Prevention and management of pulmonary conditions in patients with cancer before therapy

General recommendations

Although US Preventive Services Task Force recommends against screening for COPD in the general population, identification of COPD or other pulmonary disorders, such as asthma or pulmonary fibrosis, may be beneficial when planning potentially pneumotoxic therapies. A somewhat arbitrary cut-off of 15 years of smoking history or presence of respiratory symptoms (e.g., chronic cough or dyspnea) regardless of smoking history is suggested as an indication for pulmonary function testing (PFT) or chest imaging in newly diagnosed cases of cancer. If either is abnormal, a consultation with a pulmonologist may be useful. The benefits of smoking cessation in the general smoking population are well established. Smoking cessation after cancer diagnosis is associated with improved treatment outcomes. It is therefore important to screen for tobacco use and encourage smoking cessation in patients with cancer.

Adults with cancer should receive yearly inactivated influenza vaccination. Even though immune response to the inactivated vaccines is likely reduced in patients receiving chemotherapy, the risk of influenza-related morbidity and mortality is high and vaccination seems prudent. An exception is patients receiving anti-B cell antibodies. Because immunogenicity is so poor in these patients, influenza vaccination should be delayed for at least six months. Intranasally administered live attenuated influenza vaccine should not be given to immunocompromised individuals, including those with cancer. Individuals 65 years of age or older should receive high-dose inactivated influenza vaccine regardless of whether cancer is present.

Pneumococcal infections are an important cause of morbidity and mortality in patients with cancer. Pneumococcal vaccine should be administered to all patients with cancer, preferably before initiating chemotherapy because immunogenicity to the polysaccharide vaccine is significantly diminished afterward. The Infectious Diseases Society of America and the United States Advisory Committee on Immunization Practices recommend that both a pneumococcal polysaccharide vaccine (e.g., PPSV23, Pneumovax) and a pneumococcal conjugate vaccine (PCV13, Prevnar 13) be administered. Pneumococcal vaccine naïve patients should receive a single dose of PCV13 followed by a dose of PPSV12 at least 8 weeks later. Patients who have previously received one or more doses of PPSV23, a single dose of PCV13 should be given at least one year after the last PPSV23. A repeat dose of PPSV23, if needed, should be administered no sooner than 8 weeks after PCV13 and at least 5 years after the most recent PPSV23. Specific pneumococcal vaccines vary by country and patients should be vaccinated according to their national guidelines.