ARCHIVED

Medical Policy

Policy Num:      08.001.020
Policy Name:    Neutron Beam Radiotherapy
Policy ID:          [08.001.020]  [Ar / B / M+ /P]  [8.01.09]

Last Review:      May 10, 2019
Next Review:      Policy Archived
Issue:                  5:2019

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Related Policies BCBS: None

Related Policies TSSS: None

Neutron Beam Radiotherapy

Summary

Neutron beam therapy is a form of radiotherapy that is used primarily for the treatment of unresectable or recurrent tumors. This policy does not address boron neutron capture therapy for cancer. 

Radiobiological principles demonstrate that radiation therapy using a neutron beam is associated with a higher linear energy transfer when compared to conventional photon or electron radiation therapy. This increased energy results in greater effectiveness. Some tumors appear to be more susceptible to the cytotoxic effect of neutrons. Studies show that local tumor control over 5 years was 75% in neutron use and 32% when compared to conventional photon and electron therapy. Acute toxicity was similar in all three therapy modalities although late severe toxicity, grade 3 and grade 4 is more prevalent with neutrons when compared to the other modalities. The modality using the neutron beam has also been shown to provide greater local control in salivary gland tumors in cases of advanced, recurrent, incomplete or inoperable resection.

Objective

The objective of this review  is to compare neutronbeam therapy  with conventional  photon or electron radiation in achieving control  in unresectable or recurrent tumors

Policy Statements

Neutron beam radiotherapy of advanced salivary gland tumors and soft tissue sarcomas is considered medically necessary in cases meeting the criteria below:
 Salivary gland tumors in which disease-free surgical margins are not obtainable or where local recurrence has developed.
- Tumors classified as T3b or greater (i.e., tumors larger than 4 cm).
 Advanced or recurrent soft tissue sarcomas without nodal involvement or distant metastases.
- Primary treatment of T2 tumors (i.e., tumors larger than 5 cm).
- Treatment of tumor recurrence (i.e., T1 or T2 tumors).
 Advanced unresectable adenocarcinoma of the prostate, using neutrons in combination with photon radiotherapy (i.e., mixed-beam therapy)
- Tumor extends into or beyond the prostatic capsule (i.e., tumors classified C or T3);
- Tumor extends into neighboring tissues (i.e., tumors classified D or T4).

Policy Guidelines

N/A

Benefit Application

BlueCard/National Account Issues

The National Cancer Institute has established technical standards for neutron beam radiotherapy facilities. The positive results reported in the literature were from facilities meeting these standards. Plans may wish to consider using these standards in selecting the site where the therapy is rendered.

Background

N/A

Regulatory Status

N/A

Rationale

2002 Update
This policy is based on 1987 and 1992 TEC Assessments (1, 2). A search of the literature was completed through the MEDLINE database for the period of January 1996 through October 2002. No published data were identified that suggest additional indications beyond those listed in the policy statement. Therefore, the policy statement is unchanged.

Population Reference No. 1 

Individuals: With unrespectable or recurrent tumors. Interventions of interest are: Neutron beam therapy. Comparators of interest are: Conventional photon or electron radiation therapy.  Relevant outcomes include: Local tumor control.

Supplemental Information

N/A

Practice Guidelines and Position Statements

N/A

Medicare National Coverage

N/A

References

1. Technology Evaluation & Coverage 1987: p. 141
2. TEC Evaluations 1992: p. 191

Codes

Appplicable Modifiers

N/A

Policy History