BlueCross BlueShield of Tennessee Medical Policy Manual

Photodynamic Therapy (PDT) for the Treatment of Certain Cancers

DESCRIPTION

Photodynamic therapy (PDT) has been investigated for use in a wide variety of cancers, including esophageal, lung, cholangiocarcinoma, bladder, breast, brain (administered intraoperatively), and head and neck cancers. PDT utilizes a photosynthesizing drug given intravenously that preferentially accumulates in cancerous tissues. After a period of time ranging from a few minutes to 48 hours, the treated cancer cells are exposed to a low-energy single wavelength laser light that activates the drug. A light source (e.g., fiberoptic endoscope, quartz fiberoptic cable with a modified tip) endoscopically delivers the laser light to the targeted tumor tissue. Light-activation of the drug produces a toxic form of oxygen that causes destruction of the cancer cells. Photodynamic therapy may also be called phototherapy, photoradiation therapy, photosensitizing therapy, or photochemotherapy.

Note: This policy does not address PDT for the treatment of skin lesion or Barrett’s esophagus. PDT should not be confused with extracorporeal photopheresis which involves withdrawing blood from an individual, irradiating it with ultraviolet light, and then returning the blood to the individual.

POLICY

MEDICAL APPROPRIATENESS

IMPORTANT REMINDERS

SOURCES 

BlueCross BlueShield Association. Evidence Positioning System. (8:2019). Oncologic applications of photodynamic therapy, including Barrett's esophagus (8.01.06). Retrieved August 6, 2019 from https://www.evidencepositioningsystem.com/. (81 articles and/or guidelines reviewed)

Hauge, T., Hauge, P., Warloe, T., Drolsum, A., Johansen, C., Viktil, E., et al. (2016). Randomized controlled trial of temoporfin photodynamic therapy plus chemotherapy in nonresectable biliary carcinoma--PCS Nordic study. Photo-diagnosis Photodynamic Therapy, 13, 330-3. Abstract retrieved September 8, 2017 from PubMed database.

Lu, Y., Liu, L., Wu, J., Bie, L., and Gong, B. (2015). Efficacy and safety of photodynamic therapy for unresectable cholangiocarcinoma: A meta-analysis. Clinical Research in Hepatology & Gastroenterology, 39 (6), 718-24. Abstract retrieved September 8, 2017 from PubMed database.

Moole, H., Tathireddy, H.,  Dharmapuri,S., Moole, V., Boddireddy, R., et al. (2017). Success of photodynamic therapy in palliating patients with nonresectable cholangiocarcinoma: a systematic review and meta-analysis. World Journal of Gastroenterology, 23 (7), 1278-1288. (Level 2 evidence)

National Comprehensive Cancer Network. (2019, August). NCCN clinical practice guidelines in oncology (NCCN Guidelines®) Hepatobiliary cancers version 3.2019. Retrieved August 6, 2019 from the National Comprehensive Cancer Network.

National Comprehensive Cancer Network. (2019, June). NCCN clinical practice guidelines in oncology (NCCN Guidelines®) Non-small cell lung cancer version 5.2019. Retrieved August 6, 2019 from the National Comprehensive Cancer Network.

National Comprehensive Cancer Network. (2019, May). NCCN clinical practice guidelines in oncology (NCCN Guidelines®) Esophageal and esophagogastric junction cancers version 2.2019. Retrieved August 6, 2019 from the National Comprehensive Cancer Network.

National Institute for Health and Clinical Excellence (NICE). (2005, November). Photodynamic therapy for localised inoperable endobronchial cancer. Retrieved August 28, 2018 from http://www.nice.org.uk.

National Institute for Health and Clinical Excellence (NICE). (2006, December). Palliative photodynamic therapy for early stage oesophageal cancer. Retrieved August 28, 2018 from http://www.nice.org.uk.

National Institute for Health and Clinical Excellence (NICE). (2007, January). Palliative photodynamic therapy for advanced oesophageal cancer. Retrieved August 28, 2018 from http://www.nice.org.uk. 

National Institute for Health and Clinical Excellence (NICE). (2004, August). Photodynamic therapy for advanced bronchial carcinoma. Retrieved August 28, 2018 from http://www.nice.org.uk.

National Institute for Health and Clinical Excellence (NICE). (2005, July). Photodynamic therapy for bile duct cancer. Retrieved August 28, 2018 from http://www.nice.org.uk. 

National Institute for Health and Clinical Excellence (NICE). (2009, March). Photodynamic therapy for brain tumours. Retrieved August 28, 2018 from http://www.nice.org.uk. 

U. S. Food and Drug Administration. (2000, June). Center for Devices and Radiological Health. Pre-market approval decisions for June 2000. P990021. Retrieved March 11, 2011 from http://www.accessdata.fda.gov.

U. S. Food and Drug Administration. (2003, August). Center for Devices and Radiological Health. Pre-market approval decisions for August 2003. P020021. Retrieved March 11, 2011 from http://www.accessdata.fda.gov.

Winifred S. Hayes, Inc. Medical Technology Directory. (2013, November; last update search October 2017). Photodynamic therapy for head and neck cancer. Retrieved August 28, 2018 from www.Hayesinc.com/subscribers. (50 articles and/or guidelines reviewed)

Zhang, X., Mo, R., Zhao, H., Luo, X., & Yang, Y. (2018). A comparative effectiveness meta-analysis of photodynamic therapy and stent drainage for unresectable cholangiocarcinoma. Photodiagnosis and Photodynamic Therapy, doi:10.1016/j.pdpdt.2018.06.018 [Epub ahead of print]. Abstract retrieved August 28, 2018 from PubMed database.

ORIGINAL EFFECTIVE DATE:  3/1985

MOST RECENT REVIEW DATE:  9/26/2019

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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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