BlueCross BlueShield of Tennessee Medical Policy Manual

Electronic Brachytherapy for Non-Melanoma Skin Cancer

DESCRIPTION

Electronic brachytherapy has been proposed as a form of radiotherapy for the treatment of non-melanoma skin cancer which includes squamous cell carcinoma and basal cell carcinoma. Squamous cell carcinoma and basal cell carcinoma are the most common types of nonmelanoma skin cancer, affecting between up to three million people per year. Other types (e.g., T-cell lymphoma, Merkel cell tumor, basosquamous carcinoma, Kaposi sarcoma) are much less common. Although these cancers rarely cause mortality, they can impact quality of life, functional status, and physical appearance.

A number of different brachytherapy techniques have been developed, including low-dose rate systems, iridium-based systems, and high-dose rate (HDR) systems. This technique focuses a uniform dose of x-ray source radiation to the lesion with the aid of a shielded surface application.  A pliable mold is constructed of silicone or polymethyl-methacrylate and fitted to the tumor surface.  This mold allows treatment to be delivered to non-flat surfaces such as the nose or ear.  A radioactive source is then inserted into the mold to contact the surface lesion and deliver a uniform radiation dose.

POLICY

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IMPORTANT REMINDERS

ADDITIONAL INFORMATION 

The evidence consists entirely of case series, usually with a mixed patient population of basal and squamous cell carcinomas.  No controlled studies were found in the published literature that validate the application of electronic brachytherapy for non-melanoma skin cancer or provide comparisons to alternative treatment options.

SOURCES 

American Academy of Dermatology and AAD Association. (2016). Position statement on electronic surface brachytherapy for basal cell carcinoma (BCC) and squamous cell carcinomas (SCC). Retrieved June 27, 2016 from:  http://www.aad.org/Forms/Policies.

American College of Radiology (ACR) and American Brachytherapy Society (ABS). (2015). ACR-ABS practice parameter for the performance of radionuclide-based high-dose-rate brachytherapy. Retrieved June 27, 2016 from http://www.acr.org.

American College of Radiology (ACR) and American Brachytherapy Society (ABS). (2016). ACR-ABS practice parameter for electronically - generated, low energy radiation sources (ELS). Retrieved April 17, 2017 from http://www.acr.org.

American College of Radiology (ACR) and the American Association of Physicists in Medicine (AAPM).(2015) Practice parameter for the performance of high-dose rate brachytherapy physics. Retrieved April 17, 2017 from http://www.acr.org.

American College of Radiology (ACR) and the American Association of Physicists in Medicine (AAPM).(2015) Practice parameter for the performance of low-dose rate brachytherapy physics. Retrieved April 17, 2017 from http://www.acr.org.

Ballester-Sanchez, R., Pons-Llanas, O., Candela-Juan, C., Celado-Alvarez, F.J., de Unamuno-Bustos, B., Llavador-Ros, M., et al. (2015). Efficacy and safety of electronic brachytherapy for superficial and nodular basal cell carcinoma. Journal of Contemporary Brachytherapy, 7 (3), 231-238. (Level 3 evidence)

Bhatnagar, A. (2013). Nonmelanoma skin cancer treated with electronic brachytherapy: results at 1 year. Brachytherapy, 12 (2), 134-140. (Level 4 evidence)

Bhatnagar, A., Patel, R., Werschler, W., Cielley, R., and Strimling, R. (2016, November) High-dose rate electronic brachytherapy: a nonsurgical treatment alternative for nonmelanoma skin cancer. Journal of Clinical and Aesthetic Dermatology. Nov. 2016, Vol. (, No. 11; 16-22. (Level 4 evidence)

Bhatnager, A., & Loper, A. (2010). The initial experience of electronic brachytherapy for the treatment of non-melanoma skin cancer. Radiation Oncology, 5 (87), 1-9. (Level 4 evidence)

BlueCross BlueShield Association. Medical Policy Reference Manual. (7:2016). Electronic Brachytherapy for Nonmelanoma Skin Cancer (8.01.62). Retrieved April 17, 2017 from BlueWeb. (13 articles and/or guidelines reviewed)

Delishaj, D., Rembielak, A., Manfredi, B., Ursino, S., Pasqualetti, F., Laliscia, C., et. al., (2016) Non-melanoma skin cancer treated with high-dose-rate brachytherapy: a review of literature. Journal of Contemporary Brachytherapy; 8, 6: 533-540. (Level 2 evidence)

Kasper, M and Chaudhary, A. (2015, November) Novel treatment options for nonmelanoma skin cancer: focus on electronic brachytherapy. Medical Devices: Evidence and Research. 2015:8 493–502 (Level 5 evidence)

National Comprehensive Cancer Network® (NCCN) (2016, October) Basal cell skin cancer - version 1.2017. Retrieved April 17, 2017 from: www.nccn.org.

U.S. Food and Drug Administration. (2009, February). Centers for Devices and Radiological Health. 510(k) Premarket Notification Database. K08373 (Axxent®). Retrieved August 12, 2015 from http://www.accessdata.fda.gov. 

U.S. Food and Drug Administration. (2013, September). Centers for Devices and Radiological Health. 510(k) Premarket Notification Database. K132092 (Esteya™). Retrieved August 12, 2015 from http://www.accessdata.fda.gov .

Wisconsin Physician Services Insurance Corporation (2017, January) Local Coverage Determination (LCD): Category III Codes (L35490). Retrieved April 17, 2017 from https://www.cms.gov/.

ORIGINAL EFFECTIVE DATE:  12/12/2015

MOST RECENT REVIEW DATE:  6/8/2017

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