Coverage Policy Manual
Policy #: 2005007
Category: Radiology
Initiated: February 2005
Last Review: January 2024
  PET or PET/CT for Cervical Cancer
Description:
Note:  This policy is intended for those members with contracts that do not have requirements for prior approval for imaging procedures through an independent imaging review organization.
 
Positron Emission Tomography (PET) imaging uses radiotracers that can reveal both anatomical and physiological information. The glucose analog, 2-[fluorine-18]-Fluoro-2-deoxy-D-glucose (FDG) is useful in cancer imaging because it has been found that tumor cells show increased utilization of glucose compared to non-malignant tissue and is the most common radiotracer that is utilized. For certain malignancies PET scans have been shown to be more accurate than other non-invasive tests in detecting malignant disease. However, as with all diagnostic tests, PET scans do not detect cancer 100% of the time that cancer is present (a false negative test), nor do all positive PET scans represent the presence of malignant disease (a false positive test). A false negative test may occur because a critical volume of malignant cells is necessary for a PET scan to be positive. PET scans may be false positive in the presence of inflammation or granulomatous disease.  
 
PET scans for patients with cervical cancer have been proposed for the following indications:  
        • Detection of pre-treatment metastasis in newly diagnosed cervical cancer;
        • Detection of residual or recurrent cancer following treatment
 
Cervical cancer is a major world health problem for women.  Persistent human papillomavirus (HPV) is the most import factor in the development of cervical cancer.  Other epidemiologic risk factors associated with cervical cancer are a history of smoking, parity, contraceptive use, early age of onset of coitus, larger number of sexual partners, history of sexually transmitted disease, and chronic immunosuppression.
 
Definitions
 
Screening – testing in the absence of an established or clinically suspected diagnosis
 
Diagnosis - testing based on a reasonable clinical suspicion of a particular condition or disorder
 
Diagnostic Workup – initial staging of documented malignancy
 
Management – testing to direct therapy of an established condition, which may include preoperative or postoperative imaging, or imaging performed to evaluate the response to nonsurgical intervention. In oncologic imaging, management applies to patients with measurable disease and to imaging performed before or after planned treatment intervention, therapy response, restaging or clinically suspected recurrence.
 
Surveillance – periodic assessment following completion of therapy. In oncologic imaging, surveillance applies to asymptomatic patients in remission and/or without measurable disease
 
Cannot be performed or is nondiagnostic – applies when the test:
    • Is positive or indeterminate for clinically significant pathology when the information provided about the abnormality by the test is not sufficient to direct subsequent management
    • Is negative when the negative likelihood ratio of the test is both insufficient to confidently exclude the absence of suspected disease and unable to direct subsequent management. This typically applies in scenarios with moderate to high clinical pretest probability with negative testing or low pretest probability with clear evidence for net benefit
    • Has been previously nondiagnostic because of a persistent clinical factor (e.g., body habitus, immobility) that is very likely to make retesting nondiagnostic as well Cannot be performed due to a medical contraindication (e.g., contrast nephrotoxicity, allergy, or in highly radiation sensitive populations such as pediatrics and pregnancy) or reasonable unavailability related to lack of local expertise or service availability
Standard or conventional imaging: Refers to imaging that does not require a PET/CT. Depending on the clinical scenario and individual patient circumstances, this may include computed tomography, magnetic resonance imaging, ultrasound and/or scintigraphy.
Policy/
Coverage:
Act 583 applies to all contracts subject to AR state law (this includes fully insured contracts, self-funded church sponsored health plans, and self-funded state and local government sponsored health plans except the Arkansas State and Public School Employees program). For a list of the plans subject to AR state law, please see policy guidelines below.
 
As required by Act 583 of the Arkansas Legislature, positron emission tomography to screen for or to diagnose cancer in a patient upon the recommendation of the patient's physician when the patient has a prior history of cancer is covered when the following criteria are met:
 
a) Documentation of the malignancy by pathologic or equivalent report, and
b) Performed no more often than every 6 months, and
c) Ordered by or in consultation with a specialist trained in pediatric oncology for an individual under the age of 18 (given the enhanced risk of radiation exposure in young).
 
Special Note regarding “prior history of cancer”: In applying Act 583 to any PET scan prior approval or coverage decision for those fully-insured contracts and self-funded church or government plans to which Act 583 applies, the patient-member will be considered to have a “prior history of cancer” as referenced in Act 583 if the patient-member either (a) has active cancer at the time a prior approval request is submitted, as documented by a pathologic or equivalent report or (b) previously had cancer, whether or not in remission at the time the prior approval request is submitted, as documented by a pathologic or equivalent report.
 
For additional information, please see policy 2021004 (PET or PET/CT for Cancer Surveillance and Other Oncologic Applications)
 
Policy Guidelines
List of Plans subject to Act 583:
 
  • Fully Insured Contracts
    • Arkansas Blue Cross Blue Shield
    • Health Advantage
    • Octave
  • Self-funded State and Local Government Sponsored Health Plans
    • Arkansas State Police
    • Arkansas State University (ASU)
    • Benton County
    • City of Rogers
    • City of Siloam Springs
    • MEMS
    • Mississippi County Hospital System
    • Northwest Arkansas Community College
    • Rogers Water Utilities
    • Southern Arkansas University (grandfathered plan)
    • St. Bernards Regional Medical Center
    • University of Central Arkansas
    • Washington County
  • Self-Funded Church Sponsored Health Plans
 
As stated above, this does not apply to Arkansas State and Public School Employee health plan participants and beneficiaries. For Arkansas State and Public School Employee health plan participants and beneficiaries, please see policy 2023025 (PET or PET/CT for Oncologic Applications for ASE/PSE Contracts) for additional information.
 
For Federal Employee Health Benefit Program and Medicare Advantage plan participants please use the appropriate policy set to review.
 
For other requests for PET or PET/CT scans, the following policy/coverage criteria applies:
 
Effective April 14, 2024
 
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
 
FDG-PET/CT for patients with cervical cancer meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes for:  
 
Diagnostic Workup:
    • Indicated for patients with a definitive diagnosis of stage IB1 or higher as an alternative to CT chest, abdomen, and pelvis
 
Management:
 
Indicated in ANY of the following scenarios:
    • Standard imaging cannot be performed or is nondiagnostic for recurrent or progressive disease; or
    • Following radiation or chemoradiation when performed at least 12 weeks following therapy; or
    • Signs or symptoms concerning for recurrent or metastatic disease.
 
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
 
PET/CT for patients with cervical cancer does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes and is not covered for any indication or any circumstance other than those listed above including but not limited to:   
    • Surveillance
For contracts without primary coverage criteria, PET/CT for patients with cervical cancer is considered investigational and is not covered for any indication or any circumstance other than those listed above including but not limited to:
    • Surveillance
Investigational services are specific contract exclusions in most member benefit certificates of coverage.
 
Note: Standard or conventional imaging: Refers to imaging that does not require a PET/CT. Depending on the clinical scenario and individual patient circumstances, this may include computed tomography, magnetic resonance imaging, ultrasound and/or scintigraphy.
 
Effective April 9, 2023 - April 13, 2024
 
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
 
FDG-PET/CT for patients with cervical cancer meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes for:
Diagnostic Workup:
        • Indicated for patients with a definitive diagnosis of stage IB1 or higher as an alternative to CT chest, abdomen, and pelvis
Management:
Indicated in ANY of the following scenarios:
        • Standard imaging cannot be performed or is nondiagnostic for recurrent or progressive disease; or
        • Assessment of response to definitive chemoradiation when performed at least 12 weeks following therapy; or
        • Signs or symptoms concerning for recurrent or metastatic disease.
 
For all fully insured contracts, all self-funded church-sponsored health plans and all self-funded government-sponsored health plans other than the Arkansas State and Public School Employees program, the Federal Employee Health Benefit Program and Medicare Advantage plans, as required by Act 583 of the Arkansas Legislature, please see ABCBS policy 2021004, Surveillance and Other PET Oncologic Applications.
  
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
 
PET/CT for patients with cervical cancer does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes and is not covered for any indication or any circumstance other than those listed above including but not limited to:   
    • Surveillance*
For contracts without primary coverage criteria, PET/CT for patients with cervical cancer is considered investigational and is not covered for any indication or any circumstance other than those listed above including but not limited to:
    • Surveillance*
Investigational services are specific contract exclusions in most member benefit certificates of coverage.
 
*For all fully insured contracts, all self-funded church-sponsored health plans and all self-funded government-sponsored health plans other than the Arkansas State and Public School Employees program, the Federal Employee Health Benefit Program and Medicare Advantage plans, as required by Act 583 of the Arkansas Legislature, please see ABCBS policy 2021004, Surveillance and Other PET Oncologic Applications.
  
Note: Standard or conventional imaging: Refers to imaging that does not require a PET/CT. Depending on the clinical scenario and individual patient circumstances, this may include computed tomography, magnetic resonance imaging, ultrasound and/or scintigraphy.
 
Effective March 13, 2022 to April 08, 2023
 
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
FDG-PET/CT for patients with cervical cancer meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes for:
Diagnostic Workup
        • Indicated when standard imaging cannot be performed or is nondiagnostic for metastatic disease.
Management
Indicated in EITHER of the following scenarios:
        • Radiation planning for definitive treatment only
        • When Standard imaging cannot be performed or is nondiagnostic for recurrent or progressive disease
 
For all fully insured contracts, all self-funded church-sponsored health plans, and all self-funded government-sponsored health plans (e.g., state and public-school employee plans), other than the Federal Employee Health Benefit Program and Medicare Advantage plans, as required by Act 583 of the Arkansas Legislature, please see ABCBS policy 2021004, Surveillance and Other PET Oncologic Applications.
 
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
PET/CT for patients with cervical cancer does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes:  
    • Surveillance*
For contracts without primary coverage criteria, PET/CT for patients with cervical cancer is considered investigational and is not covered for any indication or any circumstance other than those listed above including but not limited to:
    • Surveillance*
Investigational services are specific contract exclusions in most member benefit certificates of coverage.
 
* For all fully insured contracts, all self-funded church-sponsored health plans, and all self-funded government-sponsored health plans (e.g., state and public-school employee plans), other than the Federal Employee Health Benefit Program and Medicare Advantage plans, as required by Act 583 of the Arkansas Legislature, please see ABCBS policy 2021004, Surveillance and Other PET Oncologic Applications.
 
Note: Standard or conventional imaging: Refers to imaging that does not require a PET/CT. Depending on the clinical scenario and individual patient circumstances, this may include computed tomography, magnetic resonance imaging, ultrasound and/or scintigraphy.
 
 
Effective Prior to March 13, 2022
 
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
FDG-PET/CT for patients with cervical cancer meets member benefit certificate primary coverage criteria of effectiveness for improving health outcomes for:
Diagnostic Workup
Indicated for patients with a definitive diagnosis of stage IB2 or higher
 
Management
Indicated in EITHER of the following (preferred for stage IB2-IV cervical cancer):
    • When standard imaging studies are equivocal or nondiagnostic for recurrent or progressive disease; or
    • Assessment of response to definitive chemoradiation when performed at least 12 weeks following therapy.
 
For all fully insured contracts, all self-funded church-sponsored health plans, and all self-funded government-sponsored health plans (e.g., state and public-school employee plans), other than the Federal Employee Health Benefit Program and Medicare Advantage plans, as required by Act 583 of the Arkansas Legislature, please see ABCBS policy 2021004, Surveillance and Other PET Oncologic Applications.
 
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
PET/CT for patients with cervical cancer does not meet member benefit certificate primary coverage criteria of effectiveness for improving health outcomes for:
    • Screening and surveillance*;
    • Any other indication not specifically listed as covered above.
 
*For all fully insured contracts, all self-funded church-sponsored health plans, and all self-funded government-sponsored health plans (e.g., state and public-school employee plans), other than the Federal Employee Health Benefit Program and Medicare Advantage plans, as required by Act 583 of the Arkansas Legislature, please see ABCBS policy 2021004, Surveillance and Other PET Oncologic Applications.
 
For members with contracts without primary coverage criteria, PET/CT scan for patients with cervical cancer is considered investigational for:
    • Screening and surveillance;
    • Any other indication not specifically listed above
Investigational services are specific contract exclusions in most member benefit certificates of coverage.
 
 
Effective Prior to August 2021
 
Meets Primary Coverage Criteria OR Is Covered For Contracts Without Primary Coverage Criteria
FDG-PET/CT for patients with cervical cancer meets member benefit certificate primary coverage criteria of effectiveness for improving health outcomes for:
 
Diagnostic Workup
Indicated for patients with a definitive diagnosis of stage IB2 or higher
 
Management
Indicated in EITHER of the following (preferred for stage IB2-IV cervical cancer):
    • When standard imaging studies are equivocal or nondiagnostic for recurrent or progressive disease; or
    • Assessment of response to definitive chemoradiation when performed at least 12 weeks following therapy.
 
Does Not Meet Primary Coverage Criteria OR Is Investigational For Contracts Without Primary Coverage Criteria
PET/CT for patients with cervical cancer does not meet member benefit certificate primary coverage criteria of effectiveness for improving health outcomes for:
    • Screening and surveillance;
    • Any other indication not specifically listed as covered above.
For members with contracts without primary coverage criteria, PET/CT scan for patients with cervical cancer is considered investigational for:
    • Screening and surveillance;
    • Any other indication not specifically listed above
 
Investigational services are specific contract exclusions in most member benefit certificates of coverage.
 
Effective June 2012 to May 2021
 
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
PET or PET/CT meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness for:
  • Initial treatment strategy (initial staging) as an adjunct test for the presurgical detection of extrapelvic disease (deselection for surgery)
  • Assessing treatment response 3 months after completion of concurrent chemoradiation
  • Subsequent treatment strategy (re-staging when a change in treatment is anticipated) for known cervical cancer, AND the patient has new signs or symptoms indicative of a reoccurrence of cancer
 
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
PET or PET/CT does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes:
  • In lieu of biopsy to establish a diagnosis of cancer (Podoloff, 2009)
  • In patients with stable disease when PET findings alone are used to recommend therapy (Podoloff, 2009)
  • As a surveillance tool (i.e., routine monitoring in asymptomatic patients) (Podoloff, 2009)
  • Monitoring patients during radiation therapy (Schwarz, 2009)
 
For members with contracts without primary coverage criteria, PET or PET/CT for the following indications is considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
  • In lieu of biopsy to establish a diagnosis of cancer (Podoloff, 2009)
  • In patients with stable disease when PET findings alone are used to recommend therapy (Podoloff, 2009)
  • As a surveillance tool (i.e., routine monitoring in asymptomatic patients) (Podoloff, 2009)
  • Monitoring patients during radiation therapy (Schwarz, 2009)
 
Effective prior to June 2012
Positron emission tomography with FDG meets primary coverage criteria for effectiveness and is covered for staging in newly diagnosed cervical cancer when conventional imaging is negative for extra-pelvic metastasis.  
 
PET with FDG, for the detection of residual or recurrent disease, is not covered based on benefit certificate primary coverage criteria that there be scientific evidence of effectiveness.
 
For contracts without primary coverage criteria, PET with FDG, for the detection of residual or recurrent disease, is considered investigational.  Investigational services are an exclusion in the member certificate of coverage.
 
PET Scans (Positron Emission Tomography) for any diagnosis other than those that are addressed through specific policy are not covered based on benefit certificate primary coverage criteria that there be scientific evidence of effectiveness.
 
For contracts without primary coverage criteria, PET Scans (Positron Emission Tomography) for any diagnosis other than those that are addressed through specific policy are considered investigational and are not covered.    Investigational services are exclusion in the member certificate of coverage.
 
Specific coverage policies are listed individually.
 
Effective June 2012
PET or PET/CT meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness for:
    • Initial treatment strategy (initial staging) as an adjunct test for the presurgical detection of extra-pelvic disease (deselection for surgery)
    • Assessing treatment response 3 months after completion of concurrent chemoradiation
    • Subsequent treatment strategy (re-staging when a change in treatment is anticipated) for known cervical cancer, AND the patient has new signs or symptoms indicative of a reoccurrence of cancer
 
PET or PET/CT does not meet  member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness for:
    • In lieu of biopsy to establish a diagnosis of cancer (Podoloff, 2009)
    • In patients with stable disease when PET findings alone are used to recommend therapy (Podoloff, 2009)
    • As a surveillance tool (i.e., routine monitoring in asymptomatic patients) (Podoloff, 2009)
    • Monitoring patients during radiation therapy (Schwarz, 2009)
For members with contracts without primary coverage criteria, PET or PET/CT for the following indications is considered investigational.  Investigational services are specific contract exclusions in most member benefit certificates of coverage.
    • In lieu of biopsy to establish a diagnosis of cancer (Podoloff, 2009)
    • In patients with stable disease when PET findings alone are used to recommend therapy (Podoloff, 2009)
    • As a surveillance tool (i.e., routine monitoring in asymptomatic patients) (Podoloff, 2009)
    • Monitoring patients during radiation therapy (Schwarz, 2009)
Effective prior to June 2012
 
Rationale:
2013 Update:
A literature search  was performed on PubMed through December 2012.  There were no published articles identified that would prompt a change in the coverage statement.
 
Perez-Medina and colleagues (2013) published a prospective evaluation of 52 patients with locally advanced cervical cancer.  All had undergone a laparoscopic infrarenal paraaortic lymphadenectomy.   . Eighteen patients (34.6%) had pathologically proven paraaortic lymph node (PALN) metastases. Among them, 4 (12.5%) had negative FDG-PET (false negatives). Furthermore, 2 positive FDG-PET patients were not affected after histologic analysis (11.1% false positives). No complications occurred in our series. Sensitivity, specificity, and positive and negative predictive value of the FDG-PET were 77.7, 94.1, 87.5, and 88.9, respectively, for the detection of PALN metastases.  The authors concluded that the sensitivity and specificity of FDG-PET remains limited, so PALN dissection should be part of the pretherapeutic staging in every patient with LACC before definitive concurrent chemoradiotherapy.
 
Tejwani and colleagues (2012):
Anatomic biologic contouring (ABC) with PET/CT, using a distinct “halo” to unify contouring methods in treatment planning for lung and head and neck cancers has been previously introduced. The objective of this study was to assess the utility of PET/CT in planning and treatment response for cervical cancer.  Forty-two patients with stages II-IIIB cervix cancer were planned for irradiation using PET/CT. A CT-based Gross Tumor Volume (GTV-CT) was delineated by two independent observers while the PET remained obscured.  The pre- and post-treatment anatomic biologic values were compared. A “halo” was observed around areas of maximal SUV uptake. The mean halo SUV was 1.91 ± 0.56 (SD). The mean halo thickness was 2.12 ± 0.5 (SD) mm. Inter-observer GTV variability decreased from a mean volume difference of 55.36 cm3 in CT-based planning to 12.29 cm3 in PET/CT-based planning with a respective decrease in standard deviation (SD) from 55.78 to 10.24 (p <0.001). Comparison of mean pre-treatment and post-treatment ABV’s revealed a decrease of ABV from 48.2 to 7.8 (p<0.001). The authors concluded that:  PET/CT is a valuable tool in radiation therapy planning and evaluation of treatment response for cervical cancer. A clearly visualized “halo” was successfully implemented in GTV contouring in cervical cancer, resulting in decreased inter-observer variability in planning. PET/CT has the ability to quantify treatment response using anatomic biologic value.
 
NCCN Guidelines Version 2.2013
Stage IB and IIA Disease:  Depending on their stage and disease bulk, patients with stage IB or IIA tumors can be treated with surgery, radiation therapy (RT), or concurrent chemoradiation.  A combined PET/CT scan can be performed to rule out extrapelvic disease before deciding how to treat these patients. Radiologic imaging is recommended for assessing stage IB2 and IIA2 tumors.
 
Advanced Disease:  This category has traditionally included patients with stage IIB to IVA disease (i.e., locally advanced disease).  However, many oncologists now include patients with IB2 and IIA2 disease in the advanced disease category.  For patients with more advanced tumors who are undergoing primary chemoradiation, the volume of RT is critical and guided by assessment of nodal involvement in the pelvic and para-aortic nodes.  Radiologic imaging studies (including PET/CT) are recommended for stage IB2 or greater disease.
 
The following studies were identified at www.clinicaltrials.gov:
NCT00416455 – “Utility of Preoperative FDG-18 PET/CT and Ferumoxtran-10 MRI Scan Before Chemotherapy and Radiation Therapy in Finding Lymph Node Metastasis in Patients With Locally Advanced Cervical Cancer or High-Risk Endometrial Cancer”.  NCI sponsored, 28 locations with expected enrollment 380.
 
NCT00895349 – “Impact of Positron Emission Tomography (PET) Imaging in Women With Locally Advanced Cervical Cancer (PET LACE Trial)”_(Canada)_Randomized trial: Purpose of this trial is to improve the clinical management and outcome of patients with locally advanced cervical cancer by using PET-CT imaging; estimated enrollment 288 with completion date of October 2017
 
NCT01663753 – “Diagnostic Performance of 18F-FDG-PET and Diffusion-weighted MRI in the Assessment of Stage IB to IIB2 Cervical Squamous-cell Carcinoma Response to Concomitant Radiochemotherapy and Brachytherapy (ERRICC)”._(France)_The main objective of this study is to evaluate the sensitivity of 18F-FDG-PET in the assessment of cervical cancer response to radiochemotherapy and brachytherapy; estimated enrollment 148 with completion date of November 2014.
 
2014 Update
A literature was conducted using the MEDLINE database through December 2013.  There was no new information identified that would prompt a change in the coverage statement.
 
2015 Update
 
A literature search conducted through January 2015 did not reveal any new information that would prompt a change in the coverage statement. The key identified literature is summarized below.
 
In a meta-analysis of 20 studies, Chu and colleagues reported pooled sensitivity and specificity for FDG-PET or FDG-PET/CT of 0.87 (95% CI, 0.80 to 0.92) and 0.97 (95% CI, 0.96 to 0.98), respectively, for distant metastasis in recurrent cervical cancer (Chu, 2014). For local regional recurrence, pooled sensitivity and specificity were 0.82 (95% CI, 0.72 to 0.90) and 0.98 (95% CI, 0.96 to 0.99), respectively.
 
Current NCCN guidelines state that PET/CT “may aid in treatment planning but is not accepted for formal staging purposes.”  A single PET/CT at 3 to 6 months after therapy for locally advanced cervical cancer is recommended to detect persistent or recurrent disease. PET/CT is not recommended for surveillance.
 
2018 Update
 
A literature search conducted using the MEDLINE database through February 2018 did not reveal any new information that would prompt a change in the coverage statement.
 
2019 Update
Annual policy review completed with a literature search using the MEDLINE database through February 2019. No new literature was identified that would prompt a change in the coverage statement.
 
2020 Update
A literature search was conducted through February 2020.  There was no new information identified that would prompt a change in the coverage statement.  
 
2021 Update
Annual policy review completed with a literature search using the MEDLINE database through January 2021. No new literature was identified that would prompt a change in the coverage statement.
 
2022 Update
A literature review was performed through September 2021. Following is a summary of the key literature to date.
 
DIAGNOSTIC WORKUP
Cervical cancer is staged using the FIGO system. Pelvis MRI is most useful for determination of tumor location, size, invasion, and presence of regional nodal disease. (2, 3) A systematic review of 57 single-institution trials showed MRI was more accurate than CT for overall staging of cervical cancer. (4) A retrospective American College of Radiology Imaging Network/Gynecology Oncology Group (ACRIN/GOG) study comparing MRI and CT for early-stage cervical cancer found that contrast-enhanced multi-detector CT was equivalent to MRI for overall preoperative staging, but MRI performed significantly better for visualization of the primary tumor and detection of parametrial invasion. (5) In a second
ACRIN/GOG Intergroup Study, MRI was superior to CT and clinical examination for evaluating uterine body involvement and measuring tumor size. (6) This benefit was also seen for preoperative selection of women for fertility-sparing surgery and for evaluation of residual tumor in the cervix after a cone biopsy with negative margins. In a small retrospective study in patients with negative margins after conization, MRI was 100% concordant in showing no residual cancer. (7) MRI may also play a role in radiation planning to aid with CT contouring. (8)
 
The National Comprehensive Cancer Network (NCCN)recommends sentinel lymph node detection in patients with Stage IA1 with LVI, IA2, 1B1, and IIA1 and clinically lymph node-negative cervical cancer. The use of sentinel lymph node detection has been shown to decrease extent and morbidity of surgery without compromise to outcome. Patients with higher stage disease may require full lymph node dissections. (9, 10). PET/CT is a useful modality for evaluating for extrauterine disease. (11, 12) Lin et al reported a PET sensitivity of 85.7%, specificity of 94.4%, and accuracy of 92% for detecting para-aortic lymph node metastasis in CT-negative advanced cervical cancer patients. (13) Another review also concluded that PET/CT appeared better than conventional imaging for detection of metastatic lymph nodes with a reported sensitivity of 78%-84% for PET/CT, 72% for MRI, and only 47% for CT alone. (14) Per NCCN, whole body PET/CT is preferred for stage IB1/IB2 disease prior to fertility sparing treatment,
and for stage IB3 and higher disease as part of initial work-up (level of evidence category 2A). (9)
 
MANAGEMENT
PET imaging is preferred for patients with high risk stage IB2 or above disease treated with definitive chemoradiation therapy. Early data suggest PET/CT during and/or after concurrent chemoradiation therapy may be a useful test for predicting local and distant failures and overall survival.15 In the setting of recurrent disease, PET/CT has reported sensitivities ranging from 90.3%-92.7% and specificities ranging from 81%-100%.16 NCCN designates whole-body PET/CT as preferred for follow-up of stage IIA1-IVA disease, with imaging as indicated based on symptomatology and clinical concern for recurrent/metastatic disease. (9)
 
SURVEILLANCE
In the setting of fertility-sparing surgery, MRI is commonly used for postoperative follow up. In a single-institution study, serial MRI follow up detected recurrent cervical cancer at a rate of 4%. Review of the literature shows that the recurrence rate after trachelectomy varies from 0%-25%. (17, 18) Routine surveillance is not indicated in cervical cancer patients treated with radical hysterectomy, radiation, or concurrent chemotherapy, in accordance with National Comprehensive Cancer Network (NCCN) guidelines and Society of Gynecologic Oncology recommendations. (9, 19)
 
Current References
    1. Adegoke O, Kulasingam S, Virnig B. Cervical cancer trends in the United States: a 35-year population-based analysis. J Womens Health 2012;21(10):1031-7. PMID: 22816437
    2. Balleyguier C, Sala E, Da Cunha T, et al. Staging of uterine cervical cancer with MRI: guidelines of the European Society of Urogenital Radiology. Eur Radiol. 2011;21(5):1102-10. PMID: 21063710
    3. Sala E, Rockall AG, Freeman SJ, et al. The added role of MR imaging in treatment stratification of patients with gynecologic malignancies: what the radiologist needs to know. Radiology. 2013;266(3):717-40. PMID: 23431227
    4. Patel S, Liyanage SH, Sahdev A, et al. Imaging of endometrial and cervical cancer. Insights Imaging. 2010;1(5-6):309-28. PMID: 22347925
    5. Hricak H, Gatsonis C, Coakley FV, et al. Early invasive cervical cancer: CT and MR imaging in preoperative evaluation - ACRIN/GOG comparative study of diagnostic performance and interobserver variability. Radiology. 2007;245(2):491-8. PMID: 17940305
    6. Mitchell DG, Snyder B, Coakley F, et al. Early invasive cervical cancer: tumor delineation by magnetic resonance imaging, computed tomography, and clinical examination, verified by pathologic results, in the ACRIN 6651/GOG 183 Intergroup Study. J Clin Oncol. 2006;24(36):5687-94. PMID: 17179104
    7. Lakhman Y, Akin O, Park KJ, et al. Stage IB1 cervical cancer: role of preoperative MR imaging in selection of patients for fertility-sparing radical trachelectomy. Radiology. 2013;269(1):149-58. PMID: 23788721
    8. Wang F, Tang Q, Lv G, et al. Comparison of computed tomography and magnetic resonance imaging in cervical cancer brachytherapy: a systematic review. Brachytherapy. 2017;16(2):353-65. PMID: 27965118
    9. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Cer vical Cancer (Version 1.2021). Available at http://www.nccn.org. ©National Comprehensive Cancer Network, 2021.
    10. U.S. Food & Drug Administration (FDA). Lymphoseek (technetium Tc 99m tilmanocept) injection, for subcutaneous, intradermal, subareolar, or peritumoral use. (2013 [Revised 06/2019]) Available from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/202207s009lbl.pdf.
    11. Subak LL, Hricak H, Powell CB, et al. Cervical carcinoma: computed tomography and magnetic resonance imaging for preoperative staging. Obstet Gynecol. 1995;86(1):43-50. PMID: 7784021
    12. Pannu HK, Fishman EK. Evaluation of cervical cancer by computed tomography: current status. Cancer. 2003;98(9 Suppl):2039-43. PMID: 14603540
    13. Lin WC, Hung YC, Yeh LS, et al. Usefulness of (18)F-fluorodeoxyglucose positron emission tomography to detect para-aortic lymph nodal metastasis in advanced cervical cancer with negative computed tomography findings. Gynecol Oncol. 2003;89(1):73-6. PMID: 12694656
    14. Havrilesky LJ, Kulasingam SL, Matchar DB, et al. FDG-PET for management of cervical and ovarian cancer. Gynecol Oncol. 2005;97(1):183-91. PMID: 15790456
    15. Liu FY, Lai CH, Yang LY, et al. Utility of (18)F-FDG PET/CT in patients with advanced squamous cell carcinoma of the uterine cervix receiving concurrent chemoradiotherapy: a parallel study of a prospective randomized trial. Eur J Nucl Med Mol Imaging. 2016;43(10):1812-23. PMID: 27160224
    16. Sironi S, Picchio M, Landoni C, et al. Post-therapy surveillance of patients with uterine cancers: value of integrated FDG PET/CT in the detection of recurrence. Eur J Nucl Med Mol Imaging. 2007;34(4):472-9. PMID: 17106701
    17. Chung HH, Jo H, Kang WJ, et al. Clinical impact of integrated PET/CT on the management of suspected cervical cancer recurrence. Gynecol Oncol. 2007;104(3):529-34. PMID: 17049971
    18. Sahdev A, Jones J, Shepherd JH, et al. MR imaging appearances of the female pelvis after trachelectomy. Radiographics. 2005;25(1):41-52. PMID: 15653585
    19. Salani R, Khanna N, Frimer M, et al. An update on post-treatment surveillance and diagnosis of recurrence in women with gynecologic malignancies: Society of Gynecologic Oncology (SGO) recommendations. Gynecol Oncol. 2017;146(1):3-10. PMID: 28372871
 
2023 Update
Annual policy review completed with a literature search using the MEDLINE database through September 2022. No new literature was identified that would prompt a change in the coverage statement.
 
NCCN Guidelines for Cervical Cancer (Version 2022) were reviewed with no change from Version 2021 with regard to PET applications.
 
2024 Update
Annual policy review completed with a literature search using the MEDLINE database through September 2023.
 
NCCN Guidelines for Cervical Cancer (Version 1.2024) states that PET imaging is preferred for patients with high risk stage IB2 or above disease treated with adjuvant radiation or chemoradiation therapy.
 
CPT/HCPCS:
78811Positron emission tomography (PET) imaging; limited area (eg, chest, head/neck)
78812Positron emission tomography (PET) imaging; skull base to mid thigh
78813Positron emission tomography (PET) imaging; whole body
78814Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; limited area (eg, chest, head/neck)
78815Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid thigh
78816Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; whole body
References: Balleyguier C, Sala E, Da Cunha T, et al.(2011) Staging of uterine cervical cancer with MRI: guidelines of the European Society of Urogenital Radiology. Eur Radiol. 2011;21(5):1102-10. PMID: 21063710

Belhocine T, Thille A, et al.(2002) Contribution of whole-body 18FDG PRT imaging in the management of cervical cancer. Gynecol Oncol 2002; 87:90-7.

Chao A, Ho KC, Wang CC, et al.(2008) Positron emission tomography in evaluating the feasibility of curative intent in cervical cancer patients with limited distant lymph node metastases. Gynecol Oncol, 2008; 110:172-178.

Chu Y, Zheng A, Wang F, et al.(2014) Diagnostic value of 18F-FDG-PET or PET-CT in recurrent cervical cancer: a systematic review and meta-analysis. Nucl Med Commun. Feb 2014;35(2):144-150. PMID 24177043

Grigsby PW, Siegel BA, et al.(2003) Posttherapy surveillance monitoring of cervical cancer by FDG-PET. Int J Radiat Oncol Biol Phys 2003; 55:907-13.

Grigsby RW, Siegel BA, et al.(2004) Posttherapy [18F] fluorodeoxyglucose positron emission tomography in carcinoma of the cervix: response and outcome. J Clin Oncol 2004; 22:2167-71.

Havrilesky LJ, Kulasingam SL, Matchar DB, et al.(2005) FDG-PET for management of cervical and ovarian cancer. Gynecol Oncol, 2005; 97:183-191.

Havrilesky LJ, Wong TZ, et al.(2003) The role fo PET scanning in the detection of recurrent cervical cancer. Gynecol Oncol 2003; 90:186-90.

Lin WC, Hung YC, et al.(2003) Usefulness of (18)F-fluorodeoxyglucose positron emission tomography to detect para-aortic lymph nodal metastasis in advanced cervical cancer with negative computed tomography findings. Gynecol Oncol 2003; 89:73-6.

Lin WC.(2003) Usefulness of (18) F-fluorodeoxyglucose positron emission tomograph to detect para-aortic lymph nodal metastasis in advanced cervical cancer with negative computed tomography findings. Gynecol Oncol, 2003; 89:73-76.

Miller TR, Pinkus E, et al.(2003) Improved prognostic value of 18F-FDG PET using a simple visual analysis of tumor characteristics in patients with cervical cancer. J Nucl Med 2003; 44:192-7.

Nakamoto Y, Eisbruch A, et al.(2002) Prognostic value of positron emission tomography using F-18-fluorodeoxyglucose in patients with cervical cancer undergoing radiotherapy. Gynecol Oncol 2002; 84:289-95.

National Comprehensive Cancer Network(2022) NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Cervical Cancer (Version 1.2022). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Cervical Cancer (Version 1.2022).

National Comprehensive Cancer Network.(2024) Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Cervical Cancer (Version 1.2024). Available at http://www.nccn.org.

NCCN(2013) Cervical Cancer NCCN Guidelines, Version 2.2013.

Park DH, Kim KH, et al.(2000) Diagnosis of recurrent uterine cervical cancer: computed tomography versus positron emission tomography. Korean J Radiol 2000; 1:51-5.

Perez-Medina T, Pereira A, Mucientes J, et al.(2013) Prospective evaluation of 18-fluoro-2-deoxy-d-glucose positron emission tomography for the discrimination of paraaortic nodal spread in patients with locally advanced cervical carcinoma. Int J Gynecol Cancer. 2013 Jan;23(1):170-5.

Podoloff DA, Ball DW, Ben-Josev E, et al.(2009) NCCN task force report: Clinical utility of PET in a variety of tumor types. JNCCN, 2009; Supp7:S1-S23.

Reinhardt MJ, Ehritt-Braun C, et al.(2001) Metastatic lymph nodes in patients with cervical cancer: detection with MR imaging and FDG PET. Radiology 2001; 218:776-82.

Rose PG, Adler LP, et al.(1999) Positron emission tomography for evaluating para-aortic nodal metastasis in locally advanced cervical cancer before surgical staging: a surgicopathologic study. J Clin Oncol 1999; 17:41-5.

Ryu SY, Kim MH, et al.(2003) Detection of early recurrence with 18F-FDG PET in patients with cervical cancer. J Nucl Med 2003; 44:347-52.

Salani R, Khanna N, Frimer M, et al.(2017) An update on post-treatment surveillance and diagnosis of recurrence in women with gynecologic malignancies: Society of Gynecologic Oncology (SGO) recommendations. Gynecol Oncol. 2017;146(1):3-10. PMID: 28372871

Schwarz JK, Grigsby P, Dehdashti F, et al.(2009) The role of 18-F-FDG PET in assessing therapy response in cancer of the cervix and ovaries. J Nucl Med, 2009; 50: Supp 5: 64S-73S.

Schwarz JK.(2007) Association of posttherapy positron emission tomography with tumor response and survival in cervical carcinoma. JAMA, 2007; 298:2289-2295.

Sugawara Y, Eisbruch A, et al.(1999) Evaluation of FDG PET in patients with cervical cancer. J Nucl Med 1999; 40:1125-31.

Tejwani A, Lavaf A, Parikh, et al.(2012) The role of PET/CT in decreasing inter-observer variability in treatment planning and evaluation of response for cervical cancer Am J Nucl Med Mol Imaging. 2012; 2(3): 307–313.

Yeh LS, Hung YY, et al.(2002) Detecting para-aortic lymph nodal metastasis by positron emission tomography of 18F-fluorodeoxyglucose in advanced cervical cancer with negative magnetic resonance imaging findings. Oncol Rep 2002; 9:1289-92.

Yen TC.(2003) Value of dual-phase 2-fluoro-2-deoxy-d-glucose positron emission tomography in cervical cancer. J Clin Oncol, 2003; 21:3651-3658.
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