improved survival with COVID-19 vaccination
To determine whether COVID-19 mRNA vaccines were associated with improved responses to immune checkpoint blockade, we first compared the OS among a cohort of patients with stage III/IV NSCLC treated at The University of Texas MD Anderson Cancer Center (MDACC) between January 2015 and September 2022 (Supplementary Table
1a).
We identified 180 patients who received a COVID mRNA vaccine within 100 days of ICI initiation, and 704 patients who were treated with ICI and did not receive a COVID vaccine (Supplementary Table
1a). Of the 180 patients who received an mRNA vaccine within 100 days of ICI initiation, 117 received the BNT162b2 vaccine and 63 received mRNA-1273 (Extended Data Fig.
1a); 24 received a priming dose only, 57 received a booster only, 93 received both a prime and a boost dose, 5 received 2 booster doses, and 1 received a priming dose and 2 booster doses within 100 days of ICI initiation (Extended Data Fig.
1b); 81 received 1 dose of COVID-19 mRNA vaccination within 100 days, 98 received 2 doses, and 1 received 3 doses (Extended Data Fig.
1c).
After controlling for 39 covariables with Cox proportional hazards regression, including clinical stage, histology, steroid use, performance status, mutation status, comorbidities and treatment year, we found that receipt of a COVID-19 mRNA vaccine within 100 days of initiation of ICI was associated with significantly improved median OS (20.6 months versus 37.3 months) and 3 year OS (30.8% versus 55.7%, adjusted hazard ratio (HRadj = 0.51, 95% confidence interval (CI) = 0.37–0.71,
P < 0.0001) (Fig.
1a and Supplementary Tables
2 and
3).
This survival advantage was similar for patients with stage III unresectable NSCLC (HRadj = 0.37, 95% CI = 0.16–0.89,
P = 0.0268) (Fig.
1b and Supplementary Tables
4 and
5) and stage IV NSCLC (HRadj = 0.52, 95% CI = 0.37–0.74,
P = 0.0002) (Fig.
1c and Supplementary Tables
6 and
7); patients who received mRNA vaccines from either vaccine manufacturer (Extended Data Fig.
1a); and patients who had or had not received a previous COVID-19 mRNA vaccine (Extended Data Fig.
1b). Patients who received two vaccines in the 100 days surrounding initiation of ICI experienced similar OS compared with those who received only one vaccine (Extended Data Fig.
1c).
These results were also consistent when considering only those patients whose closest mRNA vaccine was within 100 days before their first ICI (Extended Data Fig.
1d), when narrowing the vaccination window to 50 instead of 100 days (Extended Data Fig.
1e), when restricting to only those patients treated during the pandemic (Extended Data Fig.
1f), after correcting for immortal time bias (Extended Data Fig.
1g) and with propensity score matching (PSM; Extended Data Fig.
1h,i).
LIMITATION:
Patients who received a COVID-19 vaccine within 100 days of chemotherapy (a group that did not include targeted therapies owing to significant heterogeneity and limited patient numbers within different drug cohorts) bu
t did not receive ICI had no detectable survival benefit (Extended Data Fig.
2a). Likewise, patients who received a pneumonia or influenza vaccine within 100 days of initiating ICI (Extended Data Fig.
2b–e) and those with resectable stage III tumours (Extended Data Fig.
2f,g) experienced no improvement in survival.