ASTRO Coverage Recommendations for Proton Beam Therapy

Roxanne Nelson, BSN, RN

July 20, 2017

The use of proton beam therapy is somewhat controversial, owing to its high cost. The American Society for Radiation Oncology (ASTRO) has updated its recommendations for medical insurance coverage for this modality.

ASTRO's policy paper provides guidance to all insurers, including Medicare, Medicaid, and commercial payers, about the clinical indications that are appropriate for proton bean therapy and that should be covered.

"Recent research has expanded our understanding of the types of malignancies and clinical scenarios where proton beam therapy is most advantageous. This policy update reflects the most current knowledge regarding which patients will benefit from — and therefore should have access to — this cutting-edge treatment," said ASTRO Chair David C. Beyer, MD.

"We also remain firmly committed to developing evidence to identify new areas where this technology might be beneficial as well as situations where it is not needed," Dr Beyer explained in a statement.

Controversy Over Use

Proton beam therapy offers a high degree of precision, allowing an escalated radiation dose to be targeted directly on a tumor while sparing the adjacent healthy tissue. Although not new, the use of proton beam therapy in medical settings has greatly increased during the past decade, but it remains controversial because of cost and also because there is little evidence as to how it compares with other forms of radiotherapy.

There are currently 11 proton beam therapy centers in North America, and 13 more centers are in development.

The updated ASTRO guidelines are based on new evidence that was published since the original policy was issued in 2014.

Recommendations for Coverage

In the new model, ASTRO identifies two categories for the appropriate use of proton beam therapy.

For group 1, coverage is recommended; for group 2, coverage is recommended if additional requirements are also met.

Group 1 indications – for which coverage is recommended – include the following:

  • Both malignant and benign primary central nervous system tumors

  • Advanced and/or unresectable head and neck cancers

  • Malignancies of the paranasal sinuses and other accessory sinuses

  • Retroperitoneal sarcomas that have not metastasized

  • Cases requiring reirradiation but in which the cumulative critical structure dose would exceed tolerance dose

  • Hepatocellular cancer (no longer required to be treated in a hypofractionated regimen)

  • Ocular tumors, including intraocular melanomas

  • Tumors that are close to or located at the base of skull

  • Primary or metastatic spinal tumors in which conventional treatment would exceed tolerance or in cases in which the spinal cord has previously been irradiated

  • Primary or benign solid tumors in children treated with curative intent and for occasional palliative treatment of childhood tumors when one of the criteria noted above apply

  • Patients with genetic syndromes that require minimization of the total volume of radiation, including patients with neurofibromatosis type 1 and those with retinoblastoma

For group 2, the model policy notes that all other indications not listed in group 1 are suitable for coverage with evidence development (CED). Patients treated under the CED paradigm should be covered by insurance as long as they are enrolled either in an institutional review board–approved clinical trial or in a multi-institutional patient registry that follows Medicare requirements for CED.

There are currently no indications that are considered inappropriate for CED; group 2 has a number of indications, which include the following:

  • Non-T4 and resectable head and neck cancers

  • Thoracic tumors that include nonmetastatic primary lung and esophageal cancers, as well as mediastinal lymphomas

  • Abdominal tumors that include nonmetastatic primary pancreatic, biliary, and adrenal cancers

  • Pelvic malignancies that include nonmetastatic rectal, anal, bladder, and cervical cancers

  • Nonmetastatic prostate cancer

  • Breast cancer

The model policy update was developed by ASTRO's Payer Relations Subcommittee. The committee points out that model policies differ from practice guidelines, which are written for physicians and outline recommendations to optimize clinical care.

ASTRO. ASTRO Model Policies: Proton Beam Therapy (PBT). Full text

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