Medical Policy

 

Subject: Tisagenlecleucel (Kymriah™)
Document #: MED.00124 Publish Date:    02/28/2018
Status: Revised Last Review Date:    01/25/2018

Description/Scope

This document addresses uses of tisagenlecleucel (Kymriah, Novartis Pharmaceuticals Corporation, East Hanover, NJ), an autologous chimeric antigen receptor (CAR) T-cell immunotherapy that targets the CD19 surface antigen expressed in B cell malignancies. Tisagenlecleucel is produced by genetically engineering an individual’s own functioning immune cells to express tumor antigen recognition signals that target and destroy malignant cells in certain types of B-cell precursor cancer.

Note: Please see the following related documents for additional information:

Position Statement

Medically Necessary:

Tisagenlecleucel is considered medically necessary for the treatment of B-cell acute lymphoblastic leukemia (ALL), when all of the following criteria are met:

  1. Disease is considered refractory, or in second or later relapse, in any of the following scenarios:
    1. Second or later bone marrow relapse; or
    2. Bone marrow relapse after allogeneic stem cell transplant; or
    3. Primary refractory or chemo-refractory after relapse; and
  2. Documentation of CD19 tumor expression; and
  3. Pediatric or young adult (25 years of age or younger); and
  4. Performance score on Karnofsky or Lansky Scale is greater than or equal to 50% or Eastern Cooperative Oncology Group (ECOG) performance score is 0-3; and
  5. One-time, single administration treatment.

Note: According to the black box warning in the FDA Product Information Label (2017), tisagenlecleucel should be administered at a designated treatment center that has received site certification.

Investigational and Not Medically Necessary:

Tisagenlecleucel is considered investigational and not medically necessary as a treatment for B-cell ALL, when the medically necessary criteria are not met, and for all other indications, including but not limited to:

  1. Use as first-line therapy for ALL;
  2. Use in combination with other chemotherapy agents;
  3. Repeat treatment in individuals who have received tisagenlecleucel or other CAR-T treatment previously.
Rationale

On August 30, 2017, tisagenlecleucel received approval by the U.S. Food and Drug Administration (FDA) for the treatment of children and young adults, 25 years of age or younger, with B-cell acute lymphoblastic leukemia (ALL) that is refractory or in second or later relapse (FDA Product Information [PI] Label, 2017). Tisagenlecleucel was granted priority review and breakthrough therapy designations by the FDA.

FDA approval of tisagenlecleucel was based on a single arm, open-label, multi-center, phase II study to determine the efficacy and safety of a single infusion of tisagenlecleucel in children and young adults with relapsed/refractory B-cell ALL (ELIANA; NCT 02435849). A total of 63 study participants were enrolled and included in the interim analysis (median follow-up 4.8 months). The study inclusion criteria included age 3 years at screening to 21 years at time of diagnosis, positive for CD19 tumor expression, adequate organ function, bone marrow with ≥ 5% lymphoblasts by morphologic assessment at screening, life expectancy of at least 12 weeks, and Karnofsky (participants age ≥ 16 years) or Lansky (participants age < 16 years) performance status of ≥ 50 at screening. Participants were excluded from the study based on criteria which included the following: isolated extra-medullary disease relapse, diagnosis of a concomitant genetic syndrome (for example, Fanconi anemia, Kostmann syndrome, Shwachman syndrome or any other known bone marrow failure syndrome), Burkitt's lymphoma/leukemia (i.e. mature B-cell ALL), prior malignancy (except carcinoma in situ of the skin or cervix treated with curative intent and with no evidence of active disease), treatment with a prior gene therapy product or anti-CD19/anti-CD3 therapy, active or latent hepatitis B or C, or any uncontrolled infection, human immunodeficiency virus (HIV) positive test, presence of grade 2 to 4 acute or extensive chronic graft-versus-host disease (GVHD), and active central nervous system (CNS) involvement by malignancy (defined by CNS-3 per National Comprehensive Cancer Network® [NCCN] guidelines). Study participants were primary refractory, chemo-refractory after first relapse, relapsed after second-line therapy or ineligible for allogeneic SCT. All study enrollees received lymphodepleting chemotherapy (fludarabine and cyclophosphamide) prior to infusion with tisagenlecleucel (Grupp, 2017). A total of 63% (n=40) of study participants achieved a complete remission (CR) and 19% (n=12) achieved a CR with incomplete blood count recovery (CRi). The primary outcome, overall remission rate (ORR=CR+Cri), was 83% (n=54). Secondary objectives included minimal residual disease (MRD), relapse-free survival (RFS), overall survival (OS) and safety. The 6-month OS was 89% and the disease-free survival was 60%. All participants who achieved a CR or CRi also tested negative for minimal residual disease (95% confidence interval [CI], 71-91; p<0.0001). With a median follow-up of 4.8 months from response, the median duration of CR/CRi was not reached (range: 1.2-14.1+ months). A total of 11 participants died after receiving an infusion with tisagenlecleucel; 7 were disease-related, 3 were attributed to infections, and 1 to intracerebral hemorrhage. Cytokine release syndrome (CRS) occurred in a total of 79% of study participants; 49% of CRS was grade 3 or 4. Treatment with anti-cytokine therapy, high dose vasopressors, invasive ventilation, and dialysis were needed to stabilize participants that developed CRS. There were no CRS-related deaths and no cases of cerebral edema reported (FDA PI Label, 2017).

In 2014, Maude and colleagues published the results of a phase II clinical trial in children and adults diagnosed with relapsed/refractory ALL (n=30). A total of 25 children and young adults (5-22 years of age) and 5 older adults (26-60 years of age) received tisagenlecleucel. CR was achieved in 27 study participants (90%), including 2 with blinatumomab-refractory disease and 15 who had previously undergone stem-cell transplantation. There was a 6-month event-free survival rate of 67% (95% CI, 51-88%) and an OS rate of 78% (95% CI, 65-95). All study participants developed CRS. Severe CRS developed in 27% of participants and was associated with a higher disease burden prior to infusion. CRS was effectively treated with the anti-interleukin-6 receptor antibody, tocilizumab (Maude, 2014).

The NCCN Clinical Practice Guidelines (CPG) for ALL (V5.2017) has a 2A recommendation for individuals under the age of 26 with refractory disease or for those with two or more relapses who have experienced treatment failure with at least two tyrosine kinase inhibitors (TKIs).

Tisagenlecleucel is also being investigated for safety and efficacy in adult ALL, relapsed/refractory diffuse large B-cell lymphoma, multiple myeloma, lymphocytic leukemia and Hodgkin’s lymphoma.

Background/Overview

ALL is an aggressive type of leukemia characterized by the proliferation of immature lymphoid cells in the bone marrow, peripheral blood and other organs. In 2017, there will be an estimated 5970 new cases of ALL and 1440 deaths (American Cancer Society, 2017). ALL is the most common cancer diagnosed in children in the United States and occurs at an annual rate of approximately 41 cases per 1 million people aged 0 to 14 years and approximately 17 cases per 1 million people aged 15 to 19 years. On average, approximately 3100 children and young adults (<20 years old) are diagnosed with ALL each year (National Cancer Institute, 2017). Although more than 80% of individuals treated for ALL achieve a CR, approximately 15-20% will relapse (Oskarsson, 2016). At this time, hematopoietic stem cell transplant (HSCT) is the most effective treatment option for relapsed/refractory ALL. Achievement of CR is a vital step in the transplantation process, but many individuals are ineligible due to failure to achieve this remission (Topp, 2015).

CAR-T therapy may play an important role as a bridge to transplant by providing another therapeutic option to induce remission in individuals who would otherwise have been ineligible for a HSCT due to progression of disease; tisagenlecleucel is a type of CAR-T therapy (NCCN, 2017).

The process of producing tisagenlecleucel begins with harvesting peripheral blood cells from an individual. The T-cells are isolated and genetically engineering to recognize CD19 on targeted tumor cells (the genetically engineered cells are called CAR-T cells). These cells are then stimulated to multiply and the resulting product is infused back into the individual, reengineered to target and destroy malignant cells expressing CD19 (NCCN, 2017).

Adverse Events and Warnings 

Black box warnings from the FDA PI Label (2017) include the following information and recommendations:

Additional warnings from the FDA PI Label (2017) include the following information and recommendations:

Definitions

Allogeneic cells: Harvested from a histocompatible donor.

Autologous cells: Harvested from the individual's own cells.

Bone marrow: A spongy tissue located within flat bones, including the hip and breast bones and the skull. This tissue contains stem cells, the precursors of platelets, red blood cells, and white cells.

Chemotherapy: The medical treatment of a disease, particularly cancer, with drugs or other chemicals.

Chimerism: Cell populations derived from different individuals; may be mixed or complete.

Complete response/remission (CR): The disappearance of all signs of cancer in response to treatment; this does not always mean the cancer has been cured; also called a complete response.

Cytotoxic: Destructive to cells.

ECOG (Eastern Cooperative Oncology Group) Performance Status: A scale used to determine the individual's level of functioning; this scale may also be referred to as the WHO (World Health Organization) or Zubrod score; based on the following scale:

0

Fully active, able to carry on all pre-disease performance without restriction

1

Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work

2

Ambulatory and capable of all selfcare but unable to carry out any work activities. Up and about more than 50% of waking hours

3

Capable of only limited selfcare, confined to bed or chair more than 50% of waking hours

4

Completely disabled. Cannot carry on any selfcare. Totally confined to bed or chair

5

Deceased

Graft versus host disease: A life-threatening complication of bone marrow transplants in which the donated marrow causes an immune reaction against the recipient's body.

Hematopoietic stem cells: Primitive cells capable of replication and formation into mature blood cells in order to repopulate the bone marrow.

Karnofsky Score: A measure of the individual's overall physical health, judged by their level of activity; the score uses the following scale (generally reserved for individuals 16 years of age and older):

100%

Normal, no complaints, no signs of disease

90%

Capable of normal activity, few symptoms or signs of disease

80%

Normal activity with some difficulty, some symptoms or signs

70%

Caring for self, not capable of normal activity or work

60%

Requiring some help, can take care of most personal requirements

50%

Requires help often, requires frequent medical care

40%

Disabled, requires special care and help

30%

Severely disabled, hospital admission indicated but no risk of death

20%

Very ill, urgently requiring admission, requires supportive measures or treatment

10%

Moribund, rapidly progressive fatal disease processes

0%

Death

Lansky Score: A measure of the individuals overall physical health, judged by their level of activity; the score uses the following scale (generally reserved for individuals less than 16 years of age): 

100

Fully active, normal

90

Minor restrictions in physically strenuous activity

80

Active, but tires more quickly

70

Both greater restriction of and less time spent in play activity

60

Up and around, but minimal active play; keeps busy with quieter activities

50

Gets dressed but lies around much of the day, no active play but able to participate in all quiet play and activities

40

Mostly in bed; participates in quiet activities

30

In bed; needs assistance even for quiet play

20

Often sleeping; play entirely limited to very passive activities

10

No play; does not get out of bed

0

Unresponsive

Refractory: Tumors that show less than 50% reduction in tumor burden in response to chemotherapy upon or during the course(s) of chemotherapy.

Relapse: The return of signs and symptoms of cancer after a period of improvement.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services may be Medically Necessary when criteria are met:

HCPCS

 

Q2040

Tisagenlecleucel, up to 250 million CAR-positive viable T cells, including leukapheresis and dose preparation procedures, per infusion [Kymriah]

ICD-10 Procedure

 

XW033C3

Introduction of engineered autologous chimeric antigen receptor T-cell immunotherapy into peripheral vein, percutaneous approach, new technology group 3 [when specified as Kymriah]

XW043C3

Introduction of engineered autologous chimeric antigen receptor T-cell immunotherapy into central vein, percutaneous approach, new technology group 3 [when specified as Kymriah]

ICD-10 Diagnosis

 

 

C91.00-C91.02

Acute lymphoblastic leukemia (ALL)

 

Z51.12

Encounter for antineoplastic immunotherapy

 

When services are Investigational and Not Medically Necessary:
For the procedure and diagnosis codes listed above when criteria are not met or for all other diagnoses not listed; or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.

References

Peer Reviewed Publications:

  1. Grupp S, Laetsch T, Buechner J, et al. Analysis of a global registration trial of the efficacy and safety of CTL019 in pediatric and young Adults with relapsed/refractory acute lymphoblastic leukemia (ALL). Blood. 2016; 128(22):221. Available at: http://www.bloodjournal.org/content/128/22/221?sso-checked=true. Accessed on December 20, 2017.
  2. Maude SL, Frey N, Shaw PA, et al. Chimeric antigen receptor T cells for sustained remissions in leukemia. N Engl J Med. 2014; 371(16):1507-1517.
  3. Maude S, Pulsipher M, Boyer M, et al. Efficacy and safety of CTL019 in the first US phase II multicenter trial in pediatric relapsed/refractory acute lymphoblastic leukemia: results of an interim analysis. Blood. 2016: 128:2801. Available at: http://www.bloodjournal.org/content/128/22/2801. Accessed on December 20, 2017.
  4. Oskarsson T, Söderhäll S, Arvidson J, et al. Relapsed childhood acute lymphoblastic leukemia in the Nordic countries: prognostic factors, treatment and outcome. Haematologica. 2016; 101(1):68-76.
  5. Porter DL, Hwang WT, Frey NV, et al. Chimeric antigen receptor T cells persist and induce sustained remissions in relapsed refractory chronic lymphocytic leukemia. Sci Transl Med. 2015; 7(303):303.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. Kymriah [Product Information], Novartis Pharmaceuticals Corporation, East Hanover, NJ; August 2017. Available at: https://www.fda.gov/downloads/BiologicsBloodVaccines/CellularGeneTherapyProducts/ApprovedProducts/UCM573941.pdf. Accessed on December 20, 2017.
  2. National Marrow Donor Program and the Medical College of Wisconsin. Center for International Blood and m Marrow Transplant Research: Karnofsky/Lansky Performance Status. 2009. Available at: https://www.cibmtr.org/DataManagement/TrainingReference/Manuals/DataManagement/Documents/appendix-l.pdf. Accessed on December 20, 2017.
  3. NCCN Clinical Practice Guidelines in Oncology®. © 2017 National Comprehensive Cancer Network, Inc. For additional information visit the NCCN website: http://www.nccn.org/index.asp. Accessed on December 20, 2017.
    • Acute Lymphocytic Leukemia (V5.2017). Revised October 27, 2017.
  4. Novartis Pharmaceuticals. Determine efficacy and safety of CTL019 in pediatric patients with relapsed and refractory B-cell ALL (ELIANA). NCT 02435849. Updated September 29, 2017. Available at: https://clinicaltrials.gov/ct2/show/NCT02435849?term=ELIANA&rank=1. Accessed on December 20, 2017.
  5. Novartis Pharmaceuticals. Risk Evaluation and Mitigation Strategy (REMS) program: Kymriah treatment centers. Available at: https://www.hcp.novartis.com/products/kymriah/acute-lymphoblastic-leukemia-children/treatment-centers/. Accessed on December 20, 2017. 
Websites for Additional Information
  1. American Cancer Society. Key Statistics for Acute Lymphocytic Leukemia. http://www.cancer.org/cancer/leukemia-acutelymphocyticallinadults/detailedguide/leukemia-acute-lymphocytic-key-statistics. Updated on January 05, 2017. Accessed on December 20, 2017.
  2. National Cancer Institute (NCI). Adult acute lymphoblastic leukemia treatment (PDQ®). Updated July 21, 2017. Available at: https://www.cancer.gov/types/leukemia/hp/adult-all-treatment-pdq. Accessed on December 20, 2017.
  3. NCI. CAR T Cells: Engineering patients’ immune cells to treat their cancers. Updated December 14, 2017. Available at: https://www.cancer.gov/about-cancer/treatment/research/car-t-cells. Accessed on December 20, 2017.
  4. NCI. Childhood acute lymphoblastic leukemia treatment (PDQ®). Updated December 1, 2017. Available at: https://www.cancer.gov/types/leukemia/hp/child-all-treatment-pdq
Index

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

Document History

Status

Date

Action

Revised

01/25/2018

Medical Policy & Technology Assessment Committee (MPTAC) review.

Revised

01/17/2018

Hematology/Oncology Subcommittee Review. Updated Description/Scope. Added a “Note” referencing designated treatment centers to the MN Statement. Updated Rationale, Background/Overview, Coding and References sections.

Reviewed

11/02/2017

MPTAC review.

Reviewed

11/01/2017

Hematology/Oncology Subcommittee review. Updated header language from “Current Effective Date” to “Publish Date.” Updated Coding section to include 01/01/2018 HCPCS changes.

New

09/13/2017

MPTAC review.

New

09/11/2017

Hematology/Oncology Subcommittee review. Initial document development.

Preliminary Discussion

05/04/2017

MPTAC Pre-FDA approval review.

Preliminary Discussion

05/03/2017

Hematology/Oncology Subcommittee review. Pre-FDA approval review.