Is the pneumonia vaccine contraindicated in patients with cancer, particularly those undergoing chemotherapy or radiation therapy?

Pneumococcal Vaccine is NOT Contraindicated in Cancer Patients

Pneumococcal vaccines (both PCV13/PCV15/PCV20 and PPSV23) are specifically recommended for cancer patients, including those undergoing chemotherapy or radiation therapy, as these are inactivated vaccines that are safe in immunocompromised hosts. 1 The critical distinction is that only live vaccines are contraindicated during active cancer treatment—pneumococcal vaccines are inactivated and therefore safe to administer. 1

Key Safety Principle

The NCCN explicitly states that live vaccines are contraindicated during chemotherapy and immunosuppressive therapy, but pneumococcal vaccines are inactivated polysaccharide or conjugate vaccines that do not carry this risk. 1 The 2024 NCCN guidelines specifically recommend pneumococcal vaccination for all cancer patients as part of their infection prevention strategy. 1

Recommended Vaccination Strategy

For cancer patients with solid tumors:

• All unvaccinated adults should receive PCV13 (or PCV15/PCV20), followed by PPSV23 within 6-12 weeks 1
• Vaccination can occur independent of chemotherapy timing, and simultaneous administration with chemotherapy is acceptable 1
• Vaccinated patients demonstrate better survival and fewer hospitalizations 1

For hematologic malignancies:

• Same pneumococcal vaccination strategy applies (PCV13/15/20 followed by PPSV23) 1
• Patients with lymphoma, leukemia, and multiple myeloma should receive vaccination, though antibody response may be diminished compared to immunocompetent individuals 1

Optimal Timing Considerations

While vaccine response may be reduced during active chemotherapy, the benefits outweigh waiting:

• Ideal timing: Vaccinate at least 2 weeks before initiating chemotherapy or immunosuppressive therapy 1
• During chemotherapy: Vaccination between chemotherapy cycles may yield higher response rates than during active infusion 1
• Avoid same-day administration: Do not give vaccines on the same day as cytotoxic therapy, as this may reduce lymphocytic proliferative responses 1
• Recent evidence: A 2020 randomized trial in gastric and colorectal cancer patients found no significant difference in immunogenicity between vaccinating 2 weeks before versus on the first day of chemotherapy 2

Post-Transplant Vaccination

For hematopoietic stem cell transplant (HCT) recipients:

• Begin pneumococcal vaccination 3-6 months post-transplant 1
• Administer 4 doses if using PCV20 (3 doses 1-2 months apart, fourth dose 6 months after third) 1
• If using PCV15, give 3 doses followed by PPSV23 at 6-12 months post-primary series 1
• CAR T-cell therapy patients follow similar schedules to allogeneic transplant recipients 1

Expected Immune Response

Important caveats about efficacy:

• Antibody response is generally lower in cancer patients compared to healthy controls, but most achieve seroprotection 1, 3, 4
• Patients with solid tumors typically mount adequate responses similar to healthy individuals 5
• Patients with lymphomas (especially chronic lymphocytic leukemia) and those receiving B-cell depleting therapies have the poorest responses 1, 5
• Those vaccinated during intensive chemotherapy may require revaccination 3 months after therapy completion once immune competence is restored 1

Common Pitfalls to Avoid

1. Do not confuse with live vaccines: Pneumococcal vaccines are NOT live vaccines—they are safe during cancer treatment 1
2. Do not delay unnecessarily: While optimal timing is before chemotherapy, vaccination during treatment is still beneficial given the high morbidity and mortality of pneumococcal infections 1, 6
3. Do not give during high-dose corticosteroids: Consider postponing vaccination in patients receiving >20 mg prednisone daily 1
4. Do not forget revaccination: Immunocompromised patients may need revaccination due to more rapid antibody decline 1

Absolute Contraindications (What to Actually Avoid)

The only pneumococcal vaccine contraindication is severe allergic reaction to a previous dose or vaccine component. 1 Cancer itself and cancer treatments are NOT contraindications—they are actually strong indications for vaccination. 1