Avastin (bevacizumab)

Transcription

1 Avastin (bevacizumab) Policy Number: Last Review: 04/2018 Origination: 03/2017 Next Review: 04/2019 Policy Blue Cross and Blue Shield of Kansas City (Blue KC) will provide coverage for Avastin when it is determined to be medically necessary because the following criteria have been meet. When Policy Topic is covered Patient must have ONE of the following: 1. Metastatic colorectal cancer AND ONE of the following: a. 1st line treatment i. Concurrent intravenous 5-Fluorouracil-based chemotherapy b. 2nd line treatment with ONE of the following regimens: i. Fluoropyrimidine- irinotecan-based chemotherapy ii. Fluoropyrimidine- oxaliplatin-based chemotherapy iii. 5-Fluorouracil-based chemotherapy 2. Non-Squamous non-small cell lung cancer a. 1st line treatment b. Unresectable, locally advanced, recurrent or metastatic c. Concurrent therapy with carboplatin and paclitaxel 3. Glioblastoma multiforme (GBM) a. Single agent therapy b. Progressive disease following prior therapy 4. Metastatic renal cell carcinoma a. Concurrent therapy with interferon-alfa 5. Platinum-resistant recurrent epithelial ovarian, fallopian tube, or primary peritoneal cancers a. Concurrent therapy with ONE of the following: i. paclitaxel ii. pegylated liposomal doxorubicin iii. topotecan 6. Persistent, recurrent, or metastatic Cervical cancer a. Concurrent therapy with ONE of the following: i. paclitaxel and cisplatin ii. paclitaxel and topotecan

2 DOSING: Adult FDA-approved uses: See FDA labeling Pediatric FDA-approved uses: Safety and effectiveness have not been established Drug must be sourced from an approved specialty infusion provider. When Policy Topic is not covered Avastin is considered investigational in patients who are less than 18 years of age and for all other indications EXCEPT, Avastin is considered always medically necessary and does not require prior authorization for Ocular disease resulting from intravitreal neovascularization, including: a. Neovascular (Wet) Age-Related Macular Degeneration (AMD) b. Diabetic Macular Edema c. Macular edema secondary to retinal vascular occlusion d. Progressive high myopia e. Ocular histoplasmosis f. Proliferative diabetic retinopathy g. Retinopathy of prematurity h. Angioid streaks i. Neovascular glaucoma Considerations Avastin requires prior authorization through the Clinical Pharmacy Department. This Blue Cross and Blue Shield of Kansas City policy Statement was developed using available resources such as, but not limited to: Food and Drug Administration (FDA) approvals, Facts and Comparisons, National specialty guidelines, Local medical policies of other health plans, Medicare (CMS), Local providers. Description of Procedure or Service Background Neoplastic tissue originates as host-derived cells that proliferate atypically due to loss of ability to control growth. The initial growth is dependent on existing vasculature. An additional supply of nutrients as well as waste removal must be provided in order for tumors to grow beyond 2-3mm3. In response to tumor-related signaling factors tumor angiogenesis occurs. Vascular endothelial growth factor (VEGF) is an important regulating factor of both normal and abnormal angiogenesis. VEGF interacts with two different receptor tyrosine kinases, VEGFR-1 and VEGFR-2 to alter angiogenesis. Increased levels of VEGF and VEGFR-2 have been observed in multiple cancer types and the levels of expression are related to increased vascularization within tumors. This tumor neovascularization has prognostic significance (1). Anti-VEGF pharmacotherapies have been developed with a goal of inhibiting tumor angiogenesis and thereby inhibiting growth and metastasis (2-4). Avastin (bevacizumab) is a Vascular Endothelial Growth Factor (VEGF) inhibitor. Avastin (bevacizumab) binds to human vascular endothelial growth factor (VEGF) and prevents interaction of VEGF with its receptors (Flt-1, KDR) on the surface of endothelial cells (2-4).

3 Regulatory Status FDA-approved indications: Avastin (bevacizumab) is an angiogenesis inhibitor indicated for: (5) 1. Metastatic colorectal cancer for the first- or second-line treatment of patients with metastatic carcinoma of the colon or rectum in combination with intravenous 5- fluorouracil based chemotherapy. 2. Metastatic colorectal cancer in combination with fluoropyrimidine- irinotecan- or fluoropyrimidine- oxaliplatin- based chemotherapy for second-line treatment in patients who have progressed on a first-line Avastin-containing regimen. 3. Non-squamous non-small cell lung cancer (NSCLC), with carboplatin and paclitaxel for first line treatment of unresectable, locally advanced, recurrent, or metastatic disease. 4. Glioblastoma, as a single agent for adult patients with progressive disease following prior therapy. 5. Metastatic renal cell carcinoma in combination with interferon alfa. 6. Metastatic carcinoma of the cervix, in combination with paclitaxel and cisplatin or paclitaxel and topotecan in persistent, recurrent, or metastatic disease 7. Platinum-resistant recurrent epithelial ovarian, fallopian tube or primary peritoneal cancer, in combination with paclitaxel, pegylated liposomal doxorubicin or topotecan Limitation of Use: Avastin is not indicated for adjuvant treatment of colon cancer (5). Off Label Uses: In comparative trials and uncontrolled case series report improvements in visual acuity and decreased retinal thickness by optical coherence tomography following treatment with intravitreal Avastin for ocular diseases resulting from intravitreal neovascularization (7-8). Avastin carries a boxed warning for GI perforations including wound-healing complications and hemorrhage. The reported incidence of GI perforations was 2% and hemorrhage was 31%. In both instances, fatalities occurred. The drug is only approved to be started 28 days after surgery and until the surgical wound is fully healed to prevent wound-healing complications (5). Rationale Avastin (bevacizumab) is medically necessary for the treatment of angiogenesis-dependent neoplasms as approved by the FDA. These indications are (1) first- or second-line treatment with intravenous 5-FU of metastatic colorectal cancer; (2) first line treatment with carboplatin and paclitaxel of unresectable, locally advanced, recurrent or metastatic non-squamous nonsmall cell lung cancer, (3) single agent treatment for adults patients with progressive glioblastoma and (4) treatment with interferon alfa of metastatic renal cell carcinoma, and (5) metastatic colorectal cancer, with fluoropyrimidine-irinotecan or fluoropyrimidine-oxaliplatin based chemotherapy for second-line treatment in patients who have progressed on a first-line Avastin; and cervical cancer, in combination with paclitaxel and cisplatin or paclitaxel and topotecan in persistent, recurrent, or metastatic disease (5). In addition, there is an evidence base to support the off-label intravitreal use of Avastin (bevacizumab) for the treatment of ocular disease resulting from neovascularization (6). Prior authorization is required to ensure the safe, clinically appropriate and cost effective use of Avastin (bevacizumab) while maintaining optimal therapeutic outcomes.

4 References 1. Nussenbaum F, Herman IM. Tumor angiogenesis: insights and innovations. J Oncol 2010;2010: Epub 2010 April Herbert B. Newton. Curr Treat Options Neurol Jul;10(4): Vredenburgh JJ, Desjardine A, Herndon JE, et al. Bevacizumab plus irinotecan in recurrent glioblastoma multiform. J Clin Oncol 2007 Oct20; 25(30): Norden A.D, Young, G.S, Setayesh, K, et al. Bevacizumab for recurrent malignant giomas. Neurology 2008;70: Avastin [prescribing information]. South San Francisco, CA: Genentech, Inc. December American Academy of Ophthalmology. Age-Related Macular Degeneration Preferred Practice Guideline. January 2015: Comparison of Age-related Macular Degeneration Treatments Trials (CATT) Research Group*Writing Committee: Martin DF, Maguire MG, et al. Ranibizumab and bevacizumab for treatment of neovascular age-related macular degeneration. Two-year results. Ophthalmology 2012;119: Chakravarthy U, Harding SP, Rogers CA, et al. Ranibizumab versus bevacizumab to treat neovascular age-related macular degeneration: One-year findings from the IVAN randomized trial. Ophthalmology 2012;119: Billing Coding/Physician Documentation Information Avastin is considered a medical benefit. J9035 Injection, bevacizumab, 10 mg C16+ Malignant neoplasm of stomach C18+ Malignant neoplasm of colon C19 Malignant neoplasm of rectosigmoid junction C20 Malignant neoplasm of rectum C34+ Malignant neoplasm of bronchus and lung C45+ Mesothelioma C48+ Malignant neoplasm of retroperitoneum and peritoneum C50+ Malignant neoplasm of breast C53+ Malignant neoplasm of cervix uteri C56+ Malignant neoplasm of ovary C57+ Malignant neoplasm of other and unspecified female genital organs C61 Malignant neoplasm of prostate C64+ Malignant neoplasm of kidney, except renal pelvis C65+ Malignant neoplasm of renal pelvis C68+ Malignant neoplasm of other and unspecified urinary organs C71+ Malignant neoplasm of brain Z17.1 Estrogen receptor negative status [ER-] Additional Policy Key Words Policy Implementation/Update Information 03/2017 New policy titled Avastin (bevacizumab)

5 State and Federal mandates and health plan contract language, including specific provisions/exclusions, take precedence over Medical Policy and must be considered first in determining eligibility for coverage. The medical policies contained herein are for informational purposes. The medical policies do not constitute medical advice or medical care. Treating health care providers are independent contractors and are neither employees nor agents Blue KC and are solely responsible for diagnosis, treatment and medical advice. No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, photocopying, or otherwise, without permission from Blue KC.