In December 2020, the U.S. Food and Drug Administration (FDA) authorized the first COVID-19 vaccines for emergency use: the Pfizer-BioNTech COVID-19 vaccine and the Moderna COVID-19 vaccine. The Johnson & Johnson (J&J) COVID-19 vaccine (also called the Janssen vaccine) was authorized in February 2021. Other COVID-19 vaccines are being developed and may eventually be approved, as well.
On April 13, 2021, the FDA and the Centers for Disease Control (CDC) called for a pause in the use of the J&J vaccine “out of an abundance of caution” to give healthcare providers time to better understand and treat a rare health condition involving blood clots that occurred in six people who received the J&J vaccine. Read more about the J&J vaccine below.
Because the vaccines do not contain live viruses, they can be used in people with weakened immune systems, including people being treated for cancer. The FDA has found that these vaccines are safe and highly effective for preventing COVID-19, especially serious illness and death from the disease. It is still unclear how long the protection lasts and whether you can give someone else COVID-19 if you are exposed to the virus after being vaccinated. So it's recommended that mask wearing and physical distancing in public continue for some time.
Experts have recommended that most people with cancer or a history of cancer should get a COVID-19 vaccine. Still, you should talk to your doctor about whether getting vaccinated is the right decision for your individual situation.
Research has shown that people with cancer seem to have much less protection after the first Pfizer vaccine injection compared to people without cancer. But after the second shot — given early, after 3 weeks instead of 4 weeks, in the study — people with cancer had suitable protection. This result emphasizes the importance of getting the second injection of a vaccine on time.
The CDC has advised states to prioritize certain groups for vaccination first. When people with medical conditions, such as cancer, become eligible varies from state to state. As more vaccine becomes available, more groups will be able to be vaccinated. Check your state’s COVID-19 vaccine eligibility criteria or talk to your doctor to find out if you are eligible to get vaccinated.
- About the mRNA vaccines: Pfizer and Moderna
- About the Johnson & Johnson vaccine
- COVID-19 vaccine side effects
- When you're fully vaccinated
Update on COVID-19 Vaccines
Listen to the podcast episode to hear Halle Moore, M.D., explain how the vaccines are different, how she is advising people with certain allergies about the vaccines, and what people currently being treated for breast cancer need to know before being vaccinated.
About the mRNA vaccines: Pfizer and Moderna
The Pfizer-BioNTech and Moderna vaccines work by using genetic material called messenger RNA (mRNA). The mRNA vaccines contain a small piece of the coronavirus’s mRNA, and that tells your body to make copies of a protein in the virus called the spike protein. Your immune system then builds up immune cells and special proteins (antibodies) to fight the spike protein. So, if you’re ever exposed to the COVID-19 virus, your immune system is ready to recognize the virus and protect you from infection.
Because mRNA is just a small piece of the virus copied in a lab, the vaccine cannot cause COVID-19, and it is considered safe for people with weakened immune systems. However, it is unclear whether the vaccine may be less effective and offer less protection against COVID-19 in people with weakened immune systems.
The Pfizer-BioNTech vaccine can be used in people age 16 and older, and the Moderna vaccine can be used in people age 18 and older. Both mRNA vaccines are given as two separate injections in the upper arm muscle. The Pfizer-BioNTech vaccine consists of two doses given 3 weeks apart, and the Moderna vaccine consists of two doses given 1 month apart. You will be most protected against COVID-19 about 2 weeks after your second shot.
About the Johnson & Johnson vaccine
The J&J COVID-19 vaccine works differently than the mRNA vaccines. The J&J vaccine is called a viral vector vaccine. It is made from an adenovirus (the type of virus that causes the common cold). The adenovirus in this vaccine is not a live virus — it has been changed in a lab so that it can't reproduce in the body or cause disease. Also, a gene found in the COVID-19 virus has been added to this modified adenovirus. This gene tells your body to make copies of the COVID-19 virus's spike protein. Then your immune system gets activated and builds up immune cells and antibodies to fight the spike protein. Once this happens, your immune system is ready to protect you if you are exposed to the COVID-19 virus.
The J&J vaccine can be used in people age 18 and older. It is given as a single injection in the upper arm muscle. You are considered fully vaccinated 2 weeks after you get the single shot of this vaccine.
On April 13, 2021, the FDA and CDC recommended that use of the J&J vaccine be paused after six women who received the vaccine developed a rare blood clotting disorder about 9 days after being vaccinated.
It’s important to know that the rare clotting disorder, which is being called vaccine-induced immune thrombotic thrombocytopenia, abbreviated VITT, is rare. Approximately 6.8 million doses of the J&J vaccine have been given in the United States and six cases of VITT have been reported.
“We don’t know the true rate of this condition,” explained Brian Wojciechowski, M.D., a medical oncologist and Breastcancer.org medical adviser. “You can’t really say there’s been six cases and there’s been 7 million vaccines, so divide the number of cases by the number of vaccines and you have the rate. Those are just six cases that have been reported. There may be other cases that have not been reported or were not recognized as this condition. What I know about conditions like this, such as [a very similar condition caused by the blood thinner heparin called HITT], is that they’re very rare. I don’t want to say it’s extremely rare, I think we need to look at it more. I think the FDA needs to investigate any other cases that may have come up. But it should be fairly uncommon.”
A thrombosis is a blood clot. In the six cases reported after the J&J vaccine, the clot was in the veins that drain blood from the brain. This is why you may have seen the disorder called cerebral venous sinus thrombosis (CVST). The blood clots also can form in the legs, abdomen, or heart and can cause a stroke.
Thrombocytopenia means a person has very low levels of platelets, a type of cell that helps the blood to clot. More research is needed, but it is thought that the J&J vaccine may trigger an immune system response that is destroying platelets but also causing the platelets to release tiny particles that lead to blood clots forming.
Symptoms of these rare clots include:
- severe headache
- severe abdominal pain
- severe leg pain or redness, especially in only one leg
- shortness of breath or chest pain
Because these rare clots are seen in people with very low platelet counts, they can’t be treated with heparin, the most commonly used blood thinning medicine.
“We are recommending a pause in the use of this vaccine out of an abundance of caution,” Dr. Peter Marks, director of the FDA Center for Biologics Evaluation and Research, and Dr. Anne Schuchat, principal deputy director of the CDC, said in the joint statement. “The goal is to give doctors and other healthcare provides the time to learn how to diagnose and treat the clotting disorder.”
"The issue with these types of blood clots is if one administered standard treatment, one can actually cause tremendous harm or the outcome can be fatal," Marks said at a media briefing. "One needs to make sure providers are aware if they see people with low blood platelets or blood clots, to inquire about recent vaccination and act accordingly."
The FDA said the benefits of the J&J vaccine still outweigh the risks for most people, and that people may still get the J&J vaccine at some vaccination sites if they and their healthcare provider determine it is safe for them. If you have an upcoming appointment to get the J&J vaccine, you should talk to your doctor about whether the J&J vaccine is safe for you. Some vaccination sites are switching from the J&J vaccine to the Pfizer or Moderna vaccine while the pause is in effect.
If you received the J&J vaccine 30 or more days ago, your risk of developing the rare clotting disorder is very low. There are no known cases that started 3 weeks after receiving the vaccine.
If you received the J&J vaccine in the past few days, the flu-like symptoms that you may have are normal. But if you have any of these symptoms:
- severe headache
- severe abdominal pain
- severe leg pain or redness, especially in only one leg
- shortness of breath or chest pain
you should contact your doctor or seek medical care immediately and explain that you’ve had the J&J vaccine, as well as the date you received it.
COVID-19 vaccine side effects
The most common side effects of the COVID-19 vaccines have been:
- pain or soreness in the arm where you receive the injection
- muscle or joint pain
These side effects are usually minor, last a few days, and happen more often after the second dose. Side effects are expected and are actually a sign that the vaccine is working by causing an immune response. Research shows that women may experience worse side effects from the COVID-19 vaccines than men.
Some people have experienced swollen or enlarged lymph nodes, including the axillary lymph nodes (the lymph nodes in the armpit) on the side where the injection was given. Doctors call this “axillary adenopathy.”
If you have had breast cancer, and especially if you’ve had underarm lymph nodes removed, you could experience lymphedema or worsening of lymphedema as a side effect of the COVID-19 vaccines. To lower this risk, people with a history of breast cancer should ask to have the vaccine injection in the arm on the opposite side of the body where the breast cancer was. If you have had breast cancer in both breasts, talk with your doctor to decide which arm you should choose for the injection. The COVID-19 vaccines can be given in the upper hip area as an alternative, but the providers at your vaccination site may not be trained or comfortable with giving the vaccine this way, so this may not be a feasible option for most people at this time.
For people without a history of breast cancer, swelling of the axillary lymph nodes after vaccination is harmless, but they can feel like breast lumps and cause some women to worry they could be a sign of breast cancer. These swollen lymph nodes can also show up on a mammogram, even if you can’t feel them. This could result in a false positive, which is when a mammogram shows an abnormal area that looks like a cancer but it turns out to be normal. A false positive mammogram result can lead to unnecessary stress and additional testing.
The Society of Breast Imaging has recommended that women should try to schedule their routine screening mammogram at least a month after getting vaccinated so that any swelling in the axillary lymph nodes has time to go away. But if your mammogram is already scheduled, it is not necessary to cancel your mammogram or your COVID-19 vaccine appointment. Just be sure to tell the person performing your mammogram if you were recently vaccinated, in which arm, and whether it was your first or second dose. This will help the breast radiologist accurately interpret your mammogram result.
People are monitored for about 15 to 30 minutes after receiving each injection to make sure they don’t have a rare serious allergic reaction to the vaccine. If you have a history of severe allergic reactions, you should talk with your doctor and perhaps see an allergist or immunologist to figure out whether getting a COVID-19 vaccine is safe for you.
The person who gives you the COVID-19 vaccine should ask if you have had any severe allergic reactions in the past. Make sure you tell them if you have experienced an allergic reaction so they monitor you for at least 30 minutes after you receive your injection. Vaccination centers should have medicines, equipment, and safety measures in place to care for anyone who has an allergic reaction. It’s a good idea to ask if these safety measures are in place at your vaccination center if you have had a serious allergic reaction in the past.
It's important to know if you have had an allergic reaction to polyethylene glycol (PEG) or polysorbate in the past. These ingredients are in certain medicines, including some cancer therapies, and are also used in the COVID-19 vaccines.
The Pfizer and Moderna vaccines contain PEG. They do not contain polysorbate, but polysorbate is closely related to PEG. The J&J vaccine contains polysorbate.
The CDC has said that if you have had a severe allergic reaction to PEG in the past, then you should not get the Pfizer or Moderna mRNA vaccines and should ask your doctor about getting the J&J vaccine instead. If you have had a severe allergic reaction to polysorbate in the past, then you should not get the J&J vaccine and should ask your doctor about getting one of the mRNA vaccines instead.
Medicines that contain PEG are called “pegylated” by doctors. Medicines are sometimes pegylated to change how they work in the body. Sometimes there are pegylated and non-pegylated versions of the same medicine.
Pegylated cancer medicines include:
- Doxil (chemical name: pegylated liposomal doxorubicin), a chemotherapy medicine used to treat breast cancer. Also marketed as Caelyx in some countries.
- Neulasta (chemical name: pegfilgrastim), a medicine used to treat neutropenia (low white blood cell levels) during chemotherapy.
Polysorbate is used in many medicines to change how they work in the body or as a preservative. Cancer medicines that contain polysorbate include:
- Abraxane (chemical name: albumin-bound or nab-paclitaxel)
- Adriamycin (chemical name: doxorubicin)
- Aranesp (chemical name: darbepoetin alfa)
- Cinvanti, Emend (chemical name: aprepitant)
- Doxil (chemical name: pegylated liposomal doxorubicin); also marketed as Caelyx in some countries
- Epogen (chemical name: epoetin alfa)
- Methotrexate (marketed with many brand names)
- Procrit (chemical name: epoetin alfa)
- Taxol (chemical name: paclitaxel)
- Taxotere (chemical name: docetaxel)
If you have had a severe allergic reaction to any of these medicines, talk to your doctor about whether getting a COVID-19 vaccine is safe for you.
When you’re fully vaccinated
As more people have been vaccinated against COVID-19, the CDC has issued guidelines on what fully vaccinated people can do.
People are considered fully vaccinated:
- 2 weeks after their second dose of the Pfizer or Moderna vaccine
- 2 weeks after the single dose of the Johnson & Johnson vaccine
If you’re fully vaccinated, CDC recommendations say you can:
- gather indoors without a mask with other fully vaccinated people of all ages
- gather indoors without a mask with people of any age from one other household who aren’t at risk for severe complications from COVID-19
- travel within the United States without a COVID test before or after travel
- travel within the United States without quarantining after travel
- travel internationally without a test before travelling, depending on your destination
It’s important to know that international travelers coming to the United States are still required to show a negative COVID test result or documentation of recovery from COVID-19 before boarding a flight to the United States.
Even if you’re fully vaccinated, the CDC still recommends:
- wearing a mask if you’re visiting indoors with people who have a higher risk of severe COVID-19 complications
- wearing a mask when you go out in public
- wearing a mask if you gather with unvaccinated people from more than one other household
- avoiding medium or large gatherings
- wearing a mask when you travel on planes, buses, trains, and other types of public transportation
- getting a COVID-19 test 3 to 5 days after international travel
- washing your hands with soap and water for at least 20 seconds or using hand sanitizer after you’ve been out in public
- watching out for symptoms of COVID-19, especially if you’ve been around someone who is sick
- getting tested and staying home and away from others if you have symptoms
A gathering is considered medium or large if people can’t stay 6 feet apart. Poorly ventilated indoor spaces have a higher risk of spreading COVID-19 than outdoor spaces.
Adam Leitenberger, editorial director
Jamie DePolo, senior writer
This content was developed with contributions from the following experts:
Halle Moore, M.D., director of breast oncology, Cleveland Clinic
Marisa Weiss, M.D., chief medical officer
Brian S. Wojciechowski, M.D., medical adviser
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