Medical Policy: 02.04.62
Original Effective Date: August 2016
Reviewed: August 2017
Revised: August 2017
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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.
The Philadelphia chromosome (Ph), a derivative chromosome 22 resulting from a translocation between chromosomes 9 and 22 causing the BCR-ABL fusion, is present in approximately 95% of chronic myeloid leukemia (CML) and 25-30% of adult acute lymphoblastic leukemia (ALL) cases. In general, the ratio of the fusion to a reference control can be used for diagnosis, prognosis, and ongoing therapeutic monitoring.
BCR-ABL cytogenetic testing detects the presence of the 9;22 translocation and the BCR-ABL fusion gene within somatic cells. This test may also identify an additional copy of Ph in cells or an atypical 9/22 translocation. Cytogenetic testing is indicated as an initial evaluation for patients suspected to have chronic myeloid leukemia (CML) or adult acute lymphoblastic leukemia (ALL) and then for monitoring disease status.
Qualitative BCR-ABL testing is indicated as an initial evaluation for patients known to have a positive FISH cytogenetic test for BCR-ABL. The qualitative BCR-ABL test can determine the specific type (isoform) of the Philadelphia chromosome present which is important for appropriate diagnosis and treatment.
Patients with CML are treated with the drug Imatinib, or a second generation tyrosine kinase inhibitor, at diagnosis. The treatment is highly effective however it is essential that any relapse in the disease is identified as soon as possible to ensure the best clinical outcome for the patient. As such the expression level of the fusion gene is monitored in patients over time.
For CML, inadequate initial response to tyrosine kinase inhibitors (TKIs) is defined as failure to achieve complete hematologic response at 3 months, only minor cytologic response at 6 months, or major (rather than complete) cytogenetic response at 12 months.
Unlike in CML, ALL resistance to TKIs is less well studied. In patients with ALL receiving a TKI, a rise in the BCR-ABL mRNA level while in hematologic complete response or clinical relapse warrants mutational analysis.
Loss of response to TKIs is defined as hematologic relapse, cytogenetic relapse, or 1-log increase in BCR-ABL1 transcript ratio and therefore loss of major molecular response.
The ELN (European LeukemiaNet), European Society for Medical Oncology (ESMO), and National Comprehensive Cancer Network (NCCN) provide recommendations about when BCR-ABL1 KD mutation analysis should be performed in patients treated with TKIs. According to the ELN and the ESMO recommendations, mutation analysis is recommended at diagnosis only in AP-/BP-CML patients, before starting first-line therapy. However, in the absence of prospective studies based on mutation screening up front and the low rate of mutation detection, it is questionable whether this is sensible or cost-effective. The NCCN recommends mutation analysis in TKI-pretreated AP-/BP-CML patients
The ELN and the ESMO recommendations differentiate between first-line and second-line treatment, while the NCCN guidelines do not differentiate across lines of treatment. According to the ELN and the ESMO recommendations, BCR-ABL1 KD mutation analysis should be performed during second-line treatment in case of hematologic or cytogenetic failure, whereas based on the NCCN guidelines, mutation analysis should also be performed in case of loss of response, inadequate response, or increased BCR-ABL1 transcript levels.
|blank cell||At diagnosis||During first-line therapy with imatinib||During second-line therapy with dasatinib or nilotinib|
|ELN and ESMO recommendations||Only in patients with AP-/BP-CML||
In case of hematologic or cytogenetic failure, including:
|NCCN recommendations||In case of disease progression to AP or BP||In patients with CP-CML who have inadequate initial response, defined as failure of achieving PCyR or BCR-ABL1/ABL1 ≤10% (on the international scale) at 3 months or CCyR at 12 and 18 months||In patients with CP-CML at any sign of loss of response, defined as hematologic or cytogenetic relapse or 1-log increase in BCR-ABL1 transcript level and loss of MMR|
ELN, European LeukemiaNet; ESMO, European Society for Medical Oncology; AP, accelerated phase; BP, blast phase; CML, chronic myeloid leukemia; MMR, major molecular response; CyR, cytogenetic response; PCyR, partial cytogenetic response; CP, chronic phase; NCCN, National Comprehensive Cancer Network; CCyR, complete cytogenetic response.
National Cancer Institute (NCI): Regarding BCR-ABL mutation analysis in individuals with chronic myelogenous leukemia (CML), the NCI notes “In case of treatment failure or suboptimal response, patients should undergo BCR/ABL kinase domain mutation analysis to help guide therapy with the newer tyrosine kinase inhibitors or with allogeneic transplantation (2016)
The National Comprehensive Cancer Network (NCCN, 2017) recommends bone marrow cytogenetics to confirm a diagnosis of CML. If bone marrow is not available, FISH on a peripheral blood specimen using probes for both BCR and ABL can confirm the diagnosis. NCCN recommends BCR-ABL transcript levels be obtained by quantitative RT-PCR:
These recommendations are category 2A: "based upon lower-level evidence, there is uniform NCCN consensus that the intervention is appropriate."
BCR/ABL1 qualitative testing for the presence of the fusion gene may be considered medically necessary for diagnosis of chronic myeloid leukemia, lymphoblastic lymphoma, acute myeloid leukemia, acute lymphocytic leukemia.
BCR/ABL1 testing at baseline prior to initiation of treatment and at appropriate intervals during therapy may be considered medically necessary for monitoring treatment response and remission.
To report provider services, use appropriate CPT* codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes and / or diagnosis codes.
Association for Clinical Genetic Science (ACGS). Professional guidelines for clinical cytogenetics. Published July 2011.
National Comprehensive Cancer Network (NCCN) NCCN Clinical Practice Guidelines in Oncology (NCCN Guidlines®), Chronic Myeloid Leukemia, Version 1.2018
National Comprehensive Cancer Network (NCCN) NCCN Clinical Practice Guidelines in Oncology (NCCN Guidlines®), Acute Lymphoblastic Leukemia, Version 1.2017
National Comprehensive Cancer Network (NCCN) NCCN Clinical Practice Guidelines in Oncology (NCCN Guidlines®), Acute Lymphoblastic Leukemia, Version 3.2017
Baccarani M, Deininger MW, Rosti G, et al. European LeukemiaNet recommendations for the
management of chronic myeloid leukemia: 2013. Blood. 2013;122(6):872-84.
Radich JP. Monitoring response to tyrosine kinase inhibitor therapy, mutational analysis, and new treatment options in chronic myelogenous leukemia. J Natl Compr Canc Netw. 2013;11(5 Suppl):663-6.
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