BlueCross BlueShield of Tennessee Medical Policy Manual

Hematopoietic Stem-Cell Transplantation for Miscellaneous Solid Tumors in Adults

DESCRIPTION

Solid tumors in adults are a heterogeneous group of disorders encompassing a wide spectrum of body systems. The use of hematopoietic stem-cell transplantation (HSCT) has been investigated for the treatment of selected solid tumors in adults including lung cancer; malignant melanoma; tumors of the gastrointestinal tract (include colon, rectum, pancreas, stomach, esophagus, gallbladder, and bile duct); male and female genitourinary systems (e.g., renal cell carcinoma, cervical carcinoma, cancer of the uterus, fallopian tubes, and prostate gland); tumors of the head and neck; soft tissue sarcoma; thyroid tumors; tumors of the thymus; and tumors of unknown primary origin.

The success of autologous HSCT is predicated on the ability of cytotoxic chemotherapy with or without radiation to eradicate cancerous cells from the blood and bone marrow. This permits subsequent engraftment and repopulation of bone marrow space with presumably normal hematopoietic stem cells obtained from the patient prior to undergoing marrow ablating chemotherapy. Hematopoietic stem cells may be obtained from the transplant recipient (autologous HSCT) or from a donor (allogeneic HSCT).  Autologous HSCT is typically performed as consolidation therapy when the patient’s disease is in complete remission.

The conventional practice of allogeneic HSCT involves administration of cytotoxic agents (e.g., cyclophosphamide, busulfan) with or without total body irradiation at doses sufficient to destroy endogenous hematopoietic capability in the recipient. The beneficial treatment effect in this procedure is a result of a combination of initial eradication of malignant cells and subsequent graft-versus-malignancy (GVM) effect mediated by non-self immunologic effector cells that develop after engraftment of allogeneic stem cells.

HSCT is an established treatment for certain hematologic malignancies; however, its use in solid tumors in adults continues to be largely experimental. Initial enthusiasm for the use of autologous HSCT for solid tumors has waned with the realization that dose intensification often fails to improve survival. With the advent of nonmyeloablative allogeneic transplant, interest has shifted to exploring the generation of alloreactivity to metastatic solid tumors via a graft-versus-tumor effect of donor-derived T cells.

POLICY

• Hematopoietic stem-cell transplant as a treatment for soft tissue sarcomas in adults is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)

• Autologous or allogeneic stem-cell transplant as a treatment for other solid tumor malignancies in adults, including but not limited to the following, is considered investigational:

• • Lung cancer, any histology

  • Colon cancer

  • Rectal cancer

  • Pancreas cancer

  • Stomach cancer

  • Esophageal cancer

  • Gallbladder cancer

  • Cancer of the bile duct

  • Renal cell cancer

  • Cervical cancer

  • Uterine cancer

  • Cancer of the fallopian tubes

  • Prostate cancer

  • Nasopharyngeal cancer

  • Paranasal sinus cancer

  • Neuroendocrine tumors

  • Thyroid tumors

  • Tumors of the thymus

  • Tumors of unknown primary origin

  • Malignant melanoma

See also:

• Autologous Hematopoietic Stem-Cell Transplantation for Malignant Astrocytomas and Gliomas

• Donor Lymphocyte Infusion for Hematologic Malignancies Treated with an Allogeneic Hematopoietic Stem Cell Transplant

• Hematopoietic Stem Cell Transplant for Breast Cancer

• Hematopoietic Stem Cell Transplantation for Central Nervous System Embryonal and Ependymoma Tumors

• Hematopoietic Stem Cell Transplantation in the Treatment of Germ Cell Tumors

• High Dose Chemotherapy with Autologous Stem-Cell Transplant for Primary Amyloid Light-Chain (AL) Amyloidosis

• High Dose (Myeloablative) Chemotherapy with Bone Marrow, Peripheral Stem Cell, or Cord Blood Transplant for Hematopoietic Stem Cell Support

• Nonmyeloablative Allogeneic Stem Cell Transplantation (Reduced Intensity Stem Cell Transplant) for Treatment of Malignancy

• Pancreas / Pancreas-Kidney / Pancreatic Islet Cell Transplantation

• Tandem High Dose Chemotherapy with Hematopoietic Stem Cell Support

MEDICAL APPROPRIATENESS

• Please refer to the Milliman Care Guidelines - Bone Marrow and Peripheral Blood Stem Cell Transplantations for specific disease guidelines.

IMPORTANT REMINDERS

• Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g. statement.

• We develop Medical Policies to provide guidance to Members and Providers.  This Medical Policy relates only to the services or supplies described in it.  The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy.  For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed.  If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.

ADDITIONAL INFORMATION

Peer reviewed studies on the use of stem cell transplant in the treatment of solid tumors of adults addressed in this policy are limited. There is insufficient evidence to permit conclusions regarding improved health outcomes.

SOURCES

BlueCross BlueShield Association. Medical Policy Manual. (9:2010). Hematopoietic stem cell transplantation for miscellaneous solid tumors (8.01.24). Retrieved November 12, 2010 from Blue Web. (16 articles and/or guidelines reviewed)

Cancer Care Ontario. (2009, January). Stem cell transplantation in adults: Recommendations. Retrieved November 23, 2010 from http://www.guideline.gov/content.aspx?id=14435&search=stem+cell.

Complete Guide to Medicare Coverage Issues [Computer software]. (2010, August). Stem cell transplantation (NCD 110.8.1, p. 2-54 to 2-55). Ingenix.

National Comprehensive Cancer Network. (2010). NCCN clinical practice guidelines in oncology. Ovarian cancer (V.2.2011). Retrieved November 23, 2010 from http://www.nccn.org/professionals/physician_gls/PDF/ovarian.pdf.

Pedrazzoli, P., Ledermann, J., Lotz, J., Leyvraz, S., Aglietta, M., Rosti, G., et al. (2006) High dose chemotherapy with autologous hematopoietic stem cell support for solid tumors other than breast cancer in adults. Annals of Oncology, 17 (10), 1479-1488. (Level 1 evidence - Independent)

ORIGINAL EFFECTIVE DATE:  5/14/2011    

MOST RECENT REVIEW DATE:  5/14/2011    

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Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

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