2.0 DESCRIPTION
Prophylactic mastectomy, prophylactic
oophorectomy, and prophylactic hysterectomy are surgical procedures
that aim at completely removing organs or tissue in the absence
of malignant disease to reduce the risk of individuals at high risk
from developing cancer. These surgeries are also called
risk-reducing surgeries. A high risk individual is one
with a family history or personal history of
cancer in the breast, and/or ovaries,
or uterus; or personal history of cancer in the breast
and/or ovaries or as otherwise defined
by the National Comprehensive Cancer Center (NCCN) or the American
College of Obstetricians and Gynecologists (ACOG), including individuals
with a hereditary cancer syndrome. Carefully
selected indications have been developed for prophylactic mastectomy
and are included in this policy For this
section, where NCCN and ACOG guidelines differ, NCCN guidelines
should take precedence.
3.0 POLICY
3.1 Bilateral
prophylacticProphylactic bilateral mastectomies
are covered for patients at increased risk of developing breast
carcinoma who have one or more of the following:
3.1.1 Atypical
hyperplasia of lobular or ductal origin confirmed on biopsy; or
3.1.2 A history of breast cancer in
multiple first-degree relatives and/or multiple successive generations
of family members with breast and/or ovarian cancer (FamilyHereditary
Breast and Ovarian Cancer Syndrome). A positive Breast
Cancer (BRCA) genetic test is not necessary; or
3.1.3 One
or more of the following pathogenic genetic mutations, when indicated
by NCCN or ACOG recommendations, effective September 1, 2017: ATM,
BRCA1, BRCA2, CDH1, CHEK2, PALB2, PTEN, STK11, TP53; or
3.1.4 Chest wall radiation
prior to 30 years of age, effective September 1, 2017; or
3.1.5 Any other clinical factor
for which NCCN or ACOG recommend the consideration of a prophylactic bilateral
mastectomy, effective September 1, 2017; or
3.1.6 Fibronodular, dense breasts which
are mammographically and/or clinically difficult to evaluate and
the patient presents with either any of
the above (or both) clinical presentations.
3.2 Unilateral prophylacticProphylactic
contralateral mastectomies are covered when the contralateral breast
has been diagnosed with cancer for patients with:
3.2.1 Diffuse
microcalcifications in the remaining breast, especially when ductal
in-situ carcinoma has been diagnosed in the contralateral breast;
or
3.2.2 Lobular carcinoma in-situ;
or
3.2.3 Large breast and/or ptotic,
dense or disproportionately-sized breast that is difficult to evaluate mammographically
and clinically; or
3.2.4 In whom
observational surveillance is elected for lobular carcinoma in-situ
and the patient develops either invasive lobular or ductal carcinoma;
or
3.2.5 A history of breast cancer in
multiple first-degree relatives and/or multiple successive generations
of family members with breast and/or ovarian cancer (FamilyHereditary
Breast and Ovarian Cancer Syndrome). A positive BRCA
genetic test is not necessary.;
or
3.2.6 One or more of the following
pathogenic genetic mutations, when indicated by NCCN or ACOG recommendations,
effective September 1, 2017: ATM, BRCA1, BRCA2, CDH1, CHEK2, PALB2,
PTEN, STK11, TP53; or
3.2.7 Any other clinical factor
for which NCCN or ACOG recommend the consideration of a prophylactic contralateral
mastectomy, effective September 1, 2017.
3.3 Prophylactic
salpingo-oophorectomy
is or
oophorectomy (or salpingectomy, when indicated ACOG or NCCN recommendations)
are covered for women who meet any of the following
criteria:
3.3.1 Women
who have been diagnosed with an hereditary ovarian cancer syndrome
based on a family pedigree constructed by an authorized provider
competent in determining the presence of an autosomal dominant inheritance
pattern; or
3.3.2 Women
with a personal history of steroid hormone receptor-positive breast
cancer; or
3.3.3 Women
with a personal history of breast cancer and at least one first
degree relative (mother, sister, daughter) with a history of ovarian
cancer; or
3.3.4 Women
who have two or more first degree relatives with a history of breast
or ovarian cancer; or
3.3.5 Women with one first degree
relative and one or more second degree relative (grandmother, aunt,
or niece) with ovarian cancer.
3.3.6 Some families have pedigrees
that are very small, and therefore have only one first degree relative
with ovarian cancer or young-onset breast, colon, or endometrial
cancer that may suggest increased risk for ovarian cancer. These
individuals may also be considered for prophylactic oophorectomy.
Effective January 1, 2006.
3.3.7 One or more of the following
pathogenic genetic mutations, when indicated by NCCN or ACOG recommendations,
effective September 1, 2017: BRCA1, BRCA2, BRIP1, Lynch Syndrome
(MSH2, MLH1, MSH6, PMS2, EPCAM), RAD51C, RAD51D, PTEN; or
3.3.8 Any other clinical factor
for which NCCN or ACOG recommend the consideration of a prophylactic salpingo-oophorectomy,
salpingectomy, or oophorectomy, effective September 1, 2017.
3.4 Prophylactic hysterectomy is
covered:
3.4.1 For women
who are about to undergo or are undergoing tamoxifen therapy.
3.4.2 For women who have been diagnosed
with Hereditary Non-Polyposis Colorectal Cancer (HNPCC) or Lynch
Syndrome or are found to be carriers of HNPCC or
Lynch Syndrome-associated mutations.
3.4.3 Opportunistic salpingo-oophorectomies,
salpingectomies, and oophorectomies concurrent with a prophylactic
hysterectomy may be covered when indicated by ACOG or NCCN guidelines.
