Subject:
Radiation Therapy for Pancreatic Cancer
Description:
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IMPORTANT NOTE:
The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.
Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.
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Over the past several decades, methods to plan and deliver radiation therapy have evolved in ways that permit more precise targeting of tumors with complex geometries. Earlier methods involved two-dimensional treatment planning based on flat images, and radiation beams with cross-sections of uniform intensity that were sequentially aimed at the tumor along 2 or 3 intersecting axes. These methods were collectively termed conventional external beam radiation therapy (EBRT).
Subsequent enhancement evolved using 3-dimensional images, usually from computed tomography (CT) scans, to delineate the tumor, its boundaries with adjacent normal tissue, and organs at risk for radiation damage. Radiation oncologists used these images, displayed from a "beam's-eye-view", to shape each of several beams (e.g., with compensators, blocks, or wedges) to conform to the patient's tumor geometry perpendicular to the beam's axis. Computer algorithms were developed to estimate cumulative radiation dose delivered to each volume of interest by summing the contribution from each shaped beam. Methods also were developed to position the patient and the radiation portal reproducibly for each fraction, and immobilize the patient, thus maintaining consistent beam axes across treatment sessions. However, "forward" planning used a trial and error process to select treatment parameters (the number of beams and the intensity, shape, and incident axis of each beam). The planner/radiotherapist modified one or more parameters and recalculated dose distributions, if analysis predicted underdosing for part of the tumor or overdosing of nearby normal tissue. Furthermore, since beams had uniform cross-sectional intensity wherever they bypassed shaping devices, it was difficult to match certain geometries (e.g., concave surfaces). Collectively, these methods are termed 3-dimensional conformal radiation therapy (3D-CRT).
Other methods were subsequently developed to permit beam delivery with non-uniform cross-sectional intensity. This often relies on a device (multi-leaf collimator, MLC) situated between the beam source and patient that moves along an arc around the patient. As it moves, a computer varies aperture size independently and continuously for each leaf. Thus, MLCs divide beams into narrow "beamlets", with intensities that range from zero to 100% of the incident beam. Beams may remain on as MLCs move around the patient (dynamic MLC), or they may be off during movement and turned on once the MLC reaches prespecified positions ("step and shoot" technique). Another method of delivering radiation beam uses a small radiation portal emitting a single narrow beam that moves spirally around the patient, with intensity varying as it moved. This method, also known as tomotherapy or helical tomotherapy, is described as the use of a linear accelerator inside a large "donut" that spirals around the body while the patient laid on the table during treatment. Each method (MLC-based or tomotherapy) is coupled to a computer algorithm for "inverse" treatment planning. The planner/radiotherapist delineates the target on each slice of a CT scan, and specifies that target's prescribed radiation dose, acceptable limits of dose heterogeneity within the target volume, 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 and shape of beam ports, and beam and beamlet intensities, to achieve the treatment plan's goals. Collectively, these methods are termed intensity-modulated radiation therapy (IMRT).
According to ECRI Institute, there are two different approaches to image-guided radiation therapy that are in current use: pre-treatment imaging and real-time guidance. IMRT is an example of a method that uses pre-treatment imaging to prepare a treatment plan. In contrast, real-time guidance utilizes real-time imaging (at the time of treatment) to guide treatment. It provides real-time, online images of the radiation target area from a computed tomography (CT) scanner before, during, and after therapy. Patient positioning, radiation field alignment, and collimator positioning can be verified and adjusted before and during irradiation. This approach should, in theory, provide more accurate radiation delivery than conventional IMRT. Organ motion, day-to-day variations in tumor position, and differences in patient positioning in each treatment session could be taken into account with real-time imaging.
Policy:
(NOTE: This policy only applies to adult members. It does not apply to pediatric members.
For Medicare Advantage, please refer to the Medicare Coverage Section below for coverage guidance.)
I. Radiation therapy for pancreatic cancer is considered medically necessary for any of the following:
A. Preoperatively (neoadjuvant) when disease is borderline resectable and when given following 2 to 6 months of chemotherapy
B. Locally advanced/unresectable when given following 4 to 6 months of chemotherapy with no evidence of systemic progression
C. Postoperatively (adjuvant) resectable
D. Palliation
II. Radiation therapy for pancreatic cancer is not considered medically necessary when given preoperatively (neoadjuvant) for disease that is otherwise fully resectable.
III. Radiation treatment techniques
A. Three-dimensional conformal radiation therapy (3DCRT) to a dose of 45-54 Gy in 25-30 fractions is considered medically necessary in the preoperative, unresectable or postoperative settings.
B. Motion management techniques should be employed when respiration significantly impacts on stability of the target volume.
C. Stereotactic body radiation therapy (SBRT) using up to 5 fractions is considered medically necessary for:
1. Definitive treatment for medically or surgically inoperable or locally advanced cases following a minimum of 2 cycles of chemotherapy and restaging in which there is no evidence of tumor progression and the disease volume can be entirely encompassed in the radiation treatment volume.
2. Preoperative treatment in borderline resectable cases following a minimum of 2 cycles of chemotherapy and restaging in which there is no evidence of tumor progression and the disease volume can be entirely encompassed in the radiation treatment volume.
D. For palliative situations, up to 15 fractions in 1 phase of 3D conformal radiation therapy is considered medically necessary.
E. IMRT is not considered medically necessary in the preoperative, unresectable, postoperative, or palliative settings.
F. SBRT is not considered medically necessary in the palliative setting, postoperative setting, or for SBRT as planned neoadjuvant treatment when the primary tumor is fully (and not borderline) resectable.
Medicare Coverage:
There is no National Coverage Determination (NCD) or Local Coverage Determination (LCD) for jurisdiction JL for External beam photon radiation therapy (EBRT), Stereotactic body radiation therapy (SBRT) or 3DCRT. Therefore, Medicare Advantage Products will follow the Horizon BCBSNJ Medical Policy for Radiation Treatment of Pancreas Adenocarcinoma.
Novitas Solutions, Inc, the Local Medicare Carrier for jurisdiction JL, has issued a determination for Intensity-Modulated Radiation Therapy (IMRT). Medicare Advantage Products will follow LCD L36711 for Intensity Modulated Radiation Therapy (IMRT). For additional information and eligibility, refer to Local Coverage Determination (LCD): Intensity Modulated Radiation Therapy (IMRT) (L36711). Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=36711&ver=18&name=314*1&UpdatePeriod=749&bc=AAAAEAAAAAAAAA%3d%3d&
Local Coverage Article: Billing and Coding: Intensity Modulated Radiation Therapy (IMRT) (A56725). Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=36711&ver=18&name=314*1&UpdatePeriod=749&bc=AAAAEAAAAAAAAA%3d%3d&.
[INFORMATIONAL NOTE: Pancreatic cancer is the fourth leading cause of cancer mortality in the United States. Surgical resection is integral to the curative management of pancreatic cancer. Unfortunately only twenty percent of individuals present with resectable disease. As such, treatment paradigms have centered on the resectability of the disease, with recommendations differing among those that are resectable, borderline resectable and unresectable.
Locally advanced (unresectable)
For those with unresectable, locally advanced disease, the role of radiation remains unclear. The use of chemoradiation was established by the GITSG trial which reported an improved median overall survival (OS) with radiation (40 Gy split-course) in combination with 5-FU vs. radiation alone to 60 Gy (8.3 months vs. 5.5 months). On the other hand, LAP-07 reported no difference in OS between those patients who were randomized (following 4 cycles of gemcitabine) to 54 Gy chemoradiation or to two additional months of chemotherapy. This is in contrast to the findings in a retrospective analysis (GRECOR) where, following 3 months induction chemotherapy, patients who did not exhibit progression received either continued chemotherapy or chemoradiation (55 Gy with continuous 5-FU). In this analysis, those receiving chemoradiation had a higher OS compared to those receiving chemotherapy alone (15 vs. 11.7 months).
For this group of patients, ASCO recommends for most patients “initial systemic therapy with combination regimens...” followed by chemoradiation or SBRT for those 1) with “local disease progression after induction chemotherapy, but without evidence of systemic spread” or 2) “who have responded to an initial 6 months of chemotherapy or have stable disease but have developed unacceptable chemotherapy-related toxicities or show a decline in performance status, as a consequence of chemotherapy toxicity” or 3) who have a “response or stable disease after 6 months of induction chemotherapy.”
Such an approach was solidified in the recently published ASTRO Clinical Practice Guideline for Pancreatic Cancer. For example, in patients with 1) borderline resectable, 2) select locally advanced patients appropriate for downstaging prior to surgery and 3) locally advanced patients not appropriate for downstaging to eventual surgery, chemoradiation or SBRT alone was recommended following systemic chemotherapy.
Postoperative (adjuvant)
The underpowered but landmark Gastrointestinal Tumor Study Group (GITSG) study established the role of postoperative chemoradiation by demonstrating a survival benefit with this treatment strategy. The GITSG study included 43 patients, randomized to surgery alone or surgery followed by chemoradiation. This trial used a 40 Gy split course regimen that is rarely used today. Though underpowered, there was a 5-year improvement in overall survival (OS). Studies from the Mayo Clinic and Johns Hopkins have supported the use of chemoradiation following resection. The Mayo Clinic study retrospectively reviewed 472 patients. The Johns Hopkins study included 616 patients. Both studies demonstrated improved 5-year overall survivals in the cohorts receiving chemoradiation. A Johns Hopkins-Mayo Clinic Collaborative Study analyzed patients receiving adjuvant chemoradiation compared with surgery alone. In a retrospective review of 1,045 patients with resected pancreatic cancer, 530 patients received chemoradiation. Median and overall survivals were significantly improved in the chemoradiation group. In contrast, the heavily criticized European Organization for Research and Treatment of Cancer (EORTC) and European Study Group for Pancreatic Cancer (ESPAC) studies have not supported the use of adjuvant chemoradiation. These studies were heavily criticized for trial design, inclusion of more favorable histologies, lack of quality assurance, and use of split course radiation.
In 2017, ASCO recommended 6 months of adjuvant chemotherapy for “all patients with resected pancreatic cancer who did not receive preoperative therapy” and adjuvant chemoradiation “to patients who did not receive preoperative therapy and present after resection with microscopically positive margins (r1) and/or node=positive disease after completion of 4 to 6 months of systemic adjuvant chemotherapy.”
In the recently published Clinical Practice Guideline for Pancreatic Cancer, the authors state that “the current literature supports a recommendation for adjuvant chemotherapy alone following RO surgical resection for node negative patients.” For “node positive disease following RO surgical resection and adjuvant systemic chemotherapy with no evidence of disease recurrence on restaging, chemoradiation should be discussed.”.
NCCN® states “in the adjuvant setting, treatment with chemotherapy is recommended; the role of radiation is being evaluated in clinical studies.” However, “after resection, patients may receive adjuvant RT for features that portend high risk for local recurrence (ie, positive resection margins and/or lymph nodes).”
Preoperative (neoadjuvant)
Given the limited data and varying results, the use of radiation in cases that are anatomically resectable is considered not medically necessary. In the Clinical Practice Guideline for Pancreatic Cancer, the authors state that “based on the level of available evidence, the indications for considering anatomically resectable pancreas cancer patients for preoperative therapy are controversial” and as such “there is not enough high-level evidence to support this recommendation outside of a registry or a clinical trial.”
NCCN® also states that “neoadjuvant therapy for patients with resectable tumors should ideally be conducted in a clinical trial.”
On the other hand, the use of radiation is supported in cases that are borderline resectable. Several studies have confirmed the ability of radiation to improve resection rates while improving the likelihood of achieving negative margins.
NCCN Guidelines® indicate that “data suggest that RT in the neoadjuvant setting may lead to an increased likelihood of a margin-negative resection” and that “it is sometimes recommended that patients receive ≥2-6 cycles of neoadjuvant chemotherapy prior to RT.”
SBRT
While data on the use of SBRT in cancer of the pancreas continues to emerge, there is a growing consensus on its use following 2 to 3 cycles of chemotherapy. Mellon et al. (2015) reported on 159 patients with borderline resectable and locally advanced disease. Patients received chemotherapy for 2 to 3 months followed by a total of 30 Gy to tumor and 40 Gy dose painted to tumor-vessel interfaces administered with 5 SBRT daily treatments. The resection and negative margin rate for borderline resectable patients who completed treatment was 51% and 96% respectively. Median survival was 34.2 months for surgically resected patients and 14.0 months for unresected patients. Locally advanced pancreas cases that received FOLFIRINOX (leucovorin calcium [folinic acid], fluorouracil, irinotecan hydrochloride, oxaliplatin) and SBRT underwent a negative margin (R0) resection with a trend towards improved survival. Grade 3 or higher possible radiation toxicity was 7%. A phase II multi-institution trial evaluating gemcitabine and SBRT in locally advanced unresectable patients by Herman et al. (2015) reported a median survival of 13.9 months and freedom from disease progression at one year of 78%. Of the 49 patients entered, 4 patients (8%) underwent negative margin and negative lymph node resections. Both early and late gastrointestinal toxicity was reported as minimal. A single institution review of 88 patients by Moningi et al. (2015) had similar findings. Of the 19 patients who underwent surgery, 79% had locally advanced disease and 84% had margin negative resections. SBRT in resected pancreatic adenocarcinoma with close or positive margins combined with post-radiation chemotherapy (Rwigema et al., 2012) achieved freedom from local progression at 6 months, 1, and 2 years of 94.7%, 66% and 44% in a series of 24 patients. Overall median survival was 26.7 months and the 1- and 2-year statistics were 80.4% and 57.2% respectively. Gastrointestinal toxicities were minor with no patients having a grade 3 or 4 toxicity. Given the available data, SBRT is supported for locally advanced and borderline resectable.
3D vs. IMRT
It is recognized that, as compared to 3D conformal radiation, IMRT inherently allows for improved comformality and a reduction in medium- to high-dose to immediately adjacent organs at risk (OARs) with the trade-off of an increased integral dose. Such results have been confirmed in several dosimetric studies (ie Chapman et al) while others studies reported otherwise (ie Ling et al). However, it remains unclear whether such potential improvements with IMRT consistently result in clinical benefits. In the Clinical Practice Guideline for Pancreatic Cancer, the authors state that “clinical data on associated improvement of acute and sub-acute gastrointestinal toxicities is limited. Some studies have reported lower but not statistically significant rates of anorexia, nausea, and emesis with modulated techniques” while “retrospective data suggests equivalent clinical outcomes between patients treated with IMRT and 3-D CRT…”
Though the Guideline “recommends IMRT/VMAT treatment planning techniques” it does so based on the inherent properties of IMRT including “greater conformality” and “lower dose to OARs” characteristics that hold true for IMRT to any location. On the other hand, given limited clinical evidence supporting a benefit to IMRT, a “potential reduction in acute and late toxicities…” is insufficient to consider IMRT medically necessary. That said, exceptions will be considered on a case-by-case basis.]
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Horizon BCBSNJ Medical Policy Development Process:
This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.
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Index:
Radiation Therapy for Pancreatic Cancer
Radiation Treatment of Pancreas Adenocarcinoma
Pancreas Adenocarcinoma, Radiation Treatment of
Stereotactic Radiotherapy of Pancreas Adenocarcinoma
Stereotactic Radiotherapy of Pancreatic Cancer
Pancreatic Cancer, Stereotactic Radiotherapy
Pancreatic Adenocarcinoma, Stereotactic Radiotherapy
SBRT, Pancreatic Cancer
Pancreatic Cancer, Radiation Therapy for
References:
1. Brown MW, Ning H, Arora B, et al. A dosimetric analysis of dose escalation using two intensity-modulated radiation therapy techniques in locally advanced pancreatic carcinoma. Int J Radiat Oncol Biol Phys. 2006 May 1; 65(1):274-283.
2. Brunner TB, Nestle U, Grosu AL, et al. SBRT in pancreatic cancer: What is the therapeutic window? Radiother Oncol. 2015 Jan; 114(1):109-116. http://www.sciencedirect.com/science/article/pii/S0167814014004654.
3. Ceha HM, van Tienhoven G, Couma DJ, et al. Feasibility and efficacy of high dose conformal radiotherapy for patients with locally advanced pancreatic carcinoma. Cancer. 2000 Dec 1; 89(11):2222-2229.
4. Chauffert B Mornex F, Bonnetain F, et al. Phase III trial comparing intensive induction chemoradiotherapy (60 Gy, infusional 5-FU and intermittent Cisplatin) followed by maintenance Gemcitabine with Gemcitabine alone for locally advanced unresectable pancreatic cancer. Definitive results of the 2000-01 FFCD/SFRO study. Ann Oncol. 2008 Sep; 19(9):1592-1599.
5. Clinicaltrials.gov. Search for SBRT and pancreas.
6. Corsini MM, Miller RC, Haddock MG, et al. Adjuvant radiotherapy and chemotherapy for pancreatic carcinoma: The Mayo Clinic experience (1975-2005). J Clin Oncol. 2008 Jul 20; 26(21):3511-3516.
7. Fuss M, Wong A, Fuller CD, et al. Image-guided intensity-modulated radiotherapy for pancreatic carcinoma. Gastrointest Cancer Res. 2007 Jan-Feb; 1(1):2-11.
8. Gastrointestinal Tumor Study Group (GITSG). Further evidence of effective adjuvant combined radiation and chemotherapy following curative resection of pancreatic cancer. Cancer. 1987 Jun 15; 59(12):2006-2010.
9. Goyal K, Einstein D, Ibarra RA, et al. Stereotactic body radiation therapy for nonresectable tumors of the pancreas. J Surg Res. 2012 May 15; 174(2): 319-325.
10. Herman JM, Chang DT, Goodman KA, et al. Phase 2 multi-institutional trial evaluating Gemcitabine and stereotactic body radiotherapy for patients with locally advanced unresectable pancreatic adenocarcinoma. Cancer. 2015 Apr 1; 121(7):1128-1137.
11. Herman JM, Swartz MJ, Hsu CC, et al. Analysis of Fluorouracil-based adjuvant chemotherapy and radiation after pancreaticoduodenectomy for ductal adenocarcinoma of the pancreas: Results of a large, prospectively collected database at the Johns Hopkins Hospital. J Clin Oncol. 2008 Jul 20; 26(21):3503-3510.
12. Hsu CC, Herman JM, Corsini MM, et al. Adjuvant chemoradiation for pancreatic adenocarcinoma: The Johns Hopkins Hospital-Mayo Clinic collaborative study. Ann Surg Oncol. 2010 Apr; 17(4):981-990.
13. Klinkenbijl JH, Jeekel J, Sahmoud T, et al. Adjuvant radiotherapy and 5-Fluorouracil after curative resection of cancer of the pancreas and periampullary region: Phase III trial of the EORTC gastrointestinal tract cancer cooperative group. Ann Surg. 1999 Dec; 230(6):776-782.
14. Komaki R, Wadler S, Peters T, et al. High-dose local irradiation plus prophylactic hepatic irradiation and chemotherapy for inoperable adenocarcinoma of the pancreas. A preliminary report of a multi-institutional trial (Radiation Therapy Oncology Group Protocol 8801). Cancer. 1992 Jun 1; 69(11):2807-2812.
15. Koong AC, Christofferson E, Le QT et al. Phase II study to assess the efficacy of conventionally fractionated radiotherapy followed by a stereotactic radiosurgery boost in patients with locally advanced pancreatic cancer. Int J Radiat Oncol Biol Phys. 2005 Oct; 63(2):320-323. http://www.redjournal.org/article/S0360-3016(05)01153-3/abstract.
16. Koong AC, Le QT, Ho A, et al. Phase I study of stereotactic radiosurgery in patients with locally advanced pancreatic cancer. Int J Radiat Oncol Biol Phys. 2004 Mar 15; 58(4):1017-1021.
17. Mahadevan A, Miksad R, Goldstein M, et al. Induction gemcitabine and stereotactic body radiotherapy for locally advanced nonmetastatic pancreas cancer. Int J Radiat Oncol Biol Phys. 2011 Nov 15; 81(4):e615-e622.
18. Mellon EA, Hoffe SE, Springett GM, et al. Long-term outcomes of induction chemotherapy and neoadjuvant stereotactic body radiotherapy for patients with locally advanced unresectable pancreatic adenocarcinoma. Acta Oncol. 2015 Jul; 54(7):979-985.
19. Moertel CG, Frytak S, Hahn RG, et al. Therapy of locally unresectable pancreatic carcinoma: A randomized comparison of high dose (6000 rads) radiation alone, moderate dose radiation (4000 rads + 5-Fluorouracil), and high dose radiation + 5-Fluorouracil: The Gastrointestinal Tumor Study Group. Cancer. 1981 Oct 15; 48(8):1705-10.
20. Moningi S, Dholakia AS, Raman SP, et al. The role of stereotactic body radiation therapy for pancreatic cancer: A single-institution experience. Ann Surg Oncol. 2015 Jul; 22(7):2352-2358.
21. Murphy JD, Chang DT, Abelson J, et al. Cost-effectiveness of modern radiotherapy techniques in locally advanced pancreatic cancer. Cancer. 2012 Feb 15; 118(4):1119-1129.
22. National Comprehensive Cancer Network (NCCN) Guidelines® Version 1.2020 – November 26, 2019. Pancreatic Adenocarcinoma. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Pancreatic Adenocarcinoma 1.2020. 2019 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines® and illustrations herein may not be reproduced in any form for any purpose without the express written permission of the NCCN®. To view the most recent and complete version of the NCCN Guidelines®, go online to NCCN.org.
23. Neoptolemos JP, Dunn JA, Stocken DD, et al. Adjuvant chemoradiotherapy and chemotherapy in resectable pancreatic cancer: a randomised controlled trial. Lancet. 2001 Nov 10; 358(9293): 1576-1585.
24. Patel M, Hoffe S, Malafa M, et al. Neoadjuvant GTX chemotherapy and IMRT-based chemoradiation for borderline resectable pancreatic cancer. J Surg Oncol. 2011 Aug 1; 104(2):155-161.
25. Pollom EL, Alagappan M, von Eyben R, et al. Single- versus multifraction stereotactic body radiation therapy for pancreatic adenocarcinoma: Outcomes and toxicity. Int J Radiat Oncol Biol Phys. 2014 Nov 15: 90(4):918-925.
26. Poppe M, Narra V, Yue NJ, et al. A comparison of helical intensity-modulated radiotherapy, intensity-modulated radiotherapy, and 3D-conformal radiation therapy for pancreatic cancer. Med Dosim. 2011 Winter; 36(4):351-7.
27. Rwigema JC, Heron DE, Parikh SD, et al. Adjuvant stereotactic body radiotherapy for resected pancreatic adenocarcinoma with close or positive margins. J Gastrointest Cancer. 2012 Mar; 43(1):70-76.
28. Schellenberg D, Goodman KA, Lee F, et al. Gemcitabine chemotherapy and single-fraction stereotactic body radiotherapy for locally advanced pancreatic cancer. Int J Radiat Oncol Biol Phys. 2008 Nov 1; 72(3):678-686.
29. Trakul N, Koong AC, Chang DT. Stereotactic body radiotherapy in the treatment of pancreatic cancer. Semin Radiat Oncol. 2014 Apr: 24(2):140-147.
30. Van Tienhoven G, Versteijne E, Suker, M, et al. Preoperative chemoradiotherapy versus immediate surgery for resectable and borderline resectable pancreatic cancer (PREOPANC-1): A randomized, controlled, multicenter phase III trial. American Society of Clinical Oncology (ASCO) 2018. Presented June 4, 2018. Abstract LBA4002.
31. Yang W, Fraass BA, Reznik R, et al. Adequacy of inhale/exhale breathhold CT based ITV margins and image-guided registration for free-breathing pancreas and liver SBRT. Radiat Oncol. 2014 Jan 9; 9(1):11.
32. Yovino S, Poppe M, Jabbour S, et al. Intensity-modulated radiation therapy significantly improves acute gastrointestinal toxicity in pancreatic and ampullary cancers. Int J Radiat Oncol Biol Phys. 2011 Jan; 79(1); 158-162.
Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)
CPT*
HCPCS
* CPT only copyright 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
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Medical policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to this policy should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.
The Horizon BCBSNJ Medical Policy Manual is proprietary. It is to be used only as authorized by Horizon BCBSNJ and its affiliates. The contents of this Medical Policy are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of this Medical Policy may be updated or changed without notice, unless otherwise required by law and/or regulation. However, benefit determinations are made in the context of medical policies existing at the time of the decision and are not subject to later revision as the result of a change in medical policy
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