Photodynamic Therapy (PDT) for the Treatment of Certain Cancers
DESCRIPTION
Photodynamic therapy (PDT) has been investigated for use in a wide variety of cancers, including esophageal, lung, cholangiocarcinoma, bladder, breast, brain (administered intraoperatively), and head and neck cancers. PDT uses a photosensitizing agent that is activated by light energy to selectively induce a phototoxic reaction in certain dysplastic or malignant tissue. Photodynamic therapy may also be called phototherapy, photoradiation therapy, photosensitizing therapy, or photochemotherapy.
Note: This policy does not address PDT for the treatment of skin lesion or Barrett esophagus. PDT should not be confused with extracorporeal photopheresis which involves withdrawing blood from an individual, irradiating it with ultraviolet light and then returning the blood to the individual.
POLICY
Photodynamic therapy for the treatment of certain cancers is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Photodynamic therapy for the treatment of other conditions/diseases, including, but not limited to, the following: bladder, breast, brain, and other head and neck cancers, is considered investigational.
Any device utilized for this procedure must have FDA approval specific to the indication, otherwise it will be considered investigational.
MEDICAL APPROPRIATENESS
Photodynamic therapy is considered medically appropriate if ANY ONE of the following are met:
Palliative treatment for ANY ONE of the following:
Obstructing esophageal cancer when treatment cannot be performed satisfactorily with Nd:YAG (neodymium-doped yttrium aluminum garnet) laser therapy
Obstructing endobronchial lesions
Unresectable cholangiocarcinoma (bile duct cancer) when used with stenting
Treatment of early-stage endobronchial non-small cell lung cancer (NSCLC) when surgery and radiotherapy are not indicated
IMPORTANT REMINDERS
Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g. statement.
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan or government program (e.g., TennCare), the express terms of the health plan or government program will govern.
SOURCES
BlueCross BlueShield Association. Evidence Positioning System. (8:2023). Oncologic applications of photodynamic therapy, including Barrett esophagus (8.01.06). Retrieved May 9, 2024 from www.bcbsaoca.com/eps/. (83 articles and/or guidelines reviewed)
Guidolin, K., Ding, L., Yan, H., Englesakis Hba, M., Chadi, S., Quereshy, F., & Zheng, G. (2022). Photodynamic therapy for colorectal cancer: a systematic review of clinical research. Surgical Innovation, 29 (6), 788–803. (Level 2 evidence)
Hauge, T., Hauge, P., Warloe, T., Drolsum, A., Johansen, C., Viktil, E., et al. (2016). Randomized controlled trial of temoporfin photodynamic therapy plus chemotherapy in nonresectable biliary carcinoma--PCS Nordic study.
Lu, Y., Liu, L., Wu, J., Bie, L., and Gong, B. (2015). Efficacy and safety of photodynamic therapy for unresectable cholangiocarcinoma: A meta-analysis. Clinical Research in Hepatology & Gastroenterology, 39 (6), 718-724. Abstract retrieved September 8, 2017 from PubMed database.
Mohan, B., Chandan, S., Khan, S., Kassab, L., Ponnada, S., Artifon, E., et al. (2022). Photodynamic therapy (PDT), radiofrequency ablation (RFA) with biliary stents in palliative treatment of unresectable extrahepatic cholangiocarcinoma: a systematic review and meta-analysis. Journal of Clinical Gastroenterology, 56 (2), e153–e160. Abstract retrieved March 10, 2023 from PubMed database.
Moole, H., Tathireddy, H., Dharmapuri,S., Moole, V., Boddireddy, R., et al. (2017). Success of photodynamic therapy in palliating patients with nonresectable cholangiocarcinoma: a systematic review and meta-analysis. World Journal of Gastroenterology, 23 (7), 1278-1288. (Level 2 evidence)
National Comprehensive Cancer Network. (2024, April). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Esophageal and esophagogastric junction cancers v.3.2024 Retrieved May 9, 2024 from the National Comprehensive Cancer Network.
National Comprehensive Cancer Network. (2024, April). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Non-small cell lung cancer v.5.2024. Retrieved May 9, 2024 from the National Comprehensive Cancer Network.
National Comprehensive Cancer Network. (2024, April). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Biliary Tract cancers v.2.2024. Retrieved May 9, 2024 from the National Comprehensive Cancer Network.
National Institute for Health and Clinical Excellence (NICE). (2004, August). Photodynamic therapy for advanced bronchial carcinoma. Retrieved August 28, 2018 from http://www.nice.org.uk.
National Institute for Health and Clinical Excellence (NICE). (2005, July). Photodynamic therapy for bile duct cancer. Retrieved August 28, 2018 from http://www.nice.org.uk.
National Institute for Health and Clinical Excellence (NICE). (2005, November). Photodynamic therapy for localised inoperable endobronchial cancer. Retrieved August 28, 2018 from http://www.nice.org.uk.
National Institute for Health and Clinical Excellence (NICE). (2006, December). Palliative photodynamic therapy for early stage oesophageal cancer. Retrieved August 28, 2018 from http://www.nice.org.uk.
National Institute for Health and Clinical Excellence (NICE). (2007, January). Palliative photodynamic therapy for advanced oesophageal cancer. Retrieved August 28, 2018 from http://www.nice.org.uk.
National Institute for Health and Clinical Excellence (NICE). (2009, March). Photodynamic therapy for brain tumours. Retrieved August 28, 2018 from http://www.nice.org.uk.
Photo-diagnosis Photodynamic Therapy, 13, 330-333. Abstract retrieved September 8, 2017 from PubMed database.
U. S. Food and Drug Administration. (2000, June). Center for Devices and Radiological Health. Pre-market approval decisions for June 2000. P990021. Retrieved March 11, 2011 from http://www.accessdata.fda.gov.
U. S. Food and Drug Administration. (2003, August). Center for Devices and Radiological Health. Pre-market approval decisions for August 2003. P020021. Retrieved March 11, 2011 from http://www.accessdata.fda.gov.
ORIGINAL EFFECTIVE DATE: 3/1985
MOST RECENT REVIEW DATE: 6/13/2024
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Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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