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Policy
Medical Policy Manual
Approved: Do Not Implement Until 4/13/17
Hematopoietic Stem Cell Transplantation for Miscellaneous Solid Tumors in Adults
DESCRIPTION
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.
An 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.
An allogeneic HSCT involves stem cells collected from a donor who is selected based on the results of human
leukocyte antigen (HLA) typing. Antigens are protein markers on the cells which help our bodies distinguish
between self and non-self. 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. The beneficial treatment effect in this procedure is the result of a combination of the initial eradication
of malignant cells and the subsequent graft-versus-malignancy effect mediated by the non-self immunologic effector
cells.
HSCT is an established treatment for certain hematologic malignancies; however, its use in solid tumors in adults
continues to be largely experimental.
POLICY
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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:
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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
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Policy
Medical Policy Manual
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Approved: Do Not Implement Until 4/13/17
Uterine cancer
For Neuroblastoma, please refer to the MCG Care Guideline – Medical Oncology GRG.
See Also: Hematopoietic Stem Cell Transplantation in the Treatment of Germ Cell Tumors
IMPORTANT REMINDERS
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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, the
express terms of the health plan 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 Blood and Marrow Transplantation. (2015). Indications for autologous and allogeneic
hematopoietic cell transplantation: guidelines from the American Society for Blood and Marrow Transplantation.
Retrieved October 21, 2015 from
http://c.ymcdn.com/sites/www.asbmt.org/resource/resmgr/Docs/Indications_for_Auto_and_All.pdf
BlueCross BlueShield Association. Medical Policy Manual. (1:2016). Hematopoietic stem cell transplantation for
miscellaneous solid tumors (8.01.24). Retrieved September 22, 2016 from Blue Web. (29 articles and/or guidelines
reviewed)
Centers for Medicare & Medicaid Services. CMS.gov. NCD for stem cell transplantation (110.8.1). Retrieved
October 21, 2015 from http://www.cms.gov/medicare-coverage-database/overview-and-quicksearch.aspx?from2=search1.asp&
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, (2007) 133, 1-11. (Level 4 evidence)
ESMO/European Sarcoma Network Working Group. (2014). Soft tissue and visceral sarcomas: ESMO clinical
practice guidelines for diagnosis, treatment and follow-up. Annals of Oncology, 25 (Supplement 3), iii102-iii112.
Retrieved November 17, 2016 from https://annonc.oxfordjournals.org/content/25/suppl_3/iii102.full.pdf+html
National Comprehensive Cancer Network. (2016). NCCN clinical practice guidelines in oncology®. Colon Cancer
(V.2.2016). Retrieved September 22, 2016 from National Comprehensive Cancer Network.
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Policy
Medical Policy Manual
Approved: Do Not Implement Until 4/13/17
National Comprehensive Cancer Network. (2016). NCCN clinical practice guidelines in oncology®. Kidney Cancer
(V.3.2016). Retrieved September 22, 2016 from National Comprehensive Cancer Network.
National Comprehensive Cancer Network. (2016). NCCN clinical practice guidelines in oncology®. Esophageal and
Esophagogastric Junction Cancers (V.2.2016). Retrieved September 22, 2016 from National Comprehensive
Cancer Network.
National Comprehensive Cancer Network. (2016). NCCN clinical practice guidelines in oncology®. Gastric Cancer
(V.3.2016). Retrieved September 22, 2016 from National Comprehensive Cancer Network.
National Comprehensive Cancer Network. (2016). NCCN clinical practice guidelines in oncology®. Pancreatic
Adenocarcinoma (V.2.2016). Retrieved September 22, 2016 from National Comprehensive Cancer Network.
National Comprehensive Cancer Network. (2016). NCCN clinical practice guidelines in oncology®. Non-small cell
lung cancer (V.4.2016). Retrieved September 22, 2016 from National Comprehensive Cancer Network.
National Comprehensive Cancer Network. (2016). NCCN clinical practice guidelines in oncology®. Cervical cancer
(V.1.2016). Retrieved September 22, 2016 from National Comprehensive Cancer Network.
National Comprehensive Cancer Network. (2016). NCCN clinical practice guidelines in oncology®. Uterine
Neoplasms (V.2.2016). Retrieved September 22, 2016 from National Comprehensive Cancer Network.
National Comprehensive Cancer Network. (2016). NCCN clinical practice guidelines in oncology®. Prostate Cancer
(V.3.2016). Retrieved September 22, 2016 from National Comprehensive Cancer Network.
National Comprehensive Cancer Network. (2016). NCCN clinical practice guidelines in oncology®. Melanoma
(V.3.2016). Retrieved September 22, 2016 from National Comprehensive Cancer Network.
National Comprehensive Cancer Network. (2016). NCCN clinical practice guidelines in oncology®. Neuroendocrine
Tumors (V.2.2016). Retrieved September 22, 2016 from National Comprehensive Cancer Network.
National Comprehensive Cancer Network. (2016). NCCN clinical practice guidelines in oncology®. Thyroid
Carcinoma (V.1.2016). Retrieved September 22, 2016 from National Comprehensive Cancer Network.
National Comprehensive Cancer Network. (2016). NCCN clinical practice guidelines in oncology®. Thymomas and
Thymic Carcinomas (V.3.2016). Retrieved September 22, 2016 from National Comprehensive Cancer Network.
Schlemmer, M., Wendtner, C., Falk, M., Abdel-Rahman, S., Licht, T., Baumert, J., et al. (2006). Efficacy of
consolidation high-dose chemotherapy with ifosfamide, carboplatin and etoposide (HD-ICE) followed by autologous
peripheral blood stem cell rescue in chemosensitive patients with metastatic soft tissue sarcomas. Oncology, 2006,
71 (1-2), 32-39. (Level 4 evidence)
Sureda, A., Bader, P., Cesaro, S., Dreger, P., Duarte, R., Dufour, C., et al. (2015). Indications for allo- and autoSCT for haematological diseases, solid tumours and immune disorders: current practice in Europe, 2015. Bone
Marrow Transplantation, 50, 1037-1056. (Level 4 evidence)
EFFECTIVE DATE
4/13/2017
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