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Protecting your Health: Immunizations in Cancer Survivors

By Karen Effinger, MD, MS | Children’s Healthcare of Atlanta


Vaccines have become a hot topic with the introduction of the new COVID-19 immunizations. News cycles are filled with information about vaccination rates and the hope these vaccines promise. However, for many people, along with hope comes fear. While the COVID-19 vaccines are new, questions about immunizations are not. Survivors and their families often have questions during and after cancer therapy. It’s always important to talk to your oncologist or pediatrician if you have questions about vaccines.

Vaccines are generally safe. However, people with a weakened immune system can get sick from live virus vaccines. Guidelines say to avoid live virus vaccines during cancer therapy and for at least three months after chemotherapy and two years after a bone marrow transplant (BMT). If patients remain on immune suppression due to graft-versus-host disease or after a solid organ transplant, they typically are not given live vaccines.

Other non-live vaccines are safe, even for patients receiving cancer therapy. However, the immune system may not react the same and give lifelong protection if people are receiving cancer therapy. For this reason, we typically do not give vaccines to patients receiving cancer therapy except for the flu vaccine. Because cancer patients can become very sick from the flu and may respond to the vaccine, we recommend the flu vaccine every year even during treatment.

It is important for cancer survivors to catch-up on missed vaccines after they complete their therapy. Survivors should ask their oncologists when it is safe to restart immunizations (usually 3-6 months after chemotherapy.) For survivors who underwent a BMT, immunity from prior vaccines is typically lost. Therefore, vaccines need to be repeated. The BMT team gives families instructions about when it is safe to start this process based on national guidelines.

The approved COVID-19 vaccines have been found to be safe in adults and have been recommended by the American Society of Clinical Oncology. There is no preference for specific vaccines. However, survivors with an allergy to PEG-asparaginase should not receive the Pfizer or Moderna vaccines due to concerns for allergic reactions. The Johnson & Johnson vaccine does not contain PEG and should be safe. Patients should talk to their oncologist or pediatrician for more information.

While all vaccines are important, the HPV (human papillomavirus) vaccine is one of the few vaccines that prevents cancer. HPV is a virus associated cervical, anal, and oropharyngeal (mouth/throat) cancers and genital warts. Most people will be exposed to HPV at some point in their lives; however, many people will clear the virus without developing cancer. Recent studies have shown that childhood cancer survivors are at increased risk for developing cancer from HPV compared to those who did not have childhood cancer. For this reason, we strongly recommend that survivors receive this vaccine, and the Children’s Oncology Group includes HPV vaccination in their guidelines for survivorship care. Vaccination can start as early as nine years of age and is recommended through 26 years of age. If survivors have questions about any vaccinations, they should talk to their primary care provider or oncologist.


Karen Effinger, MD, MS

Dr. Effinger specializes in pediatric oncology survivorship, and in the late effects of childhood cancer and stem cell transplantation.

Get Out and Move! A Survivor’s Guide to Exercise

Karen E. Effinger, MD, MS

We all know that physical activity and exercise are good for our health, but it’s especially important for childhood cancer survivors. Research has shown that adult survivors of childhood cancer who get regular vigorous exercise have better long-term health and live longer than those who don’t. Some survivors are at risk for heart disease, and studies have shown that these survivors can decrease their risk by performing aerobic exercise. Aerobic exercise, also known as “cardio,” includes activities like walking fast, dancing, swimming, running, and cycling. Studies have also shown that physical activity helps mood, concentration and memory in all survivors.

The American Cancer Society and American Heart Association provide age-based recommendations for physical activity.

Preschoolers (ages 3-5)

  • 3 hours of active play per day
  • Replace sitting activities with play

Kids/Teens (ages 6-17)

  • 60 minutes per day of moderate to vigorous physical activity
  • Vigorous activity at least 3 days per week
  • Muscle and bone-strengthening activities at least 3 days per week

Adults (age 18+)

  • 150 minutes per week (30 minutes, 5 days per week) of moderate physical activity or 75 minutes of vigorous activity or a combination of both
  • Muscle and bone-strengthening activities at least 2 days per week
  • Spend less time sitting

Survivors should follow these guidelines in order to improve their overall health. Strength training should include all muscle groups and should not exceed 2-3 times per week. For survivors who received treatment that may impact their heart, weightlifting should be limited. Survivors at risk for heart disease who would like to perform more intense exercise should be evaluated by a cardiologist first.

Tips for increasing exercise include:

  • Start out slow – don’t try activities that are too hard or not interesting
  • Pick activities you like
  • Find a friend or family member to do activities with
  • Alternate exercises to work different muscles
  • Instead of the elevator, take the stairs
  • Walk down the hall or march in place when a commercial comes on tv
  • Turn the screen into an exercise machine through exercise or activity videos
  • Take a brain break before homework to help with focus
  • Remember: Some is better than none!

Research has shown that active kids, teens, and young adults have better quality of life, heart health, lung health, bone health, attention, memory, school performance, and sleep. Exercise also decreases risk for chronic medical conditions (like diabetes, high blood pressure and high cholesterol), obesity, anxiety, depression, and fatigue. Survivors are encouraged to get as much physical activity as possible.


Food for Thought: Feeding Concerns in Survivorship

Kaitlin B. Proctor, PhD
William Sharp, PhD,
Jordan Gilleland-Marchak, PhD, ABPP

Long-term survivorship care involves comprehensive medical monitoring, including weight, growth, and nutrition. Survivors who received certain treatment agents are at increased risk for cardiac, bone mineral density, or metabolic problems, making adequate nutrition and weight management especially important. Aspects of the cancer treatment may also place some survivors at higher risk for difficulties with feeding and weight management. Side effects from some cancer treatments may lead to difficult or painful eating experiences. These experiences may create an association with feeding that may result in a child avoiding food due to fear of pain or discomfort. Alternatively, a young child may have missed some developmentally normative experiences with learning to feed during treatment due to reliance on internal feeds or required changes in dietary intake (e.g., focusing on meals involving highly preferred foods to meet caloric needs). A subset of survivors experience ongoing challenges related to feeding or food aversion which continue even after active symptoms causing pain or discomfort with eating have resolved.

What is normal: Periods of pickiness and/or changing food preferences, as well as variations in hunger, appetite, and interest in eating. This may include changes like suddenly refusing a previously enjoyed food or refusing all foods with certain characteristics, like foods that are green. For children who are exhibiting developmentally normal pickiness related to food, you may consider trying one of the following strategies:

1. Provide consistent, structured mealtimes with predictable expectations.

2. Provide multiple opportunities to try novel foods prepared in a variety of ways, as research has shown that it takes eight to 15 exposures for a child to develop comfort with a new food. When offering new foods, present small amounts of the new food initially as this experience will likely be challenging for children with picky eating. For example, provide a few bites rather than a heaping portion until the child is consistently more comfortable with the food. Reducing the amount of food may increase the child’s likelihood of exploring the new food and promote success.

3. Enrich the meal environment through the use of praise for desired mealtime behaviors, such as sampling bites of non-preferred or new foods, as well as other mealtime behaviors like remaining at the table, using good table manners, etc.

4. Minimize attention (even negative attention, like coaxing or scolding) for undesirable mealtime behaviors like whining or negative statements about food.

Beyond picky eating: A subset of survivors may restrict the volume and/or variety of food being consumed during meals based on their medical history. This may present as severe food selectivity (such as complete rejection of one or more food groups along with high preference for snacks, fats, and processed foods), as well as frequent and intense behaviors to avoid food, which may be confusing and challenging for families. Children with this level of mealtime concern meet criteria for Avoidant Restrictive Food Intake Disorder (ARFID).

Possible symptoms include:

. Poor weight gain/growth or significant weight loss
. Dependence on a bottle, formula (e.g., Ensure, Pediasure), or feeding tube
. Mealtime tantrums or prolonged meals lasting longer than 40 minutes
. Distress and anxiety with foods, especially new foods
. Inability to increase the texture of foods (e.g., moving from purees to table foods)
. Extreme pickiness (accepting less than 12 foods)
. Excessive weight gain as a result of severe food selectivity.

Children whose feeding problems impact health or nutritional status may require higher levels of support. If you are concerned, talk with your child’s survivorship care provider or primary care physician to discuss whether a referral for additional assessment would be beneficial. It is important to match the level of support with the severity of the feeding problems. For mild feeding concerns, nutrition education with a dietitian or outpatient intervention with speech-language pathologists, oral motor therapists, or behavioral therapists can be beneficial to address specific feeding difficulties.

Children’s Healthcare of Atlanta offers a multi-disciplinary feeding program for children with more complex feeding problems. This program has demonstrated excellent effects for patients and families. Additional information on pediatric feeding disorders can be found at feedingmatters.org.