Loosening COVID-19 Restrictions and Immunocompromised People: Do You Feel Left Behind?

Jamie DePolo: Hello. As always, thanks for listening. Our guest is Brian Wojciechowski, MD, who practices medical oncology in Delaware County, Pennsylvania, at Riddle, Taylor, and Crozer hospitals and also serves as Breastcancer.org’s medical adviser. A native of South Philadelphia, he trained at Temple University School of Medicine and Lankenau Medical Center. Dr. Wojciechowski is a sought after speaker on the topics of medical ethics and the biology of cancer. 

If you are being treated for breast cancer, you may be considered immunocompromised, meaning your immune system isn’t functioning at its full capacity. As mask mandates are being dropped and other COVID-19 restrictions are loosening, many immunocompromised people feel left behind and are worried that other people’s eagerness to get back to “normal” may make them sick. Dr. Wojciechowski joins us to talk about what looser COVID restrictions mean for immunocompromised people and how they can continue to protect themselves. Dr. Wojo, welcome to the podcast.

Brian Wojciechowski, MD: Well, thanks for having me, Jamie. 

Jamie DePolo: So, I want to start by asking if there are different levels of being immunocompromised. I mean, I know that someone who’s had an organ transplant has to take immunosuppressive drugs for the rest of his or her or their lives and they’re considered severely compromised. But what about people being treated for breast cancer? Are there certain treatments that compromise the immune system more than others?

Brian Wojciechowski, MD: Yeah, there certainly are, Jamie, and there’s a lot of different levels of immunocompromised. You know, you have things like just being elderly and just having diabetes would be considered mildly immunocompromised, not something we worry about too much. But then you have the other extreme, I would call that severely immunocompromised people, people who have had organ transplant, like you say, and who are on immunosuppressive medications chronically, people who are on high doses of steroids chronically, people who have HIV which is poorly controlled, people with rheumatologic disorders like RA and lupus who are on immunosuppressive medications, and lastly and most importantly for our audience, people who are receiving active chemotherapy.

And when I say chemotherapy, I’m talking about cytotoxic chemotherapy, not tamoxifen or aromatase inhibitors, not necessarily targeted therapy, like you’re in your last month of Herceptin. I’m talking about drugs like Taxol, Adriamycin, Cytoxan, things like that. 

So, people who are actively getting those drugs, and probably for about a month or two after getting those drugs as the immune system continues to recover, I would put those people in the category of severely or at least moderately immunocompromised. And those are the people that we worry about in terms of COVID risk. 

Jamie DePolo: And what about, I do want to ask you, what about immunotherapy? Because now that Keytruda is being used to treat breast cancer, I know it’s an immunotherapy, so it’s acting on the immune system, but I also know that it’s trying to rev up the immune system. So, would somebody on Keytruda be considered immunocompromised?

Brian Wojciechowski, MD: I would say if they’re getting Keytruda along with chemotherapy, yes. But if they’re just getting Keytruda and it’s been, you know, three months after they stop their cytotoxic chemotherapy, then I’m less worried about that patient.

Jamie DePolo: Okay. Now, in May of last year, of 2021, the Centers for Disease Control said that people who were fully vaccinated didn’t have to wear a facemask or practice social distancing in most places. So, what does that mean for somebody who is immunocompromised? Because we’ve written about studies showing that people who are immunocompromised don’t have the same response to the COVID-19 vaccine and they make fewer antibodies. And in most cases, what I’ve read, it strongly suggests that those people should continue to wear a mask and social distance. But if other people are not, what does that mean for them? 

Brian Wojciechowski, MD: Well, the first thing to say is that, yes, people who are severely immunocompromised should still practice masking and social distancing. And I’m onboard with that and so is the CDC. One thing that’s important to be aware of is that it’s true that the vaccines are less effective in immunocompromised people, but we’re not talking about not being effective at all. We’re talking about if someone with a normal immune system, the vaccine is 90% effective, for someone who’s immunocompromised it might be down to like 50 to 70%. So, we’re not talking about no protection at all. 

So, I want to reassure the patients out there who are thinking about this and worried about their immunocompromised state that, you know, the vaccines still have efficacy. And even if it doesn’t prevent you from getting COVID — because the vaccine is not a hundred percent — it does decrease the chance of getting very sick, hospitalized, or dying from COVID by five to tenfold. So, it’s still pretty effective. 

The next thing I wanted to mention was the masking piece. And I think everyone sort of has a different comfort level in terms of how aggressive they want to be in terms of protecting themselves, you know? I mean, I’ve seen people run the gamut, people who refuse, people who haven’t gone out to dinner in years versus people who are just a lot less cautious. 

And I think if you are going to take a proactive position on protecting yourself, it’s important to just realize that not every mask is created equal. And if you’re going to do it I wouldn’t even bother with anything less than either a surgical mask or a well-fit N95. The well-fit N95 is obviously the most effective kind of mask, the surgical mask is somewhat less effective, but anything below that like a cloth mask or a gaiter, I honestly wouldn’t even bother with. So, if you’re going to do it, do it right and wear an effective mask. 

But I think people who are severely immunocompromised have to be more cautious than the average person, and that means keeping up the defenses and social distancing, especially when indoors. It’s much harder to get COVID from someone else if you’re outside. It’s much, much harder. I think the typical scenario is that you’re in a room with someone, in close contact, and you’re exposed to their respiratory excretions — so coughing or breathing. 

Where people get burned is when, you know, you could be masked all day long and then you sit down with someone and eat lunch right across from them. That kind of eliminates all the hard work you did, you know? So, that’s where you really have to take precautions when you are in an immunocompromised state. 

Jamie DePolo: Okay, thank you. Thank you, that’s reassuring. And before I go to the next question, I do kind of want to go back, when we were talking about vaccines. Could you go over — I know the recommendations for immunocompromised people are different. Actually, it’s four doses. Am I right on that? That’s like considered a full vaccine dose as opposed to like two doses and a booster. 

Brian Wojciechowski, MD: So, with COVID vaccination there’s your primary series, which for most people is two doses, and then there’s boosters. And there’s two boosters available now, I think. 

If you’re immunocompromised, you’re actually eligible for three primary doses and then boosters after that. So, in theory, an immunocompromised person now could’ve had five total doses. And you have to have the boosters because immunity wanes over time, especially so for an immunocompromised person. But they have shown that three doses in the primary series is more effective than two for the immunocompromised people. Thanks for remembering to bring that up, Jamie. 

Jamie DePolo: Okay. Yeah, I think that’s important because there has been so much onus and conflicting… just changing messages about, “this is what a full vaccine series is, this is what this is.” And I know it’s a brand new thing and everybody is trying to figure out what’s best to do, so thank you for clarifying that. 

So, we talked about masking, we talked about social distancing. I read an interesting article where a woman who was immunocompromised was musing sort of out loud, you know, should she identify herself with a button or a tee shirt or something because she wanted people to be careful around her. She understands that people don’t want to wear a mask if they are not at high risk, but she is and she wanted some way to tell people like, “Hey, I am especially vulnerable. Please be careful around me.” 

What’s your take on that? Do you think that’s… is it weird? I mean, do you think there’s any value in that or just talking to someone? I don’t know. 

Brian Wojciechowski, MD: Yeah, I don’t think it’s weird at all. I mean, you know, in my profession in the hospital every day, I’m seeing immunocompromised people every day, so I just naturally take certain precautions. But I will admit I am not as careful out there in the real world. And I think that is something I would appreciate someone wearing, and I would welcome that. Because then I feel like you have to balance the rights of people who are vulnerable versus the rights of people who want to get on with, you know, “normal” living. And I think that would be helpful, honestly, so I would welcome anything like that. I would act accordingly if I was around someone who was trying to signal that they are immunocompromised and that they are more at risk than the average person. 

Jamie DePolo: Okay. Now, I’m curious, too — you mentioned treating patients being in the hospital. How are you talking to your patients about this? Are they asking these kinds of questions?

Brian Wojciechowski, MD: I try to reassure my patients, mostly. You know, I have seen a lot of people with COVID, and I’ve seen a lot of my patients who are on chemotherapy who have gotten COVID, and most of them have done just fine. If you’re vaccinated, like I said before, the chance of getting COVID, the chance of dying from COVID, the chance of getting very sick from COVID, the chance of getting long COVID are all very much decreased even if you are immunocompromised. So, I try to reassure people if you want to go out, if you’re wearing a good fitting mask, and you’re vaccinated, if you have that one-two punch and if you try to avoid people who are obviously sick, then you have a really good shot at not getting COVID or not getting really sick with COVID. 

I also tell people that we have learned a lot about how to treat COVID, so we know how to use steroids. There’s medicines that can be given if you’ve been exposed even if you don’t have COVID. If you’ve been exposed and you’re immunocompromised, you can get a treatment for that. If you get COVID you can get antivirals, you can get the monoclonal antibody. So, you know, there’s a lot of good treatments out there, and I’m seeing less and less people dying of COVID these days. And what’s been consistent throughout the whole pandemic, in the hospitals where I work, the vast majority of people who are now sick and dying from COVID in the hospitals are those who have not been vaccinated. 

Jamie DePolo: Okay, thank you for that. I have one question. When you talked about the antivirals and the monoclonal antibodies: if somebody is in active cancer treatment, do they have to stop treatment to start COVID treatment if they do happen to get sick? Or do they both play together? 

Brian Wojciechowski, MD: In most cases — and I think this is what you’re asking — in most cases when a patient on treatment gets COVID, they will stop their treatment temporarily. And you’re usually talking about a delay of a week or two depending on how bad their case is. 

Jamie DePolo: Okay. So, it’s not extreme.

Brian Wojciechowski, MD: Right. They can get the antiviral and the monoclonal antibody treatments. 

Jamie DePolo: Okay. And then one final question — and I don’t know if you know this, but I’ve been wondering, and I haven’t had a chance to ask a doctor, so I’m going to ask you. Given the boosters and how we get a flu — or most people get a flu shot every year, I get a flu shot every year — do you think that a COVID booster is going to be something that we get regularly every year, every nine months? Do you have any thoughts on that? Or what do you see from what you’ve been reading and people you’ve been talking to? 

Brian Wojciechowski, MD: Well, you know, I’m not epidemiologist or an infectious disease specialist, so take what I say bearing that in mind. 

Jamie DePolo: I will. I will.

Brian Wojciechowski, MD: But my gut feeling is that since — at least with the current vaccines — since immunity does tend to wane over time, I think we are looking at something like the flu schedule where you’re getting a booster every six months or every year. Inevitably, I think they will come out with better vaccines in the future, so it might not be quite as frequent. But if you made me bet on it right now, I would bet on a six- to 12-month booster schedule moving forward.

Jamie DePolo: Okay. Or potentially even better treatments so that they worked faster, more effective, so it wasn’t such a crisis if somebody did get sick?

Brian Wojciechowski, MD: I think we’re getting there right now, honestly, with the treatments that we have. 

Jamie DePolo: Okay. Well, thank you so much, Dr. Wojciechowski. This has been really informative, and I know it set my mind at ease a little bit. I have an autoimmune disorder, so I’m one of those people that’s always worrying, continuing to wear a KN95 or N95 mask when I go out, so thank you for that. This has been reassuring. I appreciate it.

Brian Wojciechowski, MD: My pleasure. I’ve been very passionate about this issue, and I’ve done a lot of research and spent a lot of time on Facebook, for better or for worse, trying to educate and reassure people. To what effect, I don’t know, but hopefully people felt reassured by the message.