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), 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: PDT can also be delivered via external application for the treatment of skin lesions. This policy does not address the external application for the treatment of skin lesion, or the treatment of the pre-cancerous condition of Barrett’s esophagus. Also, PDT should not be confused with extracorporeal photopheresis, which involves withdrawing blood from the patient, irradiating it with ultraviolet light, and then returning the blood to the patient.

POLICY

See also:  Ablation Treatments for Barrett’s Esophagus

MEDICAL APPROPRIATENESS

IMPORTANT REMINDERS

ADDITIONAL INFORMATION  

The American College of Gastroenterology recommends that an expert gastrointestinal pathologist confirm the diagnosis of dysplasia in Barrett's esophagus.

SOURCES 

Agency for Healthcare Research and Quality. (2014). Guide to clinical preventive Services, 2014. Section 2. Recommendations for adults. Retrieved November 8, 2016 from http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/guide.

American College of Chest Physicians. (2013, May). Diagnosis and treatment of bronchial intraepithelial neoplasia and early lung cancer of the central airways: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Retrieved December 15, 2015 from the National Guideline Clearinghouse (NGC: 9879).

BlueCross BlueShield Association. Medical Policy Reference Manual. (8:2017). Oncologic applications of photodynamic therapy, including Barrett's esophagus (8.01.06). Retrieved September 8, 2017 from BlueWeb. (84 articles and/or guidelines reviewed)

Hauge, T., Hauge, P., Warloe, T., Drolsum, A., Johansen, C., Viktil, E., et al. (2016, March) Randomized controlled trial of temoporfin photodynamic therapy plus chemotherapy in nonresectable biliary carcinoma-PCS Nordic study.

Kidane, B., Hirpara, D., & Yasufuku, K. (2016). Photodynamic therapy in non-gastrointestinal thoracic malignancies. International Journal of Molecular Science, 17 (1), 135-149. (Level 5 evidence - Independent)

Lu, Y., Liu, L., Wu, J., Bie, L., and Gong, B. (2015, December) 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, February) 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. (2017, August). NCCN clinical practice guidelines in oncology (NCCN Guidelines®) Esophageal and esophagogastric junction cancers (2:2017). Retrieved September 8, 2017 from www.nccn.org.

National Comprehensive Cancer Network. (2017, August). NCCN clinical practice guidelines in oncology (NCCN Guidelines®) Hepatobiliary cancers (3:2017). Retrieved September 8, 2017 from www.nccn.org.

National Comprehensive Cancer Network. (2017, July). NCCN clinical practice guidelines in oncology (NCCN Guidelines®) Non-small cell lung cancer (8:2017). Retrieved September 8, 2017 from www.nccn.org.

National Institute for Health and Clinical Excellence (NICE). (2008, April). Interstitial photodynamic therapy for malignant parotid tumours. Retrieved March 10, 2011 from http://www.nice.org.uk.

National Institute for Health and Clinical Excellence (NICE). (2005, November). Photodynamic therapy for localised inoperable endobronchial cancer. Retrieved November 2, 2012 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 September 7, 2017 from http://www.nice.org.uk.

National Institute for Health and Clinical Excellence (NICE). (2007, January). Palliative photodynamic therapy for advanced oesophageal cancer. Retrieved March 10, 2011 from http://www.nice.org.uk.

National Institute for Health and Clinical Excellence (NICE). (2004, August). Photodynamic therapy for advanced bronchial carcinoma. Retrieved November 2, 2012 from http://www.nice.org.uk.

National Institute for Health and Clinical Excellence (NICE). (2005, July). Photodynamic therapy for bile duct cancer. Retrieved November 2, 2012 from http://www.nice.org.uk.

National Institute for Health and Clinical Excellence (NICE). (2009, March). Photodynamic therapy for brain tumours. Retrieved March 10, 2011 from http://www.nice.org.uk.

Ortner, M., Caca, K., Berr, F., Liebetruth, J., Mansmann, U., Huster, D., et al. (2003, November) Successful photodynamic therapy for nonresectable cholangiocarcinoma: a randomized prospective study.Gastroenterology, 125 (5), 1355-63. Abstract retrieved October 10, 2017 from PubMed database.

Photo-diagnosis Photodynamic Therapy, 13, 330-3. Abstract retrieved September 8, 2017 from PubMed database.

U. S. Food and Drug Administration. (2000, June). Center for Devices and Radiological Health. Medical devices. Diomed 630 PDT Laser - P990021. Retrieved March 11, 2011 from http://www.accessdata.fda.gov .

U. S. Food and Drug Administration. (2000, June). Center for Drug Evaluation and Research. Pre-market approval P990021 (Photofrin®). Retrieved September 7, 2017 from http://www.accessdata.fda.gov.

U. S. Food and Drug Administration. (2003, August). Center for Devices and Radiological Health. Medical devices. Wizard X-cell photodynamic therapy balloon with fiber optic diffuser - P020021. Retrieved March 11, 2011 from http://www.accessdata.fda.gov.

Winifred S. Hayes, Inc. Medical Technology Directory. (2013, November; last update search October 2016). Photodynamic therapy for head and neck cancer. Retrieved November 8, 2016 from www.Hayesinc.com. (50 articles and/or guidelines reviewed)

Witzigmann, H., Berr, F., Ringel, U., Caca, K., Uhlmann, D., Schoppmeyer, K., et al. (2006) Surgical and palliative management and outcome in 184 patients with hilar cholangiocarcinoma: palliative photodynamic therapy plus stenting is comparable to R1/R2 resection. Annals of Surgery, 244 (2), 230-240. (Level 2 evidence)

Yi, E., Chang, J. E., Leem, C., Kim, S., & Jheon, S. (2016). Clinical results of photodynamic therapy in tracheobronchial malignancy. Journal of photochemistry and Photobiology B: Biology, 156, 56-60. Abstract retrieved November 8, 2016 from PubMed database.

Yu, C., Avci, P., Canteenwala, T., Chiang, L. Y., Chen, B. J., & Hamblin, M. R. (2016). Photodynamic therapy with Hexa(sulfo-n-butyl)[60]Fullerene against sarcoma in vitro and in vivo. Journal of Nanoscience and Nanotechnology, 16 (1), 171-181. Abstract retrieved November 8, 2016 from PubMed database.

Zoepf, T., Jakobs, R., Arnold, J., Apel, D., and Riemann, J. (2005, November) Palliation of nonresectable bile duct cancer: improved survival after photodynamic therapy. American Journal of Gastroenterology, 100 (1), 2426-30. Abstract retrieved October 10, 2017 from PubMed database.

EFFECTIVE DATE

3/85

 

 

7/88

Reevaluated

 

8/98

Reevaluated by MPRC.

 

6/1/2000

(2/14/00 Approved by MPRC)

 

7/1/2001

(3/12/01 - Approved by MPRC)

 

4/10/2003

(4/10/03 - Maintenance / MTAS Review)

 

6/1/2004

(2/9/04 - Approved by MPRC)

 

12/8/2005

(12/8/05 - Maintenance / MTAS Review)

 

10/11/2007

(10/11/07 - Maintenance / MTAS Review)

 

9/10/2009

(9/10/09 - Maintenance / MTAS Review)

 

4/14/2011

(4/14/11 - Maintenance / MTAS Review)

 

12/13/2012

(12/13/12 - Maintenance / MTAS Review)

 

10/9/2014

(10/9/14 - Maintenance / MTAS Review)

 

1/28/2016

(1/28/16 - Maintenance / MTAS Review)

 

2/22/2017

(1/12/17 - Criteria corrections/clarification approved by MTAS)

 

12/20/2017

(10/26/17 - Approved by MTAC)

 

4/28/2018

(4/28/18 - Barrett’s esophagus content was moved to Ablation Treatments for Barrett’s Esophagus policy)

ORIGINAL EFFECTIVE DATE:  10/12/2013

MOST RECENT REVIEW DATE:  4/28/2018

ID_BA

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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