Medical Policy: 08.01.11 

Original Effective Date: February 2005 

Reviewed: January 2017 

Revised: January 2017 

 

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:

Electronic brachytherapy is the administration of high dose radiotherapy (HDR) brachytherapy without the use of radioactive isotope and with minimal shielding requirements due to the low energies utilized with the system. Therefore, it can be used in controlled settings without a specially shielded vault, such as in the office of an authorized user or in an operating room. Electronic brachytherapy is a treatment modality being utilized to treat breast cancer, non-melanoma skin cancer, gynecological cancers and other cancer indications.

 

Electronic brachytherapy uses a disposable miniature low energy (50Kv) X-ray tube into a pre-positioned applicator within body/tumor cavities or a contact applicator and a flexible clamp for skin surfaces (tumor surface) to rapidly deliver high doses of radiotherapy. Through the manipulation of radiation intensity and dose distribution, electronic brachytherapy delivers more intense therapy directly to cancer sites with minimal radiation exposure to surrounding healthy tissue.  Other potential advantages of this treatment modality compared with standard radiotherapy includes a shorter treatment schedule and the avoidance of radioisotopes.

 

Non-melanoma Skin Cancer

Non-melanoma skin cancer consists primarily of squamous cell carcinoma and basal cell carcinoma and are the most common types of malignancy in the United States. Other types (e.g. T-cell lymphoma, Merkel cell tumor, basosquamous carcinoma, Kaposi sarcoma) are much less common. The primary risk factor for non-melanoma skin cancer is sun exposure, with additional risk factors such as toxic exposures, other ionizing radiation exposure, and immunosuppression playing smaller roles. Although these cancers rarely cause mortality, they can impact quality of life, functional status and physical appearance.

 

Treatment of non-melanoma skin cancer is primarily surgical. The choice of surgical procedure depends on the histologic type, size and location of the lesion. Patient characteristics and preferences may also be part of the decision making process, with consideration of comorbidities, patient risk factors such as anticoagulation and cosmetic outcomes. Local excisional procedures, such as electrodessication and curettage or cryotherapy, can be used for low risk lesions, while surgical excision is indicated for lesions that are not low risk. Mohs surgery is a type of excisional procedure that uses microscopic guidance to achieve greater precision and sparing of normal tissue. In patients who meet criteria for Mohs surgery, 5 year cure rates for basal cell cancer range from 98% to 99%, making Mohs surgery the preferred procedure for those who qualify.

 

Radiotherapy is indicated for certain non-melanoma skin cancers that are not amendable to surgery. In some cases, this is due to the location of the lesion on the eyelid, nose, or other structures that make surgery more difficult and which may be expected to have less desirable cosmetic outcome. In other cases, surgery may be relatively contraindicated due to clinical factors such as bleeding risk or advanced age.  When radiotherapy is used for non-melanoma skin cancer, the primary modality is external beam radiation. A number of different brachytherapy techniques have also been developed, including low dose rate systems, iridium-based systems, and high dose rate (HDR) systems. 

 

Electronic brachytherapy for skin application (surface brachytherapy) uses a direct contact applicator and a flexible clamp. The lightweight surface applicator (less than 150g) can be precisely oriented to the desired location on the patient i.e. the target lesion. Surface applicators range in size from 10mm to 50mm providing flexibility in treating a variety of lesion sizes. A miniaturized X-ray source is placed in the applicator and energized to deliver radiation for a few minutes. With the reduced shielding requirement, the physician can remain near the patient. Furthermore, faster dose fall-off of the low-energy miniaturized X-ray source minimizes exposure to healthy adjacent tissues.

 

The assessment of efficacy for a therapeutic intervention involves a determination of whether the intervention improves health outcomes compared with available alternatives. The optimal study design for this purpose is randomized controlled trials that compare the therapeutic intervention with existing alternative treatments and includes clinically relevant measures of health outcomes. Nonrandomized comparative studies and uncontrolled studies can sometimes provide useful information on health outcomes but are prone to biases such as non-comparability of treatment groups, placebo effect and variable natural history of the condition.

 

Per review of the peer reviewed medical literature the available evidence on electronic brachytherapy for non-melanoma skin cancer consists of case series. No controlled trials were identified in the published literature that compared outcomes of electronic brachytherapy with alternative treatments.

Summary

For individuals who have non-melanoma skin cancer who receive electronic brachytherapy, this evidence consists of case series, and usually with a mixed patient population of basal and squamous cell carcinomas. No controlled trials were identified that compared electronic brachytherapy with alternative treatment options. Controlled trials are needed that compare electronic brachytherapy with alternatives, either other forms of radiotherapy or surgical approaches. As a result of the lack of high-quality evidence of efficacy, the evidence is insufficient to determine the effects of this technology on net health outcomes and electronic brachytherapy is considered investigational for the treatment of non-melanoma skin cancer.

 

Breast Cancer and Other Cancers

Radiation therapy may be a component of therapy in the treatment of breast cancer, gynecological cancers and other cancer indications. Electronic brachytherapy to include the use of electronic brachytherapy during intraoperative radiotherapy (IORT) are being researched and proposed for the treatment of cancer. Purportedly, electronic brachytherapy is utilized to provide intracavity and interstitial brachytherapy and uses x-ray energy to allow more flexibility than radioisotope based brachytherapy systems that are currently in use.  

 

To perform electronic brachytherapy the surgeon inserts a balloon catheter into the area where the cancer is present or has been surgically removed and fills the balloon with saline to approximate surgically created lumpectomy cavity or natural cavity. The surgeon then inserts the x-ray source attached to a flexible cable into the central lumen of the appropriately filled balloon applicator, permitting delivery of radiation to the target site via a disposable micro-miniature x-ray tube. Electronic brachytherapy can be used as a single treatment at the time of surgery (i.e. intraoperative radiation therapy (IORT)) or  the balloon applicator can be safely left in place between treatments to be delivered over time in multiple fractions (doses for various electronic brachytherapy applications uses are typically hypofractionated (single large fraction or several large dose fractions). 

 

Electronic brachytherapy is designed to mimic the therapeutic effects of iridium (Ir)-192, a commonly used radioisotope for high dose rate brachytherapy. The purported advantages of using electronic brachytherapy is the dose fall-off rate is lower, so the patient receives less dose to critical organs and healthy tissue; there are no radioisotopes which eliminates the need for a heavy shielded environment; and shorter treatment schedules:

  • For breast application: The electronic brachytherapy system delivers a prescribed, targeted dose of radiation directly to the site where cancer recurrence is most likely. Compared to traditional radiotherapy, electronic brachytherapy requires fewer treatments and minimizes exposure to healthy tissue and organs, such as ribs, lungs, heart and opposite breast. 
  • For vaginal application for gynecological cancers: The electronic brachytherapy system is designed to simplify the radiation therapy process and make it more accessible to patients who are suitable candidates for vaginal brachytherapy. While reducing the number of required treatments, electronic brachytherapy delivers a targeted prescribed dose of radiation directly to the site where cancer recurrence is most likely, minimizing exposure to healthy tissue such as the bladder and rectum.

Per review of the peer reviewed medical literature the available evidence on electronic brachytherapy for the treatment of breast cancer and gynecological cancers comes from studies which are small, mostly case series (single institutions) with limited follow up. There is insufficient evidence in the published literature comparing outcomes of electronic brachytherapy with standard radioisotope based brachytherapy.   

 

Also, per ASTRO’s emerging technology committee report on electronic brachytherapy there are currently no accepted calibration standards for electronic brachytherapy and there are uncertainties associated with the absorbed dose measurement at low energies. This means that potentially different doses of radiation could differ even with the same prescription. The clinical impact of the rapid dose fall off is unknown and the effects of electronic brachytherapy on tumor and normal tissue is not well understood.

 

Summary

There is insufficient evidence in peer reviewed scientific literature to support electronic brachytherapy for the treatment of breast cancer , gynecological cancers, and other cancer indications. Studies are small, mostly case series (single institutions) with limited follow up. Furthermore, studies comparing health outcomes of electronic brachytherapy with health outcomes of standard radioisotope based brachytherapy are lacking. Randomized controlled comparative clinical trials are needed demonstrating improvements in net health outcomes to include the long term assessment of treatment efficacy and effects. Therefore, electronic brachytherapy is considered investigational.  

 

Practice Guideline and Position Statements

 

American Society for Radiation Oncology (ASTRO)

The American Society for Therapeutic Radiology and Oncology (ASTRO) Emerging Technology Committee's report on EBT (Park et al, 2010) stated that "advantages of electronic brachytherapy over existing technologies are as yet unproven in terms of efficacy or patient outcomes".  The report explains the impact of clinical use of electronic brachytherapy could be far-reaching, and if used improperly, potentially harmful to patients.  The report explains that electronic brachytherapy is currently an unregulated treatment delivery modality for cancer therapy, with minimal clinical data available from small single institution, studies, none with significant follow-up.  It also noted that there are currently no accepted calibration standards for electronic brachytherapy.  Thus, there can be large uncertainties associated with absorbed dose measurement at low energies.  Furthermore, the report stated that the effects of electronic brachytherapy on tumor and normal tissues are not yet well understood, given the paucity of clinical studies.

 

Thus, electronic brachytherapy is a widely unregulated method of delivering cancer treatment. Randomized trials or comparison studies demonstrating improvement in health outcomes and long-term assessments of treatment efficacy and effects are warranted.

 

Xoft device is currently solely approved for partial breast brachytherapy, with is analogous to Ir-192 HDR brachytherapy techniques that have been available since 2002. Accelerated partial breast irradiation (APBI) with HDR brachytherapy itself is an experimental modality, using electronic brachytherapy to deliver APBI could also be considered investigational. The RBE (radio-biologic equivalence) calculations for these electronic brachytherapy devices suggest the RBE may be only 1.3 and dose comparisons to HDR sources are not yet validated. Such calculations are theoretical, and must be validated by clinical studies. Since kVp (kilovoltage) must be specified, unlike fixed energy for any given day of treatment with HDR sources, the energy spectrum, and ultimately the dose calculation, may be altered by small changes in kVp, increasing the complexity of brachytherapy treatment with electronic brachytherapy relative to HDR.

American Academy of Dermatology

In 2013, the American Academy of Dermatology issued a position statement on electronic surface brachytherapy for basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) which was revised August 9, 2014. 

 

This position statement is intended to offer dermatologists guiding principles regarding provision of electronic surface brachytherapy services in order to provide high quality care for patients, but is not intended to establish a legal or medical standard of care:

  • Based on current evidence, surgical management remains the most effective treatment for BCC and SCC, providing the highest cure rates.
  • The Academy supports consideration of electronic surface brachytherapy as a secondary option for the treatment of BCC and SCC, for use in special circumstances, such as when surgical intervention is contraindicated or refused and after the benefits and risks of treatment alternatives have been discussed with the patient.
  • The Academy believes additional research is needed on electronic surface brachytherapy particularly on long term outcomes. 

 

National Comprehensive Cancer Network (NCCN)

The National Comprehensive Cancer Network (NCCN) guidelines did not discuss electronic brachytherapy in the following:

  • Breast Cancer Version 2.2016
  • Uterine Neoplasms Version 1.2017
  • Cervical Cancer Version 1.2017
  • Merkel Cell Carcinoma Version 1.2017

Basal Cell Skin Cancer and Squamous Skin Cancer Version 1.2017 
Principles of Radiation Therapy

  • There is insufficient long term efficacy and safety data to support the routine use of electronic surface brachytherapy. 

     

     

Regulatory Status

The Esteya® Electronic Brachytherapy System (Nucletron BV) and the Xoft® Axxent® Electronic Brachytherapy System (iCAD Inc.) are 2 systems that recently received FDA clearance through the 510(k) process.   

 

Prior Approval:

 

Not applicable

 

Policy:

Electronic brachytherapy is considered investigational for all indications including but not limited to the following:

  • Non-melanoma skin cancers (basal cell carcinoma (BCC)/squamous cell carcinoma (SCC)
  • Breast cancer
  • Gynecological cancers (endometrial/vaginal/cervical)

There is insufficient evidence in peer reviewed scientific literature to support electronic brachytherapy for the treatment of non-melanoma skin cancers, breast cancer , gynecological cancer, and other cancer indications. Studies are small, mostly case series studies with limited follow up. Furthermore, studies comparing health outcomes of electronic brachytherapy with alternative treatment options are lacking. Randomized controlled clinical trials are needed that compare electronic brachytherapy with alternatives, either other forms of radiotherapy or surgical approaches.  The evidence is insufficient to determine the effects of this technology on net health outcomes and therefore, electronic brachytherapy is considered investigational for all indications.  

 

Procedure Codes and Billing Guidelines:

To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or diagnosis codes.

  • 0394T High dose rate electronic brachytherapy, skin surface application, per fraction, includes basic dosimetry, when performed
  • 0395T High dose rate electronic brachytherapy, interstitial or intracavitary treatment, per fraction, includes basic dosimetry, when performed

 

Selected References:

  • Edmundson GK et al. Accelerated treatment of breast cancer: dosimetric comparisons between interstitial HDR brachytherapy, MammoSite balloon brachytherapy, and external beam quadrant radiation. Int J Radiat Oncol Biol Phys 2003 Oct 1;57(2Suppl):S307-8.
  • Fisher B, Anderson S, Bryant J et al. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. NEJM 2002 Oct 17;347(16):1233-41.
  • King TA, et al. Long-term results of wide-field brachytherapy as the sole method of radiation therapy after segmental mastectomy for T1,2 breast cancer. AM J Surg 2000 Oct;180(4):299-304.
  • Pawlik TM, et al. Potential applicability of balloon catheter-based accelerated partial breast irradiation after conservative surgery for breast carcinoma. Cancer 2004 Feb 1;100(3):490-8.
  • Huang E, Buchholz TA, Meric F et al.  Classifying local disease recurrences after breast conservation therapy based on location and histology. Cancer 2002; 95(10): 2059-67.
  • Dragun AE, Aguero EG, Harmon JF et al. Chest wall dose in MammositeTM  breast brachytherapy: radiobiologic estimations of late complication risk based on dose-volume considerations. Brachytherapy. 2005; 4(4):259-63.
  • Vicini FA Beitsch PD, Quiet CA et al. First analysis of patient demographics, technical reproducibility, cosmesis, and early toxicity: results of the American Society of Breast Surgeons MammoSite breast brachytherapy trial. Cancer. 2005 Sep 15; 104(6):1138-48.
  • McCormick B. Partial-breast radiation for early staged breast cancers: hypothesis, existing data, and a planned phase III trial. J Natl Compr Canc Netw. 2005 May;3(3):301-7.
  • Chen PY, Vicini FA, Benitez P et al. Long-term cosmetic results and toxicity after accelerated partial-breast irradiation: a method of radiation delivery by interstitial brachytherapy for the treatment of early-stage breast carcinoma. Cancer 2006; 106(5):991-9.
  • Jeruss JS, Vicini FA, Beitsch PD et al. Initial outcomes for patients treated on the American Society of Breast Surgeons MammoSite clinical trial for ductal carcinoma-in-situ of the breast. Ann Surg Oncol 2006; 13(7):967-76.
  • Kuske RR, Winter K, Arthur DW et al. Phase II trial of brachytherapy alone after lumpectomy for select breast cancer: toxicity analysis of RTOG 95-17. Int J Radiat Oncol Biol Phys 2006; 65(1):45-51.
  • The American Society of Breast Surgeons. Consensus Statement for Accelerated Partial Breast Irradiation. October 2008.
  • Blue Cross Blue Shield Association Technology Evaluation Center. Accelerated Partial Breast Irradiation as Sole Radiotherapy After Breast-Conserving Surgery for Early Stage Breast Cancer. 2007 TEC Assessment.
  • Benitez P, Keisch M, Vicini F et al. Five-year results: the initial clinical trial of Mammosite balloon brachytherapy for partial breast irradiation in early-stage breast cancer. Am J Surg 2007;194(4):456-62.
  • Ko EC, Koprowski CD, Dickson-Witmer D et al. Partial vs. whole breast irradiation in a community hospital: A retrospective cohort analysis of 200 patients. Brachytherapy. 2010 Feb 12 [Epub ahead of print]
  • Harper JL, Watkins JM, Zauls AJ et al. Six-year experience: long-term disease control outcomes for partial breast irradiation using MammoSite balloon brachytherapy. Am J Surg. 2010 Feb; 199(2): 204-9. Epub 2009 Oct 17.
  • Nelson JC, Beitsch PD, Vicini FA et al. Four-year clinical update from the American Society of Breast Surgeons MammoSite brachytherapy trial. Am J Surg. 2009 Jul; 198(1):83-91. Epub 2009 Mar 6.
  • Antonucci JV, Wallace M, Goldstein NS et al. Differences in patterns of failure in patients treated with accelerated partial breast irradiation versus whole-breast irradiation: a matched-pair analysis with 10-year follow-up. Int J Radiat Oncol Biol Phys. 2009 Jun 1; 74(2): 447-52. Epub 2008 Dec 6.
  • Sher DJ, Wittenberg E, Suh WW et al. Partial-breast irradiation versus whole-breast irradiation for early-stage breast cancer: a cost-effectiveness analysis. Int J Radait Oncol Biol Phys. 2009 Jun 1; 74(2): 440-6. Epub 2008 Oct 27.
  • ECRI Institute Electronic Brachytherapy. Plymouth Meeting (PA): 2009 Jun 12. 6 p. [ECRI hotline response].
  • Park CC, Yom SS, Podgorsak MB et al. American Society for Therapeutic Radiology and Oncology (ASTRO) Emerging Technology Committee report on electronic brachytherapy. Int J Radiat Oncol Biol Phys. 2010 Mar 15; 76(4): 963-72.
  • Dickler A, Ivanov O, Francescatti D. Intraoperative radiation therapy in the treatment of early-stage breast cancer utilizing xoft axxent electronic brachytherapy. World J Surg Oncol. 2009 Mar 2; 7:24.
  • Dickler A, Kirk MC, Coon A et al. A dosimetric comparison of Xoft Axxent electronic brachytherapy and iridium-192 high-dose-rate brachytherapy in the treatment of endometrial cancer. Brachytheapy. 2008 Oct-Dec; 7(4):351-4. Epub 2008 Sep 9.
  • ECRI Institute Electronic Brachytherapy. Plymouth Meeting (PA): 2011 August 9. 8 p. [ECRI hotline response].
  • Dooley WC, Wurzer JC, Megahy M et al. Electronic  brachytherapy as adjuvant therapy for early stage breast cancer: a retrospective analysis. OncoTargets Ther. 2011 Jan 12; 4:13-20.
  • Dooley WC, Algan O, Dowlatshahi K et al. Surgical perspectives from a prospective, nonrandomized, multicenter study of breast conserving surgery and adjuvant electronic brachytherapy for the treatment of breast cancer. World J Surg Oncol. 2011 Mar 7; 9:30.
  • Ivanov O, Dickler A, Lum BY et al. Twelve-month follow-up results of a trial utilizing Axxent electronic brachytherapy to deliver intraoperative radiation therapy for early-stage breast cancer. Ann Surg Oncol. 2011 Feb; 18(2):453-8. Epub 2010 Aug 25.
  • Mehta VK, ALgan O, Griem KL et al. Experience with an electronic brachytherapy technique for intracavitary accelerated partial breast irradiation. Am J Clin Oncol. 2010 Aug; 33(4):327-35.
  • Njeh CF, Saunders MW, Langton CM. Accelerated Partial Breast Irradiation (APBI): A review of available techniques. Radiat Oncol. 2010 Oct 4; 5:90.
  • Vicini F, Arthur D, Wazer D et al. Limitations of the American Society of Therapeutic Radiology and Oncology Consensus Panel Guidelines on the use of accelerated partial breast irradiation. Int J Radiat Oncol Biol Phys 2011; 79(4):977-84.
  • Shaitelman SF, Vicini FA, Beitsch P et al. Five-year outcome of patients classified using the American Society for Radiation Oncology Consensus Statement Guidelines for the application of accelerated partial breast irradiation. Cancer 2010; 116(20):4677-85.
  • Beitsch P, Vicini F, Keisch M et al. Five-year outcome of patients classified in the “unsuitable” category using the American Society of Therapeutic Radiology and Oncology (ASTRO) Consensus Panel Guidelines for the Applications of Accelerated Partial Breast Irradiation: An Analysis of Patients Treated on the American Society of Breast Surgeons MammoSite® Registry Trial. Ann Surg Oncol 2010; 17(Suppl 3):S219-25.
  • American Society of Breast Surgeons. Consensus Statement for Accelerated Partial Breast Irradiation Revised August, 2011.
  • ECRI Institute Contura Multi-lumen Balloon Catheter (SenoRx, Inc.) for Accelerated Partial Breast Irradiation. Plymouth Meeting (PA): Dec 8, 2011. Custom Hotline Product Brief.
  • American College of Radiology Expert Panel on Radiation Oncology-Breast; Moran MS, Bai HX, Haffty BG et al. ACR Appropriateness Criteria®. Ductal Carcinoma In Situ. 2011.
  • American College of Radiology Expert Panel on Radiation Oncology-Breast; Bellon JR, Haffty BG, Harris EER et al. ACR Appropriateness Criteria®. Conservative Surgery and Radiation-Stage I and II Breast Carcinoma. 2011.
  • Wilder RB, Curcio LD, Khanijou RK et al. Preliminary results in 173 breast cancer patients treated with post-lumpectomy MammoSite Single-lumen brachytherapy or multi-catheter brachytherapy. Breast J. 2010 Nov-Dec; 16(6):581-6.
  • Yashar C, Scanderbeg D, Kuske R et al. Initial clinical experience with the strut-adjusted volume implant (SAVI) breast brachytherapy device for accelerated partial-breast irradiation (APBI): First 100 patients with more than 1 year of follow-up. Int J Radiat Oncol Biol Phys. 2011 Jul 1;80(3):765-70.
  • Smith GL, Xu y, Buchholz TA et al. Association between treatment with brachytherapy vs whole-breast irradiation and subsequent mastectomy, complications, and survival among older women with invasive breast cancer. JAMA. 2012;307(17):1827-37.
  • ECRI Institute Product Brief. Axxent Electronic Brachytherapy System (Xoft, Inc) for Adjuvant Treatment of Breast, Vaginal and Skin Cancers. December 2012.
  • Conference of Radiation Control Program Directors, Inc. (CRCPD). Technical White Paper: Guidance for State Programs that Regulate the New Therapy Modality Electronic Brachytherapy. January 2011.
  • American Society for Radiation Oncology (ASTRO) Brachytherapy Model Policy. January 2012.
  • American Society of Radiation Oncology (ASTRO), Emerging Technology Committee Report on Electronic Brachytherapy, May 23, 2008, Catherine C. Park, M.D. et al. Int. J. Radiation Oncology Biol.Phys. Vol. 76, No. 4 pp 963-972, 2010  
  • Xoft, Inc
  • American Academy of Dermatology Position Statement on Electronic Surface Brachytherapy for Basal Cell Carcinoma (BCC) and Squamous Cell Carcinoma (SCC), (Approved by the Board of Directors November 13, 2013; revised March 22, 2014; revised August 9, 2014).
  • ECRI Custom Product Brief Guidance. Axxent Electronic Brachytherapy System (Xoft, Inc.) for Adjuvant Treatment of Breast, Vaginal and Skin Cancers. Updated April  8, 2016.  Published March 23, 2007
  • National Comprehensive Cancer Network (NCCN) Breast Cancer Version 2.2016.
  • National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology Squamous Cell Skin Cancer Version 1.2017.
  • National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology Basal Cell Skin Cancer Version 1.2017.
  • National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology Uterine Neoplasms Version 1.2017.
  • Dooley W, Thropay J, Schreiber G, et. al. Use of Electronic Brachytherapy to Deliver Postsurgical Adjuvant Radiation Therapy for Endometrial Cancer: A Retrospective Multicenter Study. OncoTargets and Therapy 2010:3 197-203
  • National Guideline Clearinghouse. Lee LJ, Jhingran A, Kidd E, et. al. ACR Appropriateness Criteria Management of Vaginal Cancer. American College of Radiology (ACR); 2013. 11p.
  • National Guideline Clearinghouse. Klopp A, Smith BD, Alektiar K, et. al. The Role of Postoperative Radiation Therapy for Endometrial Cancer: An ASTRO Evidence-Based Guideline. Pract Radiat Oncol. 2014;(Suppl):1-22
  • UpToDate Radiation Therapy Techniques for Newly Diagnosed, Non-Metastatic Breast Cancer, Lori J. Pierce, M.D. Topic last updated December 5, 2016
  • UpToDate Radiation Therapy Techniques in Cancer Treatment. Timur Mitin M.D., PhD, Topic last updated January 14, 2016.
  • UpToDate Adjuvant Treatment of Intermediate Risk Endometrial Cancer, Heidi J Gray, M.D., Wui-Jin Koh, M.D., Topic last updated April 10, 2014.
  • Dickler A, Putawala M, Thropay J, et. al. Prospective Multi-Center Trial Utilizing Electronic Brachytherapy for the Treatment of Endometrial Cancer, Radiation Oncology 2010, 5:67
  • Beithsch P, Patel R, Lorenzetti J, et. al. Post-Surgical Treatment of Early-Stage Breast Cancer with Electronic Brachytherapy: An Intersociety, Multicenter Brachytherapy Trial, OncoTargets and Therapy 2010:3 211-218
  • Bhatnagar A, Loper A, The Initial Experience of Electronic Brachytherapy for the Treatment of Non-Melanoma Skin Cancer, Radiat Oncol 2010 Sep 28:5:87
  • Njeh C, Saunders M, Langton C, Accelerated Partial Breast Irradiation (APBI): A Review of Available Techniques. Radiat Oncol 2010 5;90
  • PubMed. Patel RR, Beitsch PD, Nichols TD, et. al. Postsurgical Treatment of Early Stage Breast Cancer with Electronic Brachytherapy: Outcomes and Health Related Quality of Life at 1 Year. Am J Clin Oncol 2013 Oct:36(5):430-5
  • PubMed. Kamrava M, Chung MP, Demarco J. et. al. Electronic Brachytherapy for Postsurgical Adjuvant Vaginal Cuff Irradiation Therapy in Endometrial and Cervical Cancer: A Retrospective Study. Brachytherapy 2013 Mar-Apr 12(2):141-7
  • Medscape Alexander M. Castellino, PhD, Concerns Over Sudden Increase in Radiation for Skin Cancer, October 21, 2015.
  • National Institute for Health and Clinical Excellence (NICE), Medtech Innovation Briefing (MIB76), Axxent Electronic Brachytherapy System for Early Stage Breast Cancer. Published August 2016.
  • Bhatnagar A. Nonmelanoma skin cancer treated with electronic brachytherapy: results at 1 year. Brachytherapy 2013 Mar-Apr;12(2):134-40. PMID 23312675
  • Pons-Llanas O, Ballester-Sanchez R, Celada Alverez FJ, et. al. Clinical implementation of new electronic brachytherapy system for skin brachytherapy. J Contemp Brachytherapy 2015 Jan;6(4):417-23. PMID 25834587
  • Tormo A, Calada F, Rodriguez S. et. al. Non-melanoma skin cancer treated with HDR Valencia applicator: clinical outcomes. J Contemp Brachytherapy 2014 June;6(2):167-72. PMID 25097557
  • Paravati AJ, Hawkins PG, Martin AN, et. al. Clinical and cosmetic outcomes in patients treated with high-dose rate electronic brachytherapy for nonmelanoma skin cancer. Pract Radiat Oncol 2015 Nov-Dec;5(6):e659-64. PMID 26432680
  • National Comprehensive Cancer Network (NCCN) Cervical Cancer Version 1.2017.
  • National Comprehensive Cancer Network (NCCN) Merkel Cell Carcinoma Version 1.2017.
  • UpToDate. Approach to adjuvant treatment of endometrial cancer. Steven C. Plaxe M.D, Arno J. Mundt M.D., Topic last updated January 4, 2016.

 

Policy History:

  • January 2017 - Annual Review, Policy Revised 
  • January 2016 - Annual Review, Policy Revised 
  • February 2015  - Annual Review, Policy Renewed 
  • March 2014 - Annual Review, Policy Revised
  • May 2013 - Annual Review, Policy Revised 
  • June 2012 - Annual Review, Policy Renewed
  • June 2011 - Annual Review, Policy Renewed

Wellmark medical policies address the complex issue of technology assessment of new and emerging treatments, devices, drugs, etc.   They are developed to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Wellmark medical policies contain only a partial, general description of plan or program benefits and do not constitute a contract. Wellmark does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Wellmark or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. Our medical policies may be updated and therefore are subject to change without notice.

 

*CPT® is a registered trademark of the American Medical Association.