Coverage Policy Manual
Policy #: 2011069
Category: Radiology
Initiated: October 2011
Last Review: January 2024
  PET or PET/CT for Anal Carcinoma
Description:
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.
 
There are no controlled studies on the effectiveness of PET scan imaging for anal cancer, and anal cancer was not included in the Medicare National Oncologic Pet Registry.
 
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:
Effective March 13, 2022
 
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
 
FDG-PET/CT scanning for Anal 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 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
 
The use of Positron emission tomography (PET) scanning for anal 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, the use of Positron emission tomography (PET) scanning for anal 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 Prior to March 13, 2022
 
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
 
FDG-PET/CT for patients with anal carcinoma meets member benefit certificate primary coverage criteria for effectiveness in improving health outcomes for:
 
Diagnostic Workup  
As clinically indicated when standard imaging studies are equivocal or nondiagnostic for metastatic disease.
  
Treatment Management  
As clinically indicated for ANY of the following:
    • Radiation planning for definitive treatment only; or
    • When standard imaging studies are equivocal or nondiagnostic for recurrent or progressive disease; or
    • Restaging of local recurrence when salvage surgery is planned.
 
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 anal carcinoma does not meet member benefit certificate primary coverage criteria for effectiveness in 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 for patients with anal carcinoma is considered investigational for:  
    • Screening and surveillance;
    • Any other indication not specifically listed as covered above.  
Investigational services are specific contract exclusions in most member benefit certificates of coverage.
 
Effective January 2018 to May 2021
 
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
 
PET scan imaging meets member benefit certificate Primary Coverage Criteria for effectiveness:
    • when post-op follow-up digital rectal exam demonstrates recurrence of disease (based on uncontrolled studies and “Expert Opinion”).
    • For staging of initial disease and treatment planning
 
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
 
PET scan imaging does not meet member certificate of benefit Primary Coverage Criteria for effectiveness for the following:
    • For staging of initial disease or treatment planning (NCCN Guidelines for Anal Carcinoma, V1.2013)
    • In lieu of biopsy to establish a diagnosis of cancer (Pedoloff, 2009)
    • As a surveillance instrument to determine activity of disease in asymptomatic patients
    • As a monitoring tool during therapy to determine response to therapy
 
These non-covered uses of PET and/or PET/CT are considered investigational because they have not been shown in scientific studies to improve health outcomes, and these uses are recommended against in scientific reviews.
 
For contracts without primary coverage criteria, the following uses of PET scanning are considered investigational and are not covered:
    • For staging of initial disease or treatment planning (NCCN Guidelines for Anal Carcinoma, V1.2013)
    • In lieu of biopsy to establish a diagnosis of cancer (Pedoloff, 2009)
    • As a surveillance instrument to determine activity of disease in asymptomatic patients
    • As a monitoring tool during therapy to determine response to therapy
 
Investigational services are an exclusion in the member benefit contract.
 
Effective Prior To January 2018
 
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
 
PET scan imaging meets member benefit certificate Primary Coverage Criteria for effectiveness when post-op follow-up digital rectal exam demonstrates recurrence of disease (based on uncontrolled studies and “Expert Opinion”).
 
 
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
 
PET scan imaging does not meet member certificate of benefit Primary Coverage Criteria for effectiveness for the following:
    • For staging of initial disease or treatment planning (NCCN Guidelines for Anal Carcinoma, V1.2013)
    • In lieu of biopsy to establish a diagnosis of cancer (Pedoloff, 2009)
    • As a surveillance instrument to determine activity of disease in asymptomatic patients
    • As a monitoring tool during therapy to determine response to therapy
 
These non-covered uses of PET and/or PET/CT are considered investigational because they have not been shown in scientific studies to improve health outcomes, and these uses are recommended against in scientific reviews.
 
For contracts without primary coverage criteria, the following uses of PET scanning are considered investigational and are not covered:
    • For staging of initial disease or treatment planning (NCCN Guidelines for Anal Carcinoma, V1.2013)
    • In lieu of biopsy to establish a diagnosis of cancer (Pedoloff, 2009)
    • As a surveillance instrument to determine activity of disease in asymptomatic patients
    • As a monitoring tool during therapy to determine response to therapy
 
Investigational services are an exclusion in the member benefit contract.
Rationale:
NCCN Guidelines, Version 1.2013
PET/CT scanning does not replace a diagnostic CT.  The routine use of PET/CT for staging or diagnostic treatment planning or staging has not been validated.
Patient follow-up:  If evidence of progression found on digital rectal exam should be followed by biopsy as well as restaging with CT and/or PET imaging
 
Canadian Agency for Drugs and Technologies and Health Technology Assessment of Positron Emission Tomography in Oncology
The April 2010 Canadian Agency for Drugs and Technologies in Health assessment of PET in Oncology does not include an assessment of PET for anal carcinoma.
 
NCCN Task Force Report (Podoloff DA, 2009)
There is no review of, or recommendation for or against, the use of PET for anal carcinoma.
 
Expert Panel Review (Fletcher JW, 2008)
The March 2008 Recommendations on the Use of FDG-PET in Oncology by a number of “experts” from the U.S. and England did not review, or make recommendations for or against, PET for anal carcinoma.
 
The 2008 Agency for Health Research & Quality Technology Assessment on Positron Emission Tomography for Nine Cancers did not include assessment of PET for anal cancer.
 
Neither the 2008 or 2009 National Oncologic PET Registry reports provides any statistical information for or against PET for anal carcinoma
 
Literature Review
No controlled studies with comparison groups have been published. No studies on the effect of PET on overall survival have been published; and no comparative studies on the effect of PET on patient outcome (other than from Kaplan-Meier curves) have been published. .All published reports as of the date of this coverage statement, are from small series of patients.
 
Mistrangelo M, et al.  Int J Radiat Oncol Biol Phys, 2012; 84:66-72
Uncontrolled cohort comparison of PET/CT versus CT, sentinel node biopsy, and anal biopsy results in staging and in follow-up of anal cancer.  Sentinel node biopsy was superior to both PET/CT & CT in detecting inguinal lymph nodes.  PET/CT upstaged 37.5% of patients and downstaged 25% of patients in initial staging.  PET/CT at 3 months was more accurate than CT at predicting outcomes, but median follow-up was only 20 months, and the comparison was uncontrolled.  
 
Engledow AH, et al.  Colorectal Dis, 2011;13:532-537
Patients with a histologically confirmed anal SCC underwent standard staging investigations, including computed tomography, magnetic resonance imaging and examination under anesthetic. A tumor, node metastasis (TNM) system was used. All patients subsequently underwent additional whole-body 18-FDG PETCT scanning. Management was planned accordingly, blinded to ¹FDG PETCT findings, at a multidisciplinary meeting, and reviewed again following disclosure of PETCT results.
 
Forty patients (24 men), with a median age of 57 years (range 38-87 years), were prospectively recruited. All primary tumors were 18-FDG avid. PETCT did not alter the T stage but did result in disease upstaging (N and M stages). Management was altered in five (12.5%) patients: one patient was identified to have an isolated distant metastasis, and four patients had 18-FDG-avid lymph nodes not otherwise detected, all of which were tumor-positive on fine needle aspiration cytology/biopsy.
 
Vercellino L, et al. Int J Colorectal Dis, 2011; 26:201-21
Patients with anal carcinoma were referred to our department from October 2004 until July 2008. The diagnostic performance was evaluated on a per-examination basis and on a per-site basis, together with impact of PET/CT on patient management. The standard of truth was histology when available and, in all cases, follow-up data during at least 6 months.
 
Fifty-eight FDG PET/CT performed in 44 patients were analysed—22 for initial staging and 36 during follow-up. The detection rate of non-excised tumors on initial examination was 93%. During post treatment follow-up, FDG PET/CT had, on a per-examination basis, sensitivity for the detection of persistent or recurrent disease of 93% and specificity of 81%, and on a per-site basis, 86% and 97%,respectively. Its negative predictive value was 94% on a per-examination basis and 98% on a per-site basis. FDG PET/CT had an impact on management in nine patients out of 44 (20%), which was relevant in eight of them (89%).
 
Day FL, et al.  Br J Cancer, 2011; 105:498-50
A total of 48 patients with biopsy-proven anal SCC underwent FDG-PET scans at baseline and post chemoradiotherapy (54 Gy, concurrent 5-FU/mitomycin). Kaplan-Meier analysis was used to determine survival outcomes according to FDG-PET metabolic response.
 
A total of 48 patients with biopsy-proven anal SCC underwent FDG-PET scans at baseline and post chemoradiotherapy (54 Gy, concurrent 5-FU/mitomycin). Kaplan-Meier analysis was used to determine survival outcomes according to FDG-PET metabolic response.
 
In all, 79% patients (n=38) had a complete metabolic response (CMR) at all sites of disease, 15% (n=7) had a CMR in regional nodes but only partial response in the primary tumor (overall partial metabolic response (PMR)) and 6% (n=3) had progressive distant disease despite CMR loco-regionally (overall no response (NR)). The 2-year progression-free survival (PFS) was 95% for patients with a CMR, 71% for PMR and 0% for NR (P<0.0001). The 5-year overall survival (OS) was 88% in CMR, 69% in PMR and 0% in NR (P<0.0001). Cox proportional hazards regression analyses for PFS and OS found significant associations for incomplete (PMR+NR) vs complete FDG-PET response to treatment only, (HR 4.1 (95% CI: 1.5-11.5, P=0.013) and 6.7 (95% CI: 2.1-21.6, P=0.002), respectively).
 
Kidd EA, et al.  Radiother Oncol, 2010; 95:388-291
The study population consisted of 77 patients with stages 0-IIIB anal cancer who underwent pre-treatment FDG-PET. Tumor histology included 65 squamous cell, 11 basaloid, and 1 small cell cancers. SUV(max) and sites of lymph node metastasis were recorded. We analyzed the association between SUV(max) and prognostic factors.
 
The mean SUV(max) was 10.0 (range 1.0-43.1). The stage distribution included: 2 stage 0, 7 stage I, 49 stage II, 10 stage IIIA, 9 stage IIIB. SUV(max) and clinical tumor size were not associated (R(2)=0.338). Histology did not significantly influence SUV(max) (mean SUV(max) 10.0 for squamous versus 9.90 for basaloid). Higher SUV(max) was associated with an increased risk of nodal metastasis at diagnosis (p<0.0001). Higher SUV(max) was associated with worse disease-free survival (p=0.05). Patients with high anal tumor SUV(max) at diagnosis were at an increased risk of persistent or recurrent disease on post-therapy FDG-PET performed less than 4months after completing therapy.
 
2014 Update
A literature search conducted through April 2014 did not reveal any new information 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.
 
2017 Update
A literature search conducted through February 2017 did not reveal any new information that would prompt a change in the coverage statement.   
 
2018 Update
Jones et al performed a systematic review and meta-analysis of 12 studies to compare the role of FDG-positron emission tomography (PET) or PET/computed tomography (CT) with conventional imaging in the detection of primary and nodal disease in anal cancer, and to assess the impact of PET or PET/CT on the management of anal cancer (Jones, 2015). For the detection of primary disease, CT and PET had a sensitivity of 60 % (95 % confidence interval [CI]45.5-75.2) and 99 % (95 % CI 96-100), respectively. Compared with conventional imaging, PET upstaged 15 % (95 % CI) and downstaged 15 % (95 % CI) of nodal disease. This led to a change in nodal staging in 28 % of patients (95 % CI). When only studies performing contemporary PET/CT were considered, the rate of nodal upstaging was 21 % (95 % CI) and the TNM stage was altered in 41 % of patients. Following chemoradiotherapy, 78 % (95 % CI) of patients had a complete response on PET. The authors concluded that compared with conventional imaging, the additional staging of PET scan changed nodal staging in 28 percent of patients.
 
Winton et al published the results of a study to determine the effect of FDG-PET on the nodal staging, radiotherapy planning and prognostication of patients with primary anal cancer (Winton, 2009). Sixty-one consecutive patients with anal cancer who were referred to a tertiary medical center between August 1997 and November 2005 were staged with conventional imaging (CIm) (including computed tomography (CT), magnetic resonance imaging, endoscopic ultrasound and chest X-ray) and by FDG-PET. The stage determined by CIm and the proposed management plan were prospectively recorded and changes in stage and management as a result of FDG-PET assessed. Patients were
treated with a uniform radiotherapy technique and dose. The accuracy of changes and prognostication of FDG-PET were validated by subsequent clinical follow-up.The tumour-stage group was changed in 23% (14 out of 61) as a result of FDG-PET (15% up-staged, 8% down-staged). Fourteen percent of T1 patients , 42% of T2 patients and 40% of T3-4 patients assessed using Cim, had a change in their nodal or metastatic stage following FDG-PET. Sensitivity for nodal regional disease by FDG-PET and CIm was 89% and 62%, respectively. The staging FDG-PET scan altered
management intent in 3% and radiotherapy fields in 13%. The estimated 5-year overall survival (OS) and progression-free survival (PFS) for the cohort were 77.3% (95% confidence interval (CI)) and 72.2% (95% CI), respectively. The estimated 5-year PFS for FDG-PET and CIm staged N2-3 disease was 70% (95% CI) and 55.3% (95% CI), respectively. The authors concluded that FDG-PET demonstrated increased sensitivity over CIm for staging nodal disease in anal cancer and changes treatment intent or radiotherapy prescription in a significant proportion of patients.
 
Current NCCN (2.2017) guidelines for anal cancer state that PET and CT may be considered for:
 
· Workup of patients with anal canal cancer and anal margin lesions.
· Treatment planning in anal carcinoma.
 
However, NCCN (2.2017) guidelines also emphasize that PET/CT does not replace a diagnostic CT. The European Society for Medical Oncology (ESMO) guidelines consider PET/CT to be an optional component of the staging evaluation (Glynne-Jones et al, 2014).
 
2018 Update
Annual policy review completed with a literature search using the MEDLINE database through February 2018. No new literature was identified 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
Anal cancer is staged using the American Joint Committee on Cancer TNM system. The vast majority of patients with locoregional disease will undergo concurrent chemoradiation treatment regardless of tumor or nodal staging. Evaluation of pelvic lymph nodes with CT or MRI Pelvis is recommended for initial staging, as is CT of the Chest and Abdomen to assess disseminated disease (since veins of the anal region are part of the venous network associated with systemic circulation). (1)
 
PET/CT can be used to verify staging before treatment, which may alter the radiation plan for curative combined modality therapy. PET/CT has been reported to be useful in the evaluation of pelvic lymph nodes, even when appearing normal-sized by CT. A meta-analysis of 12 studies found that CT and PET had a sensitivity of 60% and 99%, respectively, for the detection of primary disease. Compared with conventional imaging, PET upstaged 15% and downstaged another 15% of nodal disease. This led to a change in nodal staging in 28% and TNM staging in 41% of patients.2 A more recent meta-analysis published by Mahmud et al. found a pooled sensitivity of 99% for PET or PET/CT and 67% for CT scan alone. PET imaging also had a sensitivity of 93% and specificity of 76% for detecting nodal disease. A total of 5.1-% to 37.5% of patients were upstaged and 8.2-% to 26.7% were downstaged, with 12.5-% to 59.3% of patients requiring treatment changes. However, the majority of the changes in treatment were in radiation planning. (3)
 
MANAGEMENT
Following completion of concurrent chemoradiation therapy, the National Comprehensive Cancer Network (NCCN)recommends that initial followup of anal cancer include digital rectal exam 8- to 12 weeks after treatment. Patients with persistent disease but without evidence of progression may be managed with close follow-up for up to 6 months to ensure complete response after completion of radiation and chemotherapy. In the event of biopsy-proven progressive disease or recurrence, reimaging can be performed with conventional advanced imaging or PET/CT scan when salvage surgery is indicated. (1) The 5-year overall survival was 64% in a small study of 39 patients treated with radical salvage surgery. (4)
 
SCREENING AND SURVEILLANCE
Local recurrence of early stage disease is detectable by exam or anoscopy. For patients at high risk for recurrence (locally advanced [T3/T4], inguinal node positive, or locally persistent/progressive/recurrent anal squamous cell cancer), surveillance may include CT chest, CT or MRI abdomen/pelvis with contrast annually for a duration of 3 years per the NCCN guidelines. (1) However, due to the lack of prospective trials and because most recurrences are locoregional, the European Society of Medical Oncology, European Society of Surgical Oncology, and the European Society for Radiotherapy and Oncology do not endorse routine advanced imaging. (5)
 
 
References
    1. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Anal Carcinoma (Version 1.2021. Available at http://www.nccn.org. ©National Comprehensive Cancer Network, 2021.
    2. Jones M, Hruby G, Solomon M, et al. The Role of FDG-PET in the Initial Staging and Response Assessment of Anal Cancer: A Systematic Review and Meta-analysis. Ann Surg Oncol. 2015;22(11):3574-81. PMID: 25652048
    3. Mahmud A, Poon R, Jonker D. PET imaging in anal canal cancer: a systematic review and meta-analysis. Br J Radiol. 2017;90(1080):20170370. PMID: 28972796
    4. Mullen JT, Rodriguez-Bigas MA, Chang GJ, et al. Results of surgical salvage after failed chemoradiation therapy for epidermoid carcinoma of the anal canal. Ann Surg Oncol. 2007;14(2):478-83. PMID: 17103253
    5. Glynne-Jones R, Nilsson PJ, Aschele C, et al. Anal cancer: ESMO-ESSO-ESTRO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2014;25 Suppl 3:iii10-20. PMID: 2500120
 
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 Anal Carcinoma (Version 2022) reviewed with no change from Version 2021 with regard to PET applications in Anal Carcinoma.
 
2024 Update
Annual policy review completed with a literature search using the MEDLINE database through September 2023. No new literature was identified that would prompt a change in the coverage statement.
 
NCCN Guidelines for Anal Carcinoma (Version 3.2023) reviewed with no change from Version 2022 with regard to PET applications in Anal Carcinoma.
 
In 2021, European Society of Medical Oncology (ESMO) updated its clinical practice guidelines for anal cancer and made the following recommendations (Rao et al, 2021). ESMO recommends MRI pelvis and CT chest, abdomen, and pelvis for initial staging, and states that PET-CT may be considered, though they note that further research is needed to validate its utility as a supplement to conventional imaging. ESMO recommends the use of CT chest, abdomen, and pelvis at diagnosis and follow-up. They state that while PET/CT may be considered to assist in radiation therapy planning, there is insufficient evidence to recommend routine PET/CT for assessment of treatment response or follow-up. Due to the lack of prospective trials and because most recurrences are locoregional, the European Society of Medical Oncology does not endorse routine advanced imaging for screening and surveillance.
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: American College of Radiology Appropriateness Criteria, Positron emission tomography. Accessed at http://ac.search.acc.org, 2011-10-17.

Day FL, Link E, Ngan S, et al.(2011) FDC-metabolic response predicts outcomes in anal cancer managed with chemoradiotherapy. Br J Cancer, 2011; 105:498-504.

Engledow AH, Skipworth JR, Blackman G, et al.(2011) The role of FDG combined PET & CT in the clinical management of anal squamous cell carcinoma. Colorectal Dis, 2011; 13:532-537.

Fletcher JW, Djulbegovic B, Soares HP, et al.(2008) Recommendations on the use of 18F-FDG PET in oncology. J of Nucl Med, 2008; 49:480-508.

Glynne-Jones R, Nilsson PJ, Aschele C, et al(2014) Anal cancer: ESMO-ESSO-ESTRO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2014;25 Suppl 3:iii10-20. PMID: 2500120

Jones M, Hruby G Solomon et al.(2015) The role of FDG-PET in the initial staging and response assessment of anal cancer: a systematic review and meta-analysis. Ann Surg ONcol 2015;22:3574-3581. PMID 25652048.

Kidd EA, Dehdashti F, Siegal BA, et al.(2010) Anal cancer maximum F18 FDG uptake on PET is correlated with prognosis. Radiother Oncol, 95; 288-291.

McEwan AJ, Gulenchyn K, Oprina MB, et al.(2008) Positron emission tomography for nine cancers (bladder, brain, cervical, kidney, ovarian, pancreatic, prostate, small cell lung, testicular). University of Alberta Evidence-based Practice Center, Edmonton, Canada. AHRQ Technology Assessment Program, December 1, 2008; pp136-144.

Mistrangelo M, Pelosi E, Bello M, et al.(2012) Role of positron omission tomography computed tomography in the management of anal cancer. Int J Radiat Oncol Biol Phys, 2012; 84:66-72.

Mujoomdar M, Moulton K, Nkansah E.(2010) Positron emission tomography in oncology: A systematic review of clinical effectiveness and indications for use. Ottawa: Canadian Agency for Drugs & Technologies in Health, 2010.

National Comprehensive Cancer Network (NCCN) Version 2013.1.(2013) Version 2013.1 Last accessed 10/23/2012.

National Comprehensive Cancer Network (NCCN)(2012) Version 2012.1 Last accessed 10/17/2011.

National Comprehensive Cancer Network (NCCN).(2017) National Comprehensive Cancer Network (NCCN). (2017) NCCN Clinical Practice Guidelines in Oncology: Bone Cancer. Version 2.2017. https://www.nccn.org/professionals/physician_gls/pdf/bone.pdf. Glynne-Jones R, Nilsson PJ, Aschele C, et al. Anal cancer: ESMO-ESSO-ESTRO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2014; 25 Suppl 3:iii10.

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

National Comprehensive Cancer Network.(2023) NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Anal Carcinoma (Version 3.2023). Available at http://www.nccn.org.

Podoloff DA, Ball DW, en-Josef E, et al.(2008) NCCN task force report: Clinical utility of PET in a variety of tumor types. JNCCN, 2008; 7 (Suppl 2):S9 – S10.

Rao S, Guren MG, Khan K, et al.(2021) Anal cancer: Anal cancer: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2021;32(9):1087-100.

Vercellino L, Montravers F, deParades V, et al.(2011) Impact of PET/CT in the staging & follow-up of anal carcinoma. Int J Colorectal Dis, 2011; 26:201-210.

Winton Ed, Heriot AG, Ng M, et al.(2009) The impact of 18-fluorodeoxyglucose positron emission tomography on the staging, management and outcome of anal cancer. Br J Cancer. 2009;100(5):693. PMID 19259091
Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants or to the Tyson Group Health Plan participants.
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