Brachytherapy for Prostate Cancer
Medical Policy: 08.01.04
Original Effective Date: December 1998
Reviewed: April 2012
Revised: October 2009
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Brachytherapy is a form of radiation therapy for cancer, in which a radioactive material is implanted into the cancerous tissue. The most familiar technique of this is the use of radioactive seeds that are permanently implanted in the prostate tissue. These seeds contain radioisotopes of relatively low energy, short half- lives, low dose rates, and limited range. The seeds are between 4 and 5 millimeters in size. Placement of the seeds is guided by transrectal ultrasound. Its purpose is to deliver a direct tumoricidal dosage of radiation to the tumor itself, while sparing tissue surrounding the tumor.
Permanent prostate brachytherapy as monotherapy is a standard treatment for patients with low-risk disease defined as clinical tumor classification T1, T2a , and Gleason score ≤ 6 and a serum PSA level of 10 ng/ml or less. For patients with intermediate-risk cancers, defined as clinical tumor classification of T2b, T2c, or Gleason score 7, or, PSA > 10ng/mL < 20ng/mL, permanent brachytherapy may be combined with external beam radiation therapy with or without neoadjuvant androgen deprivation therapy. Evolving evidence has demonstrated advantages in local control and metastasis-free survival with a permanent brachytherapy boost in combination with external beam radiation therapy in patients with high-risk disease, defined as clinical tumor classification of T3a, or Gleason score 8-10, or PSA > 20ng/mL.
High-dose rate (HDR) brachytherapy is a form of radiotherapy for localized prostate cancer in which the radiation is delivered directly to the prostate tumor through temporary implants at a dose rate of > 12Gy/hr and usually significantly higher. Hollow needles are inserted into the prostate gland guided by transrectal ultrasound to follow a preplanned treatment template. The radioactive substance, usually iridium-192 (192Ir) is inserted into each needle via remote afterloading. HDR brachytherapy is designed to allow for more effective radiation targeting to the prostate tumor while limiting radiation exposure to critical surrounding structures such as the rectum and urethra. Total irradiation time is generally no more than 10 to 12 minutes. According to the American Brachytherapy Society, HDR brachytherapy should be considered as a method of dose escalation for any patient receiving radiotherapy for prostate cancer, citing its particular value as a boost in combination with external beam radiation therapy for intermediate- or high-risk disease.
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Prior Approval:
Not applicable
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Policy:
Permanent brachytherapy may be considered medically necessary for the following applications;
- As monotherapy for the treatment of localized prostate cancer
- As monotherapy in intermediate-risk patients with additional potential predictive factors including perineural invasion and < 30% cores positive
- As boost therapy in conjunction with external beam radiation therapy, conformal three-dimensional radiotherapy or hormonal therapy for patients with more advanced tumors including intermediate- and high-risk disease
High-dose rate brachytherapy may be considered medically necessary as monotherapy or in conjunction with external beam radiation therapy in the treatment of localized prostate cancer
High dose rate temporary brachytherapy as salvage treatment for prostate cancer is considered investigational.
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Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
- 76965 Ultrasonic guidance for interstitial radioelement application
- 77776 Interstitial radiation source application; simple
- 77777 Interstitial radiation source application; intermediate
- 77778 Interstitial radiation source application; complex
- 77785 Remote afterloading high dose rate radionuclide brachytherapy; 1 channel
- 77786 Remote afterloading high dose rate radionuclide brachytherapy; 2-12 channels
- 77787 Remote afterloading high dose rate radionuclide brachytherapy; over 12 channels
- 55875 Transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or without cystoscopy
- 76873 Ultrasound, transrectal; prostate volume study for brachytherapy treatment planning (separate procedure)
- 77326 Brachytherapy isodose plan; simple (calculation made from single plane, 1 to 4 sources/ribbon application, remote afterloading brachytherapy, 1 to 8 sources)
- 77327 Brachytherapy isodose plan; intermediate (multiplane dosage calculations, application involving 5 to 10 sources/ribbons, remote afterloading brachytherapy, 9 to 12 sources)
- 77328 Brachytherapy isodose plan; complex (multiplane isodose plan, volume implant calculations, over 10 sources/ribbons used, special spatial reconstruction, remote afterloading brachytherapy, over 12 sources)
- 77790 Supervision, handling, loading of radiation source
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Selected References:
- Crook J, Lukka H, Klotz L, Bestic N, Johnston M; Genitourinary Cancer Disease Site Group of the Cancer Care Ontario practice Guidelines Initiative: Systematic overview of the evidence for brachytherapy in clinically localized prostate cancer. Canadian Medical Association Journal 2001 Apr 3; 164(7): 976-81.
- Nag, S. The American Brachytherapy Society, Oak Brook, Il, USA. Brachytherapy for prostate cancer: summary of American Brachytherapy Society recommendation. Seminars in Urologic Oncology 2000 May; 18 (2):133-6.
- Beyer, D. The evolving role of prostate brachytherapy. Cancer Control 2001, 8 (2): 163-170.
- Wallner K, Merrick G, True L, Cavanagh W, Simpson C, Butler W. I-125 versus Pd-103 for low-risk prostate cancer: morbidity outcomes from a prospective randomized multicenter trial. Cancer J. 2002 Jan-Feb;8(1):67-73.
- Norderhaug I,et al. Brachytherapy for prostate cancer: a systematic review of clinical and cost effectiveness. Eur Urol. 2003 Jul;44(1):40-6.
- Sherertz T, Wallner K, Merrick G, Cavanagh W, Butler W, Reed D, True L The prognostic significance of Gleason pattern 5 in prostate cancer patients treated with Pd 103 plus beam radiation therapy. Cancer J. 2004 Sep-Oct;10(5):301-6
- Franca CA, Vieira SL, Bernabe AJ, Penna AB. The seven-year preliminary results of brachytherapy with Iodine-125 seeds for localized prostate cancer treated at a Brazilian single-center. Int Braz J Urol. 2007 Nov-Dec;33(6):752-62; discussion 762-3.
- Hurwitz MD. Technology Insight: combined external-beam radiation therapy and brachytherapy in the management of prostate cancer. Nat Clin Pract Oncol 2008; 5(11):668-76.
- Corner C, Rojas AM, Bryant L et al. A phase II study of high-dose rate afterloading brachytherapy as monotherapy for the treatment of localized prostate cancer. Int J Radiat Oncol Biol Phys 2008; 72(2): 441-6.
- Demanes DJ, Brandt D, Schour L et al. Excellent results from high-dose rate brachytherapy and external beam for prostate cancer are not improved by androgen deprivation. Am J Clin Oncol. 2009 Aug; 32(4): 342-7.
- Joseph KJ, Alvi R, Skarsgard D et al. Analysis of health related quality of life (HRQoL) of patients with clinically localized prostate cancer, one year after treatment with external beam radiotherapy (EBRT) alone versus EBRT and high dose rate brachytherapy (HDRBT). Radiat Oncol. 2008; 3-20.
- Hoskin PJ, Motohashi K, Bownes P et al. High dose rate brachytherapy in combination with external beam radiotherapy in the radical treatment of prostate cancer: initial results of a randomized phase three trial. Radiother Oncol. 2007;84 (2):114-120.
- National Comprehensive Cancer Network (NCCN®). Practice Guidelines in Oncology. Prostate Cancer; v.2.2009. Available at: http://www.nccn.org/professionals/physicians_gls/pdf/prostate.pdf.
- Demanes DJ, Martenez AA, Ghilezan M et al. High dose-rate monotherapy: Safe and effective brachytherapy for patients with localized prostate cancer. Int J Radiat Oncol Biol Phys 2011 Feb 9. [Epub ahead of print].
- Martinez AA, Demanes A, Vargas C et al. High dose rate prostate brachytherapy: an excellent accelerated- hypofractionated treatment for favorable prostate cancer. Am J Clin Oncol 2010; 33(5):481-8.
- Martinez AA, Gonzalez J, Ye H et al. Dose escalation improves cancer-related events at 10-years for intermediate- and high-risk prostate cancer patients treated with hypofractionated high dose rate boost and external beam radiotherapy. Int J Radiat Oncol Biol Phys.2011; 79(2):363-70.
- Deutsch I, Zelefsky MJ, Zhang Z et al. Comparison of relapse-free survival in patients treated with ultra-high dose IMRT versus combination HDR brachytherapy and IMRT. Brachytherapy 2010; 9(4): 313-8.
- Wilder RB, Barme GA, Gilbert RF et al. Preliminary results in prostate cancer patients treated with high dose rate brachytherapy and intensity modulated radiation therapy (IMRT) vs. IMRT alone. Brachytherapy 2010; 9(4): 341-8.
- The American Brachytherapy Society (ABS) Prostate High-Dose rate Task Group. Available online at: http://www.americanbrachytherapy.org/guidelines/HDRTaskGroup.pdf. Last access April 2, 2011.
- Yamada Y, Rogers L, Demanes DJ et al. American Brachytherapy Society consensus guidelines for high-dose-rate prostate brachytherapy. Brachytherapy. 2012 Jan-Feb; 11(1):20-32.
- Davis BJ, Horwitz EM, Lee WR et al. American Brachytherapy Society consensus guidelines for transrectal ultrasound-guided permanent prostate brachytherapy. Brachytherapy. 2012 Jan-Feb; 11(1):6-19.
- Frank SJ, Grimm PD, Sylvester JE et al. Interstitial implant alone or in combination with external beam radiation therapy for intermediate-risk prostate cancer: a survey of practice patterns in the United States. Brachytherapy. 2007 Jan-Mar; 6(1):2-8.
- Taira AV, Merrick GS, Butler WM et al. Long-term outcome for clinically localized prostate cancer treated with permanent interstitial brachytherapy. Int J Radiat Oncol Biol Phys 2011; 79:1336-42.
- Rosenthal SA, Bittner NHJ, Beyer DC et al. American Society for Radiation Oncology (ASTRO) and American College of Radiology (ACR) practice guideline for the transperineal permanent brachytherapy of prostate cancer. In J Radiat Oncol Biol Phys 2011; 79:335-41.
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Policy History:
Date Reason Action
May 2011 Annual review Policy renewed
April 2012 Annual review Policy renewed
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*Current Procedural Terminology © 2012 American Medical Association. All Rights Reserved.
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