Cigna Molecular Diagnostic Testing for Hematology and Oncology Indications - (0520) Form

The following Coverage Policy applies to health benefit plans administered by Cigna Companies. Certain Cigna Companies and/or lines of business only provide utilization review services to clients and do not make coverage determinations. References to standard benefit plan language and coverage determinations do not apply to those clients. Coverage Policies are intended to provide guidance in interpreting certain standard benefit plans administered by Cigna Companies. Please note, the terms of a customer’s particular benefit plan document [Group Service Agreement, Evidence of Coverage, Certificate of Coverage, Summary Plan Description (SPD) or similar plan document] may differ significantly from the standard benefit plans upon which these Coverage Policies are based. For example, a customer’s benefit plan document may contain a specific exclusion related to a topic addressed in a Coverage Policy. In the event of a conflict, a customer’s benefit plan document always supersedes the information in the Coverage Policies. In the absence of a controlling federal or state coverage mandate, benefits are ultimately determined by the terms of the applicable benefit plan document. Coverage determinations in each specific instance require consideration of 1) the terms of the applicable benefit plan document in effect on the date of service; 2) any applicable laws/regulations; 3) any relevant collateral source materials including Coverage Policies and; 4) the specific facts of the particular situation. Each coverage request should be reviewed on its own merits. Medical directors are expected to exercise clinical judgment where appropriate and have discretion in making individual coverage determinations. Where coverage for care or services does not depend on specific circumstances, reimbursement will only be provided if a requested service(s) is submitted in accordance with the relevant criteria outlined in the applicable Coverage Policy, including covered diagnosis and/or procedure code(s). Reimbursement is not allowed for services when billed for conditions or diagnoses that are not covered under this Coverage Policy (see “Coding Information” below). When billing, providers must use the most appropriate codes as of the effective date of the submission. Claims submitted for services that are not accompanied by covered code(s) under the applicable Coverage Policy will be denied as not covered. Coverage Policies relate exclusively to the administration of health benefit plans. Coverage Policies are not recommendations for treatment and should never be used as treatment guidelines. In certain markets, delegated vendor guidelines may be used to support medical necessity and other coverage determinations. This Coverage Policy addresses testing for harmful or likely harmful changes in the genetic information of cells that occur after conception, for selected cancers and blood disorders. These changes, also called variants, are referred to as acquired or somatic. They are not inherited or passed down by blood relatives. The changes may occur in any cell of the human body except the egg or sperm cell. They may increase a person’s risk or tendency to have a certain disease or disorder. Several types of testing are discussed in this Coverage Policy, including testing for a single change in a gene or part of a gene and testing for multiple changes in a gene or genes. Also discussed are tests that measure how a gene is turned on or off, which is referred to as gene expression. Test results can help determine how advanced a disease is and the chance of it coming back. Results can also help decide on a treatment and how well the disease may respond, or is responding to treatment. Medical Coverage Policy: 0520 Coverage Policy Coverage for Genetic Testing and Counseling varies across plans. Refer to the customer’s benefit plan document for coverage details. For additional information regarding coverage for specific genetic tests please refer to the Genetic Testing Collateral: Molecular Tests and Biomarkers. General Criteria for Somatic Pathogenic or Likely Pathogenic Variant Genetic Testing Medically Necessary A tissue-based molecular tumor biomarker, broad molecular profile panel or gene expression classifier (GEC) testing is considered medically necessary when ALL of the following criteria are met: • the individual is a candidate for a targeted therapy associated with a specific tumor biomarker(s) or disease site results of testing will directly impact clinical decision making the testing method is considered to be scientifically valid and proven to have clinical utility based on prospective evidence no other tumor biomarker, broad molecular profile panel or gene expression classifier test has been performed on this tumor sample for the same indication disease-specific criteria are not described elsewhere in the Coverage Policy • ANY of the following:  identification of the specific biomarker or risk assessment using a GEC has been validated by the National Comprehensive Cancer Network™ (NCCN Guidelines™) as a category 1, 2A or 2B recommendation for the individual’s tumor type of disease  identification of the specific biomarker or use of a GEC has been demonstrated in published peer-reviewed literature to improve diagnosis, management or clinical outcomes for the individual’s condition being addressed  biomarker confirmation is required by a US Federal Drug Administration (FDA)- approved or cleared test as described within the section heading “Indications and Usage” of the FDA-approved prescribing label prior to initiating therapy  broad molecular profile panel testing for EITHER of the following: o advanced, metastatic solid tumors o ANY of the following hematologic malignancies: acute myeloid leukemia • myelodysplastic disease • myeloproliferative disease • multiple myeloma • systemic mastocytosis Medical Coverage Policy: 0520 Targeted somatic testing for PIK3CA is considered medically necessary when the following criteria are met: Post-menopausal female or male with advanced or metastatic, ER/PR positive and HER2 negative breast cancer Patient has progressed on endocrine therapy Targeted molecular testing for NTRK fusions (NTRK1/2/3 fusions) is considered medically necessary when the individual has a solid tumor known to respond to treatment with an FDA approved drug therapy targeting NTRK gene fusions. Liquid biopsy by cell-free DNA laboratory testing methods (e.g., cDNA, ctDNA) is considered medically necessary when tissue testing is not available or contraindicated for EITHER of the following: advanced or metastatic solid tumors • biomarker confirmation is required by an FDA-approved or cleared test as described within the section heading “Indications and Usage” of the US FDA-approved prescribing label prior to initiating therapy Testing of bone marrow samples for minimal residual disease (MRD) using high- throughput immunosequencing (e.g., Clonoseq) is considered medically necessary for ANY of the following indications or when designated by NCCN as a category 1, 2A or 2B recommendation: multiple myeloma (MM) • B-cell acute lymphoblastic leukemia (ALL) • chronic lymphoblastic leukemia (CLL) • peripheral and cutaneous T-cell lymphoma (TCL) Other testing (e.g., non-high-throughput immunosequencing) for MRD using a validated technology when recommended by NCCN Guidelines™ as a Category 1, 2A, or 2B recommendation is considered medically necessary. Not Covered or Reimbursable Molecular testing for hematology and oncology indications is not covered or reimbursable if the criteria described above are not met. -------------------------------------------------------------------------------------------------------- Tumor Profile/Gene Expression Classifier Testing Medically Necessary Gene expression classifier testing (GEC) is considered medically necessary when ALL of the following criteria are met: Medical Coverage Policy: 0520 individual is a candidate for chemotherapy (i.e., chemotherapy not excluded due to other factors) adjuvant chemotherapy is being considered and this testing is being ordered to assess recurrence risk no other GEC has been performed on this tumor sample for the same indication and the associated criteria are met for ANY of the following indications: Test Name Cancer Type and Indication For a woman with anatomic stage I or stage 2 invasive breast cancer when ALL of the following criteria are met: MammaPrint® 70-Gene Breast Cancer Recurrence Assay (CPT code 81521) Tumor Grade Well differentiated Moderately differentiated Poorly differentiated or undifferentiated Nodes Tumor Size None 1-3 3.1-5 cm 2.1-5 cm None 1-3 2.1-5 cm Any size histologic type is ductal/No Special Type (NST), lobular, mixed (ductal/lobular), or micropapillary • high clinical risk of recurrence* estrogen receptor (ER)- positive/progesterone receptor (PR)- positive • human epidermal growth factor receptor 2 (HER2)-negative • up to three positive nodes None 1-3 1.1-5 cm Any size For recently diagnosed anatomic stage 1 or stage 2 infiltrating breast cancer when ALL of the following criteria are met: Oncotype DX® for Early- Stage, Invasive Breast Cancer Assay (CPT code 81519) histologic type is ductal/NST, lobular, mixed (ductal/lobular), or micropapillary • tumor size 0.6-1.0cm and intermediate or high grade (Grade 2 or 3) OR tumor size 1.1-5.0 cm any grade estrogen receptor positive and/or progesterone receptor positive • HER2 receptor negative • No evidence of distant metastasis • EITHER of the following criteria: millimeters) • HER2 receptor negative • No evidence of distant metastasis • EITHER of the following criteria: millimeters)  up to three positive axillary nodes in a post-menopausal woman or a man Prosigna® Breast Cancer Prognostic Gene Signature Assay (PAM50) (CPT Code 81520) EndoPredict® Risk Score (CPT code 81599) For recently diagnosed anatomic stage 1 or stage 2 breast cancer breast cancer when ALL of the following criteria are met: histologic type is ductal/NST, lobular, mixed (ductal/lobular), or micropapillary • tumor size 0.6-1.0cm and intermediate or high grade (Grade 2 or 3) OR tumor size 1.1-5.0cm any grade estrogen receptor positive and/or progesterone receptor positive • HER2 receptor negative • • No evidence of distant metastasis • Axillary node status is negative (micrometastasis is no greater than 2.0 mm) Postmenopausal Medical Coverage Policy: 0520 Test Name Cancer Type and Indication Breast Cancer Index (BCI) Risk of Recurrence and Extended Endocrine Benefit Test (CPT code 81518) Breast Cancer Index (BCI) Risk of Recurrence and Extended Endocrine Benefit Test (CPT code 81518) is considered medically necessary for a woman with early stage T1-T3 breast cancer diagnosed within the last five years when ALL of the following criteria are met: estrogen receptor (ER) positive • human epidermal growth factor receptor 2 (HER2) negative • no evidence of distant metastasis • EITHER of the following:  axillary node status is negative (micrometastasis no greater than 2.0 mm)  axillary node status is positive (LN+ with 1-3 positive nodes) no evidence of cancer at the time of testing • test results will be used to determine treatment management of the individual for extended endocrine therapy after completion of at least four years of endocrine therapy Experimental/Investigational/Unproven Gene expression testing for breast cancer is considered experimental, investigational or unproven if the criteria described above are not met. OncotypeDx Breast DCIS Score test is considered experimental, investigational or unproven. ------------------------------------------------------------------------------------------------------------- Proteomic Testing Proteomic testing is considered medically necessary when ALL of the following criteria are met: • results of testing will directly impact clinical decision making the testing method is considered to be scientifically valid and proven to have clinical utility based on prospective evidence testing has been validated by the National Comprehensive Cancer Network™ (NCCN Guidelines) as a category 1, 2A or 2B recommendation for the individual’s tumor type or disease disease-specific criteria are not described elsewhere in the Coverage Policy Medical Coverage Policy: 0520 Veristrat is considered medically necessary for advanced non-small cell lung cancer to determine second-line treatment when ALL of the following criteria are met: EGFR variant mutation status is wild-type (i.e., no pathogenic or likely pathogenic variant detected) or unknown individual has failed first-line systemic chemotherapy test results will be used to decide whether to proceed with erlotinib (Tarceva®) therapy • Proteomic testing is considered experimental, investigational or unproven if the criteria described above are not met. ------------------------------------------------------------------------------------------------------------- Circulating Tumor Cells Testing Medically Necessary AR-V7 testing from circulating tumor cells is considered medically necessary for a male with metastatic castrate resistant prostate cancer (mCRPC) considering second line therapy when BOTH of the following criteria are met: progression on androgen receptor–signaling inhibitor (ARSi) therapy (i.e., enzalutamide (Xtandi), abiraterone (Zytiga)) nuclear expression of AR-V7 will be assessed to guide subsequent therapeutic decision making Experimental, Investigational or Unproven Detection of circulating whole tumor cells for any other indication is considered experimental, investigational or unproven. ------------------------------------------------------------------------------------------------------------- Screening and Prognostic Tests for Early Detection of Prostate Cancer Medically Necessary The following prostate cancer screening and prognostic genetic tests are considered medically necessary for the early detection of prostate cancer when results will impact medical management and the associated criteria are met: Medical Coverage Policy: 0520 Name Cancer Type and Indication Percent free PSA Prostate Health Index (PHI) ™ PSA >3.0ng/mL When EITHER of the following criteria is met: ExoDX PSA >3.0 ng/mL with or without previous benign prostate biopsy • suspicious digital rectal exam (DRE) When BOTH of the following criteria are met: Progensa® PCA3 Assay PSA >3.0 ng/mL • previous benign prostate biopsy or focal high grade prostatic intraepithelial neoplasia (PIN) The miR Sentinel™ Prostate Cancer Test (CPT 0343U) (miR Scientific, LLC, New York, NY) for prostate cancer early detection prior to biopsy is not covered or reimbursable. mRNA gene expression profiling and algorithmic analysis (i.e., 12 genes) (CPT 0011M) to predict high-grade prostate cancer risk score is considered experimental, investigational or unproven. ------------------------------------------------------------------------------------------------------------- Tumor Tissue-Based Molecular and Proteomic Assays for Prostate Cancer Medically Necessary The following tumor-based assays for detection of prostate cancer are considered medically necessary when the associated criteria are met: Test Name Cancer Type and Indication ANY of the following: PSA persistence after radical prostatectomy (i.e., failure of PSA to fall to undetectable levels after radical prostatectomy) Decipher® Prostate Cancer Classifier Assay PSA recurrence after radical prostatectomy (i.e., undetectable PSA after radical prostatectomy with a subsequent detectable PSA that increases on two or more determinations Post-prostate biopsy when the individual is a candidate for active surveillance or definitive therapy for ANY of the following prostate cancer risk types:  low-risk*  favorable intermediate-risk*  unfavorable intermediate-risk*  high-risk* Prolaris® Prostate Cancer Test Post prostate biopsy when the individual is a candidate for active surveillance or definitive therapy for ANY of the following risk types: Medical Coverage Policy: 0520 Test Name Cancer Type and Indication OncotypeDX® Genomic Prostate Score  low-risk*  favorable intermediate-risk*  unfavorable intermediate-risk*  high-risk* ProMark® Proteomic Prognostic Test Post prostate biopsy for low risk* or favorable intermediate-risk* prostate cancer when the individual is a candidate for active surveillance or definitive therapy Low-risk: T1-T2a disease AND Gleason score ≤6/grade group 1 AND PSA <10ng/mL Favorable intermediate-risk: T2b-T2c disease OR Gleason score 3+4=7/grade group 2 OR PSA 10-20 ng/mL AND percentage of positive biopsy cores <50% Unfavorable intermediate-risk: One or more of the following: 2 or 3 intermediate risk factors, grade group 3, ≥50% biopsy cores positive (e.g., ≥6/12 cores) High-risk: no very-high-risk features and has exactly one high-risk feature:• cT3a OR• Grade Group 4 or Grade Group 5 OR• PSA >20 ng/mL Not Medically Necessary Tumor-based molecular assays for prostate cancer are considered not medically necessary if the criteria described above are not met. ------------------------------------------------------------------------------------------------------------- ----------------------------------------------- Myeloproliferative Neoplasms Medically Necessary Polycythemia Vera (PV) Genetic testing for JAK2 common variants (CPT code 81270, 81279), MPL common variants (CPT code 81338, 81339), and CALR exon 9 common variants (CPT code 81219) is considered medically necessary for the diagnosis of polycythemia vera (PV) when BOTH of the following criteria are met: genetic testing would impact medical management of the individual being tested • ONE of the following:  hemoglobin >16.5 g/dL in men, >16.0 g/dL in women  hematocrit >49% in men, >48% in women  increased red cell mass (RCM) more than 25% above mean normal predicted value ------------------------------------------------------------------------------------------------------------- Essential Thrombocythemia Genetic testing for JAK2 common variants (CPT code 81270, 81279), MPL common variants (CPT code 81338, 81339), and CALR exon 9 common variants (CPT code Medical Coverage Policy: 0520 81219) is considered medically necessary for the diagnosis of essential thrombocythemia or thrombocytosis (ET) when BOTH of the following criteria are met: results will impact medical management • EITHER of the following criteria are met:  platelet count ≥ 450 x 10^9/L  bone marrow biopsy showing proliferation mainly of the megakaryocyte lineage with increased numbers of enlarged, mature megakaryocytes with hyperlobulated nuclei. No significant increase or left shift in neutrophil granulopoiesis or erythropoiesis and very rarely minor (grade 1) increase in reticulin fibers ------------------------------------------------------------------------------------------------------------- Primary Myelofibrosis (PMF) Genetic testing for JAK2 common variants (CPT code 81270, 81279), MPL common variants (CPT code 81338, 81339), and CALR exon 9 common variants (CPT code 81219) is considered medically necessary for the diagnosis of primary myelofibrosis (PMF) when BOTH of the following criteria are met: • primary myelofibrosis is suspected but not confirmed, based on results of conventional testing results will impact medical management ASXL1, EZH2, TET2, IDH1/IDH2, SRSF2, and SF3B1 testing is considered medically necessary for the diagnosis of primary myelofibrosis (PMF) when ALL of the following criteria are met: primary myelofibrosis is confirmed or suspected • based on clinical findings above criteria are met • • bone marrow findings of megakaryocytic proliferation and atypia, without reticulin fibrosis >grade 1, accompanied by increased age-adjusted bone marrow cellularity, granulocytic proliferation, and often, decreased erythropoiesis testing will be completed on bone marrow sample JAK2, CALR and MPL mutation analysis was previously completed and was negative results will impact medical management. ------------------------------------------------------------------------------------------------------------- Chronic Myelogenous Leukemia (CML) and Philadelphia Chromosome Positive (PH+) Acute Lymphoblastic Leukemia (ALL) BCR-ABL T315-I mutation testing (81401, 81170) is considered medically necessary in individuals with chronic myelogenous leukemia (CML) or Philadelphia chromosome positive (Ph+) acute lymphoblastic leukemia (ALL) when ANY of the following are met: inadequate initial response to tyrosine kinase inhibitor therapy (i.e., failure to achieve complete hematological response at 3 months, minimal cytogenetic response at 6 months or major cytogenetic response at 12 months) loss of response to tyrosine kinase inhibitor therapy (i.e., hematologic relapse, cytogenetic relapse, loss of major molecular response [MMR]) Medical Coverage Policy: 0520 progression to accelerated or blast phase CML while on tyrosine kinase inhibitor therapy ------------------------------------------------------------------------------------------------------------- Occult Neoplasms Medically Necessary The following paraneoplastic (onconeural) antibodies are considered medically necessary for the evaluation of neurological symptoms when the diagnosis remains uncertain following conventional work-up and an occult neoplasm is suspected: anti-Hu (ANNA-1 [antineuronal nuclear autoantibodies-1]) ● anti-Yo (PCA-1 [Purkinje cell antibody-1]) ● anti-CV2 (CRMP5 [collapsing mediator response protein5]) ● anti-Ri (ANNA-2) ● anti-MA2 (Ta) ------------------------------------------------------------------------------------------------------------- Other Tumor Profile Testing Experimental/Investigational/Unproven Topographic genotyping for any indication is considered experimental, investigational or unproven. Adhesive patch gene expression assay for pigmented skin lesions is considered experimental, investigational or unproven. General Background For additional information regarding specific genetic tests please refer to the Genetic Testing Collateral: Molecular Tests and Biomarkers. General Criteria for Somatic Mutation Genetic Testing Somatic mutations are changes in the DNA of a cell that may occur in any cell of the body except the germ cells (i.e., egg and sperm). Somatic mutations differ from germline mutations, which are passed down by blood relatives; somatic mutations are not inherited. The genetic tests described in this Coverage Policy are used to identify disease-causing somatic mutations or the biological activity of genes originating in a tumor or hematologic malignancy. Tumor markers, also known as biomarkers, are substances that are produced by certain cells of the body in response to cancer or some noncancerous conditions. Although most tumor markers are made by normal cells as well as by cancer cells, they are produced at much higher levels in cancerous conditions. They can be found in the blood, urine, stool, tumor tissue, or other tissues or bodily fluids of some patients with cancer (National Cancer Institute [NCI], 2022. Tumor marker levels may be useful in determining the extent or stage of disease or recurrence, determining the most effective treatment for a specific disease and how well the disease will respond to treatment. Medical Coverage Policy: 0520 Published peer-reviewed evidence and professional society/organizational consensus guidelines support testing for certain tumor markers for the screening, staging, diagnosis and management of some types of cancer. However, for other tumor markers there is insufficient evidence to establish clinical utility for informing on improvement of health outcomes. To have clinical utility the specific gene or gene biomarker for which testing has been requested, or gene expression classifier assay should be demonstrated in the published, peer-reviewed scientific literature in the form of prospective clinical trial data to improve the diagnosis, management, or clinical outcomes for the individual’s tumor type or disease when the individual is a candidate for a related therapy. The identification of the gene or biomarker should also be required to initiate a related therapy that has been validated by the NCCN as a Category 1, 2A or 2B Level of Evidence and Consensus recommendation as a standard of care. The NCCN recommendations are defined as: Category 1: Based upon high-level evidence there is uniform NCCN consensus that the intervention is appropriate, Category 2A: Based upon lower-level evidence there is uniform NCCN consensus that the intervention is appropriate, Category 2B: Based upon lower-level evidence there is NCCN consensus that the intervention is appropriate and Category 3: Based upon any level of evidence, there is major NCCN disagreement that the intervention is appropriate. Multigene panels may also provide important information regarding an individual’s tumor type to direct proven therapy or support management changes for hematology-oncology indications. These tests may be clinically useful when sequential testing of individual genes or biomarkers is not feasible because of limited tissue availability, or when urgent treatment decisions are pending and sequential testing would result in a prolonged testing schedule. There is insufficient evidence in the published, peer-reviewed scientific literature to support molecular testing when the requested gene(s) or biomarker(s) is(are) correlated with a known therapy, but that therapy has not been validated in prospective clinical trials for the specific tumor type or disease site. Broad Molecular Profile Testing Broad molecular profile tests, also known as molecular profiling and comprehensive genome profiling panels are large multigene tests which assess multiple genetic alterations simultaneously in a solid tumor. Several laboratory methods may be used to assess the tumor; however, next generation sequencing techniques are most commonly used. Broad molecular tests can identify alterations to base substitutions (substitution of an amino acid), insertions and deletions (amino acids are added or removed from DNA), copy number alterations (sections of DNA are repeated) and rearrangements (amino acids are rearranged in a different order). Broad molecular profile testing may be used with the goal of identifying mutations of interest for which drug therapy may be available or for enrollment in a clinical trial. Limitations to testing include testing for more alterations than have been identified for a specific type of cancer and the identification of variations of unknown significance. Nonetheless, such testing is supported by published professional society guidelines, including from the NCCN as a key component of care for a number of advanced, metastatic, refractory and recurrent cancers. Biopsy Testing Methods A biopsy is used as a diagnostic and monitoring tool to identify abnormalities in tissue or blood. A traditional tissue biopsy is used to sample and analyze a solid biological specimen. Tissue biopsy remains the gold standard for the confirmation and diagnosis of disease, including various Medical Coverage Policy: 0520 cancers. Limitations include patient risk due the invasive nature of the test and limited availability of the tissue sample. There is increasing use of plasma cell-free DNA testing, also known as a liquid biopsy, which is used to sample and analyze nucleic acids in peripheral circulation, most commonly in plasma. At present there are no standards for analytical performance and no guidelines exist for regarding the recommended performance characteristics. Cell-free DNA testing has a high specificity rate but limitations include a compromised sensitivity with up to a 30% false-negative rate. Such testing may also identify alterations that are unrelated to a lesion of interest. Nonetheless, the use of cell-free DNA testing may be considered appropriate when a patient is medically unfit for invasive tissue sampling or there is insufficient material for analysis in advanced (III or IV), metastatic, recurrent or refractory solid cancers. Testing for Minimal Residual Disease Minimal residual disease refers to the presence of leukemic cells below the threshold of detection by conventional morphologic methods. Patients who achieve complete response by morphologic assessment alone can harbor leukemic cells in the bone marrow. Methods frequently utilized include a multiparameter (i.e., at least 6-color) flow cytometry to detect abnormal phenotypes, real-time quantitative polymerase chain reaction (RQ-PCT) assays to detect fusion genes and high-throughput next generation sequencing (NGS)-based assays to detect clonal arrangements (NCCN, 2022). An assay for minimal residual disease by high throughput sequencing methods is currently recommended as clinically useful for multiple myeloma, B-cell acute lymphoblastic leukemia, chronic lymphoblastic leukemia and peripheral and cutaneous T-cell lymphoma (NCCN, 2023; 2022; 2023; 2023). U.S. Food and Drug Administration (FDA) FDA approval is not required for the development or marketing of specific gene tumor markers profiling tests, multigene panel tests or gene classifier tests. Many high-complexity tests are laboratory-developed in a Clinical Laboratory Improvement Amendment (CLIA)-certified laboratory. However, a number of devices with reagents that are used to “qualitatively or quantitatively measure, by immunochemical techniques, tumor-associated antigens in serum, plasma, urine, or other body fluids” and intended as an aid in monitoring patients for disease progress or response to therapy or for the detection of recurrent or residual disease” are approved by the FDA 510(k) process (FDA, 2009). Tumor Profile/Gene Expression Classifier Testing Gene expression classifier assays identify genetic alterations or biological activity of several genes in a tumor. Such tests may provide a more complete picture of a tumor’s molecular signature and enable a better estimate of the risk of distant recurrence when considered along with other molecular signatures and clinical characteristics (Marrone, 2014). They have been proposed as an adjuvant tool to assist in determining overall survival (OS), recurrence probability, appropriate treatment options and responsiveness to chemotherapy and are not advocated as stand-alone tools. Numerous gene profiling assays are currently marketed for use in the U.S.. Breast Cancer Index (BCI) Risk of Recurrence & Extended Endocrine Benefit Test BCI (BioTheranostics, Inc, San Diego, CA) is a quantitative molecular assessment of estrogen signaling pathways. According to the manufacturer, BCI is intended for use in an individual diagnosed with estrogen receptor-positive (ER+), lymph node-negative (LN-) or lymph node positive (LN+; with 1-3 positive nodes) early-stage, invasive breast cancer, who are distant recurrence-free. BCI provides a quantitative assessment of the likelihood of both late (post-5 Medical Coverage Policy: 0520 years) and overall (0-10 year) distant recurrence following an initial 5 years of endocrine therapy (LN- patients) or 5 years of endocrine therapy plus adjuvant chemotherapy (LN+ patients), and prediction of likelihood of benefit from extended (>5 year) endocrine therapy. BCI results require correlation with other clinical findings. The NCCN (2023) notes BCI is predictive of benefit of extended adjuvant endocrine therapy and is also prognostic for an individual with node negative or node positive breast cancer. (Category of Evidence 2A). U.S. Food and Drug Administration (FDA) BCI has not received U.S. Food and Drug Administration (FDA) approval. EndoPredict Risk Score According to the manufacturer, the EndoPredict Risk Score (Myriad Genetics Laboratory, Inc., Salt Lake City, UT), is a 12 gene next-generation breast cancer recurrence test that integrates biology and pathology to accurately predict early and late (5-15 years) recurrence with an individualized absolute chemotherapy benefit. The test is intended for use for patients diagnosed with ER+, HER2− early-stage breast cancer with either node-negative or node-positive disease (1- 3 nodes). The NCCN (2019) notes that EndoPredict is a prognostic assay for consideration for addition of adjuvant systemic chemotherapy to adjuvant endocrine therapy; however, predictive value has not yet been determined (Category of Evidence 2A). The NCCN (2023) noted EndoPredict is a prognostic assay; however, predictive value has not yet been determined (Category of Evidence 2A). U.S. Food and Drug Administration (FDA) EndoPredict has not received U.S. FDA approval. MammaPrint® 70-Gene Breast Cancer Recurrence Assay The MammaPrint® 70-Gene Breast Cancer Recurrence Assay (Agendia, Inc. USA, Irvine, CA) utilizes a deoxyribonucleic acid (DNA) microarray assay to perform 70-gene profiling of breast cancer tissue to assess risk of recurrence. The assay is designed to determine the expression of specific genes in a tissue sample. The result is an expression profile, or “fingerprint”, of the sample. The MammaPrint Index is calculated from fresh, frozen or formalin-fixed paraffin embedded (FFPE) breast cancer tissue and the molecular prognosis profile of the sample is determined (i.e., Low Risk, High Risk) (FDA, 2015). The test has been validated in an individual being considered for adjuvant systemic therapy with Stage I or Stage 2 invasive breast cancer who has estrogen receptor (ER) positive/progesterone receptor (PR) positive, human epidermal growth factor receptor 2 (HER2)-negative disease, and up to three positive lymph nodes, when there is a high clinical risk of recurrence: Tumor Grade Well differentiated Nodes Tumor Size None 1-3 3.1-5 cm 2.1-5 cm Moderately differentiated None 1-3 2.1-5 cm Any size Poorly differentiated or undifferentiated None 1-3 1.1-5 cm Any size The NCCN (2023) notes that Mammoprint is a prognostic assay for consideration for addition of adjuvant systemic chemotherapy to adjuvant endocrine therapy; however, predictive value has not yet been determined (Category of Evidence 2A). There is consensus support in the form of Medical Coverage Policy: 0520 published guidelines by the American Society of Clinical Oncology ([ASCO], 2017) for the use of MammaPrint to inform decisions on withholding adjuvant systemic chemotherapy due to its ability to identify a good prognosis population with potentially limited chemotherapy benefit. U.S. Food and Drug Administration (FDA) MammaPrint® 70-Gene Breast Cancer Recurrence Assay (Agendia, Inc. USA, Irvine, CA) received a 510K approval for an individual with Stage I or Stage II lymph node negative breast cancer with a tumor size ≤ 5.0 cm. According to the FDA approval summary, MammaPrint FFPE is not indicated as a standalone test to determine the outcome of disease, nor to suggest or infer an individual’s likely response to therapy. Results should be taken in the context of other relevant clinicopathological factors and standard practice of medicine (2015). Oncotype DX® for Early-Stage, Invasive Breast Cancer Assay According to the manufacturer (Genomic Health, Inc., Redwood City, CA), this test is recommended for use after the original breast cancer surgery and is proposed for a newly diagnosed individual with node-negative or node-positive, ER-positive, HER2-negative invasive breast cancer. The purpose of the Oncotype DX Breast Cancer Assay is to quantify the likelihood of distant recurrence (i.e., within 10 years) in a woman or a man with breast cancer, and is used as one factor in determining whether or not a patient is a candidate for chemotherapy. This assay is not proposed for or used as a test to monitor the response of a specific chemotherapy drug. Using tumor tissue, ribonucleic acid (RNA) is extracted, purified and analyzed for expression of a panel of 21 genes using quantitative reverse transcription polymerase chain reaction (RT-PCR) on formalin-fixed, paraffin-embedded (FFPE) tumor tissue. A Recurrence Score™ (RS) is calculated from the gene expression results using a proprietary Oncotype DX algorithm. The RS is based on a scale of 0–100. A score of less than 18 is considered low-risk; 18-31 is intermediate-risk; and a score over 31 is designated as high-risk. Each RS correlates with a specific likelihood of distant recurrence at 10 years. This test is recommended by the American Society of Clinical Oncology (ASCO) (2016) and NCCN (2023) for use in a select population of women with breast cancer. NCCN notes OncotypeDx is both a predictive and prognostic assay for consideration of addition of adjuvant systemic chemotherapy to adjuvant endocrine therapy for node negative disease (Category of Evidence 1). For node positive disease NCCN notes the test is prognostic but predictive value has not yet been determined (Category of Evidence 2A). US Food and Drug Administration (FDA) Oncotype DX has not received U.S. Food and Drug Administration (FDA) approval. The assay is performed in the licensed Genomic Health laboratory where the assay was developed. Prosigna® Breast Cancer Prognostic Gene Signature Assay: Prosigna® (NanoString Technologies, Seattle, WA) is an in vitro diagnostic assay which is performed on the NanoString nCounter® Dx Analysis System using formalin-fixed paraffin embedded (FFPE) breast tumor tissue previously diagnosed as invasive breast carcinoma. It is designed to identify intrinsic breast cancer subtypes (i.e., luminal A/B, HER2 enriched, basal like) and generate a Risk of Recurrence (ROR) score, expressed as a numerical value (0-100 scale) which correlates with the probability of distant recurrence within 10 years. The Prosigna Risk of Recurrence (ROR) score is generated by Prediction Analysis of Microarray (PAM50) proprietary algorithm (NanoString Technologies, 2014- 2019). The NCCN (2023) notes that Prosigna is a prognostic assay for consideration of the addition of adjuvant systemic chemotherapy to adjuvant endocrine therapy. The predictive value has not yet been determined (Category of Evidence 2A). Medical Coverage Policy: 0520 U.S. Food and Drug Administration (FDA) Prosigna received FDA 501K approval in September, 2013. According to the FDA, the Prosigna Breast Cancer Prognostic Gene Signature Assay is indicated in female breast cancer patients who have undergone surgery in conjunction with locoregional treatment consistent with standard of care, either as: A prognostic indicator for distant recurrence-free survival at 10 years in postmenopausal women with Hormone Receptor-Positive (HR+), lymph node-negative, Stage I or 11 breast cancer to be treated with adjuvant endocrine therapy alone, when used in conjunction with other clinicopathological factors. A prognostic indicator for distant recurrence-free survival at 10 years in postmenopausal women with Hormone Receptor-Positive (HR+), lymph node-positive (1-3 positive nodes), Stage 11 breast cancer to be treated with adjuvant endocrine therapy alone, when used in conjunction with other clinicopathological factors. Prosigna is not intended for diagnosis, to predict or detect response to therapy, or to help select the optimal therapy for patients. The device is not intended for patients with four or more positive nodes. The role of Prosigna for women with node positive disease has not yet been established. Proteomic Testing Proteomics involves the quantitative and qualitative study of proteins, including the function, composition and structure and the way they interact inside cells. Protein expression may be changed by environmental conditions. Proteomics can identify and monitor biomarkers by analyzing the proteins in body fluids such as urine, serum, exhaled breath and spinal fluid. Proteomics can also facilitate drug development by providing a comprehensive map of protein interactions associated with disease pathways. A proteomic profile may be used to find and diagnose a disease or condition and to see how well the body responds to treatment (National Cancer Institute [NCI], 2023. To be clinically useful the testing method must be scientifically and clinically validated and proven to have clinical utility based on prospective evidence, testing must be validated by the National Comprehensive Cancer Network™ (NCCN Guidelines) as a category 1, 2A or 2B recommendation for the individual’s tumor type or disease and results of testing must directly impact clinical decision making. VeriStrat® VeriStrat® (Biodesix, Boulder, CO) is not an EGFR mutation test. It is a serum protein analysis for advanced non-small cell lung cancer (NSCLC) and has been proposed as a means to identify individuals who should receive treatment with erlotinib (Tarceva®, Genentech, San Francisco, CA), an epidermal growth factor inhibitor (EGFRI). According to the Biodesix website, the test stratifies individuals who are likely to have good or poor outcomes with EGFRI treatment (2015). The analysis utilizes matrix-assisted laser desorption/ionization mass spectrometry to analyze serum for eight discriminating features. The test has an established prediction algorithm which was validated in two separate populations. Classifications based on spectra acquired at the two institutions had a concordance of 97.1%. (Taguchi, 2007). According to the manufacturer, results are predictive of outcomes, independent of ECOG performance status, PD-L1 expression, mutation status, and treatment choice. Proteomic Testing Medical Coverage Policy: 0520 The clinical utility of VeriStrat has been validated in both retrospective and prospective trials as a means to identify an individual who should receive treatment with erlotinib (Tarceva®, Genentech, San Francisco, CA), an epidermal growth factor inhibitor (EGFRI). US Food and Drug Administration VeriStrat has not received U.S. Food and Drug Administration (FDA) approval. Literature Review The clinical utility of VeriStrat is supported by prospective and retrospective clinical trial evidence in the published, peer-review scientific literature. The utility of VeriStrat as compared to standard KRAS and EGFR mutation analysis was performed on 102 samples by Amann et al (2010). VeriStrat classification identified 64 of 88 (73%) as predicted to have “good” and 24 of 88 (27%) predicted to have “poor” outcomes. Statistically significant correlation to VeriStrat status and clinical survival outcome was demonstrated (p<0.001). Cost utility analysis of applying VeriStrat to guide treatment for NSCLC patients was compared to all patients receiving treatment with EGFRI, all patients receiving chemotherapy; and treatment determined by performance status. Patients where treatment was guided by VeriStrat showed the second best survival outcome (9.6 months) when compared to chemotherapy only (10.1 months);Performance status indicated (9.2 months) and EGFRI only (8.2 months) (Nelson, 2013). Carbone et al. (2012) reported results of a retrospective analysis of 436 patient samples with NSCLC that were tested in patients treated with erlotinib and those on placebo. VeriStrat status was prognostic for overall survival and progression free survival, independent of clinical features (p=0.002); however, it was not predictive of differential survival from erlotinib over placebo (p=0.48). Similar results were found for progression-free survival. Data suggest a predictive effect of VeriStrat for response to erlotinib. Subsequent studies have also sought to determine the predictive value of VeriStrat testing. Sun et al (2014) conducted a meta-analysis of current relevant publications. Eleven cohorts involving 706 patients collected from seven studies were subjected to final analysis. The statistical analysis of these articles found that the test’s “good” status predicted better clinical outcome for overall and progression free survival (p<0.001 for both overall and progression-free survival). A blinded randomized clinical trial by Gregorc et al. (2014) analyzed data collected through PROSE, a biomarker-stratified randomized phase III trial of 285 patients with stage IIIB or IV NSCLC from 14 centers across Italy. The proteomic test classification was masked for patients and investigators who gave treatments, and treatment allocation was masked for investigators who generated the proteomic classification. The primary endpoint was overall survival and the primary hypothesis was the existence of a significant interaction between the serum protein test classification and treatment. A significant interaction between treatment and proteomic classification was noted. Patients who were classified as “poor” in regards to their serum protein test status (30% of participants) were more likely to have better outcomes on chemotherapy than on erlotinib (p=0.022). The data suggests that this subset of patients should not receive erlotinib. This supports the use of a multivariate serum protein test in predicting overall survival for erlotinib versus chemotherapy in second-line therapy. However, there was no difference in treatment observed for patients with the classification of “good” (p=0.714). Although the study demonstrates which patients will not benefit from treatment with erlotinib (“poor” status), additional studies are needed to determine the best treatment option for patients with “good” status. Medical Coverage Policy: 0520 Professional Societies/Organizations For a summary of professional society recommendations/guidelines regarding gene expression classifier tests please click here. Circulating Whole Tumor Cell Testing Circulating whole tumor cells (CTCs) have been found in the peripheral blood circulation of individuals with various forms of metastatic cancer. CTCs are whole cells that have been shed by the tumor. The detection and testing of these tumor cells has been proposed as a method to stratify risk, monitor progression and monitor response to treatment. The use of circulating whole tumor cell testing has not been proven to impact meaningful health outcomes for most cancers. There is limited evidence to establish the clinical significance of circulating whole tumor cells and how identification can improve health outcomes. Pilot studies suggest that the identification of whole tumor cells may have a role in risk stratification and monitoring responses to treatment. However, the National Comprehensive Cancer Network® (NCCN®) recommends testing for the androgen receptor splice variant 7 (AR-V7)(2022) in circulating tumor cells. Lack of response of men with metastatic castrate-resistant prostate cancer is associated with detection of this biomarker. NCCN notes that testing in circulating tumor cells can be considered to help guide selection of therapy considering second line therapy when there is progression on androgen receptor–signaling inhibitor (ARSi) therapy (2A: Based upon lower-level evidence there is uniform NCCN consensus that the intervention is appropriate). With the exception of testing for the AR-V7 variant in metastatic castrate-resistant prostate cancer the role of this testing in patient management is not yet known. Larger longitudinal studies with standard techniques in clearly-defined populations of patients are needed to establish the role of such testing. Literature Review Breast Cancer Smerage et al. (2014) reported on a randomized trial of patients with persistent increase in CTCs that were tested to determine whether changing chemotherapy after one cycle of first-line chemotherapy would improve the primary outcome of overall survival (OS). Five hundred ninety- five Female patients were included with histologically confirmed breast cancer and clinical and/or radiographic evidence of metastatic disease. Patients who underwent chemotherapy had evaluation for CTCs at baseline and then after one cycle. Women whose CTCs remained elevated after the first cycle of therapy (arm C) (n=123) were randomly assigned to either maintain the initial treatment plan (n=64) or to change of chemotherapy (n=59). Changing to an alternate regimen had no difference in OS compared with continuation of the initial regimen (median 12.5 versus 10.7 months, respectively, P= .98). The CTCs did appear to have prognostic value: the median OS for arms A, B, and C were 35 months, 23 months, and 13 months, respectively). While it appears that there is prognostic value of CTCs, the role in clinical management is has not been demonstrated. Zhang et al. (2012) reported on a meta-analysis of published literature on the prognostic relevance of CTC, including patients with early and advanced disease. Forty-nine eligible studies with 6,825 patients were identified. The main outcomes analyzed were overall survival (OS) and disease-free survival (DFS) in early-stage breast cancer patients, as well as progression-free survival (PFS) and OS in metastatic breast cancer patients. Pooled hazard ratio (HR) and 95% confidence intervals (CIs) were calculated using the random and the fixed-effects models. The presence of CTC was significantly associated with shorter survival in the total population. The Medical Coverage Policy: 0520 prognostic value of CTC was significant in both early (DFS: HR, 2.86; 95% CI, 2.19–3.75; OS: HR, 2.78; 95% CI, 2.22–3.48) and metastatic breast cancer (PFS: HR, 1.78; 95% CI, 1.52–2.09; OS: HR, 2.33; 95% CI, 2.09–2.60). Subgroup analyses showed that our results were stable irrespective of the CTC detection method and time point of blood withdrawal. The authors conclude that the meta-analysis indicates that the detection of CTC is a stable prognosticator in patients with early-stage and metastatic breast cancer; however further studies are required to explore the clinical utility of CTC in breast cancer. A prospective observational study that compared serum marker levels with CTC in 267 metastatic breast cancer patients (Bidard, et al., 2012). The secondary pre-planned endpoint a study that previously reported on CTC as prognostic factor (Pierga, et al., 2011), compared prospectively the positivity rates and the value of CTC (CellSearch), of serum tumor markers (carcinoembryonic antigen (CEA), cancer antigen 15.3 (CA 15-3), CYFRA 21-1), and of serum non-tumor markers (lactate dehydrogenase (LDH), alkaline phosphatase (ALP)) at baseline and under treatment for PFS prediction, independently from the other known prognostic factors, using univariate analyses and concordance indexes. The study reported that a total of 90% of the patients had at least one elevated blood marker. The blood markers were correlated with poor performance status, high number of metastatic sites and with each other. CYFRA 21-1, a marker usually used in lung cancer, was elevated in 65% of patients. A total of 86% of patients had either CA 15-3 and/or CYFRA 21-1 elevated at baseline. Each serum marker was associated, when elevated at baseline, with a significantly shorter PFS. Serum marker changes during treatment, assessed either between baseline and the third week or between baseline and weeks six-nine, were significantly associated with PFS, as reported for CTC. Concordance indexes comparison showed no clear superiority of any of the serum marker or CTC for PFS prediction. The authors concluded that for the purpose of PFS prediction by measuring blood marker changes during treatment, currently available blood-derived markers (CTC and serum markers) had globally similar performances. There was no clear superiority found of CTC over the other serum markers. Liu et al. (2009) conducted on a prospective study that examined the correlation of CTCs with radiographic findings for disease progression. Serial CTC levels were obtained in patients (n=68) that were starting a new treatment regimen for progressive, radiographically measurable metastatic breast cancer. Blood was collected at baseline and three to four week intervals and radiographic studies were performed in nine to twelve week intervals. Median follow-up was 13.3 months. Patients who had five or more CTCs had 6.3 times the odds of radiographic disease progression when compared with patients who had less than five CTCs. Shorter progression-fee survival was observed for patients with five or more CTCs at three to five weeks and at seven to nine weeks after the start of treatment. The CTC result was statistically significantly associated with disease progression for all patients (p<.001). The association was noted to remain strong in patients treated with either chemotherapy or endocrine therapy. Potential limitations of the study include that the study included patients receiving various lines and types of therapy. The subgroup analysis for CTC-imaging correlation was performed by including biologic agents with either chemotherapy or endocrine therapy—it was noted that each group was too small to be analyzed alone. Nole et al. (2007) conducted a prospective study to evaluate the prognostic significance of CTCs detection in advanced breast cancer patients. The study included 80 patients with inclusion criteria: women with histological diagnosis of breast cancer, evidence of metastatic disease from imaging studies, starting a new line of therapy and/or treated for the advanced disease with a maximum two lines of therapy. The CellSearch system was used to test for circulating tumor cell levels before starting a new treatment and after four, eight weeks and the first clinical evaluation and every two months thereafter. At baseline, 49 patients were found to have ≥ 5 CTCs. The baseline number of CTCs were associated with progression-free survival (hazard ratio [HR] 2.5; 95% confidence interval [CI] 1.2–5.4). The risk of progression for patients with CTCs ≥ 5 at the Medical Coverage Policy: 0520 last available blood draw was five times the risk of patients with 0–4 CTCs at the same time point (HR 5.3; 95% CI 2.8–10.4). At the last available blood draw, patients with rising or persistent CTCs ≥ 5 demonstrated a statistically significant higher risk of progression with respect to patients with CTCs < 5 at both blood draws (HR 6.4; 95% CI 2.8–14.6). The authors noted that these results indicate that elevated CTCs levels measured at any time in the clinical course of a patient with metastatic breast cancer predict an imminent progression and that this analysis represents an additional step in the process of validating this method. There are still unanswered questions regarding the treatment of a patient with low or high levels of CTCs in breast cancer. Prostate Cancer Folkersma et al. (2012) reported on a prospective study that analyzed the correlation between circulating tumor cell (CTC) levels and clinicopathologic parameters (prostate-specific antigen [PSA] level, Gleason score, and TNM stage) in patients with metastatic hormone-sensitive prostate cancer (PCa) and to establish its prognostic value in overall survival (OS) and progression-free survival (PFS). The study included three arms: 30 patients with localized PCa; 30 patients with metastatic PCa; and, 30 healthy volunteers. The median follow-up was 42.9 months. A significant positive correlation was demonstrated between the CTC level and all tumor burden markers (PSA and T, N, and M stage; P<.001), except for Gleason score (tau=0.16). A cutoff of ≥4 CTCs/7.5 mL was chosen to distinguish patients with a poor prognosis. These patients had a significantly shorter median OS and PFS (24 compared to 45 months and 7 compared to 44 months, respectively; P<.001). As the CTC level increased, the OS and PFS were noted to decrease. The risk of mortality and progression for the patients with ≥4 CTCs was 4.1 (P=.029) and 8.5 (P<.001) times greater. Multivariate analyses indicated that a CTC of ≥4 was an independent prognostic factor for PFS (hazard ratio 5.9, P<.005). Several observational studies have been published that correlate CTC with disease status and progression in prostate cancer (Goodman, et al. 2009; Okegawa, et al., 2009; Okegawa, et al., 2008; Scher, et al., 2009; Olmos, et al., 2009; Danila, et al., 2007; and Shaffer, et al., 2007; Moreno, et al., 2005). Colorectal Cancer Groot Koerkamp et al. (2013) reported on systematic review of studies that investigated the prognostic value of tumor cells in blood (CTCs) or bone marrow (BM) (disseminated tumor cells [DTC]) of patients with resectable colorectal liver metastases or widespread metastatic colorectal cancer (CRC). A total of 16 studies with 1,491 patients were included in the review and the results of 12 studies (1,329 patients) included in the meta-analysis. Eight studies used RT-PCR methodology to detect tumor cells, nine studies applied immunocytochemistry (five with CellSearch) and one study applied both methods. The overall survival (hazard ratio [HR], 2.47; 95 % CI 1.74–3.51) and progression-free survival (PFS) (HR, 2.07; 95 % CI 1.44–2.98) were worse in patients with CTCs. The subgroup of studies with more than 35% CTC-positive patients was the only subgroup with a statistically significant worse PFS. The eight studies that had multivariable analysis identified the detection of CTCs as an independent prognostic factor for survival. Limitations of the study included a considerable degree of interstudy heterogeneity. The study does not demonstrate the clinical utility of CTC detection, or that the detection of CTCs is a predictive factor, or identify patients that may benefit from a specific treatment. Further studies are needed to investigate the clinical utility of detection of CTCs in metastatic colorectal cancer. Sastre et al. (2012) reported on an ancillary study of 180 patients that was a subset of a phase III study (The Maintenance in Colorectal Cancer trial) that assessed maintenance therapy with single- agent bevacizumab versus bevacizumab plus chemotherapy in patients with metastatic colorectal cancer. The ancillary study was conducted to evaluate CTC count as a prognostic and/or predictive marker for efficacy endpoints. Blood samples were obtained at baseline and after three cycles. Medical Coverage Policy: 0520 CTC enumeration was performed with CellSearch System. The study found that the median progression-free survival (PFS) interval for patients with a CTC count ≥3 at baseline was 7.8 months, as compared to 12.0 months found in patients with a CTC count <3 (p=.0002). The median overall survival (OS) time was 17.7 months for patients with a CTC count >3, compared with 25.1 months for patients with a lower count (p=.0059). After three cycles, the median PFS interval for patients with a low CTC count was 10.8 months, which was noted to be longer than the 7.5 months for patients with a high CTC count (p=.005). The median OS time for patients with a CTC count <3 was significantly longer than for patients with a CTC count ≥3, 25.1 months compared to 16.2 months, respectively (p=.0095). Further studies are needed to identify the role of CTC in treatment of metastatic colorectal cancer. Thorsteinsson et al. (2011) conducted a review of studies of CTCs in colorectal cancer (CRC). Nine studies were included in the review. Detection rates of CTC in peripheral blood of patients with non-metastatic CRC varied from 4% to 57%. Inclusion criteria included: patients diagnosed with non-metastatic colorectal cancer; CTC detected in peripheral blood samples; pre- and/or post- operative blood samples; and, samples size of more than 99 patients. Seven studies applied RT- PCR and two studies used immunocytochemical methods. Seven studies found the presence of CTC to be a prognostic marker of poor disease-free survival. The authors concluded that the presence of CTC in peripheral blood is a potential marker of poor disease-free survival in patients with non-metastatic CRC and that the low abundance of CTC in non-metastatic CRC needs very sensitive and specific detection methods. They also noted that an international consensus on choice of detection method and markers is warranted before incorporating CTC into risk stratification in the clinical setting. Rahbari et al. (2010) reported on a meta-analysis of studies to assess whether the detection of tumor cells in blood and bone marrow of patients diagnosed with colorectal cancer (CRC) can be used as a prognostic factor. Thirty-six studies were included in the review that examined the detection of free blood or bone marrow tumor cells with patients prognosis and included various methods of techniques (e.g., reverse transcriptase-PCR [RT-PCR]) and immunologic). The review indicated that the presence of CTCs detected in peripheral blood is of strong prognostic significance in patients with CRC. There was considerable interstudy heterogeneity noted in regards to differences in the detection methods, types and numbers of target genets or antigens, sampling site and time, and in demographic or clinicopathologic status of patients. Professional Societies/Organizations For a summary of professional society recommendations/guidelines regarding circulating tumor cells please click here. Screening and Prognostic Tests for Early Detection of Prostate Cancer Prostate specific antigen (PSA), an organ-specific marker, is often used as a tumor marker. The higher the level of PSA at baseline, the higher is the risk for metastatic disease or subsequent disease progression. However, it is an imprecise marker of risk. Various approaches aimed at improving the performance of PSA in early cancer detection have been tested, including the measurement of prostate biomarkers. None are clearly more accurate than total serum PSA levels (National Cancer Institute [NCI], 2023). According to the National Comprehensive Cancer Network Guideline (NCCN Guidelines™) for Prostate Cancer Early Detection (2023), tests that have been shown to increase specificity in the post-biopsy state are percent free PSA (%fPSA), 4Kscore (OPKO Health, Inc., Miami, FL), Prostate Health Index (PHI), (Beckman Coulter, Atlanta, GA) , prostate cancer gene 3 (PCA3, Progensa® PCA3, Gen-Probe, Inc., San Diego, CA), ConfirmMDx for Medical Coverage Policy: 0520 Prostate Cancer (MDX Health, Irvine, CA), Select MDx (MDx Health, Irvine, CA) and the ExoDx (Bio-Techne, Waltham, MA) tests. The NCCN also notes that biomarkers that improve the specificity of detection are for use in those individuals who wish to further define the probability of high-grade cancer. Improved specificity post biopsy has been demonstrated in the published-peer-reviewed scientific literature. The 4Kscore, percent free PSA, Prostate Health Index (PHI), Select MDx and ExoDx tests are considered clinically useful when results of the tests will impact management and there is a PSA >3 ng/mL with or without a previous benign biopsy and a suspicious digital rectal exam. Along with the 4K Score test, %free PSA and Prostate Health Index, Progensa PCA3, ConfirmMDx tests may be clinically useful when results of testing will impact management, the PSA >3 ng/mL and previous biopsy results are benign or indicate focal high-grade prostatic intraepithelial neoplasia (PIN). The role of these tests for any other indication or clinical scenario has not been established. Percent Free PSA (% free PSA): Serum PSA exists in both free form and complexed to a number of protease inhibitors. Assays for total PSA measure both free and complexed forms. Percent-free PSA may be related to biologic activity of the tumor. The NCCN (2023) notes that unbound or free PSA, expressed as a ratio of total PSA is clinically useful with the potential to improve early detection, staging and monitoring of prostate cancer. According to the NCCN, this test has received widespread clinical acceptance, specifically for patients with suspicious digital rectal exams who have previously undergone prostate biopsy because they had a total PSA (tPSA) level within the diagnostic gray zone. % free PSA may also be clinically useful to detect prostate cancer when the PSA is >3.0 ng/mL and a previous biopsy is benign or reflects PIN. 4Kscore: This test combines four prostate-specific kallikrein assay results with clinical information in an algorithm that calculates the individual patient’s percent risk for aggressive prostate cancer. It also considers age, digital rectal exam results and prior biopsy status. According to the manufacturer’s website, the 4Kscore is not indicated for men who have a diagnosis of prostate cancer, are taking or have taken 5-alpha reductase inhibitors within the last 6 months or have recently undergone a prostate procedure within the last 6 months. This test is a laboratory developed test and is not FDA approved. According to the NCCN Guidelines™ (2023), the test can be considered for patients prior to biopsy and for those with prior negative biopsy for those thought to be at higher risk for clinically significant prostate cancer, such as an individual with a suspicious digital rectal exam. No cut-off threshold has been established for the 4Kscore. The 4K Score test may also be clinically useful to detect prostate cancer when the PSA is >3.0 ng/mL and a previous biopsy is benign or reflects PIN. ConfirmMDx® for Prostate Cancer: This test is a tissue-based epigenetic assay which aids in the stratification of men being considered for repeat prostate biopsy. The test uses DNA methylation to assess the presence of cancer biomarkers (i.e., GSTP1, APC, RASSF1) in core biopsy tissue samples. ConfirmMDx is a laboratory developed test and is not FDA approved. ExoDx: According to the manufacturer, this test is a urine-based, liquid biopsy test indicated for men 50 years of age and older with a prostate-specific antigen (PSA) 2-10ng/mL, or PSA in the “gray zone”, considering an initial biopsy. The ExoDx Prostate test returns a risk score that Medical Coverage Policy: 0520 determines a patient’s risk of clinically significant prostate cancer (Gleason Score ≥7) on prostate biopsy. A score above the validated cut-point of 15.6 is associated with an increased likelihood of GS≥7 PCa on a biopsy and a score below the cut-point of 15.6 is associated with a decreased likelihood of GS≥7 PCa. NCCN Guidelines (2023) note this test may be clinically useful if the individual has a PSA >3.0 ng/mL with or without previous benign prostate biopsy and a suspicious DRE result. Progensa® PCA3: Progensa PCA3 is an in vitro nucleic acid amplification test. The assay measures the concentration of prostate cancer gene 3 (PCA3) and prostate-specific antigen (PSA) RNA (RNA) molecules and calculates the ratio of PCA3 RNA molecules to PSA RNA molecules (PCA3 Score) in post digital rectal exam (DRE) first catch male urine specimens. U.S. Food and Drug Administration (FDA): According to the U.S. Food and Drug Administration ([FDA], 2012) it is intended for use in conjunction with other patient information to aid in the decision for repeat biopsy in men 50 years of age or older who have had one or more previous negative prostate biopsies and for whom a repeat biopsy would be recommended by a urologist based on current standard of care, before consideration of Progensa PCA3 Assay results. Prostate Health Index (PHI)™: This test is a combination of existing tests (Access Hybritech PSA, Access Hybritech free PSA, and Access Hybritech p2PSA, Beckman Coulter, Atlanta, GA) for total PSA, free PSA and proPSA. According to the manufacturer’s website, a proprietary algorithm provides a probability of prostate cancer. PHI results are intended to be used as an aid in distinguishing prostate cancer from benign prostatic conditions in men 50 years of age and older with total PSA results in the 4 – 10 ng/mL range and suspicious digital rectal examination (DRE) findings. The three assays that make up this test have received FDA approval with numerous supplements. The NCCN (2023) also notes this test may be clinically useful to detect prostate cancer when the PSA is >3.0 ng/mL and a previous biopsy is benign or reflects PIN. Select MDx: According to the manufacturer website, this test is a non-invasive urine test (“liquid biopsy”). SelectMDx measures the expression of two mRNA cancer-related biomarkers (HOXC6 and DLX1). The test provides binary results that, when combined with the patient’s clinical risk factors, help the physician determine whether the patient may benefit from a biopsy or can return to routine screening. NCCN (2023) notes this test may be clinically useful if the individual has a PSA >3.0 ng/mL with or without previous benign prostate biopsy and a suspicious DRE result. Professional Society/Organizations Each of these tests is specifically mentioned in the NCCN Guideline for Prostate Cancer Early Detection as a category 2A recommendation. For additional information regarding professional society recommendations please click here. Tumor Tissue-Based Molecular and Proteomic Assays for Detection of Prostate Cancer The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines™) for Prostate Cancer (2022) notes that although risk groups, life expectancy estimates and nomograms help inform treatment decisions, there remains uncertainty regarding the risk of disease progression. Several tumor tissue-based molecular assays have been included in the guideline for prostate cancer (2022). The Medical Coverage Policy: 0520 guideline notes that men with low or favorable intermediate risk may consider the use of certain molecular tests (i.e., Decipher®, OncotypeDx Genomic Prostate Score©, Prolaris® Prostate Cancer Test, ProMark Proteomic Prostate Test), which are briefly reviewed in this section of the Coverage Policy. Although these tests have not been validated by prospective, randomized clinical trial data, retrospective case cohort studies demonstrate that these tests provide prognostic information independent of NCCN risk groups for men with low or favorable intermediate risk disease, including likelihood of death with conservative management, likelihood of biochemical recurrence after radical prostatectomy or radiotherapy and likelihood of developing metastasis after operation or salvage radiotherapy (NCCN, 2019). Decipher® Prostate Cancer Classifier Assay (GenomeDx, San Diego, CA): This test is a 22 biomarker genomic expression classifier assay which uses formalin-fixed paraffin embedded (FFPE) tissue from a radical prostatectomy specimen to predict the probability of metastasis and tumor aggressiveness. Decipher is listed as a Category 2B recommendation in the NCCN Practice Guidelines in Oncology for Prostate Cancer (2022) as an option following radical prostatectomy with PSA persistence/recurrence defined as failure of PSA to fall to undetectable levels (PSA persistence) or undetectable PSA after radical prostatectomy with a subsequent PSA that increases on two or more determinations (PSA recurrence). The Guideline also notes that Decipher may be used in men with low-risk prostate cancer, defined as T1-T2a disease, Gleason score ≤6/grade group 1 and a PSA <10ng/mL and those with favorable intermediate-risk disease, defined as T2b-Tc disease, Gleason score 3+4=7/grade group 2, PSA 10-20 ng/mL and percentage of positive biopsy cores <50%. It may also be clinically useful for an individual with unfavorable intermediate-risk, defined as one or more of the following: two or three risk factors, grade 3 Gleason group, ≥50% biopsy cores positive (e.g., ≥6/12 cores) or with high-risk type, defined as an individual with no very-high-risk features and has exactly one high-risk feature: cTA3a OR Gleason group 4 or 5 OR PSA >20 ng/mL. OncotypeDx® Genomic Prostate Score (Genomic Health©, Redwood City, CA): This test is a genomic classifier test measuring the activity of 17 genes to predict clinical risk and tumor aggressiveness. OncotypeDx Prostate uses FFPE tissue from a prostate biopsy specimen. NCCN (2022) notes that men with low or favorable intermediate risk prostate cancer may consider the use of this test after prostate biopsy for low or favorable intermediate risk prostate cancer when there is a ≥ 10 years life expectancy and the individual is a candidate for active surveillance or definitive therapy. Prolaris® Prostate Cancer Test (Myriad Genetic Laboratories, Inc., Salt Lake City, UT): This test is a gene expression classifier risk stratification tool designed to measure the expression level of 31 genes in a prostate cancer tumor biopsy tissue, in conjunction with clinical parameters such as the Gleason score and PSA. The NCCN Practice Guidelines in Oncology for Prostate Cancer notes that men with low or favorable intermediate risk prostate cancer may consider the use of this test post prostate biopsy for low or favorable intermediate risk prostate cancer when there is a ≥ 10 years life expectancy and the individual is a candidate for active surveillance or definitive therapy. According to NCCN (2022), the test may also be clinically useful for an individual with unfavorable intermediate risk or high-risk type prostate cancer. Medical Coverage Policy: 0520 ProMark® Proteomic Prognostic Test (Metamark, Waltham, MA): This test is a prognostic assay that measures the signal intensity of eight protein biomarkers in FFPE prostate biopsy tissue. Using a proprietary algorithm the test generates a risk score indicating the likelihood of having high-risk disease. Myeloproliferative Neoplasms Polycythemia Vera (PV), Essential Thrombocythemia (ET) and Primary Myelofibrosis (PMF) Identification of the JAK2, MPL and CALR exon 9 common variants in individuals with polycythemia vera (PV), essential thrombocythemia (ET) and primary myelofibrosis (PMF) may aid in diagnosis based on diagnostic criteria for each of these diseases. For some individuals with PV, JAK2 exon 12 mutation testing may also be of benefit in disease management. Likewise genetic testing for MPL common variants and targeted mutation analysis of CALR exon 9 may be appropriate to aid in the diagnosis and management of ET and PMF. According to 2016 World Health Organization (WHO) criteria (Arber, 2016), ASXL1, EZH2, TET2, IDH1/IDH2, SRSF2 and SF3B1 mutation analysis may aid in diagnosis of PMF. Chronic Myelogenous Leukemia and Philadelphia Chromosome Positive (PH+) Acute Lymphoblastic Leukemia Mutation Testing Specific mutations in the Breakpoint Cluster Region-Abelson (BCR-ABL) gene have been shown to confer resistance to imatinib both in vitro and in vivo, by affecting the binding of the drug to the tyrosine kinase enzyme (AHRQ, 2010). Of interest is the T315-I mutation which is thought to be resistant to all current TKI therapy. The mutation frequency in imatinib resistant patients with CML ranges between 2% and 20%, with variability related to detection methods as well as patient cohort characteristics and treatment. T315I mutation frequency appears to be greater in patients with Philadelphia chromosome-positive (Ph+) ALL and likely increases with the continuation of TKI treatment (Nicolini, 2009). The detection of mutations of the BCR-ABL gene has been proposed with potential impact on diagnosis and management decisions (Agency for Healthcare Research and Quality [AHRQ], 2010; National Cancer Institute [NCI], 2015; Najfeld, 2012; National Institute for Clinical Excellence [NICE], 2002). Evidence in the published, peer-reviewed scientific literature also supports the usefulness of testing for BCR-ABL resistance or inhibition. Real-time quantitative PCR (RQ-PCR) is by far the most sensitive method. It provides an accurate measure of the total leukemia cell mass and the degree to which breakpoint cluster region- Abelson (BCR-ABL) transcripts are reduced by therapy, and correlates with progression-free survival. Current international recommendations for optimal molecular monitoring of patients receiving imatinib treatment include an RQ-PCR assay expressing the BCR-ABL transcript levels, which is predictive of prognosis (Bhatia, 2012; Najfeld, 2012). Molecular responses at 12 and 18 months are also predictive of long-term outcome (Bhatia, 2012). In acute lymphocytic leukemia (ALL), because many patients have a different fusion protein from the one found in chronic myelogenous leukemia (CML), the BCR-ABL gene may be detectable only by pulsed-field gel electrophoresis or reverse-transcriptase polymerase chain reaction (RT-PCR). These tests should be performed whenever possible in patients with ALL, especially those with B-cell lineage disease (NCI, 2015a). Although certain BCR-ABL mutations may be associated with TKI therapy resistance, sensitivity and specificity values in outcome studies are not suggestive of strong predictive ability, with the exception of the T315-I mutation. Early identification of this mutation may allow for alternative Medical Coverage Policy: 0520 treatment regimens including increased dose scheduling and drug selection. Data in the published peer-reviewed scientific literature supports the clinical utility of testing for the presence of the T315-I mutation. The clinical utility of testing for other mutations to determine TKI resistance has not been established. Literature Review Several studies have reported associations between variations of BCR-ABL and response to drug therapy. AHRQ (2010) performed a systematic review of the published literature regarding variations of the BCR-ABL1 fusion gene and response to imatinib, dasatinib, and nilotinib in CML. Thirty-one studies were analyzed for outcomes of interest including overall survival and cancer specific survival; progression-free or event-free survival (as defined by each study); and treatment failure. Typically, treatment failure is defined as absence of hematologic, cytogenetic, or molecular response to treatment, according to various criteria. Data was analyzed for first-, second-, and third- line TKI therapy. Second-line TKI therapy studies (four publications) demonstrated sensitivity and specificity ranges of 0.35 to 0.83 and from 0.58 to 1.00, respectively, for high-dose imatinib and imatinib-based combination. These studies were small, the calculated sensitivity and specificity values have wide confidence intervals, and a range of different mutations was identified in each of them. No robust conclusions could be made. Eight studies (nine publications) pertained to dasatinib; some had overlapping populations. Sensitivities and specificities ranged from 0.27 to 0.90 and from 0.14 to 0.87, respectively. A lack of predictive ability is suggested. For nilotinib, three studies had relevant data. Sensitivity ranged from 0.56 to 0.71 and specificity ranged from 0.42 to 0.56 for all identified mutations. Only one included study reviewed overall survival (OS). No statistically significant differences in the time-to-death among patients with, versus without mutations were found. When any breakpoint cluster region- Abelson (BCR-ABL1) mutation was considered, almost all studies reported sensitivity and specificity values that are not suggestive of strong predictive ability. The Agency for Healthcare Research and Quality (AHRQ) notes that no study explicitly reported details on changes in treatment plans before or after testing. AHRQ determined that the presence of any BCR-ABL mutation does not appear to differentiate response to tyrosine kinase inhibitor (TKI) treatment (i.e., imatinib, dasatinib, nilotinib). AHRQ also notes that the majority of evidence pertains to the short term surrogate outcomes of hematologic, cytogenetic or molecular response. Data on overall or progression-free survival are sparse. There is consistent evidence that presence of the relatively rare T315-I mutation can predict TKI treatment failure, mainly in terms of hematologic and cytogenetic response. Jabbour et al. (2009) studied 169 patients with chronic myelogenous leukemia (CML) after imatinib failure. The goals of the study were to investigate whether in vitro sensitivity of kinase domain mutations could be used to predict the response to therapy as well as the long-term outcome of patients receiving second-generation TKIs after imatinib failure. Treatment failure was defined as loss of a cytogenetic, or complete hematologic response (CHP), or failure to achieve a CHR or any hematologic response (for patients in accelerated phase or blast phase after 3 months of therapy, or persistence of 100% Philadelphia chromosome (Ph)–positive metaphases after 6 months of therapy, or more than or equal to 35% after 12 months). Fifty-seven patients (66%) had received prior therapy with interferon-alpha before the start of imatinib; 29 (34%) had received imatinib as their first-line therapy for CML. Mutations were detected by cDNA sequencing for mutations in the kinase domain of BCR-ABL before a change to dasatinib or nilotinib in 86 patients. Ninety-four mutations were identified in 86 patients with imatinib failure. Seven patients harbored more than 1 mutation. There was no difference in patient characteristics between those with mutations at the time of imatinib failure versus those with no mutations. Forty-one patients received dasatinib and 45 received nilotinib after developing failure to imatinib therapy. Hematologic and cytogenetic response rates were similar for patients without or with KD Medical Coverage Policy: 0520 mutations. After a median follow-up of 23 months, 48 (58%) of patients without baseline mutations were alive compared with 52 (60%) with any mutation. Nicolini et al. (2009) reported the results of a retrospective observational study of 222 patients with CML in chronic-phase, accelerated-phase, or blastic-phase and Philadelphia chromosome- positive (Ph+) ALL patients with the BCR-ABL T315I mutation. After T315I mutation detection, second-generation TKIs were used in 56% of cases, hydroxyurea in 39%, imatinib in 35%, cytarabine in 26%, MK-0457 in 11%, stem cell transplantation in 17%, and interferon-alpha in 6% of cases. Median overall survival from T315I mutation detection was 22.4, 28.4, 4.0, and 4.9 months, and median progression-free survival was 11.5, 22.2, 1.8, and 2.5 months, respectively, for chronic phase, accelerated phase, blastic phase, and Ph(+) ALL patients. These results suggest that survival of patients harboring a T315I mutation is dependent on disease phase at the time of mutation detection. In an earlier study by Jabbour et al. (2006) 171 patients were screened for mutations after failing TKI therapy with a median follow-up of 38 months from start of therapy. Sixty-six mutations impacting 23 amino acids in the BCR-ABL oncogene were identified in 62 (36%) patients. Factors associated with the development of mutations were older age, previous interferon therapy and accelerated or blast phase at the start of TKI therapy. By multivariate analysis, factors associated with a worse survival were development of clonal evolution and a higher percentage of peripheral blood basophils. The presence of a BCR-ABL kinase domain mutation had no impact on survival. When survival was measured from the time therapy started, non-P-loop mutations were associated with a shorter survival than P-loop mutations. The authors concluded that BCR-ABL P- loop mutations were not associated with a worse outcome. This study suggests that outcomes of individuals who fail TKI therapy may be influenced by multiple factors. Nicolini and colleagues (2006) retrospectively analyzed the predictive impact of 94 breakpoint cluster region (BCR) - Abelson (ABL) kinase domain mutations found in 89 protein tyrosine kinase inhibitor (TKI) resistant chronic myelogenous leukemia (CML) individuals. With a median follow-up of 39 months, overall survival was worse for P-loop and another point mutation (T315-I), but not for other BCR-ABL mutations. For individuals in chronic phase only, analysis demonstrated a worse overall survival for P-loop and worse progression free survival for T315-I mutations. Professional Societies/Organizations For a summary of professional society recommendations/guidelines regarding BCR-ABL mutation analysis please click here. Occult Neoplasms While the supporting published evidence is limited, certain paraneoplastic/onconeural antibodies (i.e., anit-Hu, anti-Yo, anti-CV2, anti-RI, anti-MA1 and anti amphiphysin), are established markers used to aid in the diagnosis of paraneoplastic syndromes and occult neoplasms (i.e., cancers of unknown origin). If initial diagnostic studies (e.g., laboratory, radiography, cerebral spinal fluid analysis, and/or electromyography) are negative, testing for paraneoplastic antibodies may be warranted. If the test is positive for a paraneoplastic antibody, it may help to focus the search for the neoplasm and establish the diagnosis of cancer. Continued testing (e.g., computed tomography, ultrasound) and early diagnosis for an underlying neoplasm would allow for early treatment of the cancer and could also improve the symptoms of PNS. In 90% of patients with paraneoplastic antibodies, the underlying tumor is diagnosed within the first year of PNS symptoms (Dalmau and Rosenfeld, 2008; Spiro et al., 2007; Bataller and Dalmau, 2005). The specificity of paraneoplastic antibodies Medical Coverage Policy: 0520 reported to be greater than 90% for paraneoplastic neurologic syndromes or some types of cancer makes them useful diagnostic tools. However, not all paraneoplastic antibodies have the same sensitivity and specificity. Hu antibodies, most often associated with subacute sensory neuropathy (SSN) and small cell lung cancer, have an estimated specificity of 99% and a sensitivity of 82% (Dalmau and Rosenfeld, 2008; Honnorat and Antoine, 2007; Vedeler, et al., 2006). Well-characterized, antibodies are reactive with molecularly defined onconeural antigens, prove the paraneoplastic etiology of the neurological syndrome, and are strongly associated with cancer. The well-characterized paraneoplastic antibodies include: anti-Hu (antineuronal nuclear autoantibodies-1 [ANNA-1]), anti-Yo (PCA-1 [Purkinje cell antibody-1]), anti-CV2 (CRMP5 [collapsing mediator response protein]), anti-Ri (ANNA-2), anti-MA2 (Ta), and anti-amphiphysin. Partially-characterized antibodies are antibodies with an unidentified target antigen and have only been found in a few patients. The partially-characterized antibodies (i.e., antibodies with an unidentified target antigen) include anti-Tr (PCA-Tr), ANNA-3, PCA-2, anti-recoverin, anti-Zic4 and anti-mGluR1. The detection of partially-characterized antibodies is considered of limited diagnostic value. Antibodies that can be detected in paraneoplastic and nonparaneoplastic form and can occur with and without cancer include: anti-VGCC (voltage-gated calcium channel), anti-AchR (acetylcholine receptor), anti-nAChR (nicotine acetylcholine receptor), and anti-VGKC (volted- gated potassium channels) (Monstad, et al., 2009; De Graaf and Smitt, 2008; deBeukelaar and Smitt, 2006; Vedeler, et al., 2006; Battler and Dalmau, 2005; Karim, et al., 2005; Vincent, 2005; Graus, et al., 2004). Professional Societies/Organizations For a summary of professional society recommendations/guidelines regarding molecular testing for solid tumor cancers please click here. Other Tumor Profile Testing Topographic Genotyping Topographic genotyping refers to a method of mutational analysis that incorporates minute tumor samples selected according to histopathologic considerations, polymerase chain reaction (PCR) amplification and direct sequencing. The mutational alterations that are found are then correlated with the histology of the tumor. It has been proposed that the results of this testing will provide predictive information that will influence the management of certain cancers. Studies comparing topographic genotyping with established testing methods are lacking. There do not appear to be prospective studies published in the peer-reviewed medical literature that focus on the clinical validity, the clinical utility of the test or the impact of the test on clinical outcomes. Literature Review High-quality prospective controlled studies informing the clinical validity and clinical utility of topographic genotyping tests are lacking in the published, peer-reviewed scientific literature. Studies generally focus on the association of the topographic genotyping results with tumor characteristics (Al-Haddad, et al., 2014; Al-Haddad et al., 2013; Malhotra et al, 2014; Panarelli et al., 2012; Khalid, et al., 2009). A technology assessment and systematic review regarding topographic genotyping with PathFinderTG was commissioned by Centers for Medicare and Medicaid Services (CMS) and conducted by the Tufts Evidence-based Practice Center for the Agency for Healthcare Research and Quality (AHRQ) (Trikalinos TA, et al., 2010). The review included studies evaluating the patented technology, specifically those using loss of heterozygosity (LOH) analysis. LOH is a frequent genetic alteration that is found in many cancers. It is thought that LOH alterations may Medical Coverage Policy: 0520 have prognostic significance. Fifteen studies were included—these pertained to: lung cancer (n=4); pancreatic and biliary tree tumors (n=4); hepatocellular carcinoma (n=4); gliomas, thyroid tumors, lacrimal gland tumors and mucinous tumors of the appendix (n=1 for each). The sample size in the studies ranged from 11 to 103. The review identified no studies regarding the analytic validity of LOH based topographic genotyping with PathFinderTG. The studies were retrospective in design and utilized available archival tissue blocks. One study, molecular profiles of gliomas and reactive gliosis were determined retrospectively and they were used prospectively on 16 diagnostically challenging cases of reactive gliosis versus glial tumors. There were no studies found that evaluated whether the use of LOH based topographic genotyping with PathFinderTG affects patient outcomes. There were no studies identified that compared LOH based topographic genotyping with PathFinderTG with conventional pathology. The review found that all studies are small, they have important methodological limitations, and they do not address patient-relevant outcomes. Professional Societies/Organizations For a summary of professional society recommendations/guidelines regarding topographic genotyping please click here. Adhesive Patch Gene Expression Assay for Pigmented Skin Lesions Adhesive patch gene expression assay (e.g., Pigmented Lesion Assay, Dermtech, LaJolla, CA) has been proposed as a tool to improve the differentiation between pigmented skin lesions that may be biopsied and those that may be monitored. At present there is insufficient evidence to support improved morbidity and mortality with the use of this technology. Cutaneous melanoma (CM) is skin cancer originating from melanocytes. CM is more common in certain ethnic groups and is more common in males. The risk increases with age. It is more than 20 times more common in whites than in African Americans. Overall, the lifetime risk of getting melanoma is about 2.6% (1 in 38) for whites, 0.1% (1 in 1,000) for Blacks and 0.6% (1 in 167) for Hispanics (American Cancer Society [ACS], 2021). Melanoma is less common than basal cell or squamous cell skin cancer, but can be much more aggressive. Prognosis is directly correlated to stage at diagnosis. The origin of the increase in diagnosis of CM is unclear; it cannot be fully attributed to environmental factors (e.g. sun exposure) instead increased scrutiny appears to be the largest driver behind the increase (Welch et al, 2021). While the diagnosis of melanoma has risen dramatically, this has not translated into a commensurate decrease in melanoma related mortality. As the mortality secondary to melanoma is largely static, the recent increase in melanoma diagnosis is largely understood to represent over diagnosis (Welch et al., 2021; Ferris 2021; Rubin 2020). The current standard of care is to biopsy all lesions suspicious for melanoma (Kim et al., 2015). Multiple criteria, including the Asymmetry, Border, Color, Diameter, Evolving (ABCD(E) criteria and Glasgow 7-point criteria, as well as use of dermoscopy imaging and total body photography are used in clinical practice to help monitor and guide clinical decision making regarding biopsy. These criteria have individual sensitivities ranging from 57% to 90% and specificities of 59% to 90%. When multiple ABCDE criteria are used the sensitivity and specificity are improved with 89.3% and 65.3% for two criteria, and 65.5% and 81% for three criteria (American Academy of Dermatology, 2015). No screening protocol has been sufficiently established to be the method of choice for biopsy decision making. Guidelines remain silent on this issue and discuss only what to do once the decision to biopsy has been reached. Perhaps most importantly, in the current era, more work is needed to understand how to specifically identify lesions associated with high-risk melanoma for Medical Coverage Policy: 0520 biopsy to make improvements to overall morbidity and mortality (Ferris 2021). The NCCN Guidelines™ for Cutaneous Melanoma (2022) includes many clinical risk factors for the development of melanoma which should also be considered in biopsy decision making. These include gender, age, family history, phenotype, personal history including genetic predisposition, and environmental factors. The Pigmented Lesion Assay (PLA) is a non-invasive gene expression profile test to assess an atypical primary melanocytic (pigmented) skin lesion suspicious for melanoma, prior to the decision to biopsy. According to the manufacturer, the test is used to help guide decision-making regarding the need for biopsy and is not a diagnostic test for melanoma. Using an adhesive patch a stratum corneum skin tissue sample is collected from the surface of the lesion. Ribonucleic acid (RNA) is extracted from the from skin tissue sample and tested for the expression of LINC00518 (LINC) and preferentially expressed antigen in melanoma (PRAME). The test has not been validated in patients with Fitzpatrick skin type IV-VI (i.e., light brown, brown, dark brown or black), in the presence of other non-cancerous skin disorders, non-melanocytic lesions, or in pediatric patients. Literature review Gerami et al. (2017) reported results of a clinical validation study involving pigmented lesions (157 training and 398 validation samples) obtained noninvasively via adhesive patch biopsy. Assay results for PRAME and LINC00518 were compared to histopathologic assessment by a three- person dermopathology panel. Using the expression of PRAME and/or LINC00518 in 398 samples (87 melanomas and 311 nonmelanomas), the test differentiated melanoma from nonmelanoma samples with a sensitivity of 91% and a specificity of 69%. Study limitations which limit use in routine clinical practice include exclusion of cases where multi-expert pathology reviews were not unanimous (11%) and cases excluded due to test failure (14%). Additionally there is a lack of validation Fitzpatrick skin types IV-VI, use on mucous membranes, palms of hands and soles of feet, and for an individual less than 18 years. Brouha et al. (2020) reported utility findings and up to 12 month follow-up for a registry study based in the United States. Results of PLA testing of 3418 lesions from 53 dermatology practices, including 90 providers were uploaded to a web portal. Biopsy decision, biopsy type, lesion location, biological sex and three, six or 12-month follow-up was also requested. Clinical impact on management and clinical monitoring of a lesion based on PLA test results were assessed. Of 3418 lesions submitted, 324 lesions were PLA positive and 3,094 were negative. PLA positive lesions were biopsied in 97.53% of patients and PLA negative lesions were clinically monitored and not biopsied in 99.94% of patients. Study limitations which limit the ability to translate results to routine clinical practice include inclusion criteria (e.g., lesion selection).