BlueCross BlueShield of Tennessee Medical Policy Manual

Intensity-Modulated Radiotherapy (IMRT) of the Breast and Lung

DESCRIPTION

Intensity-modulated radiotherapy (IMRT) has been proposed as a method of radiotherapy that allows adequate dosing to the tumor while minimizing the radiation dose to surrounding normal tissues and critical structures.  IMRT, which uses computer software, CT images and magnetic resonance imaging (MRI), offers better conformality than 3-dimensional conformal radiation therapy (3D-CRT), as it is able to modulate the intensity of the overlapping radiation beams projected on the target and to use multiple-shaped treatment fields.  The radiation oncologist delineates the target on each slice of a CT scan and specifies the target’s prescribed radiation dose, adjacent normal tissue volumes to avoid and acceptable dose limits within the normal tissues.  Based on these parameters and a digitally reconstructed radiographic image of the tumor and surrounding tissues and organs at risk, computer software optimizes the location, shape and intensities of the beams to achieve the treatment plan’s goals.  Increased conformality may permit escalated tumor doses without increasing normal tissue toxicity and thus may improve local tumor control with decreased exposure to surrounding normal tissues, potentially reducing acute and late radiation toxicities.  Better dose homogeneity within the target may also improve local tumor control by avoiding underdosing within the tumor and may decrease toxicity by avoiding overdosing.

For the treatment of breast cancer, IMRT appears to produce clinical outcomes comparable with that of 3-dimensional conformal radiation therapy (3D-CRT).  Dosimetry studies have demonstrated that IMRT reduces inhomogeneity of radiation dose, thus potentially providing a mechanism for reduced skin toxicity compared with 2-dimensional radiotherapy (2D-RT).  IMRT has not demonstrated improvements in health outcomes for partial-breast irradiation or chest wall irradiation in post-mastectomy breast cancer cases.

For the treatment of lung cancer, IMRT appears to produce clinical outcomes comparable with that of 3D-CRT.  Dosimetry studies report that IMRT can reduce radiation exposure to critical surrounding structures, especially in large lung cancer.  

BCBST uses MCG Care Guidelines for all other uses of IMRT - Intensity Modulated Radiation Therapy (IMRT)

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MEDICAL APPROPRIATENESS

IMPORTANT REMINDERS

ADDITIONAL INFORMATION 

Studies on IMRT for partial-breast irradiation are limited and have not demonstrated improvements in health outcomes.  No studies have reported on health outcomes after IMRT for chest wall irradiation in post-mastectomy cases. 

SOURCES

American College of Radiology. (2012) ACR Appropriateness Criteria® nonsurgical treatment for non-small-cell lung cancer: poor performance status or palliative intent. Retrieved June 27, 2016 from the National Guideline Clearinghouse (NGC#009682).

BlueCross BlueShield Association. Medical Policy Reference Manual. (8:2016). Intensity-modulated radiotherapy of the breast and lung. (8.01.46). Retrieved May 8, 2017 from BlueWeb.  (27 articles and/or guidelines reviewed)

Cahaba Government Benefit Administrators, LLC. (2016, October). LCD for radiology: Intensity modulated radiation therapy (IMRT) (L36743). Retrieved May 8, 2017 from https://www.cms.gov.

Harris, J., Murphy, J., Hanlon, A., Le, Q., Loo, B., & Diehn, M. (2014). A population-based comparative effectiveness study of radiation therapy techniques in stage III non-small cell lung cancer. International Journal of Radiation Oncology, Biology, Physics, 88 (4), 872-884. Abstract retrieved June 27, 2016 from PubMed database.

Lei, R., Leonard, C., Howell, K., Henkenberns, P., Johnson, T., Hobart, T., et al.  (2013). Four-year clinical update from a prospective trial of accelerated partial breast intensity-modulated radiotherapy (APBIMRT). Breast Cancer Research and Treatment. 140 (1),119-133. (Level 2 evidence)

Livi, L., Meattini, I., Marrazzo, L., Simontacchi, G., Pallotta, S., Saieva, C., et al. (2015). Accelerated partial breast irradiation using intensity-modulated radiotherapy versus whole breast irradiation: 5-year survival analysis of a phase 3 randomised controlled trial. European Journal of Cancer, 51 (4), 451-463. Abstract retrieved June 27, 2016 from PubMed database.

National Comprehensive Cancer Network. (2017, April). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Breast cancer. Retrieved May 8, 2017 from the National Comprehensive Cancer Network.

National Comprehensive Cancer Network. (2017, February). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Small cell lung cancer. Retrieved May 8, 2017 from the National Comprehensive Cancer Network.

National Comprehensive Cancer Network. (2017, March). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Non-small cell lung cancer. Retrieved May 8, 2017 from the National Comprehensive Cancer Network.

National Institute for Health and Care Excellence. (2009, February) Early and locally advanced breast cancer: diagnosis and treatment. Retrieved June 27, 2016 from www.nice.org.uk

Shirvani, S., Juloori, A., Allen, P., Komaki, R., Liao, Z., Gomez, D., et al. (2013). Comparison of 2 common radiation therapy techniques for definitive treatment of small cell lung cancer. International Journal of Radiation Oncology, Biology, Physics, 87 (1), 139-147. Retrieved June 27, 2016 from PubMed database.

U. S. Food and Drug Administration (2007, May) Center for Devices and Radiologic Health. Pre-market Notification Database. K0701078. Retrieved June 27, 2016 from http://www.fda.gov.

U. S. Food and Drug Administration (2009, July) Center for Devices and Radiologic Health. Pre-market Notification Database. K090802. Retrieved June 27, 2016 from http://www.fda.gov.

U. S. Food and Drug Administration (2013, July) Center for Devices and Radiologic Health. Pre-market Notification Database. K131150. Retrieved June 27, 2016 from http://www.fda.gov.

U. S. Food and Drug Administration (2016, April) Center for Devices and Radiologic Health. Pre-market Notification Database. K160093. Retrieved June 27, 2016 from http://www.fda.gov.

Winifred S. Hayes, Inc. Medical Technology Directory. (2012, March; last search update January 2016). Whole breast irradiation for breast cancer using three-dimensional conformal radiation therapy or intensity-modulated radiation therapy. Retrieved June 27, 2016 from www.Hayesinc.com/subscribers. (98 articles and/or guidelines reviewed)

Winifred S. Hayes, Inc. Medical Technology Directory. (2016, October). Accelerated partial breast irradiation for breast cancer using conformal and intensity-modulated radiation therapy.  Retrieved May 9, 2017 from www.Hayesinc.com/subscribers. (50 articles and/or guidelines reviewed)

ORIGINAL EFFECTIVE DATE:  11/18/2015

MOST RECENT REVIEW DATE:  6/8/2017

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