BRACHYTHERAPY FOR TREATMENT OF MISCELLANEOUS CANCERS

Transcription

1 BRACHYTHERAPY FOR TREATMENT OF MISCELLANEOUS CANCERS Coverage for services, procedures, medical devices and drugs are dependent upon benefit eligibility as outlined in the member's specific benefit plan. This Medical Coverage Guideline must be read in its entirety to determine coverage eligibility, if any. The section identified as Description defines or describes a service, procedure, medical device or drug and is in no way intended as a statement of medical necessity and/or coverage. The section identified as Criteria defines criteria to determine whether a service, procedure, medical device or drug is considered medically necessary or experimental or investigational. State or federal mandates, e.g., FEP program, may dictate that any drug, device or biological product approved by the U.S. Food and Drug Administration (FDA) may not be considered experimental or investigational and thus the drug, device or biological product may be assessed only on the basis of medical necessity. Medical Coverage Guidelines are subject to change as new information becomes available. For purposes of this Medical Coverage Guideline, the terms "experimental" and "investigational" are considered to be interchangeable. BLUE CROSS, BLUE SHIELD and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. All other trademarks and service marks contained in this guideline are the property of their respective owners, which are not affiliated with BCBSAZ. Description: Brachytherapy describes the delivery of radiation therapy via radioactive ribbons or seeds, radioactive stents, or radioactive filled catheter balloons. The radioactive source (gamma, beta or alpha radioisotopes) is implanted within, or close to, the targeted site, allowing a high dose of radiation with less exposure to normal cells. Implants may be intracavity, interstitial or intraluminal and permanent or temporary. O docx Page 1 of 5

2 Criteria: For breast cancer, see BCBSAZ Medical Coverage Guideline, Brachytherapy for Treatment of Breast Cancer. For endobronchial brachytherapy, see BCBSAZ Medical Coverage Guideline, Endobronchial Brachytherapy. For intracavitary balloon catheter brachytherapy for brain tumors and brachytherapy using an electronic radiotherapy device for the treatment of brain cancer, see BCBSAZ Medical Coverage Guideline, Intracavitary Balloon Brachytherapy for Malignant and Metastatic Brain Tumors. For brachytherapy for prostate cancer, see BCBSAZ Medical Coverage Guideline, Brachytherapy for Clinically Localized Prostate Cancer Using Permanently Implanted Seeds. For high-dose brachytherapy for prostate cancer, see BCBSAZ Medical Coverage Guideline, High-Dose Rate Temporary Prostate Brachytherapy. Ovarian Cancer: Brachytherapy for recurrent ovarian cancer is considered medically necessary. Brachytherapy for primary or initial ovarian cancer is considered experimental or investigational based upon insufficient evidence to support improvement of the net health outcome as much as, or more than, established alternatives. Brachytherapy using an electronic radiotherapy device for the treatment of ovarian cancer is considered experimental or investigational based upon: 1. Insufficient scientific evidence to permit conclusions concerning the effect on health outcomes, and 2. Insufficient evidence to support improvement of the net health outcome, and 3. Insufficient evidence to support improvement of the net health outcome as much as, or more than, established alternatives, and 4. Insufficient evidence to support improvement outside the investigational settings. O docx Page 2 of 5

3 Criteria: (cont.) Other Cancers: Brachytherapy for the following is considered medically necessary: 1. Eye tumor 2. Gastrointestinal cancers Rectal cancer Recurrent colorectal cancer 3. Genitourinary cancers Bladder cancer Cervical cancer Endometrial cancer Vaginal cancer 4. Head and neck cancers Buccal mucosa cancer Esophageal cancer Lip cancer Mouth cancer Nasopharyngeal cancer Salivary gland cancer Sinus cancer Tonsillar fossa/pillar cancer 5. Pulmonary and pleural cancers 6. Soft tissue sarcoma 7. Tumors close to critical structures that cannot be resected with adequate margins Brachytherapy using an electronic radiotherapy device for all cancers, including those listed above, is considered experimental or investigational based upon: 1. Insufficient scientific evidence to permit conclusions concerning the effect on health outcomes, and 2. Insufficient evidence to support improvement of the net health outcome, and 3. Insufficient evidence to support improvement of the net health outcome as much as, or more than, established alternatives, and 4. Insufficient evidence to support improvement outside the investigational settings. O docx Page 3 of 5

4 Resources: Resources published prior to 2006 may be requested from the BCBSAZ Medical Policy and Technology Research Department. 1. Bhatnagar A. Nonmelanoma skin cancer treated with electronic brachytherapy: results at 1 year. Brachytherapy. Mar-Apr 2013;12(2): Bhatnagar A, Loper A. The initial experience of electronic brachytherapy for the treatment of nonmelanoma skin cancer. Radiat Oncol. 2010;5: Chino K, Silvain D, Grace A, Stubbs J, Stea B. Feasibility and safety of outpatient brachytherapy in 37 patients with brain tumors using the GliaSite Radiation Therapy System. Med Phys Jul 2008;35(7): Dickler A, Puthawala MY, Thropay JP, Bhatnagar A, Schreiber G. Prospective multi-center trial utilizing electronic brachytherapy for the treatment of endometrial cancer. Radiat Oncol ;5: Dogdu O, Yarlioglues M, Kaya MG, et al. Long term clinical outcomes of brachytherapy, baremetal stenting, and drug-eluting stenting for de novo and in-stent restenosis lesions: five year follow-up. Cardiol J. 2011;18(6): Ishikawa K, Aoyama Y, Hirayama H. Management of drug-eluting stent restenosis. J Invasive Cardiol. Apr 2012;24(4): Lee LJ, Damato AL, Viswanathan AN. Clinical outcomes of high-dose-rate interstitial gynecologic brachytherapy using real-time CT guidance. Brachytherapy. Jul-Aug 2013;12(4): Mitchell D, O'Callaghan AP, Boyle EM, Kavanagh EG, Walsh SR. Endovascular brachytherapy and restenosis following lower limb angioplasty: Systematic review and meta-analysis of randomized clinical trials. Int J Surg. 2012;10(3): O docx Page 4 of 5

5 Resources: (cont.) 9. National Comprehensive Cancer Network. Central Nervous System Cancers. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines ). Accessed 10/20/ ;I Welsh J, Sanan A, Gabayan AJ, et al. GliaSite brachytherapy boost as part of initial treatment of glioblastoma multiforme: a retrospective multi-institutional pilot study. Int J Radiat Oncol Biol Phys May ;68(1): Wernicke AG, Sherr DL, Schwartz TH, et al. The role of dose escalation with intracavitary brachytherapy in the treatment of localized CNS malignancies: outcomes and toxicities of a prospective study. Brachytherapy Jan-Mar 2010;9(1): O docx Page 5 of 5