant chemotherapy for either breast cancer or colorectal cancer. In breast cancer patients, we observed a statistically significant higher response in patients who received early compared to late vaccination in the chemotherapy cycle, a finding which confirmed our earlier preliminary data. In colorectal cancer patients overall virus-specific antibody responses were adequate and no significant difference was found between early and late vaccination with the influenza virus vaccine. In our cohort of colorectal cancer patients treated with adjuvant chemotherapy the serum antibody response to influenza vaccination appears to be intact. These finding might indicate that these patients not fully meet the criteria for risk group of influenza infection. Larger studies need to be carried out to confirm this hypothesis. We decided to study the serologic response in breast and colorectal cancer patients because these are the most common types of cancer treated with adjuvant chemotherapy (non metastatic disease). These tumours occur in patients of a relatively wide range of age which allows obtaining information about for example the effect of previous vaccination. The EMEA criteria were used to determine whether our patients showed an adequate antibody response to influenza vaccination. For that reason, no comparison was made with a healthy control group. Our 2009 pilot study already showed a significantly lower
M.L. Wumkes et al. / Vaccine 31 (2013) 6177–6184
antibody response in breast cancer patients receiving chemotherapy compared to healthy controls [11]. In case of a good antigenetic match between the vaccine strains and epidemic viruses, an efficacy of inactivated influenza virus vaccine in preventing influenza of 70–90% has been described in healthy adults [18,19]. Seroprotection (HI ≥40) is associated with at least a 50% reduction in risk for influenza infection [20–22]. This underlines the importance of influenza vaccination in risk groups. After twelve weeks the vaccine induced antibody levels persisted at protective levels in both groups which means that after influenza vaccination patients remain protected during at least 3 months and that subsequent chemotherapy cycles do not diminish the antibody titres. Three months protection does not cover the complete influenza season, which in the Netherlands is considered to last from week 48 to week 20. The antibody titers of the responder patients were however of a magnitude which would be expected to remain at the protective level for at least 2 additional months. The 3 month post vaccination time point was chosen to address two issues; first, whether chemotherapyinduced immunosuppression would cause a delay in the antibody response, second, whether chemotherapy would negatively influence the duration of protection (i.e. antibody levels above threshold for protection). Indeed, in the late breast cancer group, the antibody titers at month 3 for all 3 influenza strains are comparable in magnitude with that at 3 weeks. This finding could be compatible with a delay in the response. In none of the patient groups the antibody titers at 3 months had dropped below protective levels.
6183
cancer; therefore also patients with metastatic disease were included, also treatment with biotherapies (trastuzumab or bevazicumab) was permitted; both could have had an influence on the immune response. Loulergue et al. vaccinated their patients at day one of the chemotherapy; our patients were vaccinated at day 5. Ortbals et al. [12], showed a low response rate at the day of chemotherapy. Two issues require further discussion with regard to the comparison of early versus late vaccination during chemotherapy in breast cancer patients. First, a higher fraction of the early vaccinated breast cancer patients was vaccinated in the past, which potentially could result to a better antibody response. Pre-vaccination antibody titres were, however, not significantly different between the early patient group and the late group. Second, the TAC regimen was more frequently given in the late vaccinated patient group. TAC could lead to more myelosuppression compared to FEC. In the Netherlands patients treated with TAC-containing regimens are also treated with pegfilgrastim within 24–48 h after the chemotherapy. TAC is known to reduce numbers of white blood cells for relative long periods. Pegfilgrastim is a granulocyte colonystimulating factor (G-CSF), and is used to stimulate the growth of myeloid cells in the bone marrow and therefore to prevent infection. It is unknown how this would influence the response to vaccination. The patient groups were too small to investigate the effect of pegfilgrastim on the serum antibody immune response after influenza vaccination. 4.3. Antibody response in colorectal cancer patients
4.1. Limitations of the study The main limitation of the study is the small sample size. The total number of patients included and therefore the number of patients which completed this study is less than anticipated. This may have been due to the fact that at the beginning of the influenza vaccination campaign, a public debate was started on lack of effectiveness of influenza vaccination in general, and especially in risk-groups. Another factor was that for this patient category the study burden appeared to be too demanding. In our study, age and previous influenza vaccination have no statistically significant effect on the serum antibody response post influenza vaccination. However, both can have an important impact on the responsiveness to the vaccine. The lack of correlation is probably due to the relatively small patient groups. The hormone receptor status of the breast cancer patients has not been obtained; therefore a potential effect on the immune response could not be analyzed in our study. 4.2. Antibody response in breast cancer patients Previously, treatment with docetaxel has been associated with a lower antibody response to influenza vaccination [23]. However this study included a mixed population of patients with either breast cancer (n = 13) or prostate cancer treated with docetaxel as monotherapy has been studied. The overall response to influenza vaccination was found to be low, with seroconversion rates below 30%. Based on the low level of responsiveness they propose to more immunogenic influenza vaccines. In our patient cohort, docetaxel was not used as monotherapy but in combination with FEC. Comparison of the GMT response between the patients on FEC or FEC-docetaxel revealed no significant differences in any of the 3 influenza strains. Our data therefore do not indicate an additional immunosuppressive effect of docetaxel when given in addition to an FEC regimen. There are a few other possible explanations for the differences in antibody response between our study compared to the study of Loulergue et al. Breast cancer patients included in the study of Loulergue et al. were enrolled at any stage of breast
In colorectal cancer patients no difference in response to early or late vaccination was found. A possible explanation may be that oxaliplatin induces less myelosuppression than the chemotherapy regimens in breast cancer patients. It should be mentioned that our 2 patient groups not only differ in type of disease (breast or colorectal cancer) and chemotherapy regimen but also in sex distribution. Therefore, the differences in response to influenza vaccination could be due (at least in part) to a gender bias. Data in literature indicate that women show a higher antibody response to vaccination than men [24]. The better antibody response in the predominant male colorectal cancer group therefore is unlikely to be caused by a gender bias. In a recent study of Puthillath et al. [25] colorectal cancer patients show a low response to influenza vaccination irrespective of their chemotherapy regimen or timing. We find an adequate antibody response to all three influenza strains (according to EMEAcriteria). It should be noted that in the Puthillath paper, antibody responses were measured (only) at 3 months after vaccination. From their paper it cannot be concluded whether the patients on chemotherapy would have responded better at 3 weeks after vaccination. In our patient cohort it is clear that in the so-called late group, GMTs at 3 months are significantly lower than at 3 weeks (Fig. 3). Another possible explanation for the difference in outcome are that in the study of Puthillath the majority of the patients had stage IV colorectal cancer (metastatic disease) and our patients did not have metastases. Finally, Puthillath included patients with different chemotherapy regimens in their study, while we included only oxaliplatin-containing regimens. 4.4. Optimal timing of vaccination As indicated above, current guidelines on the optimal timing of vaccination in oncology patients treated with chemotherapy are mainly based on one small study, conducted in 1977, in which the response to influenza vaccination at the day of chemotherapy or at time of the white blood cell count nadir were compared. Those results showed that vaccines should not be administered at the
6184
M.L. Wumkes et al. / Vaccine 31 (2013) 6177–6184
day of chemotherapy [12]. Changes and development in vaccine formulations as well as chemotherapy regimens may explain the difference in response rates found by us compared to the 1977 study. Moreover, in our study influenza vaccination was not administered at the day of chemotherapy, but at day 5 of the cycle. Our pilot study in 2009 showed a trend towards better response after early vaccination (i.e. 4 days) in breast cancer patients. In the current study this trend is confirmed and even showed a significantly higher response after early vaccination of breast cancer patients. In most, including our own, studies patients are vaccinated with a single dose of influenza vaccine. However, it has been shown that a significant improvement in seroconversion rates can be obtained with two doses influenza vaccine in patients with hematological malignancies or solide tumors [26,27]. In the study of van der Velden et al. no great value of single and booster vaccinations with influenza virus vaccine in patients with hematological malignancies was found [28]. Whether patients on chemotherapy would benefit from an additional dose of (adjuvanted) vaccine therefore is an issue which still is open for study. In conclusion, influenza virus vaccination relatively early after the start of a cycle of chemotherapy (day 5) induces a significantly better serum antibody response when compared to vaccination at later time point (day 16) in patients with breast cancer treated with chemotherapy. In colorectal cancer patients this difference was not observed and adequate antibody responses that meet the EMEA criteria for vaccine licensure were seen in both groups. Follow up studies with larger patient numbers have to be conducted to determine the effect of the individual chemotherapy regimens, cycle number and the effect of pegfilgrastim on the influenza vaccine induced antibody response. Conflict of interest statement None declared. References [1] Cooksley CD, Hayney MS. Immunization recommendations for adults with cancer. Ann Pharmacother 2002;36:1219–29. [2] Thompson WWW, Shay DK, Weintraub E, et al. Mortality associated with influenza and respiratory synctial virus in the united states. JAMA 2003;289:179–86. [3] Health Council of the Netherlands. Influenza vaccination: revision of the indication. The Netherlands: The Hague: Health Council of the Netherlands, Publication no. 2007/09E; 2007, ISBN 978-90-5549-712-6. [4] Arrowood JR, Hayney MS. Immunization recommendations for adults with cancer. Ann Pharmacother 2002;36:1219–29. [5] Brydak LB, Guzy J, Starzyk J, et al. Humoral immune response after vaccination against influenza in patients with breast cancer. Support Care Cancer 2001;9:65–8. [6] Loulergue P, Mir O, Alexandre J, et al. Low influenza vaccination rate among patients receiving chemotherapy for cancer. Ann Oncol 2008;19:1658.
[7] Anderson H, Petrie K, Berrisford C, et al. Seroconversion after influenza vaccination in patients with lung cancer. Br J Cancer 1999;80:219–20. [8] Vilar-Compte D, Cornejo P, Valle-Salinas A, et al. Influenza vaccination in patients with breast cancer: a case-series analysis. Med Sci Monit 2006;12:CR332–6. [9] Meerveld-Eggink A, de Weerdt O, van der Velden AMT, et al. Response to influenza virus vaccination during chemotherapy in patients with breast cancer. Ann Oncol 2011;22:20131–2035. [10] Pollyea D, Brown J, Horning S. Utility of influenza vaccination for oncology patients. J Clin Oncol 2010;14:2481–90. [11] Sommer AL, Wachel BK, Smith JA. Evaluation of vaccine dosing in patients with solid tumors receiving myelosuppressive chemotherapy. J Oncol Pharm Pract 2006;12:143–54. [12] Ortbals DW, Liebhaber H, Presant CA, et al. Influenza immunization of adult patients with malignant diseases. Ann Intern Med 1977;87:552–7. [13] Masurel N, Ophof P, de Jong P. Antibody response to immunization with influenza A/USSR/77 (H1N1) virus in young individuals primed or unprimed for A/New Jersey/76 (H1N1) virus. J Hyg (Lond) 1981;87:201–9. [14] Gelinck LB, van den Bemt BJ, Marijt WA, et al. Intradermal influenza vaccination in immunocompromized patients is immunogenic and feasible. Vaccine 2009;27:2469–74. [15] Schmidt-O.T.T R, Schwarz T, Haase R, et al. Immunogenicity and reactogenicity of a trivalent influenza split vaccine in previously unvaccinated children aged 6–9 and 10–13 years. Vaccine 2007;26:32–40. [16] Damen JE. Harmonization of requirements for influenza virus vaccines: the first year’s experience with the EEC guideline. Biologicals 1993;21: 179–82. [17] Committee for Proprietary Medicinal Products (CPMP). Note for guidance on harmonisation of requirements for influenza vaccines (CPMP/BWP/214/96); 1997. [18] Fiore AE, Shay DK, Broder K, et al. Prevention and control of influenza: recommendations of the advisory committee on immunization practices (ACIP). MMWR Recomm Rep 2008;57:1–60. [19] Hicks KL, Chemaly RF, Kontoyiannis DP. Common community respiratory viruses in patients with cancer:more than just “common colds”. Cancer 2003;97:2576–87. [20] Eastwood LM, Jennings R, Milner RD, et al. Reactogenicity and immunogenicity of a surface-antigen-adsorbed influenza virus vaccine in children. J Clin Pathol 1979;32:534–7. [21] Potter CW, Oxford JS. Determinants of immunity to influenza infection in man. Br Med Bull 1979;35:69–75. [22] Centers for Disease Control and Prevention (CDC). Serum cross-reactive antibody response to a novel influenza A (H1N1) virus after vaccination with seasonal influenza vaccine MMWR Morb Mortal Wkly Rep, 58; 2009. p. 521–4. [23] Loulergue P, Alexandre J, Iurisci I, et al. Low immunogenicity of seasonal trivalent influenza vaccine among patients receiving docetaxel for a solid tumour: results of a prospective pilot study. Br J Cancer 2011;104:1670–4. [24] World Health Organization. Sex, gender and influenza. http://whqlibdoc. who.int/publications/2010/9789241500111 eng.pdf [25] Puthillath A, Trump DL, Andrews C, et al. Serological immune responses to influenza vaccine in patients with colorectal cancer. Cancer Chemother Pharmacol 2011;67:111–5. [26] Hottinger AF, George AC, Bel M, Favet L, Combescure C, Meier S, Grillet S, PosfayBarbe K, Kaiser L, Siegrist CA, Dietrich PY. H1N1 study group a prospective study of the factors shaping antibody responses to the AS03-adjuvanted influenza A/H1N1 vaccine in cancer outpatients. Oncologist 2012;17:436–45. [27] Lo W, Whimbey E, Elting L, Couch R, Cabanillas F, Bodey G. Antibody response to a two-dose influenza vaccine regimen in adult lymphoma patients on chemotherapy. Eur J Clin Microbiol Infect Dis 1993;12:778–82. [28] van der Velden AM, Mulder AH, Hartkamp A, Diepersloot RJ, van Velzen-Blad H. Biesma DH. Influenza virus vaccination and booster in B-cell chronic lymphocytic leukaemia patients. Eur J Intern Med 2001;12:420–4.