Medical Policy: 06.01.36
Original Effective Date: September 2017
Reviewed: September 2017
Revised:
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.
An estimated 161,360 new cases of prostate cancer will be diagnosed in 2017, accounting for 19% of new cancer cases in men. Researchers have estimated prostate cancer to account for 26,730 deaths in 2017, which represent 8% of male cancer deaths. The use of prostate specific antigen (PSA) screening and monitoring has allowed prostate cancer to be diagnosed at a localized stage. Despite early detection and appropriate treatment, some individual’s progress to metastatic, hormone refractory prostate cancer after the failure of several lines of anti-hormonal therapies, and approximately 85% to 90% of patients will have radiologic evidence of bone metastases which are a major cause of death, disability and decreased quality of life. Weakened bones due to cancer metastases can lead to fractures and compression of the spinal cord. They necessitate procedures such as surgery and radiation, which are designed to prevent or manage bone complications. The primary goal of treatment for bone metastases is to prevent the occurrence of debilitating bone complications that can affect an individual’s quality of life. Radiation treatment has been shown to provide palliative care in patients with advanced prostate cancer.
Radium Ra 223 dichloride (Xofigo®), also known as radium-223, is an alpha particle-emitting radiotherapeutic agent. Radium-223 injection mimics calcium and forms complexes with the bone mineral hydroxyapatite at areas of increased bone turnover. The high-energy alpha particle radiation causes breaks in the double stranded DNA of the targeted area resulting in an anti-tumor effect on the bone metastases. The short path of the alpha particles limits the damage to the surrounding normal tissue and bone marrow. The U.S. Food and Drug Administration (FDA) in May 2013, approved radium-223 for the treatment of patients with castration-resistant prostate cancer (CRPC), with symptomatic bone metastases and no known visceral metastatic disease.
The FDA approval was based on clinical data from a multicenter, phase 3, randomized trial (ALSYMPCA) that included 921 men with symptomatic CRPC, 2 or more bone metastases, and no known visceral disease. Fifty-seven percent of the patients received prior docetaxel and all patients received best supportive care. Patients were randomized in a 2:1 ratio to 6 monthly radium-223 intravenous injections or placebo. Compared to placebo, radium-223 significantly improved overall survival (medial 14.9 months vs. 11.3 months; HR, 0.70; 95% CI, 0.058-0.83; P < 0001) and prolonged time to first SRE (medial 15.6 months vs. 9.8 months). Preplanned subset analyses showed that survival benefit of radium-223 was maintained regardless of prior docetaxel use. Intention-to-treat analyses from ALSYMPCA showed that radium-223 also may reduce the risk of symptomatic skeletal related events (SREs). Grade ¾ hematologic toxicity was low (3% neutropenia, 6% thrombocytopenia and 13% anemia), likely due to the short range of radioactivity. Fecal elimination of the agent led to generally mild non-hematologic side effects, which include nausea, diarrhea, and vomiting. Radium-223 was associated with improved or slower decline of quality of life in ALSYMPCA.
The dosing regimen of radium Ra 223 dichloride (Xofigo®) is given at 4 week intervals for a total of 6 injections. It is administered by a slow intravenous injection over 1 minute. Adverse reactions from this therapy include a risk of bone marrow suppression and gastrointestinal symptoms including nausea, vomiting and diarrhea. To monitor for bone marrow suppression a hematologic evaluation of patients must be performed at baseline and prior to every dose of radium-223 (Xofigo®). According to the FDA approved label, before the first administration the absolute neutrophil count (ANC) should be ≥ 1.5 x 109/L, the platelet count ≥ 100 x 109/L and hemoglobin ≥10 g/dL. Before subsequent administrations, the ANC should be ≥ 1 x 109/L and the platelet count ≥ 50 x 109/L. If there is no recovery to these values within 6 to 8 weeks after the last administration of radium-223 (Xofigo®), despite receiving supportive care, further treatment with radium-223 (Xofigo®) should be discontinued. Additional FDA labeling includes the following: the safety and efficacy beyond 6 injections with radium-223 (Xofigo®) has not been studied; and the safety and efficacy of concomitant chemotherapy with radium-223 (Xofigo®) have not been established. Outside of a clinical trial, concomitant use with chemotherapy is not recommended due to the potential for additive myelosuppression. If chemotherapy, other systemic radioisotopes or hemibody external radiotherapy are administered during the treatment period, radium-223 (Xofigo®) should be discontinued.
Other Indications
Currently, there are ongoing phase I/II clinical trials investigating the use of radium-223 for other indications to include breast cancer, osteosarcoma, lung cancer and for use in combination with docetaxel for the use in treatment of castration-resistant prostate cancer (CRPC) and bone metastases. Presently, there is insufficient published literature to demonstrate the safety and effectiveness of radium-223 when used for these indications.
Patients who disease progresses to CRPC during primary ADT should receive a laboratory assessment to assure a castrate level of testosterone (< 50 ng/dL; <1.7 nmol/L).
All patients with metastatic CRPC should maintain castrate levels of serum testosterone (< 50 ng/dL; <1.7 nmol/L) and receive best supportive care.
Radium-223 is a category 1 option to treat symptomatic bone metastases without visceral metastases. Hematologic evaluation should be performed according to the FDA label before treatment initiation and before each subsequent does. Radium-223 given in combination with chemotherapy (such as docetaxel) outside of a clinical trial has the potential of additive myelosuppression. Radium-223 can be used with densumab or zoledronic acid.
Radium-223 dichloride (Ra 223) is a bone seeking, alpha particle-emitting radiopharmaceutical that is under early stage investigation for treatment metastatic or recurrent osteosarcoma. This agent is approved in the United States for treating bone metastases associated with castration-resistant prostate cancer. Preliminary studies suggest that this agent is active in osteosarcoma and may have less marrow toxicity and greater efficacy than beta particle-emitting radiopharmaceuticals such as Sm 153-EDTMP.
In May 2013 (amended April 2015), the America Urological Association issued a guideline for castration resistant prostate cancer, which included the following guideline statements:
Radium Ra 223 dichloride (Xofigo®) injection was approved by the FDA on May 15, 2013 for the treatment of individuals with castration-resistant prostate cancer, symptomatic bone metastases, and no known visceral metastatic disease.
Not applicable
Radium Ra 223 dichloride (Xofigo®), also known as radium-223 is considered medically necessary and, therefore, covered for a maximum of six injections for the treatment of prostate cancer when ALL of the following criteria are met:
Radium Ra 223 dichloride (Xofigo®), also known as radium-223 is considered investigational when the above criteria are not met, including but not limited to the any of the following:
Based on the peer reviewed medical literature the safety and effectiveness for indications other than the medically necessary indication listed above has not been established. Also, the FDA approved label indication state the safety and efficacy beyond 6 injections with radium-223 (Xofigo®) has not been studied; and the safety and efficacy of concomitant chemotherapy with radium-223 (Xofigo®) have not been established. Additional studies are needed to further investigate the safety and efficacy of radium-223 (Xofigo®) for the patient populations other than castration-resistant prostate cancer (CRPC). The evidence is insufficient to demonstrate the effects on net health outcomes for the indications listed above.
To report provider services, use appropriate CPT* codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes and / or diagnosis codes.
September 2017 - New Policy
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