Hematopoietic stem cell transplantation (HSCT) refers to a procedure in which hematopoietic stem cells are infused to restore bone marrow function in individuals who receive bone marrow-toxic doses of cytotoxic drugs with or without whole body radiotherapy. Hematopoietic stem cells can be harvested from bone marrow, peripheral blood or from umbilical cord blood shortly after delivery of neonates.

Autologous HSCT typically occurs after induction chemotherapy once complete remission has been achieved. The individual’s stem cells are mobilized from the bone marrow to the peripheral bloodstream and harvested. High dose chemotherapy is administered to eradicate any lingering cancer cells followed by reinfusion of the stem cells.

Allogeneic HSCT involves stem cells collected from a donor who is selected based on the results of human leukocyte antigen (HLA) typing. A close HLA match increases the likelihood of a successful transplant. Prior to the transplant, the recipient undergoes intensive treatment to destroy cancerous cells. The donor cells are infused into the bloodstream and travel to the bone marrow where they begin to produce new cells in a process known as engraftment.

HSCT is an established treatment for certain hematologic malignancies; however, its use in solid tumors in adults continues to be largely experimental.

POLICY

Autologous or allogeneic stem cell transplant as a treatment of solid tumor malignancies in adults, including, but not limited to, the following is considered investigational:
- Breast cancer
- Cancer of the bile duct
- Cancer of the fallopian tubes
- Cervical cancer
- Colon cancer
- Esophageal cancer
- Gallbladder cancer
- Lung cancer, any histology
- Malignant melanoma
- Nasopharyngeal cancer
- Neuroendocrine tumors
- Paranasal sinus cancer
- Pancreatic cancer
- Prostate cancer
- Rectal cancer
- Renal cell cancer
- Soft tissue sarcomas
- Stomach cancer
- Thyroid tumors
- Tumors of the thymus
- Tumors of unknown primary origin
- Uterine cancer

For Neuroblastoma, please refer to the MCG Care Guideline - Medical Oncology GRG.

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.

ADDITIONAL INFORMATION

Peer reviewed studies on the use of autologous or allogeneic stem cell transplantation in the treatment of solid tumors in adults are limited. There is insufficient evidence to permit conclusions regarding improved health outcomes.

SOURCES

American Society for Transplantation and Cellular Therapy (ASTCT). (2020, March). Indications for hematopoietic cell transplantation and immune effector cell therapy: guidelines from the American Society for Transplantation and Cellular Therapy. Retrieved December 9, 2022 from http://www.astct.org.

BlueCross BlueShield Association. Evidence Positioning System. (2:2023). Hematopoietic cell transplantation for miscellaneous solid tumors in adults (8.01.24). Retrieved December 7, 2023 from www.bcbsaoca.com/eps/. (34 articles and/or guidelines reviewed)

Centers for Medicare & Medicaid Services. CMS.gov. (2016, October). NCD for stem cell transplantation (110.23). Retrieved December 12, 2017 from http://www.cms.gov.

Engelhardt, M., Zeiser, R., Ihorst, G., Finke, J., & Müller, C. (2007). High-dose chemotherapy and autologous peripheral blood stem cell transplantation in adult patients with high-risk or advanced Ewing and soft-tissue sarcoma. Journal of Cancer Research & Clinical Oncology, 133, 1-11. (Level 4 evidence)

Heilig, C. E., Badoglio, M., Labopin, M., Fröhling, S., Secondino, S., Heinz, J., et al. (2020). Haematopoietic stem cell transplantation in adult soft-tissue sarcoma: an analysis from the European Society for Blood and Marrow Transplantation. ESMO Open, 5 (5), e000860, doi: 10.1136/esmoopen-2020-000860. (Level 4 evidence)

National Comprehensive Cancer Network. (2022). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Accessed December 8, 2022 from the National Comprehensive Cancer Network.

Sureda, A., Bader, P., Cesaro, S., Dreger, P., Duarte, R., Dufour, C., et al. (2015). Indications for allo- and auto-SCT for haematological diseases, solid tumours and immune disorders: current practice in Europe, 2015. Bone Marrow Transplantation, 50, 1037-1056. (Level 4 evidence)

ORIGINAL EFFECTIVE DATE: 5/14/2011

MOST RECENT REVIEW DATE: 1/11/2024

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.

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