Radiotherapy for Prostate Cancer
DESCRIPTION
Prostate cancer is the second most common cancer in American men. Prostate cancer treatment options include surgery, chemotherapy, cryotherapy, hormonal therapy, and/or radiation therapy. Highly conformal radiation techniques are recommended to treat localized prostate cancer.
Conformal 3D radiotherapy is a form of EBRT using three-dimensional images, usually from computed tomography (CT) scans, to delineate the boundaries of the tumor and discriminate tumor tissue from adjacent normal tissue and organs at risk for radiation damage. Computer algorithms were developed to estimate cumulative radiation dose delivered to each volume of interest by summing the contribution from each shaped beam. The individual receiving treatment is fitted with a plastic mold resembling a body cast. The plastic mold is used to minimize movement so the radiation can be more accurately aimed from several directions, thereby reducing radiation damage to normal tissues near the tumor.
Another type of radiotherapy being investigated is mixed-beam utilizing photons and neutrons. Neutron beam therapy uses accelerated neutral subatomic particles to target tumor mass using a high linear energy transfer.
Other forms of highly conformal radiotherapy, such as brachytherapy, IMRT and stereotactic body radiotherapy therapy, are addressed in MCG guidelines. Proton beam therapy is addressed in a separate medical policy.
POLICY
External beam radiation therapy, e.g., conformal three-dimensional (3D) radiotherapy, for the treatment of prostate cancer is considered medically necessary.
Mixed-beam (Photon-Neutron) radiotherapy for the treatment of prostate cancer is considered not medically necessary.
Any device utilized for this procedure must have FDA approval specific to the indication otherwise it will be considered investigational.
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
Agency for Healthcare Research and Quality. (2020, September). Therapies for clinically localized prostate cancer: comparative effectiveness review, number 230. Retrieved April 30, 2024 from www.ahrq.gov.
Dolezel, M., Odrazka, K., Zouhar, M., Vaculikova, M, Sefrova, J., Jansa, J., et al. (2015). Comparing morbidity and cancer control after 3D-conformal (70/74 GY) and intensity modulated radiotherapy (78/82 GY) for prostate cancer. Strahlentherapie und Onkologie, 191 (4), 338-346. Abstract retrieved February 27, 2019 from PubMed database.
National Comprehensive Cancer Network. (2024, March). NCCN clinical practice guidelines in oncology (NCCN Guidelines®) Prostate cancer v3.2024. Retrieved April 30, 2024 from the National Comprehensive Cancer Network.
National Institute for Health & Care Excellence. (2019; last update search December 2021). Prostate cancer: diagnosis and management (NICE Guidelines). Retrieved December 27, 2022 from https://www.nice.org.uk/.
ORIGINAL EFFECTIVE DATE: 8/1983
MOST RECENT REVIEW DATE: 6/13/2024
ID_BT
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.
This document has been classified as public information.