Shingles (Herpes Zoster), Vaccination, and Their Importance for Cancer Patients

What Is Shingles, and How Does It Develop?

Shingles (herpes zoster) develops when the varicella-zoster virus reactivates. In Turkish, it is also popularly known as “night burn” and “belt disease.” In childhood, this virus causes chickenpox and then remains latent in the body.

Over time, as the immune system weakens, the virus reactivates and causes shingles. Shingles features painful, blistering rashes and usually occurs on one side of the body.

One in every 3 people develops shingles during their lifetime.

Risk Factors

• Aging: particularly common in people aged 50 and over.
• A weakened immune system: conditions such as HIV or cancer, or use of immunosuppressive medication.
• Stress and trauma: physical or emotional stress can affect the immune system.

Why Are Cancer Patients at Risk of Shingles, and How Does Their Risk Compare with the General Population?

Cancer patients have a high risk of shingles for several reasons, including weakened immunity, stress, and sudden changes in quality of life. Cancer treatments, particularly chemotherapy and radiotherapy, can severely suppress the immune system. This may reactivate the varicella-zoster virus and cause shingles. Shingles incidence in cancer patients is approximately 3-9 times higher.

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If a Cancer Patient Develops Shingles During Treatment, What Factors Affect the Physician’s Treatment Process and the Patient?

Shingles during cancer treatment presents several challenges for both the treatment process and the patient:

Factors Affecting the Physician’s Treatment Process:

• Changing the Treatment Plan: plans such as chemotherapy or radiotherapy may need adjustment.
• Additional Treatments: options such as antiviral treatment and pain management should be considered.

Factors Affecting the Patient:

• Pain and Discomfort: shingles can cause severe pain, reducing quality of life.
• An Additional Burden on the Immune System: shingles places an extra burden on an already suppressed immune system.
• Psychological Effects: prolonged illness and treatment may adversely affect psychological well-being.

How Is Shingles Treated and Prevented?

Treatment Methods:

• Antiviral Drugs: antivirals such as valacyclovir and famciclovir are used.
• Pain Management: painkillers and specific drugs for neuropathic pain may be prescribed.
• Topical Treatments: topical creams may be used to treat rashes.

Prevention Methods:

• Vaccines: vaccines such as recombinant zoster vaccine (RZV) substantially reduce shingles risk.
• Strengthening the Immune System: a balanced diet, regular exercise, and avoiding stress strengthen immunity.

What Is RZV, and What Is Its Indication in Immunosuppressed Patients?

RZV is a non-live recombinant zoster vaccine. It is approved for immunosuppressed patients and is highly effective in preventing shingles. It is used particularly in adults aged 50 and over and in people with weakened immunity.

How Effective Is Recombinant Zoster Vaccine?

Recombinant zoster vaccine (RZV) is highly effective in preventing shingles. Key points on its effectiveness are listed below:

1. >90% efficacy against HZ in all groups aged ≥50:

   • The vaccine provides more than 90% efficacy against herpes zoster (shingles) in all people aged 50 and over, demonstrating high effectiveness across a broad age group.

2. 87.9% efficacy in the fourth year after initial vaccination:

   • RZV efficacy remains at 87.9% even four years after initial vaccination. This long-term protection highlights its lasting effectiveness.

3. Efficacy against PHN: 91.2% in adults aged ≥50 and 88.8% in adults aged ≥70:

   • It is also highly effective against chronic pain complications after shingles, such as postherpetic neuralgia (PHN). Efficacy against PHN is 91.2% in people aged 50 and over and 88.8% in those aged 70 and over.

At Year 11:

• • RZV efficacy against herpes zoster was 82% at year 11 (95% confidence interval, 63.0-92.2).

These results demonstrate RZV’s long-term effectiveness and lasting protection.

These data show high efficacy and long-term protection with recombinant zoster vaccine in both the general population and older adults. It offers an effective way to prevent shingles and its subsequent complications.

What Have RZV Trials Shown in Patients with Solid Tumors? Do Their Designs Provide Guidance on Different Treatments and Administration?

RZV clinical studies have shown important efficacy results in patients with solid tumors. Details and efficacy findings are outlined below:

The Zoster-028 Study

• Study: Zoster-028
• Phase: 2/3
• Number of participants: 232
• Study type: Placebo-controlled, age ≥18
• Primary endpoints: Immunogenicity and safety
• Dose timing: 2 doses (months 0, 1-2)

Efficacy Results

• Anti-gE GMCs (ELISA): Anti-gE (glycoprotein E) antibody levels increased markedly after vaccination.

• gE-Specific CD4+ T Cells: The median frequency of gE-specific CD4+ T cells increased after vaccination.

Frequently Asked Questions

How Are Doses Given Before or After Chemotherapy, and What Are the Protection and Safety Data?

Dose Administration: RZV may be given before or during chemotherapy. Ideally, the first dose is recommended at least one week before chemotherapy starts, allowing a stronger humoral immune response before immunosuppressive treatment. Doses given during chemotherapy can also elicit an immune response, and gE-specific humoral immunity may persist throughout chemotherapy.

Protection and Safety Data: In participants receiving RZV, the geometric mean concentration (GMC) of gE antibodies at M1 was 24,793.1 mIU/mL. After vaccination, the RZV group had higher anti-gE concentrations and CD4+ T cell frequencies than placebo. Local injection-site reactions and general symptoms were more common but usually mild-to-moderate and transient.

What Is the Level of Evidence for RZV in Cancer Patients in Guidelines and Recommendations?

RZV is immunogenic and safe in cancer patients. Phase 3 studies have shown high immune response rates and a favorable safety profile in patients receiving immunosuppressive treatment. Important findings include efficacy above 90% in older adults, 87% in patients with hematological malignancies, and 68% in hematopoietic stem cell transplant recipients.

Does the Type of Malignancy or Chemotherapy Regimen Matter When Vaccinating Patients Receiving Chemotherapy?

ERZV’s effectiveness and safety do not differ by malignancy type or chemotherapy regimen. However, immune responses may vary with the timing of chemotherapy initiation. Giving the first dose before chemotherapy produces a stronger humoral response. Immunogenicity was observed in both the RZV-PreChemo and RZV-OnChemo groups.

Vaccination During Chemotherapy Might Further Suppress Immunity, but There Is Often Little Time Before Chemotherapy. How Should We Proceed?

Vaccination during chemotherapy does not completely prevent an immune response, but may produce a weaker response than vaccination beforehand. If possible, the first dose is therefore recommended 8-30 days before chemotherapy starts. Doses administered during chemotherapy can still elicit an immune response, and gE-specific immunity may persist.

For an Oncologist, What Is the Ideal Timing and Guidance for Adult Vaccination?

Adult vaccination, particularly in cancer patients receiving immunosuppressive treatment, should take place before chemotherapy. The first dose is recommended at least one week beforehand to help produce a stronger humoral response. However, vaccination during chemotherapy is also possible and can elicit an immune response.

What Is the Ideal Vaccination Pathway for an Oncologist, from Recommendation to Administration?

1. Patient Assessment: Obtain detailed information about the patient and their disease.
2. Vaccination Decision: Determine whether RZV is appropriate.
3. Vaccination Planning: Plan the first dose before chemotherapy.
4. Administration and Monitoring: Administer the vaccine and monitor adverse effects.
5. Second Dose and Continuity: Ensure the second dose is given on time and that the immune response is maintained.

Can Patients Receiving Immunotherapy Be Vaccinated? Does This Differ from Chemotherapy?

RZV can also be given during immunotherapy and can elicit an immune response. Because immunotherapy strengthens immunity, it may also affect the response to vaccination. However, its immune modulation may differ from chemotherapy, making monitoring of vaccine effectiveness and safety important.

Can RZV Be Given with Other Adult Vaccines?

RZV can safely be given with other adult vaccines.

• Seasonal Quadrivalent Inactivated Influenza Vaccine (IIV4):

  • Coadministration was found safe and effective. Neither vaccine showed problems in the immune response to its antigens.

• 23-Valent Pneumococcal Polysaccharide Vaccine (PPSV23) and 13-Valent Pneumococcal Conjugate Vaccine (PCV13):

  • Coadministration showed no reduction in immune response. The safety profile was favorable.

• Tetanus, Diphtheria, and Pertussis Vaccine (Tdap):

  • Coadministration showed no safety concerns in immune responses. There is no significant interaction between RZV and Tdap.

RZV can therefore safely be given with influenza, pneumococcal, and Tdap vaccines, without problems in immune responses or safety.