Subject:
Radiation Therapy for Cervical 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. Stage IA1
A. Definitive external beam photon radiation therapy radiation using 20 to 30 fractions of 3D conformal radiation therapy (3DCRT) to the pelvis and brachytherapy is considered medically necessary.
B. Brachytherapy alone is considered medically necessary for Stage IA1 disease when all of the following conditions are met:
1. Medically inoperable or surgical refusal
2. Absence of lymphovascular space invasion (LVSI)
II. Stage IA2, IB1, IB2, IIA, IIB, IIIA, IIIB or IVA
A. Definitive external beam photon radiation therapy using 25 to 35 fractions of 3DCRT to the pelvis and brachytherapy is considered medically necessary for definitive treatment.
B. Definitive external beam photon radiation therapy using 25 to 35 fractions of 3DCRT or Intensity Modulated Radiation Therapy (IMRT) is considered medically necessary for any of the following:
1. Positive pelvic nodes on Positron Emission Tomography (PET), Magnetic Resonance Imaging (MRI) or Computed Tomography (CT) scan being treated to doses of 54 Gy or higher with external beam radiation therapy
2. Treatment of the paraaortic nodes
3. The individual is medically inoperable and brachytherapy cannot be performed.
C. Stereotactic body radiation therapy (SBRT) as an alternative to brachytherapy is considered investigational for the definitive treatment of cervical cancer.
III. Adjuvant (postoperative) treatment in an individual without evidence of distant metastases.
Up to 30 fractions of 3DCRT or IMRT and brachytherapy is medically necessary in the setting of:
A. Positive surgical margins
B. Positive pelvic nodes
C. Positive paraaortic nodes
D. Vaginal margins less than 0.5 cm
E. Extensive lymphovascular or capillary involvement
F. Deep stromal invasion
G. Large tumor size > 4cm
IV. Locoregional recurrence in an individual without evidence of distant metastases
A. Up to 30 fractions of 3DCRT with up to 4 gantry angles is medically necessary. Two phases may be medically necessary, with or without brachytherapy.
B. IMRT is medically necessary in any of the following conditions:
1. The paraaortic nodes will be treated
2. The postoperative setting where the whole pelvis will be treated to 45 Gy or higher
C. Stereotactic Body Radiation Therapy (SBRT) may be considered based on a history of previous radiation to the same or abutting region and inability to deliver therapeutic doses of radiation with other techniques.
V. Palliation in an individual with or without evidence of distant metastases
A. In the non-curative setting and where symptoms are present, 15 fractions of palliative external beam photon radiation therapy delivered with a complex isodose technique or 3D conformal radiation therapy (3DCRT) using up to 4 gantry angles is medically necessary. 1 phase is medically necessary.
B. IMRT may be medically necessary when previous external beam radiation therapy or brachytherapy has been given.
C. Brachytherapy may be considered medically necessary.
VI. Electronic brachytherapy is considered investigational for the treatment of cervical cancer.
Medicare Coverage:
There is no National Coverage Determination (NCD) or Local Coverage Determination (LCD) for jurisdiction JL for Radiation Therapy for Cervical Cancer. 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), stereotactic radiosurgery (SRS), 3DCRT, or brachytherapy. Therefore, Medicare Advantage Products will follow the Horizon BCBSNJ Medical Policy for Radiation Therapy for Cervical Cancer.
Novitas Solutions, Inc, the Local Medicare Carrier for jurisdiction JL, has issued a determination for Intensity-Modulated Radiation Therapy (IMRT). Per LCD L36711 and Local Coverage Article: Billing and Coding: Intensity Modulated Radiation Therapy (IMRT) (A56725), IMRT is covered for limited indications when LCD L36711 and A56725 criteria is met.
For additional information and eligibility, refer to Local Coverage Determination (LCD): Intensity Modulated Radiation Therapy (IMRT) (L36711) and 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: Within the United States in 2018, 13,240 new cases of cervical cancer are projected resulting in approximately 4,170 deaths. The prognosis of an individual with cervical cancer is markedly affected by the extent of disease at the time of diagnosis. Clinical staging of cervical cancer should be performed prior to developing an overall treatment and beginning definitive treatment.
I. IMRT in the Intact Cervix
The routine use of IMRT is not medically necessary for the definitive treatment of cancer of the intact cervix. Studies have demonstrated that there are several challenges with the use of IMRT in the definitive treatment of the cervix (Lim et al., 2015). First, the uterus and cervix are mobile structures and are subject to variation in between fractions (Lim et al., 2015). In addition to the inherent movement of the uterus, the cervix is also subject to variability in position secondary to bladder and bowel filling (Mackay et al, 2015; Mahmoud et al, 2017). As the position of cervix can move as much as 2 cm on a daily basis, studies have shown difficulty in daily reproducibility and dosimetry with IMRT planning (Lim et al., 2009; Lim et al., 2011; Lim et al, 2015; Small et al., 2008; Welsh et al., 2007). Furthermore, the significant and rapid tumor shrinkage seen in cervical cancer can also impact the IMRT dose distribution leading to the risk of underdosing the tumor or overdosing surrounding normal tissue (Beadle et al, 2009). Studies estimate that the cervix can shrink from 50-79% during the course of treatment (Mahmoud et al, 2017). Therefore, the routine use of IMRT in cervical cancer is not recommended. IMRT will be approved when comparative 3DCRT and IMRT plans demonstrate that a 3D plan does not meet the “Acceptable” normal tissue constraints using standard metrics published by the Radiation Therapy Oncology Group (RTOG)/NCCN. Furthermore, the use of IMRT will be considered when co-morbid medical conditions and/or surgical history may significantly increase risk to critical organs.
Lymph node involvement in cervical cancer is an important prognostic indicator. Therefore, evaluation of the risk of lymph node involvement plays a significant role in the management of cervical cancer. Cervical cancer typically spreads in stepwise manner first involving the obturator nodes, followed by the common iliac, and then the paraaortic lymph nodes. When regional pelvic nodes are grossly involved, the NCCN recommends that doses of 55 to 65 Gy be given to the grossly involved nodes with consideration of the contribution of dose from brachytherapy. Therefore, IMRT is considered medically necessary in the definitive treatment of cervical cancer with grossly involved pelvic nodes with a planned dose of 55 Gy or higher to the pelvic nodes. Extended field radiation therapy to encompass the paraaortic nodes is indicated the following clinical situations: 1. grossly involved paraaortic nodes on imaging or surgical staging 2. recurrent disease without evidence of distant metastasis and 3. gross involvement of the common iliac lymph nodes. IMRT is considered medically necessary in the definitive treatment of cervical cancer when extended field radiation therapy encompassing the paraaortic lymph nodes is clinically indicated as described above.
II. Brachytherapy
Brachytherapy is an important component of the curative treatment of cervical cancer. Brachytherapy may be given by either Low Dose Rate (LDR) or High Dose Rate (HDR) techniques. Dose recommendations are available in the literature of the American Brachytherapy Society. It is recognized that disease presentations and anatomic deformity may result in less than optimal dosimetry using conventional radiation applicators and supplementary interstitial brachytherapy may be required on an individual basis to achieve optimal therapeutic effect.
The type of implant may include tandem and ovoids, tandem alone, ovoids only, interstitial, or vaginal cylinder only. For LDR therapy, up to 2 interstitial or intracavitary applications are considered medically appropriate. For HDR interstitial therapy, when one application is used, up to 5 fractions may be appropriate. When 2 applications are used, up to 3 fractions may be appropriate. For HDR tandem and ovoids, up to 6 applications may be appropriate. For HDR vaginal cylinder, up to 3 applications may be medically necessary.
Electronic brachytherapy is considered investigational for the treatment of cervical cancer.
There is limited data on the role of stereotactic body radiation therapy as an alternative to brachytherapy in cervical cancer. The data is hampered by limited follow-up, heterogeneous patient populations, and small sample size (Mahmoud et al, 2017). Cengiz et al (2102) reported on a dosimetric comparison of SBRT and brachytherapy in 11 women with locally advanced cervical cancer. The maximum bone marrow dose was higher with the SBRT plan. They found similar dose distributions to the rectum and bladder with SBRT and brachytherapy. There was improved target coverage with SBRT. In an abstract, Mantz (2016) reports on 42 patients with cervical and endometrial cancer who received SBRT as a boost alternative following pelvic external beam radiation therapy. The study showed that SBRT was associated with no grade 3 or greater urinary or bowel toxicity with a 5 year local control rate of 78.5% (Mantz, 2016). Yanez and colleagues (2018) performed a systematic review of the use of SBRT in cervical cancer. The authors were unable to find strong evidence to support the use of SBRT as a replacement for brachytherapy in the definitive treatment of cervical cancer. Given the limited literature on SBRT in cervical cancer, SBRT as an alternative to brachytherapy is considered EIU for the definitive treatment of cervical cancer.
III. Postoperative (adjuvant) external beam radiation therapy / IMRT
The role of postoperative radiation therapy in cervical cancer is dependent on the type of surgery performed (simple or radical hysterectomy) and the surgical findings. Surgical findings associated with increased risk of recurrence include the size of the primary tumor, depth of stromal invasion, and presence of lymphovascular invasion, capillary invasion. Positive pelvic and /or para-aortic nodes, close (<0.5 cm) or positive surgical margins, and involvement of the parametrium are also associated with increased risk of recurrence. Postoperative radiation therapy often in combination with chemotherapy is utilized to decrease the risk of recurrence. When clinically indicated, postoperative radiation therapy typically is delivered using up to 30 fractions using either IMRT or 3DCRT. An intracavitary boost may be clinically appropriate in the setting of positive surgical findings.
The use of IMRT in the treatment of postoperative cervical cancer has been evaluated as a method to decrease treatment related toxicity. The risk of severe small bowel injury after conventional radiotherapy for postoperative patients with gynecologic cancer is estimated to be between 5 and 15% (Corn et al., 1994; Gallagher et al., 1986). Multiple dosimetric studies and smaller clinical studies have demonstrated that the dose to the small bowel can be decreased using IMRT and should impact on the risk of small bowel injury (Jhingran et al., 2012; Klopp et al., 2013; Salama et al., 2006). RTOG 0418 evaluated postoperative IMRT in patients with endometrial cancer and cervical cancer who received 50.4 Gy to the pelvis and vagina (Portelance et al, 2011; Klopp et al, 2013). RTOG 0418 showed that postoperative pelvic IMRT for endometrial and cervical cancer is feasible across multiple institutions with use of a detailed protocol and centralized quality assurance. The abstract of RTOG 0418 was reported by Portelance and colleagues (2011). The 2-year disease-free survival (DFS) and overall survival (OS) rates were 86.9% and 94.6%, respectively. In their analysis of RTOG 0418, Klopp and colleagues (2013) showed low rates of hematologic toxicity with IMRT when the bone marrow V40 is less than 37%. The overall survival and disease free survival compare favorably to an Intergroup postoperative study of concurrent chemoradiation with conventional RT in high risk early stage cervical cancer patients reported by Peters et al. (2000) where 3-year progression-free survival (PFS) and OS were 84% and 88%, respectively. In a report of 34 patients from Memorial Sloan-Kettering Cancer Center (MSKCC) with intermediate and high-risk cervical cancer receiving postoperative chemotherapy and concurrent IMRT, Folkert and colleagues (2013) showed a 3- and 5-year OS of 91% and PFS of 91.2% with a 44-month median follow up. There were only 2 locoregional failures, 1 vaginal and 1 pelvic (Folkert et al., 2013). These data suggest that with the tighter margins of IMRT local control can be maintained with a decrease in toxicity.
IV. Locoregional recurrence
For an individual with locoregional recurrence only without evidence of distant metastatic disease, salvage radiotherapy is medically necessary. The usual treatment employs up to 30 fractions of 3DCRT and up to 4 gantry angles. Two phases may be medically necessary, with or without brachytherapy. IMRT will be considered based on clinical presentation and anatomic location. IMRT will be approved when comparative 3D and IMRT plans demonstrate that a 3D plan does not meet the “Acceptable” normal tissue constraints using standard metrics published by the RTOG/NCCN.
V. Palliative therapy
In the non-curative setting and where symptoms are present, palliative external beam photon radiation therapy may be medically necessary. In this scenario, treatment is delivered utilizing a complex isodose technique or 3DCRT, up to 4 gantry angles, 1 phase, and up to 15 fractions. IMRT may be medically necessary when previous external beam photon radiation therapy or brachytherapy has been given. IMRT will be approved when comparative 3D and IMRT plans demonstrate that a 3D plan does not meet the “acceptable” normal tissue constraints using standard metrics published by the RTOG/NCCN.
VI. Chemotherapy
Randomized trials have shown an overall survival advantage for cisplatin-based therapy given concurrently with radiation therapy, while one trial examining this regimen demonstrated no benefit. The patient populations that benefit include FIGO stages 1B-1 to IVA cervical cancer treated with primary radiation therapy and FIGO stages I to IIA disease with poor prognostic factors (metastatic disease in pelvic lymph nodes, parametrial disease, or positive surgical margins) at primary surgery, who then go on to receive adjuvant chemoradiation. Although the positive trials vary in terms of the stage of disease and incorporate varying radiation treatment regimens with chemotherapy schedules of cisplatin alone or combined with fluorouracil; the trials demonstrate significant survival benefit for this combined approach. Based on these results strong consideration should be given to the incorporation of concurrent chemotherapy with radiation therapy in women who require radiation therapy for the treatment of cervical cancer.]
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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 Cervical Cancer
Radiation Treatment of Cervical Cancer
Cervical Cancer, Radiation Treatment of
References:
1. American Cancer Society: Cancer Facts and Figures 2018. Atlanta, Ga.: American Cancer Society, 2018. Last medical review: 11/16/2016. Last revised 1/4/2018.
2. Amin, BA, Brookland RK, Byrd DR, Compton CC, Edge SB, Gress DM, et al. Chapter 52: Part XII Female Reproductive Organs, Cervix Uteri. In: Brookland RK, Byrd DR, Compton CC, Edge SB, Gress DM, et al., eds. The AJCC Cancer Staging Manual. 8th ed. Chicago, IL; Springer. 2018:657-668.
3. ASTRO 2014 Choosing Wisely® List.
4. Beadle BM, Jhingran A, Salehpour M, Sam M, Iyer RB, Eifel PJ. Cervix regression and motion during the course of external beam chemoradiation for cervical cancer. Int J Radiat Oncol Biol Phys. 2009 Jan 1;73(1):235-41
5. Benowitz, S, Saenz, C, Mundt, AJ et al. Cervix moves significantly more than previously thought during radiation for cancer. UC San Diego News Center. 2009 Feb 10.
6. Cengiz M1, Dogan A, Ozyigit G, Erturk E, Yildiz F, Selek U, Ulger S, Colak F, Zorlu F. Comparison of intracavitary brachytherapy and stereotactic body radiotherapy dose distribution for cervical cancer. Brachytherapy. 2012 Mar-Apr;11(2):125-9.
7. Corn BW, Lanciano RM, Greven KM, et al. Impact of improved irradiation technique, age, and lymph node sampling on the severe complication rate of surgically staged endometrial cancer patients: a multivariate analysis. J Clin Oncol. 1994; 12(3):510–515.
8. Esthappan J, Chaudhari S, Santanam L, et al. Prospective clinical trial of positron emission tomography/computed tomography image-guided intensity-modulated radiation therapy for cervical carcinoma with positive para-aortic lymph nodes. Int J Radiat Oncol Biol Phys. 2008 Nov 15; 72(4):1134-1139.
9. Esthappan J, Mutic S, Malyapa RS, et al. Treatment planning guidelines regarding the use of CT/PET-guided IMRT for cervical carcinoma with positive para-aortic lymph nodes. Int J Radiat Oncol Biol Phys. 2004 Mar 15; 58(4):1289-1297.
10. Gallagher MJ, Brereton HD, Rostock RA, et al. A prospective study of treatment techniques to minimize the volume of pelvic small bowel with reduction of acute and late effects associated with pelvic irradiation. Int J Radiat Oncol Biol Phys. 1986; 12(9):1565–1573.
11. Jhingran A, Winter K, Portelance L, et al. A phase II study of intensity modulated radiation therapy to the pelvis for postoperative patients with endometrial carcinoma: Radiation Therapy Oncology Group Trial 0418. Int J Radiat Oncol Biol Phys. 2012 Sep 1; 84(1):e23-e8.
12. Kidd EA, Siegel BA, Dehdashti F, et al. Clinical outcomes of definitive intensity-modulated radiation therapy with fluorodeoxyglucose-positron emission tomography simulation in patients with locally advanced cervical cancer. Int J Radiat Oncol Biol Phys. 2010 Jul 15; 77(4):1085-1091.
13. Klopp, AH, Moughan, J, Portelance, L, et al. Hematologic toxicity on RTOG 0418: a phase II study of post-operative IMRT for gynecologic cancer. Int J Radiat Oncol Biol Phys. 2010 Nov 1; 78(3 Supp):S121.
14. Lim K, Erickson, B, Jürgenliemk-Schulz IM et al. Variability in clinical target volume delineation for intensity modulated radiation therapy in 3 challenging cervix cancer scenarios. Pract Radiat Oncol. 2015 Nov-Dec; 5(6): e557–e565.
15. Lim K, Kelly V, Stewart J, et al. Pelvic radiotherapy for cancer of the cervix: is what you plan actually what you deliver? Int J Radiat Oncol Biol Phys. 2009 May 1; 74(1):304-312.
16. Lim K, Small Jr W, Portelance L, et al. on behalf of GynIMRT Consortium. Consensus guidelines for delineation of clinical target volume for intensity-modulated pelvic radiotherapy for the definitive treatment of cervix cancer. Int J Radiat Oncol Biol Phys. 2011 Feb 1; 79(2) 348-355.
17. Lorenz E, Strickert T, Hagen B. Cervical carcinoma: postoperative radiotherapy: fifteen-year experience in a Norwegian health region. Int J Gynecol Cancer. 2009 Dec; 19(9):1595-1599.
18. Macdonald DM, Lin LL, Biehl K, et al. Combined intensity-modulated radiation therapy and brachytherapy in the treatment of cervical cancer. Int J Radiat Oncol Biol Phys. 2008 Jun 1; 71(2):618-624.
19. Mackay HJ, Wenzel L, and Mileshkin L. Nonsurgical management of cervical cancer: Locally advanced, recurrent, and metastatic disease, survivorship, and beyond. Am Soc Clin Oncol Educ Book. 2015 : e299–e309
20. Mahmoud O, Kilic S, Khan AJ. External beam techniques to boost cervical cancer when brachytherapy is not an option—theories and applications. Ann Transl Med. 2017 May; 5(10): 207.
21. Mantz C. Stereotactic Body Radiation Therapy as a Boost Alternative for Nonmetastatic Cancer of the Cervix and Endometrium: Disease Control and Quality of Life Outcomes From a Phase 2 Trial at 3 Years’ Minimum Follow-up. Int J Radiat Oncol Biol Phys. 2016;96:E286 10.
22. National Comprehensive Cancer Network (NCCN) Guidelines® Version 1.2020 – January 14, 2020. Cervical Cancer. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Cervical Cancer Version 4.2020. 2020 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. Portelance L, Moughan J, Jhingran A, et al. A Phase II Multi-institutional Study of Postoperative Pelvic Intensity Modulated Radiation Therapy (IMRT) with Weekly Cisplatin in Patients with Cervical Carcinoma: Two Year Efficacy Results of the RTOG 0418. Int J Radiat Oncol Biol Phys. October 1, 2011 Volume 81, Issue 2, Supplement, Page S3.
24. Rose PG, Ali S, Watkins E, et al. Long-term follow-up of a randomized trial comparing concurrent single agent cisplatin, cisplatin-based combination chemotherapy, or hydroxyurea during pelvic irradiation for locally advanced cervical cancer: a Gynecologic Oncology Group Study. J Clin Oncol. 2007Jul 1; 25(19):2804-2810.
25. Salama JK, Mundt AJ, Roeske J, et al. Preliminary outcome and toxicity report of extended-field, intensity modulated radiation therapy for gynecologic malignancies. Int J Radiat Oncol Biol Phys. 2006 Jul 15; 65(4):1170-1176.
26. Sedlis A, Bundy BN, Rotman AZ, Lentz SS et al. A randomized trial of pelvic radiation therapy versus no further in selected patients with stage IB carcinoma of the cervix after radical hysterectomy and pelvic lymphadenectomy: A Gynecologic Oncology Study. Gynecol Oncol. 1999 May;73(2): 177-183.
27. Small W Jr, MellLK, Anderson P, et al. Consensus guidelines for delineation of clinical target volume for intensity-modulated pelvic radiotherapy in postoperative treatment of endometrial and cervical cancer. Int J Radiat Oncol Biol Phys. 2008 Jun 1; 71(2):428-434.
28. Viswanathan AN, Thomadsen B. American Brachytherapy Society Cervical Cancer Brachytherapy Task Group.
29. Welsh JS, Mackie TR, Limmer JP. High-energy photons in IMRT: uncertainties and risks for questionable gain. Technol Cancer Res Treat. 2007 Apr; 6(2):147-149.
30. Yanez, L, Ciudad AM, Mehta MP et al. What is the evidence for the clinical value of SBRT in cancer of the cervix? Rep Pract Oncol Radiother. 2018 Nov-Dec;23(6):574-579.
31. Zwahlen DR, Ruben JD, Jones P, et al. Effect of intensity-modulated pelvic radiotherapy on second cancer risk in the postoperative treatment of endometrial and cervical cancer. Int J Radiat Oncol Biol Phys. 2009 Jun 1; 74(2):539-545.
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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