National Medical Policy

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1 National Medical Policy Subject: Policy Number: Tumor Markers for Cancer NMP522 Effective Date*: July 2013 Updated: April 2014 This National Medical Policy is subject to the terms in the IMPORTANT NOTICE at the end of this document For Medicaid Plans: Please refer to the appropriate Medicaid Manuals for coverage guidelines prior to applying Health Net Medical Policies The Centers for Medicare & Medicaid Services (CMS) For Medicare Advantage members please refer to the following for coverage guidelines first: Use Source Reference/Website Link X National Coverage Determination (NCD) Carcinoembryonic Antigen: Tumor Antigen by Immunoassay - CA 125: Tumor Antigen by Immunoassay - CA 15-3/CA 27.29: Tumor Antigen by Immunoassay - CA 19-9: X National Coverage Manual Citation Local Coverage Determination (LCD)* Molecular Diagnostic Tests (MDT) ; Bladder Tumor Markers: Article (Local)* x Other Palmetto GBA. MOLDX: sf/docscathome/moldx None Use Health Net Policy Instructions Medicare NCDs and National Coverage Manuals apply to ALL Medicare members in ALL regions. Medicare LCDs and Articles apply to members in specific regions. To access your specific region, select the link provided under Reference/Website and follow the Tumor Makers for Cancer Apr 14 1

2 search instructions. Enter the topic and your specific state to find the coverage determinations for your region. *Note: Health Net must follow local coverage determinations (LCDs) of Medicare Administration Contractors (MACs) located outside their service area when those MACs have exclusive coverage of an item or service. (CMS Manual Chapter 4 Section 90.2) If more than one source is checked, you need to access all sources as, on occasion, an LCD or article contains additional coverage information than contained in the NCD or National Coverage Manual. If there is no NCD, National Coverage Manual or region specific LCD/Article, follow the Health Net Hierarchy of Medical Resources for guidance. Current Policy Statement Health Net Inc., considers the following tumor markers medically necessary for the diagnosis and/or management of cancer (more information on each marker can be found following the table): Tumor Marker Afirma Thyroid FNA Analysis AFP (alpha-fetoprotein) AFP, lactate dehydrogenase (LDH), and beta-human chorionic gonadotropin (beta hcg) ALK Gene rearrangement B2M (beta-2 microglobulin) Bladder-tumor antigen stat test (BTA) Calcitonin CA (cancer antigen) 15-3, also known as CA or Truquant RIA CA 19.9 CA125 Carcinoembryonic antigen (CEA) CgA (chromogranin A) CD- 117 (C-kit) (cluster of differentiation-117) Cyclin D1 Cancer Thyroid Cancer Primary hepatocellular cancer Germ cell tumors Refer to policy, Molecular Tumor Markers for Non-Small lung Cancer Multiple myeloma; Chronic lymphocytic leukemia; Some lymphomas (see below) Bladder cancer Thyroid medullary carcinoma Metastatic breast cancer Pancreatic cancer; Gallbladder cancer; Cholangiocarcinoma; Carcinoma of the ampulla of Vater Epithelial ovarian cancer; Endometrial cancer Breast Cancer: Colorectal cancer; Medullary thyroid cancer Neuroendocrine tumors (e.g., carcinoid tumors, neuroblastoma, and small cell lung cancer) Gastrointestinal stromal tumors Mantle cell lymphoma Tumor Makers for Cancer Apr 14 2

3 Tumor Marker EGFR (epidermal growth factor receptor) ER/PR (estrogen receptors and progesterone receptors) 5-HIAA (5-hydrocyindoleacetic acid) HE4 (human epididymis protein 4) HER2 (human epidermal growth factor receptor 2) ImmunoCyt/uCyte+ KRAS gene sequencing MPO (myeloperoxidase) Nuclear-Matrix Protein (NMP22) NSE (neuron-specific enolase) Placental alkaline phosphatase (PLAP) PSA (prostate-specific antigen) Thyroglobulin UroVysion Cancer Refer to policy, Molecular Tumor Markers for Non-Small lung Cancer Breast cancer Carcinoid tumors Ovarian cancer Refer to policy, Her2/neu Bladder cancer Refer to policy, Molecular Tumor Markers for Non-Small lung Cancer and K-RAS Mutation Analysis of Colon Cancer Acute myeloid leukemia Bladder cancer Small cell lung cancer Germ cell seminoma and non-seminoma germ cell tumors in unknown primary cancers Prostate cancer Differentiated thyroid cancer Bladder cancer Afirma Thyroid FNA The Afirma Thyroid FNA Analysis is intended for adults with thyroid nodules at least 1 centimeter in size, that are indeterminate and who are being evaluated for the possibility of a thyroid malignancy. AFP (alpha-fetoprotein) Hepatocellular Cancer AFP is not frequently elevated in early stage hepatocellular carcinoma (HCC) thus its utility as a screening biomarker is limited. AFP testing can be useful in conjunction with other test results to guide management of patients for whom a diagnosis of HCC is suspected. AFP is also useful in monitoring individuals with HCC. AFP, lactate dehydrogenase (LDH), and beta-human chorionic gonadotropin (beta HCG) Germ Cell Tumors Tumor Makers for Cancer Apr 14 3

4 AFP, LDH and beta-hcg are critical in diagnosing germ cell tumors (GCTs), determining prognosis, and assessing treatment outcome. They are useful for monitoring all stages of nonseminomas. They are useful in monitoring metastatic seminomas because elevated marker levels are early signs of relapse. B2M (beta-2 microglobulin) Multiple Myeloma The level of beta-2 microglobulin reflects the tumor mass and is considered a standard measure of the tumor burden in multiple myeloma. Chronic Lymphocytic Leukemia Elevated levels of serum beta-2microglobulin have been shown to be a strong independent prognostic indicator for treatment-free intervals, response to treatment, and overall survival, in individuals with chronic lymphocytic leukemia (CLL) and small lymphocytic lymphoma (SLL) Lymphomas Beta-2 microglobulin may be useful prognostic indicator in anaplastic large cell lymphoma (ALCL) Beta-2 microglobulin is useful in the initial diagnostic work-up for Follicular lymphoma (FL), Diffuse Large B-Cell Lymphoma (DLBCL) Measurement of Beta-2 microglobulin may be useful in some circumstances in the initial work-up of mantle cell lymphoma, lymphoblastic lymphoma amnd Aids related B-Cell lymphoma. Bladder-tumor antigen stat test (BTA) Bladder Cancer Per the NCCN, urine molecular tests for urothelial tumor markers are now available. Most of these tests have a better sensitivity for detecting bladder cancer than urine cytology, but specificity is lower. However, it remains unclear whether these tests offer additional information that is useful for detection and management of non-muscle-invasive bladder tumors. NCCN considers this to be a 2B recommendation (i.e., Based on lower level of evidence, there is NCCN consensus that the intervention is appropriate) Calcitonin Medullary Thyroid Cancer Basal serum calcitonin and serum carcinoembryonic antigen (CEA) are generally accepted in the preoperative work-up for medullary thyroid cancer. Calcitonin is useful for post operative management and surveillance, to evaluate effectiveness of treatment and assess for recurrence of medullary thyroid cancer. CA 15-3; CA Metastatic breast cancer The NCCN states that monitoring of patients symptoms and cancer burden during treatment of metastatic breast disease is important to determine whether the treatment is providing benefit and that the patient does not have toxicity from an ineffective therapy. Increasing tumor markers (CEA, CA 15-3 and CA 27.29) are findings that are concerns for progression of disease, but may also be seen in the setting of responding disease. An isolated increase in tumor markers should rarely be used to declare progression of disease. Changes in bone lesions are often difficult to assess on plain or cross-sectional radiology or on bone scan. For these reasons, patient symptoms and serum tumor markers may be more helpful in patients with bone-dominant metastatic disease. Tumor Makers for Cancer Apr 14 4

5 CA 19.9 Pancreatic Cancer The NCCN reports that the best validated and most clinically useful biomarker in pancreatic cancer is CA CA 19-9 is commonly expressed and shed in pancreatic and hepatobiliary disease, and in many malignancies; thus it is not tumor specific. However, the degree of increase in CA 19-9 levels may be useful in differentiating pancreatic adenocarcinoma from inflammatory conditions of the pancreas. CA 19-9 is a good diagnostic marker in symptomatic individuals, but its low predictive value makes it a poor biomarker for screening. Preoperative CA 19-9 levels correlate with both AJCC staging and resectability and thus provide additional information for staging and determining resectability, along with information from imaging, laparoscopy and biopsy. CA 19-9 seems to have value as a prognostic marker. Low post operative levels or serial decrease following surgery have been found to correlate with survival for individuals undergoing resection for pancreatic cancer. Changes in CA 19-9 levels after chemotherapy in patients with advanced disease has been shown to be a reliable predictive marker for response to treatment. CA 19-9 may be undetectable in Lewis antigen-negative individuals. CA 19-9 may be falsely positive in cases of benign or malignant biliary obstruction and do not necessarily indicate cancer or advanced disease. NCCN recommends measurement of CA 19-9 levels prior to surgery (if bilirubin levels are normal), following surgery prior to administration of adjuvant therapy or for surveillance (category 2B, i.e., based on lower level evidence, there is consensus that intervention is appropriate) Biliary Tract Cancer CA 19-9 may be considered in initial workup of individuals with a suspicion of gallbladder cancer, although the markers are NOT specific for gallbladder cancer. CA 19-9 testing can be considered after biliary decompression. CA 19-9 may be considered in initial workup of individuals with a suspicion of cholangiocarcinoma, although the markers are NOT specific for cholangiocarcinoma. Ampullary Cancer Some ampullary cancers are associated with increased serum levels of CA 19-9 and/or carcinoembryonic antigen (CEA). Serial assay of these tumor markers may be useful for posttreatment follow-up. CA 125 Ovarian Cancer Per the NCCN, tumor markers (including CA-125, inhibin, AFP, and beta-hcg) can be measured if clinically indicated. Per the NCCN, CA 125 and other tumor markers may be done as clinically indicated prior to each cycle of chemotherapy. After completion of primary surgery and chemotherapy in individuals with all stages of ovarian cancer who have complete response, the recommendation is observation with follow-up. If the CA 125 level was initially elevated, the measurement of a CA 125 level or other tumor markers at each follow-up evaluation is recommended. The NCCN concurs with the Society of Gynecologic Oncology (SGO) opinion which states that individuals should discuss the pros and cons of CA 125 monitoring and that the use of CA 125 levels for surveillance is optional. The FDA has approved the use of HE4 and CA 125 for estimating the risk of ovarian cancer in women with a pelvic mass. Currently, the NCCN does not Tumor Makers for Cancer Apr 14 5

6 recommend the use of these biomarkers for determining the status of an undiagnosed pelvic mass. Endometrial Carcinoma Per the NCCN, in individuals with extrauterine disease, a serum CA 125 assay may be helpful in monitoring clinical response. However, serum CA 125 levels may be falsely increased in women who have peritoneal inflammation/infection or radiation injury, normal in women with isolated vaginal metastases and may not predict recurrence in the absence of other clinical findings. Both NCCN and SGO recommend that CA 125 and MRI/CT may be useful before surgery to assess if extrauterine disease is present. Hereditary Breast and Ovarian Cancer Syndrome (HBOC) For individuals with HBOC who have not elected salpingo-oophorectomy, the NCCN recommends considering concurrent transvaginal ultrasound (preferably day 1-10 of menstrual cycle in premenopausal women) and CA 125 (preferably after day 5 of menstrual cycle in premenopausal women) every 6 months starting at age 30y or 5-10 years before the earliest age of the first diagnosis of ovarian cancer in the family. Carcinoembryonic antigen (CEA) Breast Cancer Increasing tumor markers (CEA, CA 15-3 and CA 27.29) are findings that are concerns for progression of disease, but may also be seen in the setting of responding disease. An isolated increase in tumor markers should rarely be used to declare progression of disease. Changes in bone lesions are often difficult to assess on plain or cross-sectional radiology or on bone scan. For these reasons, patient symptoms and serum tumor markers may be more helpful in patients with bone-dominant metastatic disease. Colorectal Cancer Testing of CEA in the initial work-up is recommended for individuals who present with invasive colon cancer appropriate for resection. CEA determination should be included in the workup for individuals with metastatic synchronous adenocarcinoma. Colorectal Cancer Surveillance CEA testing is recommended at baseline and every 3-6 months for 2 years and then every 6 months for a total of 5 years, for patient with stage III disease and those with stage II disease if the clinician determines that the individual is a potential candidate for aggressive curative surgery. CEA testing is also recommended every 3-6 months for 2 years and then every 6 months for a total of 5 years, for individuals with stage IV disease with no NED after curative-intent surgery and subsequent adjuvant treatment. Surveillance of are similar to those recommendations for individuals with stage II/III disease, except that certain evaluations are performed more frequently. CEA testing is recommended every 3-6 months for the first 2 years. Routine CEA monitoring and routine CT scanning are not recommended beyond 5 years Medullary Thyroid Cancer Basal serum calcitonin and serum carcinoembryonic antigen (CEA) are generally accepted in the preoperative work-up for medullary thyroid cancer. A rapidly increasing CEA level, particularly in the setting of a stable calcitonin level may be important for predicting a worse prognosis. Tumor Makers for Cancer Apr 14 6

7 Measurement of CEA is useful for post operative management and surveillance, to evaluate effectiveness of treatment and assess for recurrence of medullary thyroid cancer. CgA (chromogranin A) Neuroendocrine tumors Chromogranin A may be used as a tumor marker; (NCCN category 3, i.e. based on any level of evidence, there is major NCCN disagreement that the intervention is appropriate) Although not diagnostic, elevated levels have been associated with recurrence. Analysis of a large prospective database showed that CgA levels elevated twice the normal limit or higher were associated with shorter survival times for individuals with metastatic neuroendocrine tumors. CgA levels can be elevated in other conditions (e.g., renal or hepatic insufficiency, hypertension, chronic gastritis) and are also commonly also elevated in the setting of concurrent proton pump inhibitors, thus caution should be used when considering initiating new therapy based on a rising CgA level in an asymptomatic individual with a tumor that appears stable. CD-117 (C-kit) (cluster of differentiation-117) Gastrointestinal Stromal Tumors Gastrointestinal stromal tumors (GISTs) that arise in adults are characterized by the near-universal expression of the CD117 antigen. The CD117 antigen is part of the KIT transmembrane receptor tyrosine kinase that is the product of the KIT (also denoted c-kit) protooncogene Cyclin D1 Non Hodgkins Lymphoma Per the NCCN, immunophenotyping/genetic testing is useful in the differential diagnosis of mature B-cell and NK/T-cell neoplasms in conjunction with clinical and morphologic correlation. In the differential diagnosis of small cell lymphomas [i.e., Chronic Lymphocytic Leukemia (CLL)/Small Lymphocytic Lymphoma (SLL), Mantle Cell Lymphoma (MCL), Hairy Cell Leukemia (HCL), Splenic Marginal Zone Lymphoma (MZL), extra-nodal MZL, nodal MZL, and Follicular Lymphoma] cyclin D1 is included in the panel for immunophenotyping. Distinguishing CLL/SLL from mantle cell lymphoma is essential and cyclin D1 expression is the most reliable marker for differentiating between CLL and MCL. In select cases, the use of cyclin D1 may be useful to differenciate PC-MZL from mantle cell lymphomas. Cyclin D1 is also include in the immunophenotyping panel for the diagnosis of medium-sized lymphomas [Burkitt lymphoma (BL), diffuse large B-cell lymphoma (DLBCL), blastoid variant of MCL.] Cyclin D1 positively confirms the diagnosis of blastoid MCL. ER/PR (estrogen receptors and progesterone receptors) Breast Cancer Per the NCCN, the work-up of individuals with invasive breast cancer should include determination of tumor estrogen/progesterone receptor (ER/PR) status and Her2 status. ER/PR tumor status is normally determined by immunohistochemistry (IHC) testing. Per NCCN, the revised AJCC cancer staging manual recommends the collection of prognostic factors, including tumor grade, estrogen receptor (ER) content, progesterone receptor (PR) content and human epidermal growth factor receptor Tumor Makers for Cancer Apr 14 7

8 2 (HER2) status, although these characteristics do not specifically influence assigned stage of disease. 5-HIAA (5-hydrocyindoleacetic acid) Carcinoid Tumor 5-hydrocyindoleascetic acid (5-HIAA), a metabolite of serotonin may also be considered as a biochemical marker in some cases, particularly in individuals with small-intestinal carcinoid tumors. Baseline levels of 5-HIAA may be considered to monitor subsequent progression of disease. HE4 (human epididymis protein 4) Per NCCN, although human epididymis protein 4 (HE4) and CA125 appear to be useful in detecting ovarian cancer, recent data showthat several markers (including CA125, HE4, etc) do not increase early enough to be useful in detecting early-stage ovarian cancer. The FDA has approved the use of HE4 and CA 125 for estimating the risk of ovarian cancer in women with a pelvic mass. Currently, the NCCN does not recommend the use of these biomarkers for determining the status of an undiagnosed pelvic mass. ImmunoCyt/uCyt+ Bladder cancer May be used for detecting primary bladder cancer in patients with signs/symptoms of bladder cancer or for detecting recurrent bladder cancer in patients with a history of bladder cancer, when used as an adjunct to cystoscopy and urinary cytology Per the NCCN, urine molecular tests for urothelial tumor markers are now available. Most of these tests have a better sensitivity for detecting bladder cancer than urine cytology, but specificity is lower. However, it remains unclear whether these tests offer additional information that is useful for detection and management of non-muscle-invasive bladder tumors. NCCN considers this to be a 2B recommendation (i.e., Based on lower level of evidence, there is NCCN consensus that the intervention is appropriate) MPO (myeloperoxidase) Acute Myeloid Leukemia Immunohistochemical staining for myeloperoxidase is the best method for determining which cells are committed to the myeloid lineage Nuclear-Matrix Protein (NMP22) Bladder Cancer Consideration may be given to the FDA approved urinary biomarker testing by fluorescence in situ hybridization or nuclear matrix protein 22 in the monitoring for recurrence. NSE (neuron-specific enolase) Small Cell Lung Cancer (SCLC) Neuroendocrine tumors account for approximately 20% of lung cancers; most (~15%) are small cell lung cancer. Most SCLCs stain positively for markers of neuroendocrine differentiation, including chromogranin A, neuron-specific enolase, neural cell adhesion molecule and synaptophysin. Placental alkaline phosphatase (PLAP) Tumor Makers for Cancer Apr 14 8

9 Occult Primary (Cancer of unknown Primary) Placental alkaline phosphatase (PLAP) is mainly found in seminomas but is also expressed in some nonseminoma germ cell tumors, and genitourinary, gastrointestinal, and pulmonary carcinomas. PSA (prostate-specific antigen) Prostate Cancer The decision to participate in an early detection program for prostate cancer is complex. Factors that should be considered include patient age, life expectancy, family history, race, and previous early detection test results. Initial suspicion of prostate cancer is based on abnormal digital rectal exam (DRE) or an elevated PSA level. Prostate cancers are characterized by clinical (TMN ) stage determined by DRE, Gleason score in the biopsy specimen, and serum PSA levels. NCCN guidelines incorporate a risk stratification scheme that uses a minimum of stage, grade and PSA to assign individuals to risk groups. These groups are used to select the appropriate options that should be considered for treatment and to predict the probability of biochemical failure after definitive local therapy. Biochemical progression-free survival can be reassessed post-operatively using age, serum PSA, and pathologic grade and stage. PSA levels are monitored in individuals choosing active surveillance and in individuals choosing active treatment. Many commercially available serum total PSA testing are currently available. They perform comparably, however, the levels are not interchangeable since they standardized against two different standards. An abnormal PSA result should be confirmed by retesting. Unbound or free PSA (fpsa) expressed as a ratio of total PSA has emerged as a clinically useful molecular form of PSA, with the potential to provide improvements in early detection, staging, and monitoring of prostate cancer. Studies have shown that the percentage of fpsa is significantly lower in men who have prostate cancer compared to men who have not. The US Food and Drug Administration (FDA) approved the use of percent-free PSA for the early detection of prostate cancer in men with PSA levels between 4-10 ng/ml. NCCN guidelines recommend the use of the percent-free PSA as an alternative in the management of patients with normal DREs and total PSA levels between 4-10ng/mL if there is a relative contraindication to biopsy. Physicians and patients electing to use percent-free PSA should be cautioned that this assay and the multi-institutional study performed to obtain its FDA approval were designed with the intention of avoiding unnecessary biopsies in men with a high likelihood of not having prostate cancer. Thyroglobulin Thyroid Cancer Thyroglobulin is most often measured in differentiated thyroid cancers (i.e., papillary, follicular, and Hurthle cell). Postoperative elevation of the thyroglobulin level above 10 nanograms per milliliter is suggestive of cancer recurrence UroVysion Bladder Cancer Per the NCCN, urine molecular tests for urothelial tumor markers are now available. Most of these tests have a better sensitivity for detecting bladder cancer than urine cytology, but specificity is lower. However, it remains unclear whether these tests offer additional information that is useful for detection and management of non-muscle-invasive bladder tumors. NCCN considers this to be Tumor Makers for Cancer Apr 14 9

10 a 2B recommendation (i.e., Based on lower level of evidence, there is NCCN consensus that the intervention is appropriate) Investigational Health Net Inc., considers the following tumor markers investigational, as their role in the management of various benign and cancerous conditions has not yet been demonstrated (may not be all inclusive): 1. BluePrint Molecular Subtyping Profile for Breast Cancer 2. BreastNext Next-Gen Cancer Panel 3. CA 50 (Cancer antigen 50) 4. CA 72-4 (Cancer antigen 72-4) 5. CA 195 (Cancer antigen 195) 6. CA 549 (Cancer antigen 549) 7. CAM 17.1 (monoclonal antimucin antibody 17.1) 8. CancerNext Next-Gen Cancer Panel 9. ColoNext 10. ConfirmMDx for Prostate Cancer 11. Decision DX-GBM brain cancer assay 12. Decision DX-UM assay 13. Direct-to-consumer (DTC) Genetic tests (eg., 23andMe) 14. EarlyCDT-Lung Risk Assessment Test 15. MammaPrint 16. Mammastrat 17. MelanoSITE Fish Test 18. OncoType DX DCIS 19. OncoVue 20. Ovanext 21. Ovasure 22. Panexia 23. Pathfinder TG 24. PreOvar KRAS-Variant Test for Ovarian Cancer 25. ProOnc TumorSource 26. Proveri Prostate Cancer Assay (PPCA) 27. ResponseDX: Colon 28. Squamous Cell Carcinoma Antigen 29. Septin 9 (SEPT9) Methylation Analysis for Colorectal Cancer 30. Target Now Molecular Profiling Test (Caris Life Sciences) 31. Molecular Intelligence (MI) (Caris Life Sciences) Definitions Tumor Makers for Cancer Apr 14 10

11 POC UC BC UCB AUC FNA HCC HCV HBV FFPE NPV AGEC HT TT IHC NSCLC FAP PFS GEP NGS Point of care Urothelial carcinoma Bladder cancer Urothelial carcinoma bladder Area under the curve Fine needle aspiration Hepatocellular carcinoma Hepatitis C virus Hepatitis B virus Formalin-fixed, paraffin-embedded Negative predictive value Afirma gene expression classifier Hemithyroidectomy Total thyroidectomy Immunohistochemistry Non small cell lung cancer Familial adenomatous polyposis Progression free survival Gene expression profiling Next generation sequencing Codes Related To This Policy NOTE: The codes listed in this policy are for reference purposes only. Listing of a code in this policy does not imply that the service described by this code is a covered or noncovered health service. Coverage is determined by the benefit documents and medical necessity criteria. This list of codes may not be all inclusive. On October 1, 2014, the ICD-9 code sets used to report medical diagnoses and inpatient procedures will be replaced by ICD-10 code sets. Health Net National Medical Policies will now include the preliminary ICD-10 codes in preparation for this transition. Please note that these may not be the final versions of the codes and that will not be accepted for billing or payment purposes until the October 1, 2014 implementation date. ICD-9 Codes (May not be all inclusive) Malignant neoplasm of esophagus Malignant neoplasm of stomach Malignant neoplasm of small intestine, including duodenum Malignant neoplasm of colon Malignant neoplasm of rectum, rectosigmoid junction, and anus Maligant neoplasm of liver and intrahepatic bile ducts Malignant neoplasm of gallbladder and extrahepatic bile ducts Malignant neoplasm of pancreas Malignant neoplasm of the female breast 181 Malignant neoplasm of placenta (e.g., choriocarcinoma) Malignant neoplasm of ovary and other uterine adnexa 185 Malignant neoplasm of prostate Malignant neoplasm of testis Carcinoma in situ of stomach Carcinoma in situ of colon Carcinoma in situ of other and unspecified parts of intestine Carcinoma in situ of liver and biliary system Carcinoma in situ of other and unspecified digestive system Tumor Makers for Cancer Apr 14 11

12 233.0 Carcinoma in situ of breast Carcinoma in situ of bladder Carcinoma in situ of other and unspecified female genital organs Carcinoma in situ of prostate Carcinoma in situ of other and unspecified male genital organs Neoplasm of uncertain behavior of placenta Neoplasm of uncertain behavior of ovary Neoplasm of uncertain behavior of prostate Neoplasm of uncertain behavior of bladder Neoplasm of bladder Elevated prostate specific antigen (PSA) V10.3 Personal history of malignant neoplasm of breast V10.04 Personal history of malignant neoplasm of stomach V10.05 Personal history of malignant neoplasm of large intestine V10.06 Personal history of malignant neoplasm of rectum, rectosigmoid junction, and anus V10.07 Personal history of malignant neoplasm, liver V10.09 Personal history of malignant neoplasm of gastrointestinal tract, other V10.43 Personal history of malignant neoplasm of ovary V10.46 Personal history of malignant neoplasm of prostate V10.47 Personal history of malignant neoplasm of testis V76.44 Special screening for malignant neoplasm of prostate V76.46 Family history of malignant neoplasm of ovary ICD-10 Codes C15.3-C15.9 Malignant neoplasm of esophagus C16.0-C16.9 Malignant neoplasm of stomach C17.0-C17.9 Malignant neoplasm of small intestine C18.0-C18.9 Malignant neoplasm of colon C19 Malignant neoplasm of rectosigmoid junction C22.0-C22.9 Malignant neoplasm of liver and extrahepatic bile ducts C24.0-C24.9 Malignant neoplasm of other and unspecified parts of biliary tracts C25.0-C25.9 Malignant neoplasm of pancreas C C Malignant neoplasm of breast C56.1-C56.9 Malignant neoplasm of ovary C58 Malignant neoplasm of placenta C C Malignant neoplasm of breast C61 Malignant neoplasm of prostate C62.00-C62.92 Malignant neoplasm of testis D00.2 Carcinoma in situ of stomach D01.0 Carcinoma in situ of colon D01.40-D01.49 Carcinoma in situ of other and unspecified parts of the intestine D01.7 Carcinoma in situ of other specified digestive organs D01.9 Carcinoma in situ of digestive organ, unspecified D05.90-D05.92 Unspecified type of carcinoma in situ of breast D07.30-D07.39 Carcinoma in situ of other and unspecified female genital organs D07.5 Carcinoma in situ of prostate D07.60-D07.69 Carcinoma in situ of other and unspecified male genital organs D09.0 Carcinoma in situ of bladder D39.10 Neoplasm of uncertain behavior of unspecified ovary D39.2 Neoplasm of uncertain behavior of placenta D40.0 Neoplasm of uncertain behavior of prostate D41.1 Neoplasm of uncertain behavior of bladder Tumor Makers for Cancer Apr 14 12

13 D49.4 Neoplasm of unspecified behavior of bladder R97.0-R97.8 Abnormal tumor markers Z12.5 Encounter for screening for malignant neoplasm of prostate Z12.73 Encounter for screening for malignant neoplasm of ovary Z Z Personal history of malignant neoplasm of digestive organs Z Z Personal history of malignant neoplasm of large intestine Z Z Personal history of malignant neoplasm of rectum, rectosigmoid junction, and anus Z85.05 Personal history of malignant neoplasm of liver Z Z Personal history of malignant neoplasm of small intestine Z85.07 Personal history of malignant neoplasm of pancreas Z85.09 Personal history of malignant neoplasm of other digestive organs Z85.3 Personal history of malignant neoplasm of breast Z85.43 Personal history of malignant neoplasm of ovary Z85.46 Personal history of malignant neoplasm of prostate Z85.47 Personal history of malignant neoplasm of testis CPT Codes EFGR (epidermal growth factor receptor) (e.g., non-small cell lung cancer) gene analysis, common variants (e.g., exon 19 LREA deletion, L858R, T790M, G719A, G719S, L861Q KRAS (v-ki-ras2 Kirsten rat sarcoma viral oncogene) (eg, carcinoma) gene analysis, variants in condons 12 and Unlisted molecular pathology procedure Unlisted multianalyte assay with algorithmic analysis Alpha-fetoprotein (AFP); serum Beta-2 microglobulin Calcitonin Carcinoembryonic antigen (CEA) Hydrocyindoleacetic acid, 5(HIAA) Lactate dehydrogenase (LD), LDH Lactate dehydrogenase (LD), (LDH); isoenzymes, separation and quantitation Myeloperoxidase (MPO) Serum assay, Oncoprotein (HER2/neu microtiter ELISA) Prosate specific antigen (PSA); complexed (direct measurement) Prosate specific antigen (PSA); total Prosate specific antigen (PSA); free Receptor assay; estrogen Receptor assay; progesterone Thyroglobulin Gonadotropin, chorionic (hcg); quantitative Gonadotropin, chorionic (hcg); qualitative Gonadotropin, chorionic (hcg); free beta chain Unlisted chemistry procedure Immunoassay for tumor antigen, qualitative or semiqualitative (e.g., bladder tumor antigen) Immunoassay for tumor antigen, quantitative; CA 15-3 (27.29) CA CA Human epididymis protein 4 (HE4) Immunoassay for tumor antigen, other antigen, quantitative (e.g. CA50, 72-4, 549); each Tumor Makers for Cancer Apr 14 13

14 86386 Nuclear Matrix protein 22 (NMP22), qualitative Cytopathology, in situ hybridization (e.g. FISH), urinary tract specimen with morphometric analysis, 3-5 molecular probes, each specimen; manual Cytopathology, in situ hybridization (e.g. FISH), urinary tract specimen with morphometric analysis, 3-5 molecular probes each specimen; using computer-assisted technology Molecular cytogenetics: DNA probe, each (eg FISH) Interphase in situ hybridization, analyze cells Immunohistochemistry (including tissue immunoperoxidase), each antibody (Code revised in 2014) Tissue in situ hybridization, (eg. FISH) each probe Morphometric analysis; in situ hybridization (quanitative or semi-quantitative) each probe; using computer-assisted technology CPT Code Revised Immunohistochemistry or immunocytochemistry, each separately identifiable antibody per block, cytologic preparation, or hematologic smear; first separately identifiable antibody per slide HCPCS Codes G0103 Prostate cancer screening; prostate specific antigen test Scientific Rationale Update April 2014 Thyroid nodules are discrete masses present in the thyroid gland that are a common clinical finding among adults in the general population. Approximately 5% of women and 1% of men have a palpable thyroid nodule on physical examination. The evaluation of thyroid nodules, which may represent benign lesions or malignant thyroid tumors, typically includes a cytopathologic examination of a biopsy specimen obtained by fine-needle aspiration (FNA). Generally, only nodules >1 cm should be evaluated, since they have a greater potential to be clinically significant cancers. Occasionally, there may be nodules <1 cm that require evaluation because of suspicious US findings, associated lymphadenopathy, a history of head and neck irradiation, or a history of thyroid cancer in one or more first-degree relatives. The NCCN notes that FNA is a very sensitive test, however, false negative results are sometimes obtained, therefore, a reassuring FNA should not override worrisome clinical findings. Cytologic examination of an FNA specimen is typically categorized as: carcinoma; follicular or Hurthle cell neoplasm; follicular lesion of undetermined significance; thyroid lymphoma; benign (i.e., nodular goiter, colloid goiter, hyperplastic /adenomatoid nodule, Hashimoto s thyroiditis) or insufficient biopsy (nondiagnostic) (NCI 2007). Thyroid nodules are subsequently classified based on cytology, with 70% to 75% of nodules being benign and approximately 5% being malignant. Approximately 20% to 25% of thyroid nodules are classified as indeterminate and represent a significant diagnostic challenge for physicians. Genetic or genomic markers have been investigated to aid in evaluating indeterminate thyroid nodules. There are two approaches to the molecular characterization of FNA aspirates that are commercially available in the United States: identification of particular molecular markers of malignancy, such as BRAF and RAS mutational status, and use of high density genomic data for molecular classification (an FNA-trained mrna classifier) The mrna classifier measures the Tumor Makers for Cancer Apr 14 14

15 activity level of 167 genes within the nodule (using the FNA aspirate). The Afirma Gene Expression Classifier measures the expression of 142 genes to reclassify ambiguous thyroid FNA samples as either benign or suspicious for cancer. The molecular portion of the test, which involves an analysis of RNA extracted from thyroid nodule aspirates, utilizes the GEC to classify indeterminate nodules as either benign or suspicious. An analysis of an additional 25 genes is included in order to help classify rare tumor subtypes. FNA samples for both cytopathology and the Gene Expression Classifier are performed at the same visit. Patient samples submitted for the Afirma Thyroid FNA Analysis are read by specialized cytopathologists at Thyroid Cytopathology Partners (TCP), an independent group based in Austin, Texas. Veracyte believes TCP to be the largest thyroid-only cytopathology practice in the country. According to Veracyte Inc., The Afirma Thyroid FNA Analysis provides a novel solution for improved thyroid nodule assessment. This advanced offering combines specialized cytopathology with the Gene Expression Classifier (GEC) for the management of patients with thyroid nodules. The GEC reclassifies FNAs (fine needle aspirates) with indeterminate cytopathology results as either benign or suspicious for cancer. By helping physicians pre-operatively identify benign nodules (negative predictive value greater than 94%) in approximately half of patients with indeterminate cytopathology, our solution may enable clinical and sonographic follow-up for these patients in lieu of diagnostic surgery. Studies show that the risk of malignancy of a benign GEC result (less than 6%) is similar to that of a benign cytopathology diagnosis. Per NCCN (2013), Molecular diagnostics to detect individual mutations [eg. BRAF, RET/PTC, RAS, Pax8-PPAR (peroxisome proliferator-activated receptors) gamma] or pattern recognition approaches using molecular classifiers may be useful in the evaluation of FNA samples that are indeterminate. The NCCN recommends molecular diagnostics for evaluating FNA results that are suspicious for Follicular or Hurthle cell neoplasms; or follicular lesion of undetermined significance. They note, Rather than proceeding to immediate surgical resection to obtain a definitive diagnosis in these categories, patients can be followed with observation if the applications of a specific molecular diagnostic test results in a predicted risk of malignancy that is comparable to the rate seen in cytologically benign thyroid FNA. It is important to note that the predictive value of molecular diagnostics may be significantly influenced by the pre-test probability of disease associated with the various FNA cytology categories. Furthermore, in the cytologically indeterminate groups, the risk of malignancy for FNA can vary widely between institutions. Because the published studies have focused primarily on adult patients with thyroid nodules, the diagnostic utility of molecular diagnostics in pediatric patients remains to be defined. Therefore, proper implementation of molecular diagnostics into clinical care requires an understanding of both the performance characteristics of the specific molecular test and its clinical meaning across a range if pre-test probabilities. The Afirma Thyroid FNA Analysis is not specifically mentioned by name in the guidelines Guidelines from the American Association of Clinical Endocrinologists (AACE), Associazione Medici Endocrinologi (AME), and European Thyroid Association (ETA) state that molecular and immunohistochemical markers may improve the accuracy of cytologic diagnosis, but they do not have consistent predictive value for malignancy and their use is still expensive and restricted to specialized centers. On the basis of current limited evidence, routine use of molecular and immunohistochemical markers in clinical practice is not recommended and should be reserved for selected cases. The Afirma Thyroid FNA Analysis is not mentioned in the guidelines. Tumor Makers for Cancer Apr 14 15

16 The American Thyroid Association guidelines (updated 2009) reported that the use of molecular markers (e.g., BRAF, RAS, RET/PTC, Pax8-PPAR gamma, or galectin-3) may be considered for patients with indeterminate cytology on FNA to help guide management. (Recommendation rating: C I.e., The recommendation is based on expert opinion.) The guidelines do not mention genomic tests, such as the Afirma Thyroid FNA Analysis. Alexander et al (2014) analyzed all patients who had received Afirma GEC testing at five academic medical centers between 2010 and Nodule and patient characteristics, fine needle aspiration cytology, Afirma GEC results, and subsequent clinical or surgical follow-up were obtained for 339 patients. Results were analyzed for pooled test performance, impact on clinical care, and site-to-site variation. Three hundred thirty-nine patients underwent Afirma gene expression classifier (GEC) testing of cytologically indeterminate nodules [165 atypical or follicular lesion of undetermined significance (AUS/FLUS); 161 follicular neoplasm (FN); 13 suspicious for malignancy] and 174 of 339 (51%) indeterminate nodules were GEC benign, whereas 148 GEC were suspicious (44%). GEC results significantly altered care recommendations, as 4 of 175 GEC benign were recommended for surgery in comparison to 141 of 149 GEC suspicious (P<.01). Of 121 Cyto Indeterminate/GEC Suspicious nodules surgically removed, 53 (44%) were malignant. Variability in siteto-site GEC performance was confirmed, as the proportion of GEC benign varied up to 29% (P=.58), whereas the malignancy rate in nodules cytologically indeterminate/gec suspicious varied up to 47% (P=.11). Seventy-one of 174 GEC benign nodules had documented clinical follow-up for an average of 8.5 months, in which 1 of 71 nodules proved cancerous. The investigators concluded these multicenter, clinical experience data confirm originally published Afirma GEC test performance and demonstrate its substantial impact on clinical care recommendations. Although nonsignificant site-to-site variation exists, such differences should be anticipated by the practicing clinician. Follow-up of GEC benign nodules thus far confirm the clinical utility of this diagnostic test. Dedhia et al (2014) reported increasing utilization of genetic expression profiling (GEP) for thyroid nodules with indeterminate FNA results will potentially decrease the number of patients requiring diagnostic thyroidectomy.a retrospective review of thyroidectomy procedures performed over 1 year at the University of Michigan in the endocrine surgery division evaluated the indications for thyroidectomy, FNA Bethesda classification, and final surgical pathology to determine how application of GEP on indeterminate FNA results would affect decision for surgery and subsequent thyroidectomy volume. During the study period, 358 thyroidectomies were performed. The indication for procedure included: FNA findings, n = 122; symptomatic multinodular goiter, n = 85; nodule >4 cm, n = 30; Graves', n = 26; other, n = 95. FNA was performed in 231 patients. Bethesda classification included: benign, n = 69; malignant, n = 55; follicular lesion of undetermined significance, n = 59; follicular neoplasm, n = 20; suspicious for malignancy, n = 16; nondiagnostic, n = 12. If standard GEP was performed for all indeterminate FNA results, it would have influenced the decision for surgery in 68 (19 %) patients. Assuming 38 % of indeterminate FNA specimens will have benign results on genetic profiling, 27 patients would not have undergone thyroidectomy, translating into a 7.2 % decrease in overall thyroidectomy volume over a year. Reviewers concluded that in an academic endocrine surgery program, the most common indication for thyroidectomy is an FNA result; however, standard application of GEP for all indeterminate thyroid FNAs would result in a minimal reduction in overall thyroidectomy volume. Harrell and Bimston (2013) analyzed the performance of the GEC over 27 months in a community hospital-based thyroid surgery practice. Authors began using GEC and Thyroid Cytopathology Partners (TCP) exclusively for thyroid FNA analysis in 1/2011, Tumor Makers for Cancer Apr 14 16

17 shortly after the Afirma GEC first became commercially available. They focused on patients with indeterminate FNA results and the outcomes of GEC analysis, with particular attention to the calculation of the negative predictive value of the Afirma test. They performed 645 FNA's in 519 patients over 27 months. 58 of the FNA's (9%) were read as indeterminate, with 36 of these classified as suspicious by GEC (62%), 20 characterized as GEC benign (34%) and 2 determined to be inadequate due to low mrna content. Of the 36 suspicious GEC patients, 30 underwent thyroidectomy and 21 of the 30 had malignant final pathology. Of the 20 benign GEC patients, 5 underwent thyroid surgery and 2 were discovered to have malignancies. Negative predictive value for the Afirma GEC in their practice environment was 89.6%. The authors concluded in a practice with a high incidence of thyroid cancer in patients with indeterminate FNA's (33% for their practice), the negative predictive value of the Afirma GEC test may not be as robust as suggested in the literature to date. Gomberawalla and Elaraj (2014) reported multiple genetic mutations have been found to be associated with thyroid cancer, and molecular testing of thyroid nodule FNA specimens has been proposed as an adjunct to the cytologic diagnosis. The reviewers examined how molecular testing of FNAs could be used to guide surgical decision-making. B-type RAF kinase mutations in papillary thyroid cancer have been found to be associated with extrathyroidal extension, lymph node metastases, and advanced stage in two meta-analyses that are based largely on retrospective data. Testing for a panel of gene mutations has been found to have high specificity and positive predictive value, whereas microarray testing using a commercially available gene-expression classifier has been found to have high sensitivity and negative predictive value for the diagnosis of malignancy in cytologically indeterminate FNAs. Although there is no consensus regarding the use of such tests, they have already started to change clinical practice. Reviewers concluded molecular testing of FNA specimens may help to avoid diagnostic thyroidectomy or may help in deciding the extent of surgery in a patient with an indeterminate FNA biopsy. The use of these tests is currently undergoing review by a task force within the American Thyroid Association. The evidence supporting the validity and utility of the Afirma Thyroid FNA Analysis is somewhat limited, although it consistently supports the assertion that the assay may be useful as a rule out test, used to help exclude malignancy in thyroid nodules with indeterminate FNA cytology. Given its relatively high NPV (i.e., approximately 90% to 96%), the likelihood of a thyroid malignancy may be decreased significantly in many patients with indeterminate FNA biopsies. In addition, evidence supporting the clinical utility indicates that GEC results may influence medical management decisions in patients with indeterminate thyroid nodules and can lead to a significant decrease in diagnostic thyroid surgeries Scientific Rationale Update February 2014 Molecular Intelligence (MI) is a group of molecular biomarker tests provided by Caris Life Sciences, based upon a previous test, Target Now Molecular Profiling. Molecular Intelligence differs from Target Now in its methodology, which incorporates nextgeneration sequencing (NGS), and in the biomarkers analyzed. The MI profile includes immunohistochemistry (IHC), fluorescence/chromogenic in situ hybridization (FISH/CISH), next-generation sequencing (NGS), and quantitative polymerase chain reaction (qpcr) methodologies performed on formalin-fixed, paraffin-embedded (FFPE) tissues or biopsies preserved in neutral buffered formalin. Molecular Intelligence is proposed to provide information based upon literature review that associates a tumor s biomarker status with therapeutic agents that may have potential or lack of potential clinical benefit. It is proposed to identify open clinical trials relevant to particular biomarkers, with information provided in the form of a MI Tumor Makers for Cancer Apr 14 17

18 Profile Report. The MI Profile is for use in solid tumors, intended for therapeutic decision support and qualification for clinical trials in the treatment of aggressive, rare, or refractory cancers. Although Caris Molecular Intelligence is available for all solid tumors, including cancers of unknown primary, it is especially helpful when treating rare tumors or cancers with undefined standard of care, (e.g. sarcoma or glioma), aggressive cancers with few standard treatment options, (e.g. melanoma, pancreatic cancer), and difficult-to-treat cancers, such as certain metastatic and refractory diseases, e.g.(ovarian or triple-negative breast cancer). Although there are studies on molecular biomarkers, there are currently no Clinical Trials and a paucity of published peer reviewed data specifically on the Molecular Intelligence assay for cancer, therefore, it is considered investigational at this time. There is no information in NCCN Guidelines on (2014) Colon Cancer, (2014) Occult Primary Cancer, (2013) Soft Tissue Sarcoma, (2014) Melanoma, (2014) Pancreatic Cancer, (2013) Ovarian Cancer. or (2014) Breast Cancer, that specifically addresses the Molecular Intelligence assay. Scientific Rationale Initial Tumor markers are indicators of cellular, biochemical, molecular, or genetic alterations whereby neoplasia can be recognized. Tumor markers fall into three broad categories proteins, genetic mutations, and epigenetic changes (e.g., differential promoter-region methylation). The utility of tumor markers is adjunctive to medical and surgical management of malignancies, serving to help detect recurrences as well as predict prognosis. The clinical value of any given tumor marker will depend on its specificity and sensitivity as well as its intended clinical use. Serum tumor markers are currently used for screening, diagnosing, and predicting prognosis and treatment response. Use of tests for screening of disease, even those with high sensitivity and specificity, should be confined as much as possible to populations at risk for the disease. Bladder Cancer According to the National Comprehensive Cancer Network (NCCN), bladder cancer is the fourth most common cancer, occurring three times more often in men than women in the U.S. Bladder cancer is rarely diagnosed in individuals younger than 40 years. Bladder cancer is divided into three categories: non-muscle-invasive tumors, muscle invasive lesions and metastatic lesions. Prognosis, management and therapeutic aims differ among the categories. The diagnosis of bladder cancer commonly is suggested by the presence of hematuria, which may be either gross or microscopic. However, hematuria is frequently seen in a wide range of benign conditions. The diagnosis of bladder cancer ultimately requires a histologic diagnosis, which usually comes from a biopsy that is obtained at cystoscopy. Cytology may provide strong evidence for the presence of malignancy, but it has a low sensitivity and occasional false positives are reported. Urine biomarkers have potential applications in individuals in whom bladder cancer is suspected based upon the presence of hematuria, symptoms, or in whom there is an unusually high risk of tumor. Urine biomarkers may also have a role in detecting recurrences in patients who have been treated for non-muscle-invasive disease. Although cystoscopy is the gold standard for surveillance in patients with a history of bladder cancer, it does not detect all recurrences nor does it visualize the upper urinary tract. Performing a biomarker test in addition to cystoscopy may minimize the risk of missing a high grade tumor. Tumor Makers for Cancer Apr 14 18

19 A number of urine biomarkers and techniques are being evaluated. Many of these are based upon immunologic detection of soluble molecules in the urine [e.g., Bladder tumor antigen (BTA-STAT, Nuclear matrix protein 22 (NMP 22)]. Other techniques analyze exfoliated cells that are isolated from urine or bladder washings by centrifugation (e.g., UroVysion, ImmunoCyt). Per 2013 NCCN guidelines on Bladder cancer, Management of bladder cancer is based on pathologic findings of biopsy specimen, with attention to histology, grade and depth of lesion. These factors are used to estimate the probability of recurrence and progression to a more advanced stage. Consideration may be given to the FDA approved urinary biomarker testing by fluorescence in situ hybridization or nuclear matrix protein 22 in the monitoring for recurrence. NCCN guidelines on bladder cancer also state that urine molecular tests for urothelial tumor markers are now available. Most of these tests have a better sensitivity for detecting bladder cancer than urine cytology, but specificity is lower. However, it remains unclear whether these tests offer additional information that is useful for detection and management of non-muscle-invasive bladder tumors. NCCN considers this to be a 2B recommendation (i.e., Based on lower level of evidence, there is NCCN consensus that the intervention is appropriate). Miyake et al (2012) investigated the influence of hematuria on the performance of the bladder tumor antigen (BTA) tests in a clinical cohort and in an experimental model. Urine samples from a cohort of 126 subjects (64 with BCa and 62 controls) were analyzed by ELISA for hemoglobin and BTA. The experimental model involved the spiking of urine with blood from the same subject, and hemoglobin, red blood cell count, and BTA levels (BTA stat and BTA-TRAK). BTA-TRAK analyses were also performed on serum samples obtained from 40 subjects (20 with confirmed with BCa). In the 126 subject cohort, correlation between hemoglobin and BTA was Of the 64 BCa samples, 72 % had a positive BTA assay, but 47 % of controls were also positive. The sensitivity and specificity of BTA to detect BCa was 72 and 53 %, respectively. Hematuria, measured by urinary hemoglobin, was a better indicator of BCa with 75 % sensitivity and 90 % specificity. Spiking of BTA-negative urine samples with as little as 1 μl/10 ml was enough to produce a positive BTA test. High levels of BTA were found equally in the serum of subjects with or without BCa (mean BTA levels 355,159 vs. 332,329 U/ml, respectively). Investigators concluded rather than detecting a bladder tumor antigen, urinary BTA assays may be measuring serum cfh introduced by bleeding, a common presenting factor in BCa subjects. The presence of hematuria in subjects without malignant disease can result in falsepositive BTA assays. Lüdecke et al (2012) tested the suitability of three point of care (POC) test systems, UBC rapid, NMP22 BladderChek and BTA stat, available on the market, with respect to interference due to blood contamination in urine samples. Urine samples were obtained from voluntary asymptomatic individuals without a history of bladder cancer. A specimen negative in all test systems was selected for further study. This sample was treated with fresh heparinized blood in a 1:10 ratio and then titrated in a dilution series. All the urine samples and their consecutive test results were photographed and a urinalysis was performed on each sample. In none of the samples of the dilution series did UBC rapid or NMP22 BladderChek show a falsepositive result due to blood contamination. In contrast, with the BTA stat testing system, false-positive results were obtained from all samples with macrohaematuria and with densities up to 150 erythrocytes/μl, indicating a suspected tumor, whereas the sample was actually proven to be tumor free. Investigators concluded for the primary diagnosis of bladder carcinoma, neither the UBC rapid nor the NMP22 BladderChek POC test systems are sensitive to the presence of blood in the urine, whereas BTA stat consistently yields false-positive results due to cross-reactivity to Tumor Makers for Cancer Apr 14 19

20 macrohaematuria and microhaematuria up to a density of 150 erythrocytes/μl, thus this system should not be employed for this examination. Todenhöfer et al (2013) investigated whether combinations of 4 of the most broadly available tests [cytology, FISH, ucyt+, and nuclear matrix protein 22 (NMP22- ELISA)] may improve their diagnostic performance. The study was comprised of 808 patients who were suspected of having urothelial carcinoma (UC). All patients underwent urethrocystoscopy and upper urinary tract imaging and, in the case of positive findings, transurethral resection/biopsy. FISH, ucyt+, cytology, and NMP22- ELISA were performed in all patients. UC was diagnosed in 115 patients (14.2%). Cytology and FISH were found to be the single tests with the best overall performance (area under the curve [AUC], 0.78/0.79). Combinations of 2, 3, and 4 markers were found to increase the AUC to various extents compared with the use of single markers. Combining cytology and FISH improved the sensitivity and performance (AUC, 0.83) compared with the single tests and identified 12 tumors that were not detected by cytology alone. The percentage of WHO grade 3/carcinoma in situ tumors not detected by cytology was reduced by 62.5% when FISH was performed in cytology-negative patients. The addition of ucyt+ as a third test further improved performance (AUC, 0.86), whereas the addition of NMP22- ELISA was not found to have any additional influence on the performance of the test combination. Investigators concluded the results of the current study support the combined use of urine markers and may form the basis of further studies investigating whether risk stratification based on urine marker combinations may individualize diagnostic algorithms and the surveillance of patients suspected of having UC. Hatzichristodoulou et al (2012) compared nuclear matrix protein 22 expression by BladderChek and ELISA, as urine-based assays for bladder cancer (BC) detection. Urine samples of 100 BC patients and 100 controls were analyzed. Comparative statistical evaluations were based on sensitivity and specificity. Seventy-one patients had primary and 29 recurrent BC. The sensitivity of BladderChek was significantly higher compared to ELISA in the overall cancer cohort and in patients with primary BC (p< and p=0.0001, respectively). Both tests demonstrated significant correlation of sensitivities and tumor stage/grade for the overall cancer cohort and for patients with primary BC. Both tests had specificity values of 100% in healthy individuals. Specificity was 93% for BladderChek and 99% for ELISA in patients with benign diseases (p=0.048). Investigators concluded BladderChek may be clinically more useful for BC detection. Due to high specificity, BladderChek could be used for high-risk screening. However, due to its low sensitivity, BladderChek cannot replace but only complement cystoscopy for BC detection. Schlake et al (2012) compared the performance of NMP-22, urinary cytology and office cystoscopy when utilized in a urology practice for 1 year. A total of 391 consecutive office cystoscopy procedures performed over 1 year were included in the study. NMP-22 and cytology were performed on the urine specimens of patients presenting for cystoscopy. Tumor resection/bladder biopsy was performed when cystoscopy, NMP-22 or urinary cytology were abnormal. Cystoscopy, NMP-22, and urinary cytology data were available in 351 encounters and 69 tumor resections were performed. Urothelial carcinoma bladder (UCB) was identified in 37 bladder specimens. NMP-22, urinary cytology and cystoscopy demonstrated sensitivity and specificity of (51%/96%), (35%/97%), and (92%/88%), respectively. Investigators concluded the study demonstrates cystoscopy was the most sensitive test in the diagnosis of UCB. NMP-22 had a higher sensitivity than urinary cytology and similar specificity to cytology. The authors concluded additional urinary marker testing has a limited role in the management of bladder cancer in the office setting. When adjunct Tumor Makers for Cancer Apr 14 20

21 testing is desired in the diagnosis and surveillance of bladder cancer, NMP-22 is a cost effective alternative to urinary cytology. Dimashkieh et al (2013) evaluated the effectiveness of multiprobe FISH and urine cytology in detecting urothelial cell carcinoma (UC) in the same urine sample. In total, 1835 cases with the following criteria were selected: valid results from both the multiprobe FISH assay and urine cytology in the same urine sample, histologic and/or cystoscopic follow-up within 4 months of the original tests, or at least 3 years of clinical follow-up information. The results of FISH and cytology were correlated with clinical outcomes derived from a combination of histologic, cystoscopic, and clinical follow-up information. Of 1835 cases, 1045 cases were from patients undergoing surveillance of recurrent UC, and 790 were for hematuria. The overall sensitivity, specificity, positive predictive value, and negative predictive value in detecting UCC were 61.9%, 89.7%, 53.9%, and 92.4%, respectively, for FISH and 29.1%, 96.9%, 64.4%, and 87.5%, respectively, for cytology. The performance of both FISH and cytology generally was better in the surveillance population and in samples with high-grade UC. In 95 of 296 cases with atypical cytology that were proven to have UCC, 61 cases, mostly high-grade UC, were positive using the multiprobe FISH assay. Investigators concluded the UroVysion multiprobe FISH assay was more sensitive than urine cytology in detecting UC, but it produced more false-positive results. The current data suggest that the use of FISH as a reflex test after an equivocal cytologic diagnosis may play an effective role in detecting UC. Comploj et al (2013) reported the results of 7422 ucyt+/immunocyt and cytology analyses that were performed over the course of 9 years at the study institution for the evaluation and follow-up of patients with urothelial carcinoma. Between January 2002 and March 2011, 2217 patients with a mean age of 69.5 years (range, 15 years-99 years) were enrolled in the study. All patients seen for the follow-up of bladder and/or upper tract urothelial cancer as well as those with a history that was suspicious for bladder cancer were recruited. In all patients, a voided urinary cytology and ucyt+/immunocyt test was performed. Patients underwent routine cystoscopy as well as cystoscopy when cytology and/or the ucyt+/immunocyt test yielded positive results. Lesions that were detected cystoscopically were biopsied and removed transurethrally. A total of 7422 ucyt+/immunocyt and cytology analyses were performed. Of the 7422 ucyt+/immunocyt tests and cytologies that were performed, 7075 (95.3%) were considered adequate. A total of 578 patients (with 1156 analyses) underwent biopsy and 728 (63%) samples had a histologically proven urothelial carcinoma. Overall sensitivity was 34.5% for cytology, 68.1% for ucyt+/immunocyt, and 72.8% for the 2 tests combined. Overall specificity was 97.9% for cytology, 72.3% for ucyt+/immunocyt, and 71.9% for the 2 tests combined. Cytology and the ucyt+/immunocyt test together had an overall sensitivity of 72.8%, with 59% for grade 1, 77% for grade 2, and 90% for grade 3 tumors (according to the 1973 World Health Organization grading classification system). Investigators concluded on the basis of their 9-year experience, the value of ucyt+/immunocyt and cytology analyses in the follow-up of patients with nonmuscle-invasive urothelial cancer is confirmed. This could potentially reduce the number and cost of routine cystoscopic examinations in patients who are followed for bladder carcinoma. Breast Cancer Per the NCCN, breast cancer is the most common malignancy in women in the U.S. and is second only to lung cancer as a cause of cancer death. Routine pathologic evaluation remains the most critical element in determining the prognosis of patients with breast cancer. Among the most potent prognostic factors available are lymph node status, tumor size and histologic grade, histologic tumor type, and lymphatic vascular invasion. Tumor Makers for Cancer Apr 14 21

22 Assay of hormone receptors has become a routine part of the evaluation of breast cancers, since the results predict the clinical response to hormone therapy, both in the adjuvant setting and for those with metastatic disease. Along with ER and PR, the determination of HER2 tumor status for all newly diagnosed invasive breast cancers and for first recurrences of breast cancer whenever possible if previously unknown or negative. Hormone receptor expression should be used to guide endocrine therapy decisions. HER2 expression should be used to select patients for whom HER2-directed therapy use is appropriate in the metastatic and adjuvant setting. (Refer to Medical Policy HER2neu ) Gene expression profiling has identified molecular signatures, such as the 21-gene recurrence score [Oncotype Dx, the Amsterdam 70-gene prognostic profile (Mammaprint), and the Rotterdam/Veridex 76-gene signature] are used in addition to conventional prognostic indicators in their ability to predict breast cancer outcome and response to treatment. (Refer to Medical Policy, Oncotype DX for Cancer and MammaPrint for additional information.) Monitoring of patients symptoms and cancer burden during treatment of metastatic breast disease is important to determine whether the treatment is providing benefit and that the patient does not have toxicity from an ineffective therapy. Increasing tumor markers (CEA, CA 15-3 and CA 27.29) are findings that are concerns for progression of disease, but may also be seen in the setting of responding disease. An isolated increase in tumor markers should rarely be used to declare progression of disease. Changes in bone lesions are often difficult to assess on plain or crosssectional radiology or on bone scan. For these reasons, patient symptoms and serum tumor markers may be more helpful in patients with bone-dominant metastatic disease. Hepatocellular Carcinoma (HCC) Hepatocellular carcinoma (HCC) is a highly lethal carcinoma. Risk factors for developing HCC include viral infections caused by Hepatitis B virus (HBV) and/or hepatitis C virus (HCV), alcoholic cirrhosis, and rarely inherited errors of metabolism. Diagnostic testing used to diagnose HCC include imaging, biopsy and AFP serology. Serum AFP has long been used as a marker for HCC, however, it is not a sensitive or specific diagnostic test for HCC, as values > 400ng/ml which are considered diagnostic of HCC, are observed only in a small percentage of individuals. AFP can be useful in conjunction with other testing to guide management of individuals for whom a diagnosis of HCC is suspected. Prostate Cancer NCCN reports that a fine balance exists between maximizing early detection of potentially curable cancers and minimizing the cost, anxiety and treatment burden associated with diagnosis of indolent tumors. NCCN states their recommendations on Prostate cancer are not population screening guidelines but rather a set of recommendations to aid men who have chosen to engage in early detection of prostate cancer. When the first recommendations for early detection programs for prostate cancer were made, serum total PSA was the only PSA-based test available. Subsequent years have seen the development of a series of PSA derivatives that are possible useful in increasing specificity and decreasing unnecessary biopsies. Many commercially available serum total PSA testing are currently available. They perform comparably, however, the levels are not interchangeable since they Tumor Makers for Cancer Apr 14 22

23 standardized against two different standards. An abnormal PSA result should be confirmed by retesting. Studies have shown that a PSA level above 4ng/ml increases the chance of detecting prostate cancer at prostate biopsy to nearly 30%-35%. Large programs for the early detection of prostate cancer have shown that nearly 70% of cancer cases can be detected using a PSA cutoff level of 4ng/ml in the first four years. Overall, appropriate use of PSA alone can provide a diagnostic lead time of nearly 5-10 years compared with digital rectal exam (DRE). Unbound or free PSA (fpsa) expressed as a ratio of total PSA has emerged as a clinically useful molecular form of PSA, with the potential to provide improvements in early detection, staging, and monitoring of prostate cancer. Most clinical work investigating the use of molecular forms of PSA for early detection of prostate cancer has focused on the percentage of PSA found circulating in the free or unbound form. Numerous studies have shown that the percentage of fpsa is significantly lower in men who have prostate cancer compared to men who have not. The U.S. Food and Drug Administration (FDA) approved the use of percent-free PSA for the early detection of prostate cancer in men with PSA levels between 4-10 ng/ml. Since the FDA approval, testing for percent free PSA has gained widespread clinical acceptance in the U.S., specifically for patients with normal DRE s who have previously undergone prostate biopsy because they had a total PSA level within the diagnostic grey zone. NCCN guidelines recommend the use of the percent-free PSA as an alternative in the management of patients with normal DREs and total PSA levels between 4-10ng/mL if there is a relative contraindication to biopsy. Physicians and patients electing to use percent-free PSA should be cautioned that this assay and the multi-institutional study performed to obtain its FDA approval were designed with the intention of avoiding unnecessary biopsies in men with a high likelihood of not having prostate cancer. Afirma Thyroid FNA Analysis The evaluation of thyroid nodules, typically includes a cytopathological examination of a biopsy specimen obtained by fine-needle aspiration (FNA), however, approximately 20% to 25% are classified as indeterminate. Evaluation of patients with indeterminate results on FNA often includes surgical resection of the nodule or the entire thyroid gland. Most patients will prove to be benign after evaluation of the surgical thyroid tissue specimen. In an effort to help resolve the diagnostic ambiguity of indeterminate thyroid nodules, recent studies have sought to identify genetic or genomic markers that may aid in differentiating benign and malignant thyroid tumors. The Afirma Thyroid FNA Analysis (Veracyte Inc.) is a recently developed test that examines the expression of genes known to be involved in cell growth, in order to identify indeterminate thyroid nodules with expression patterns characteristic of benign thyroid lesions. In the analysis, a proprietary gene expression classifier (GEC) is used to categorize nodules as either benign or suspicious. According to Veracyte Inc., the primary goal of this assay is to identify patients who likely have benign thyroid masses so that they may avoid unnecessary thyroid surgery. The Afirma Thyroid FNA Analysis (Veracyte Inc.) includes a standard cytopathological evaluation of FNA specimens and an expression analysis of 142 genes in nodules with indeterminate FNA cytopathology. The molecular portion of the test, which involves an analysis of RNA extracted from thyroid nodule aspirates, utilizes the GEC to classify indeterminate nodules as either benign or suspicious. An analysis of an additional 25 genes is included in order to help classify rare tumor subtypes. The Afirma Thyroid FNA Analysis is intended for adults (21 years of age or Tumor Makers for Cancer Apr 14 23

24 older) with thyroid nodules at least 1 centimeter (cm) in size, who are being evaluated for the possibility of a thyroid malignancy. At this time, the data regarding the Afirma Thyroid FNA Analysis is too limited to draw meaningful conclusions about the performance and value of this assay in patients with thyroid nodules. While the available evidence suggests that the test has a high negative predictive value (NPV) and may lead to a reduction in diagnostic surgeries for benign thyroid nodules, additional evidence supporting its analytical validity, clinical validity, and clinical utility is needed. Duick et al (2012) evaluated how the Afirma gene expression classifier (AGEC) impacted the joint decision of the endocrinologist and patient to operate when FNA cytology was indeterminate, but the AGEC reading of the nodule was benign. In this cross-sectional cohort study, data were contributed retrospectively by 51 endocrinologists at 21 practice sites that had previously obtained 3 benign AGEC readings in 1cm nodules with indeterminate FNA cytology readings. Information regarding demographic data, nodule size and location, decision to operate, surgery type (hemithyroidectomy [HT] or total thyroidectomy [TT]), and reason for recommending surgery was retrospectively collected. Compared to a 74% previous historical rate of surgery for cytologically indeterminate nodules, the operative rate fell to 7.6% during the period that AGEC were obtained in the clinical practices, a highly significant reduction in the decision to operate (p<0.001). The rate of surgery on cytologically indeterminate nodules that were benign by the AGEC reading did not differ from the historically reported rate of operation on cytologically benign nodules (p=0.41). The four primary reasons reported by the physicians for operating on nodules with a benign AGEC reading, in descending order: large nodule size (46.4%), symptomatic nodules (25.0%), rapidly growing nodules (10.7%), or a second suspicious or malignant nodule in the same patient (10.7%). These reasons are concordant with those typically given for operation on cytologically benign nodules. Investigators concluded in a substantial group of medical practices, obtaining an AGEC test in patients with cytologically indeterminate nodules was associated with a striking reduction in the rate of diagnostic thyroidectomy. Approximately, one surgery was avoided for every two AGEC tests run on thyroid FNAs with indeterminate cytology. In a study funded by Veracyte, Alexander et al (2012) performed a 19-month, prospective, multicenter validation study involving 49 clinical sites, 3789 patients, and 4812 fine-needle aspirates from thyroid nodules 1 cm or larger that required evaluation. The investigators obtained 577 cytologically indeterminate aspirates, 413 of which had corresponding histopathological specimens from excised lesions. Results of a central, blinded histopathological review served as the reference standard. After inclusion criteria were met, a gene-expression classifier was used to test 265 indeterminate nodules in this analysis, and its performance was assessed. Of the 265 indeterminate nodules, 85 were malignant. The gene-expression classifier correctly identified 78 of the 85 nodules as suspicious (92% sensitivity; 95% confidence interval [CI], 84 to 97), with a specificity of 52% (95% CI, 44 to 59). The negative predictive values for "atypia (or follicular lesion) of undetermined clinical significance," "follicular neoplasm or lesion suspicious for follicular neoplasm," or "suspicious cytologic findings" were 95%, 94%, and 85%, respectively. Analysis of 7 aspirates with false negative results revealed that 6 had a paucity of thyroid follicular cells, suggesting insufficient sampling of the nodule. Investigators concluded the data suggest consideration of a more conservative approach for most patients with thyroid nodules that are cytologically indeterminate on fine-needle aspiration and benign according to gene-expression classifier results. Tumor Makers for Cancer Apr 14 24

25 Chudova et al (2010) set out to develop a molecular test that distinguishes benign and malignant thyroid nodules using fine-needle aspirates (FNA). Investigators used mrna expression analysis to measure more than 247,186 transcripts in 315 thyroid nodules, comprising multiple subtypes. The data set consisted of 178 retrospective surgical tissues and 137 prospectively collected FNA samples. Two classifiers were trained separately on surgical tissues and FNAs. The performance was evaluated using an independent set of 48 prospective FNA samples, which included 50% with indeterminate cytopathology. Performance of the tissue-trained classifier was markedly lower in FNAs than in tissue. Exploratory analysis pointed to differences in cellular heterogeneity between tissues and FNAs as the likely cause. The classifier trained on FNA samples resulted in increased performance, estimated using both 30- fold cross-validation and an independent test set. On the test set, negative predictive value and specificity were estimated to be 96 and 84%, respectively, suggesting clinical utility in the management of patients considering surgery. Using in silico and in vitro mixing experiments, investigators demonstrated that even in the presence of 80% dilution with benign background, the classifier can correctly recognize malignancy in the majority of FNA samples. Investigators concluded the FNA-trained classifier was able to classify an independent set of FNAs in which substantial RNA degradation had occurred and in the presence of blood. High tolerance to dilution makes the classifier useful in routine clinical settings where sampling error may be a concern. An ongoing multicenter clinical trial will allow us to validate molecular test performance on a larger independent test set of prospectively collected thyroid FNAs. Target Now Molecular Profiling Test According to manufacturer s website, (Caris life Sciences) the Target Now Molecular Profiling Test is designed to evaluate the tumors of patients who have exhausted standard-of care-therapies in order to determine potential treatment options based on biomarkers identified within the tumor. Target Now uses formalin-fixed, paraffinembedded (FFPE) and/or frozen tumor specimens and a combination of immunohistochemistry (IHC), gene expression microarray, and targeted gene variant analysis, to establish a molecular profile of the tumor. This information is then used as the basis of a literature review to recommend potential therapies. The Target Now test is available as either Target Now Select, which focuses the analysis on five cancer types [non-small cell lung cancer (NSCLC), breast, colorectal, melanoma, and ovarian surface epithelial] or Target Now Comprehensive, which is a broader molecular profile. Von Hoff et al (2010) describing the use of the test describes molecular profiling in 86 patients with refractory metastatic cancer. Both FFPE and fresh frozen tissue specimens were required for the analysis. A molecular target was detected in 84 (98%) patients. Of these patients, 66 (78.6%) were treated according to the molecular profile results, with 18 (27%) having a progression-free survival (PFS) ratio (defined as PFS on molecular profile selected therapy divided by PFS on prior therapy) of 1.3 (95% confidence interval, 17% to 38%; P=0.007). The authors interpreted these results to suggest that using a molecular profile to guide cancer therapy resulted in a longer PFS than prior therapy in a significant proportion of patients. However, given the small study population and the fact that these results have not been replicated in an independent dataset, there is currently insufficient evidence to evaluate the use of the Target Now Molecular Profiling Test in guiding treatment decisions in cancer patients. ColoNext The ColoNext test (Ambry Genetics) is a next-generation sequencing panel that tests for variants in 14 genes that have been associated with hereditary colorectal cancer (CRC), including the genes that cause Lynch syndrome (MLH1, MSH2, MSH6, and PMS2) and the gene that causes familial adenomatous polyposis (FAP) (APC). While testing these genes may be appropriate in individuals with clinical or family histories that suggest a specific syndrome, there is no evidence that mass screening of all 14 Tumor Makers for Cancer Apr 14 25

26 genes in individuals suspected of having or being at risk for a hereditary CRC syndrome has an impact on clinical outcomes. Therefore, it is currently not possible to assess the use of the ColoNext test in the care of such individuals. DecisionDx-GBM The DecisionDx-GBM test (Castle Biosciences Inc.) is a multigene expression assay that is designed to predict which patients are likely to experience long-term (> 2 years) progression-free survival (PFS). According to the manufacturer s website, GBM specimens from four datasets were used to identify an initial set of 200 genes that were differentially expressed in long-term survivors. From these, 38 genes that were robustly associated with survival were validated in an independent dataset and a final group of 9 genes was identified. These 9 genes are: aquaporin 1 (AQP1), chitinase 3-like 1 (CHI3L1), epithelial membrane protein 3 (EMP-3), glycoprotein NMB (GPNMB), insulin-like growth factor binding protein 2 (IGFBP2), galectin 3 (LGALS3), oligodendrocyte lineage transcription factor 2 (OLIG2), podoplanin (PDPN), and reticulon 1 (RTN1). Three control genes were also identified: eukaryotic translation elongation factor 1, alpha-1 (EEF1A1); beta-glucoronidase (GUSB); and ribosomal protein S27 (RPS27). The 9 genes and 3 control genes were then validated in a third dataset. Expression of the 9 genes was found through multivariate analysis to be an independent predictor of PFS (Cox hazard ratio [HR], 2.7; P=0.0003) and overall survival (Cox HR, 2.7; P=0.0003) compared with age, performance score, and methylation status of the methylguanine methyltransferase gene (MGMT). MGMT methylation has been previously reported to be an independent predictor of response of GBM to radiation and chemotherapy. MGMT methylation was not found to be an independent predictor of survival in the DecisionDx-GBM validation studies. There is currently insufficient evidence to evaluate the performance and clinical utility of this test in the care of patients with GBM. The NCCN does not address DecisionDx-GBM test in their guidelines on Central Nervous System Cancers. The DecisionDx-UM The DecisionDx-UM (Castle Biosciences Inc.) test is a gene expression profiling test intended for use in patients with uveal melanoma (UM). It is a 15-gene polymerase chain reaction (PCR)-based assay that stratifies UM patients into two classes based on the molecular signature of tumor tissue. There is very limited published literature investigating the DecisionDx-UM test. Long term studies, preferably prospective in nature, with large study populations are needed to clearly define molecular classes of UM and adequately assess the relationship between tumor class and metastasis. There is lack of direct evidence of clinical utility and very low evidence of analytical validity and clinical validity of the test. In a prospective, multicenter study, Onken et al (2012) evaluated the prognostic performance of a 15 gene expression profiling (GEP) assay that assigns primary posterior uveal melanomas to prognostic subgroups: class 1 (low metastatic risk) and class 2 (high metastatic risk). A total of 459 patients with posterior uveal melanoma were enrolled from 12 independent centers. Tumors were classified by GEP as class 1 or class 2. The first 260 samples were also analyzed for chromosome 3 status using a single nucleotide polymorphism assay. Net reclassification improvement analysis was performed to compare the prognostic accuracy of GEP with the 7th edition clinical Tumor-Node-Metastasis (TNM) classification and chromosome 3 status. Patients were managed for their primary tumor and monitored for metastasis. The GEP assay successfully classified 446 of 459 cases (97.2%). The GEP was class 1 in 276 cases (61.9%) and class 2 in 170 cases (38.1%). Median follow-up was 17.4 months (mean, 18.0 months). Metastasis was detected in 3 class 1 cases (1.1%) and 44 class 2 cases (25.9%) (log-rank test, P<10(-14)). Although there was an association between GEP class 2 and monosomy 3 (Fisher exact test, P<0.0001), 54 of 260 tumors (20.8%) were discordant for GEP Tumor Makers for Cancer Apr 14 26

27 and chromosome 3 status, among which GEP demonstrated superior prognostic accuracy (log-rank test, P = ). By using multivariate Cox modeling, GEP class had a stronger independent association with metastasis than any other prognostic factor (P<0.0001). Chromosome 3 status did not contribute additional prognostic information that was independent of GEP (P = 0.2). At 3 years follow-up, the net reclassification improvement of GEP over TNM classification was 0.43 (P = 0.001) and 0.38 (P = 0.004) over chromosome 3 status. Investigators concluded the GEP assay had a high technical success rate and was the most accurate prognostic marker among all of the factors analyzed. The GEP provided a highly significant improvement in prognostic accuracy over clinical TNM classification and chromosome 3 status. Chromosome 3 status did not provide prognostic information that was independent of GEP. Direct-to-consumer (DTC) Genetic tests Direct-to-consumer (DTC) genetic tests, also known as at-home genetic tests, are marketed and sold directly to the customer without a doctor's order or a consultation with a genetic counselor. In recent years, the tests have become more accessible as many new genetic testing companies have emerged. Although direct-to-consumer genetic testing may promote awareness of genetic diseases, allow consumers to take a more proactive role in their health care, and offer a means for people to learn about their ancestral origins, these tests have significant risks and limitations. Consumers are vulnerable to being misled by the results of unproven or invalid tests. Without guidance from a healthcare provider, they may make important decisions about treatment or prevention based on inaccurate, incomplete, or misunderstood information about their health. More research is needed to fully understand the benefits and limitations of direct-toconsumer genetic testing. According to the National Cancer Institute, individuals are considered to be candidates for cancer risk assessment if they have a personal and/or family history (maternal or paternal lineage) with features suggestive of hereditary cancer. These features vary by type of cancer and specific hereditary syndrome. Genetic testing may be considered when the following factors are present: An individual's personal history (including ethnicity) and/or family history is suspicious for a genetic predisposition to cancer. The genetic test has sufficient sensitivity and specificity to be interpreted. The test will impact the individual's diagnosis, cancer management or cancer risk management, and/or help clarify risk in family members. A candidate for genetic testing receives genetic education and counseling before testing to facilitate informed decision making and adaptation to the risk or condition. Genetic education and counseling gives an individual time to consider the various medical uncertainties, diagnosis, or medical management based on varied test results, and the risks, benefits, and limitations of genetic testing. Review History July 2013 February 2014 April 2014 Medical Advisory Council, initial approval Update. Added Molecular Intelligence as investigational. Updated Codes. Added Afirma Thyroid FNA Analysis as medically necessary for adults with thyroid nodules at least 1 centimeter in size, that are indeterminate and who are being evaluated for the possibility of a thyroid malignancy. Code updates. Tumor Makers for Cancer Apr 14 27

28 This policy is based on the following evidence-based guidelines: 1. American College of Medical Genetics. ACMG Statement on Direct-to-Consumer Genetic Testing. April Basch E, Oliver TK, Vickers A, et al. Screening for prostate cancer with prostatespecific antigen testing: American Society of Clinical Oncology Provisional Clinical Opinion. J Clin Oncol Aug 20;30(24): Available at: 3. Gilligan TD, Hayes DF, Seidenfeld J, Temin S. ASCO Clinical Practice Guideline on Uses of Serum Tumor Markers in Adult Males With Germ Cell Tumors. J Oncol Pract Jul;6(4): Available at: 4. Harris L, Fritsche H, Mennel R, et al. American Society of Clinical Oncology 2007 update of recommendations for the use of tumor markers in breast cancer. J Clin Oncol Nov 20;25(33): Available at: update-recommendations-use-tumor-markers 5. Hayes Genetic Test Overview. GTE Report. Afirma Thyroid FNA Analysis. Aug Update Feb Hayes Genetic Test Overview. GTE Synopsis. Target Now Molecular Profiling Test (Caris Life Sciences). Sept Hayes Genetic Test Overview. GTE Synopsis. ColoNext. June Hayes Genetic Test Overview. GTE Synopsis. DecisionDx-GBM. Oct Hayes Genetic Test Overview. GTE Report. DecisionDx-UM Gene Expression Assay for Risk Stratification of Patients with Uveal Melanoma. Dec Update Apr Hayes Medical Technology Directory. Ancillary ImmunoCyt/uCyt+ Testing for Bladder Cancer Screening and Detection. Sept Update Sept Hayes Medical Technology Directory. Ancillary UroVysion Fluorescence In Situ Hybridization (FISH) Testing for Bladder Cancer Screening and Detection. Jul Update Jul Locker GY, Hamilton S, Harris J, et al. ASCO 2006 update of recommendations for the use of tumor markers in gastrointestinal cancer. J Clin Oncol Nov 20;24(33): Available at: update-recommendations-use-tumor-markers-gastrointestinal-cancer 13. National Cancer Institute. Cancer Genetics Risk Assessment and Counseling. (PDQ)last modified June Available at: National Comprehensive Care Network. NCCN Clinical Practice Guidelines in Oncology. Bladder Cancer. Version National Comprehensive Care Network. NCCN Clinical Practice Guidelines in Oncology. Breast Cancer. Version Updated Version National Comprehensive Care Network. NCCN Clinical Practice Guidelines in Oncology. Central Nervous System cancers. Version National Comprehensive Care Network. NCCN Clinical Practice Guidelines in Oncology. Genetic/Familial High-Risk Assessment: Breast and Ovarian. Version National Comprehensive Care Network. NCCN Clinical Practice Guidelines in Oncology. Multiple Myeloma. Version National Comprehensive Care Network. NCCN Clinical Practice Guidelines in Oncology. Non-Hodgkin s Lymphomas. Version National Comprehensive Care Network. NCCN Clinical Practice Guidelines in Oncology. Neuroendocrine Tumors. Version Tumor Makers for Cancer Apr 14 28

29 21. National Comprehensive Care Network. NCCN Clinical Practice Guidelines in Oncology. Occult Primary. Version I Updated Version 1, National Comprehensive Care Network. NCCN Clinical Practice Guidelines in Oncology. Ovarian Cancer. Version National Comprehensive Care Network. NCCN Clinical Practice Guidelines in Oncology. Pancreatic Adenocarcinoma. Version Updated Version 1, National Comprehensive Care Network. NCCN Clinical Practice Guidelines in Oncology. Prostate Cancer Early Detection. Version Updated Version National Comprehensive Care Network. NCCN Clinical Practice Guidelines in Oncology. Testicular Cancer. Version I National Comprehensive Care Network. NCCN Clinical Practice Guidelines in Oncology. Thyroid Carcinoma. Version National Comprehensive Care Network. NCCN Clinical Practice Guidelines in Oncology. Uterine Neoplasms. Version I Society of Gynecologic Oncology. Use of CA125 for Monitoring Ovarian Cancer. June Available at: 2/use-of-ca125-for-monitoring-ovarian-cancer/ 29. Hayes. Genetic Test Evaluation (GTE). Molecular Intelligence for Colorectal Cancer (CRC) (Caris Life Sciences). January 15, National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology. Colon Cancer. Version 2, National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology. Soft Tissue Sarcoma. Version National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology. Melanoma. Version Gharib H, Papini E, Paschke R, Duick DS, Valcavi R, Hegedus L, Vitti P, AACE/AME/ETA Task Force on Thyroid Nodules. American Association of Clinical Endocrinologists, Associazione Medici Endocrinologi, and European Thyroid Association medical guidelines for clinical practice for the diagnosis and management of thyroid nodules. Endocr Pract May-Jun;16(Suppl 1):1-43. Available at: American Thyroid Association (ATA) Guidelines Taskforce on Thyroid Nodules, Cooper DS, Doherty GM, Haugen BR, Kloos RT, Lee SL, Mandel SJ, Mazzaferri EL, McIver B, Pacini F, Schlumberger M, Sherman SI, Steward DL, Tuttle RM. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid Nov;19(11): Available at: References Update April Alexander EK, Schorr M, Klopper J, et al. Multicenter clinical experience with the Afirma gene expression classifier. J Clin Endocrinol Metab Jan;99(1): Dedhia PH, Rubio GA, Cohen MS, et al. Potential effects of molecular testing of indeterminate thyroid nodule fine needle aspiration biopsy on thyroidectomy volume. World J Surg Mar;38(3): Gomberawalla A, Elaraj DM. How to use molecular testing results to guide surgery: a surgeon's perspective. Curr Opin Oncol Jan;26(1): Harrell RM, Bimston DN. Surgical Utility of Afirma: Effects of High Cancer Prevalence and Oncocytic Cell Types in Patients with Indeterminate Thyroid Cytology. Endocr Pract Nov 18:1-16. References Updated February 2014 Tumor Makers for Cancer Apr 14 29

30 1. Caris Molecular Intelligence. Frequently asked questions for Physicians. Available at: 2. Kim, et al. The BATTLE trial: personalizing therapy for lung cancer. Cancer Discov Jun;1(1): Epub 2011 Jun Tsimberidou AM, et al. Clin Cancer Res Sep Von Hoff, et al. Pilot study using molecular profiling of patients tumors to find potential targets and select treatments for their refractory cancers. J Clin Oncol Nov 20;28(33): Epub 2010 Oct 4. References Initial 1. Ahn JS, Kim HS, Chang SG, Jeon SH. The clinical usefulness of nuclear matrix protein-22 in patients with atypical urine cytology. Korean J Urol Sep;52(9): Alexander EK, Kennedy GC, Baloch ZW, et al. Preoperative diagnosis of benign thyroid nodules with indeterminate cytology. N Engl J Med. 2012;367(8): Ali SZ Md, Fish SA Md, Lanman R Md, et al. Use of the Afirma Gene Expression Classifier for Preoperative Identification of Benign Thyroid Nodules with Indeterminate Fine Needle Aspiration Cytopathology. PLoS Curr Feb 11;5. 4. Allingham-Hawkins D, Lea A, Levine S. DecisionDx-GBM Gene Expression Assay for Prognostic Testing in Glioblastoma Multiform. PLoS Curr Oct 12 [revised 2010 Nov 26];2:RRN Barbieri CE, Cha EK, Chromecki TF, et al. Decision curve analysis assessing the clinical benefit of NMP22 in the detection of bladder cancer: secondary analysis of a prospective trial. BJU Int Mar;109(5): Bonberg N, Taeger D, Gawrych K, et al. Chromosomal instability and bladder cancer: the UroVysion(TM) test in the UroScreen study. BJU Int Jan Budman LI, Kassouf W, Steinberg JR. Biomarkers for detection and surveillance of bladder cancer. Can Urol Assoc J Jun;2(3): Chudova D, Wilde JI, Wang ET, et al. Molecular classification of thyroid nodules using high-dimensionality genomic data. J Clin Endocrinol Metab. 2010;95(12): Cook SA, Damato B, Marshall E, Salmon P. Psychological aspects of cytogenetic testing of uveal melanoma: preliminary findings and directions for future research. Eye (Lond). 2009;23(3): Comploj E, Mian C, Ambrosini-Spaltro A, Dechet C, et al. ucyt+/immunocyt and cytology in the detection of urothelial carcinoma: An update on 7422 analyses. Cancer Cytopathol Mar Couturier J, Saule S. Genetic determinants of uveal melanoma. Dev Ophthalmol. 2012;49: Dimashkieh H, Wolff DJ, Smith TM, et al. Evaluation of urovysion and cytology for bladder cancer detection: A study of 1835 paired urine samples with clinical and histologic correlation. Cancer Cytopathol Jun Duick DS, Klopper JP, Diggans JC, et al. The impact of benign gene expression classifier test results on the endocrinologist-patient decision to operate on patients with thyroid nodules with indeterminate fine-needle aspiration cytopathology. Thyroid Oct;22(10): Feil G, Stenzl A. Tumor marker tests in bladder cancer. Actas Urol Esp Jan;30(1): Gill HS, Char DH. Uveal melanoma prognostication: from lesion size and cell type to molecular class. Can J Ophthalmol Jun;47(3): Harbour JW. Molecular prognostic testing and individualized patient care in uveal melanoma. Am J Ophthalmol. 2009;148(6): Harbour JW. Genomic, prognostic, and cell-signaling advances in uveal melanoma. Am Soc Clin Oncol Educ Book. 2013;2013: Tumor Makers for Cancer Apr 14 30

31 18. Harbour JW, Chen R. The DecisionDx-UM Gene Expression Profile Test Provides Risk Stratification and Individualized Patient Care in Uveal Melanoma. PLoS Curr Apr 9;5. pii: ecurrents.eogt.af8ba80fc776c8f1ce8f5dc485d4a Hatzichristodoulou G, Kübler H, Schwaibold H, et al. Nuclear matrix protein 22 for bladder cancer detection: comparative analysis of the BladderChek and ELISA. Anticancer Res Nov;32(11): Hosseini J, Golshan AR, Mazloomfard MM, et al. Detection of recurrent bladder cancer: NMP22 test or urine cytology? Urol J Winter;9(1): Hwang EC, Choi HS, Jung SI, Kwon, et al. Use of the NMP22 BladderChek test in the diagnosis and follow-up of urothelial cancer: a cross-sectional study. Urology Jan;77(1): Huber S, Schwentner C, Taeger D, et al. Nuclear matrix protein-22: a prospective evaluation in a population at risk for bladder cancer. Results from the UroScreen study. BJU Int Sep;110(5): Kehinde EO, Al-Mulla F, Kapila K, Anim JT. Comparison of the sensitivity and specificity of urine cytology, urinary nuclear matrix protein-22 and multitarget fluorescence in situ hybridization assay in the detection of bladder cancer. Scand J Urol Nephrol Mar;45(2): Kloos RT, Reynolds JD, Walsh PS, et al. Does addition of BRAF V600E mutation testing modify sensitivity or specificity of the Afirma Gene Expression Classifier in cytologically indeterminate thyroid nodules? J Clin Endocrinol Metab Apr;98(4):E Lotan Y, Shariat SF, Schmitz-Dräger BJ, et al. Considerations on implementing diagnostic markers into clinical decision making in bladder cancer. Urol Oncol Jul-Aug;28(4): Lüdecke G, Pilatz A, Hauptmann A, et al. Comparative analysis of sensitivity to blood in the urine for urine-based point-of-care assays (UBC rapid, NMP22 BladderChek and BTA-stat) in primary diagnosis of bladder carcinoma. Interference of blood on the results of urine-based POC tests. Anticancer Res May;32(5): Malkhasian KA, Petrov SV, Ul'ianin MIu, et al. Use of fluorescent in situ hybridization in the cytogenetic diagnosis of urinary bladder urothelial carcinoma. Vopr Onkol. 2011;57(4): Miyake M, Goodison S, Rizwani W, et al. Urinary BTA: indicator of bladder cancer or of hematuria. World J Urol Dec;30(6): Onken MD, Worley LA, Char DH, et al. Collaborative Ocular Oncology Group report number 1: prospective validation of a multi-gene prognostic assay in uveal melanoma. Ophthalmology Aug;119(8): Onken MD, Worley LA, Dávila RM, et al. Prognostic testing in uveal melanoma by transcriptomic profiling of fine needle biopsy specimens. J Mol Diagn. 2006a;8(5): Onken MD, Worley LA, Ehlers JP, Harbour JW. Gene expression profiling in uveal melanoma reveals two molecular classes and predicts metastatic death. Cancer Res. 2004;64(20): Onken MD, Worley LA, Harbour JW. Association between gene expression profile, proliferation and metastasis in uveal melanoma. Curr Eye Res. 2010a;35(9): Onken MD, Worley LA, Tuscan MD, Harbour JW. An accurate, clinically feasible multi-gene expression assay for predicting metastasis in uveal melanoma. J Mol Diagn. 2010b;12(4): O'Sullivan P, Sharples K, Dalphin M, et al. A multigene urine test for the detection and stratification of bladder cancer in patients presenting with hematuria. J Urol Sep;188(3): Raitanen MP; FinnBladder Group. The role of BTA stat Test in follow-up of patients with bladder cancer: results from FinnBladder studies. World J Urol Feb;26(1): Tumor Makers for Cancer Apr 14 31

32 36. Schlake A, Crispen PL, Cap AP, et al. NMP-22, urinary cytology, and cystoscopy: a 1 year comparison study. Can J Urol Aug;19(4): Seo S, Cho S, Hong K, Shim B, Kwon S. Usefulness of NMP22 BladderChek for the diagnosis and monitoring of bladder cancer. Korean J Lab Med Feb;27(1): Srivastava R, Arora VK, Aggarwal S, et al. Cytokeratin-20 immunocytochemistry in voided urine cytology and its comparison with nuclear matrix protein-22 and urine cytology in the detection of urothelial carcinoma. Diagn Cytopathol Sep;40(9): Shariat SF, Savage C, Chromecki TF, et al. Assessing the clinical benefit of nuclear matrix protein 22 in the surveillance of patients with nonmuscle-invasive bladder cancer and negative cytology: a decision-curve analysis. Cancer Jul 1;117(13): Todenhöfer T, Hennenlotter J, Esser M, et al. Combined application of cytology and molecular urine markers to improve the detection of urothelial carcinoma. Cancer Cytopathol May;121(5): Von Hoff DD, Stephenson JJ Jr, Rosen P, et al. Pilot study using molecular profiling of patients' tumors to find potential targets and select treatments for their refractory cancers. J Clin Oncol Nov 20;28(33): Ward LS, Kloos RT. Molecular markers in the diagnosis of thyroid nodules. Arq Bras Endocrinol Metabol Mar;57(2): Important Notice General Purpose. Health Net's National Medical Policies (the "Policies") are developed to assist Health Net in administering plan benefits and determining whether a particular procedure, drug, service or supply is medically necessary. The Policies are based upon a review of the available clinical information including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the drug or device, evidence-based guidelines of governmental bodies, and evidence-based guidelines and positions of select national health professional organizations. Coverage determinations are made on a case-by-case basis and are subject to all of the terms, conditions, limitations, and exclusions of the member's contract, including medical necessity requirements. Health Net may use the Policies to determine whether under the facts and circumstances of a particular case, the proposed procedure, drug, service or supply is medically necessary. The conclusion that a procedure, drug, service or supply is medically necessary does not constitute coverage. The member's contract defines which procedure, drug, service or supply is covered, excluded, limited, or subject to dollar caps. The policy provides for clearly written, reasonable and current criteria that have been approved by Health Net s National Medical Advisory Council (MAC). The clinical criteria and medical policies provide guidelines for determining the medical necessity criteria for specific procedures, equipment, and services. In order to be eligible, all services must be medically necessary and otherwise defined in the member's benefits contract as described this "Important Notice" disclaimer. In all cases, final benefit determinations are based on the applicable contract language. To the extent there are any conflicts between medical policy guidelines and applicable contract language, the contract language prevails. Medical policy is not intended to override the policy that defines the member s benefits, nor is it intended to dictate to providers how to practice medicine. Policy Effective Date and Defined Terms. The date of posting is not the effective date of the Policy. The Policy is effective as of the date determined by Health Net. All policies are subject to applicable legal and regulatory mandates and requirements for prior notification. If there is a discrepancy between the policy effective date and legal mandates and regulatory requirements, the requirements of law and regulation shall govern. * In some states, new or revised policies require prior notice or posting on the website before a policy is deemed effective. For information regarding the effective dates of Policies, contact your provider representative. The Policies do not include definitions. All terms are defined by Health Net. For information regarding the definitions of terms used in the Policies, contact your provider representative. Policy Amendment without Notice. Health Net reserves the right to amend the Policies without notice to providers or Members. In some states, new or revised policies require prior notice or website posting before an amendment is deemed effective. No Medical Advice. The Policies do not constitute medical advice. Health Net does not provide or recommend treatment to Tumor Makers for Cancer Apr 14 32

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