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MP 2.03.04 Melanoma Vaccines

 

Medical Policy    
Section
Medicine
 
Original Policy Date
04/01/98
Last Review Status/Date
Reviewed with literature search/6:2013
Issue
6:2013
  Return to Medical Policy Index

Disclaimer

Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract.  Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage.  Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.

 


Description

Tumor vaccines are a type of active immunotherapy that attempts to stimulate the patient’s own immune system to respond to tumor antigens. There are a number of different tumor vaccines for the treatment of malignant melanoma in various stages of development.

Vaccines using crude preparations of tumor material were first studied by Ehrlich over 100 years ago, (1) but the first modern report suggesting benefit using these in cancer patients did not appear until 1967. (2) Melanoma has been viewed as a particularly promising tumor for this type of treatment because of its immunologic features, which include the prognostic importance of lymphocytic infiltrate at the primary tumor site, the expression of a wide variety of antigens, and the occasional occurrence of spontaneous remissions. (3) Melanoma vaccines can be generally categorized or prepared in the following ways (4):

  • Whole-cell vaccines prepared using melanoma cells or crude sub-cellular fractions of melanoma cell lines
    • Autologous whole-cell vaccines in which tumor cells are harvested from the tissue of excised cancers, irradiated, and potentially modified with antigenic molecules to increase immunogenicity and made into patient-specific vaccines (e.g., M-Vax, AVAX Technologies)
    • Autologous heat-shock protein-peptide complexes vaccines in which a patient’s tumor cells are exposed to high temperatures and then purified to make patient-specific vaccines (e.g., Oncophage®, Vitaspin, Antigenics, Inc.), and
    • Allogeneic whole-cell vaccines in which intact or modified allogeneic tumor cell lines from other patients are lysed by mechanical disruption or viral infection and used to prepare vaccine (e.g., Canvaxin®, CancerVaxCorp. or Melacine®, University of Southern California)
  • Dendritic cell vaccines in which autologous dendritic cells are pulsed with tumor-derived peptides, tumor lysates, or antigen encoding RNA or DNA to produce immunologically enhanced vaccines.
  • Peptide vaccines consisting of short, immunogenic peptide fragments of proteins (e.g., melanoma antigen E or MAGE; B Melanoma antigen or BAGE) used alone or in different combinations to create vaccines of varying antigenic diversity, depending on the peptide mix.
  • Ganglioside vaccines in which glycolipids present in cell membranes are combined with an immune adjuvant (e.g. GM2) to create vaccines.
  • DNA vaccines created from naked DNA expression plasmids.
  • Viral vectors in which DNA sequences are inserted into attenuated viruses for gene delivery to patient immune systems.
  • Anti-idiotype vaccines made from monoclonal antibodies with specificity for tumor antigen-reactive antibodies.

Regulatory Status

At the present time, no melanoma vaccine has received approval from the U.S. Food and Drug Administration (FDA).


Policy

Melanoma vaccines are considered investigational.

 


Policy Guidelines

There are no specific CPT codes for this service.

 


Benefit Application

BlueCard/National Account Issues

Melanoma vaccines are currently available only in clinical trials in the U.S.

 


Rationale

This policy was originally created in 1998 and was updated regularly with searches of the MEDLINE database. The most recent literature search was performed for the period of March 2012 through March 2013.

The Technology Evaluation Center (TEC) evaluated the use of vaccines to treat melanoma in a 2001 TEC Special Report, “Vaccines for the Treatment of Malignant Melanoma.” (5) In spite of the fact that the literature contained hundreds of publications on this treatment at this time, there was a striking paucity of completed Phase III clinical trials available for evaluation. The 2001 report highlighted the importance of such studies to control for patient characteristic, disease, and treatment confounders. It also highlighted the value of long-term outcomes that measure disease progression or mortality instead of the use of less reliable surrogate measures of immune response. Of note, several Phase I or II studies of melanoma vaccines (Canvaxin®, Melacine®) have not been replicated in subsequent Phase II or III studies. (4)

In an article in Nature Medicine in 2004, Rosenberg et al. (6) noted that looking at the experience of the National Cancer Institute’s Surgery Branch in evaluating 450 patients treated for metastatic cancer with vaccines (the majority—422—with metastatic melanoma), only 2.6% exhibited a positive treatment response. Reviewing 35 carefully selected representative reports from the literature (one-third in melanoma patients) involving 765 patients, the objective response rate to this treatment was again surprisingly low (only 3.8%).

Rosenberg et al. (6) suggested that an important reason for this poor performance was the inability of T cells generated by cancer vaccines to infiltrate tumors and become activated after an encounter with tumor antigen in vivo. He concluded “the lack of clinical effectiveness of currently available cancer vaccines should not be interpreted to mean that cancer vaccine approaches are at an investigational dead end. Rather, it emphasizes the need for profound changes in the application of this approach.” Among several suggestions proposed were mechanisms to increase the yield and activity of CD4+ cells and to eliminate-tumor induced or normally occurring lymphocyte-mediated immune suppressive mechanisms.

While more than 1,700 publications on melanoma vaccine use in both animals and humans have appeared since the 2001 TEC Special Report, there are currently only 12 Phase III clinical studies evaluating melanoma vaccines (7-18): 4 using allogeneic vaccines, 2 autologous whole-cell vaccines, 2 ganglioside vaccines, one autologous heat shock protein, and 3 peptide vaccines—one pulsed with dendritic cells, one administered with ipilimumab and one administered with concomitant IL-2. In 2 studies, (7, 10) vaccine treatments appeared to demonstrate superior performance in unique populations identified during post hoc data evaluation. However, no published study to date has shown a statistically significant survival benefit in the general population selected for study. In two reports, (9, 12) outcomes using vaccines appeared inferior to those observed in controls. A summary of trials showing lack of efficacy are provided in Table 1.

Hodi et al. (17) performed a Phase III study of ipilimumab, an agent that blocks cytotoxic T-lymphocyte-associated antigen 4 to potentiate an antitumor T cell response. This agent was administered in a 3-arm study comparing ipilimumab to ipilimumab with gp100 peptide vaccine to gp100 peptide vaccine alone. Ipilimumab, when used alone or with gp100, exhibited improved overall survival compared to gp100 alone in patients with previously treated melanoma. Ipilimumab has subsequently been approved by the FDA for this use.

Schwartzentruber et al. (15, 18) reported findings of their Phase III trial of gp100:209-217(210M) peptide vaccine plus high-dose IL-2 (vaccine) versus high-dose IL-2 alone (control). The vaccine arm showed significant improvement in response rate (p=0.03) and progression-free survival (PFS; p=0.008) but not median overall survival (OS; p=0.06). The authors reached the guarded conclusion that “additional data are needed to ascertain whether the finding in our study was due to a direct effect of the vaccine or to the possibility that vaccinated patients were more responsive to salvage regimens or that the nature of progression differed between the two groups or that other factors were involved.”

In a recent systematic review and meta-analysis of 4,375 patients in 56 Phase II and Phase III studies, no evidence was found that vaccine therapy provides better overall disease control or overall survival compared with other treatments. (19) However, in a second review of medical treatments in melanoma, 2 pending studies were highlighted. (20) The first is a Phase III vaccine trial of patients with stage IIIB melanoma whose tumors express MAGE-A3 antigen in lymph node metastasis. This allogeneic vaccine is unique in targeting a specific cancer germline family antigen. The second is a Phase III trivalent vaccine prepared using 3 peptides (gp100, MART-1/Melan, and tyrosine HLA-A2). Preliminary reports suggest patients exhibiting antibodies to any of the 3 peptides had insignificantly improved survival. More definitive results from both studies are pending.

There are a variety of explanations as to why, to date, melanoma vaccines have not been able to produce clinically significant improvements in treatment outcomes. (21) One possible mechanism is immune ignorance and the ability of melanoma cells to escape detection through loss of antigens or loss of HLA expression. A second mechanism is immune tolerance. This may result from the ability of the melanoma tumor to prevent a local accumulation of active helper and/or effector T cells as a result of high interstitial pressure in the tumor or lack of appropriate adhesion molecular on tumor vasculature. This may also occur as a result of normal down-regulation of the immune system at the site of T cell tumor interaction. A wide range of immune-modulating techniques are being explored to find mechanisms for enhancing the immune response induced by tumor vaccines.

Gajewski (22) published a preliminary or exploratory report on the value of molecular profiling to identify relevant immune resistance in the tumor microenvironment. This approach toward identifying subsets of patients likely to benefit from specific treatment choices, if confirmed in future studies, may help improve treatment outcomes with the use of tumor vaccines.

Ongoing Clinical Trials

A review of ClinicalTrials.gov on April 12, 2013 identified 2 active Phase III studies on melanoma vaccines. In the MAVIS trial, a polyvalent melanoma vaccine will be compared to placebo in stage IIb, IIc and III melanoma patients at high-risk of recurrence after surgical resection (NCT01546571). This multicenter, double-blind, Phase III trial is estimated to enroll 1059 patients and be completed in 2018. In a single-center, randomized, open label, Phase II/III trial of 108 stage IIb, IIc and III melanoma patients, an allogeneic, irradiated melanoma vaccine will be compared to alpha interferon 2b after surgical melanoma resection (NCT01729663). An estimated completion date was not provided. The search of ClinicalTrials.gov also identified 57 open and active Phase I and II studies.

Summary

Tumor vaccines are a type of active immunotherapy that attempts to stimulate the patient’s own immune system to respond to tumor antigens. There are a number of different tumor vaccines for the treatment of malignant melanoma in various stages of development.

A wide range of vaccine choices are available including use of autologous tumor cells, allogeneic tumor cells, and tumor-specific moieties including peptides, gangliosides, and DNA plasmids. A variety of mechanisms appear to exist as possible obstacles to successful active immunotherapy using vaccines. Current studies are focused on the use of new and different vaccine preparations, as well as on various forms of immune-modulation as potential techniques for enhancing vaccine effectiveness.

Despite considerable interest and numerous studies over the past 20 years, to date no melanoma vaccine has been approved by FDA. One randomized, controlled trial (RCT) of a gp100 melanoma vaccine has reported a significant increase in response rate and progression-free survival, and many other trials are underway or in the planning stages. However, several other RCTs have reported no improvements in disease-free and overall survival rates with the use of study vaccines. Additionally, other RCTs have closed early due to inferiority of results with study vaccines. Therefore, the use of melanoma vaccines is considered investigational.

Table 1. Phase III randomized, controlled, clinical trials of vaccine therapy evaluating cancer outcomes

Author

Patient Population

Vaccine

Control

Results

Comment

Livingston et al., 1994 (7)

Stage III n=122  

GM2/BCG (bacille Calmette-Guerin)  

BCG  

Disease-free survival (DFS) and overall survival (OS) showed no statistically significant differences  

Patients with no pre-treatment anti-GM2 antibody showed improved PFS with vaccine  

Wallack et al., 1998 (8)  

Stage III n=217  

Vaccinia melanoma oncolysate  

Vaccinia oncolysate from normal cell

DFS and OS showed no statistically significant differences  

 

Kirkwood et al., 2001 (9)  

Stage IIB/III n=774  

Ganglioside GM2-KLH21 (GMK [guanylate kinase])

 

Interferon alpha  

Trial closed after interim analysis indicated GMK inferiority  

 

Sondak et al., 2002 (10)  

Stage II n=600  

Allogeneic melanoma vaccine (Melacine®)  

 

Observation  

No evidence of DFS  

Patients with 2 or more HLA matches showed improved PFS  

Hersey et al., 2002 (11)  

Stage IIB/III n=700

Vaccinica melanoma oncolysate  

 

Observation  

Recurrence-free and overall survival not statistically improved in vaccine patients

 

Morton et al., 2006 (12)  

Stage III n=1,160

Canvaxin® + BCG + placebo

 

BCG + placebo

Trial closed after interim analysis indicated Canvaxin® inferiority  

 

Morton et al., 2006 (12)  

Stage IV n=496  

Canvaxin®+ BCG + placebo

 

BCG + placebo

Trial closed after interim analysis showed lack of efficacy  

 

Mitchell et al., 2007 (13)  

Stage III n=604  

Allogeneic whole-cell lysate administered with Detox™ (Melacine®) + interferon alpha  

 

Interferon alpha

No survival advantage but fewer adverse events in patients on vaccine  

 

Testori et al., 2008 (14)  

Stage IV n=322  

Heat shock protein gp96 complex vaccine (Oncophage®)

Physician’s choice of dacarbazine, temozolomide, IL-2 and/or resection  

No survival advantage in patients on vaccine

 

Schadendorf et al., 2006 (16)  

Stage IV n=108  

Peptide-pulsed dendritic cells  

Dacarbazine

Trial closed after interim analysis showed lack of efficacy

 

Hodi et al., 2010 (17)

Stage III or IV n=676

Ipilimumab alone or with GP100  

GP100 peptide alone  

Ipilimumab showed improved overall survival with or without GP100 compared to GP100 treatment alone  

 

Schwarzentruber et al., 2011(18)

Stage III/IV n=185

GP100 peptide + IL2  

High-dose IL2  

Objective response and increased in patients on vaccine and IL2 treatment  

 

Practice Guidelines and Position Statements

The National Comprehensive Cancer Network guidelines on the treatment of melanoma do not reference the use of vaccines in clinical trials in any of its treatment algorithms. (23) The guidelines do discuss clinical trials that have reported inferiority in melanoma vaccine treatment arms.

Medicare National Coverage

There is no National Coverage determination.

References:

  1. Ray S, Chhabra A, Mehrotra S et al. Obstacles to and opportunities for more effective peptide-based therapeutic immunization in human melanoma. Clin Dermatol 2009; 27(6):603-13.
  2. Cunningham TJ, Olson KB, Laffin R et al. Treatment of advanced cancer with active immunization. Cancer 1969; 24(5):932-7.
  3. Eggermont AM. Therapeutic vaccines in solid tumours: can they be harmful? Eur J Cancer 2009; 45(12):2087-90.
  4. Lens M. The role of vaccine therapy in the treatment of melanoma. Expert Opin Biol Ther 2008; 8(3):315-23.
  5. Blue Cross Blue Shield Association Technology Evaluation Center (TEC). Special Report: Vaccines for the Treatment of Malignant Melanoma. 2001 TEC Assessments: Volume 16, Tab 4.
  6. Rosenberg SA, Yang JC, Restifo NP. Cancer immunotherapy: moving beyond current vaccines. Nat Med 2004; 10(9):909-15.
  7. Livingston PO, Adluri S, Helling F et al. Phase 1 trial of immunological adjuvant QS-21 with a GM2 ganglioside-keyhole limpet haemocyanin conjugate vaccine in patients with malignant melanoma. Vaccine 1994; 12(14):1275-80.
  8. Wallack MK, Sivanandham M, Balch CM et al. Surgical adjuvant active specific immunotherapy for patients with stage III melanoma: the final analysis of data from a phase III, randomized, double-blind, multicenter vaccinia melanoma oncolysate trial. J Am Coll Surg 1998; 187(1):69-77; discussion 77-9.
  9. Kirkwood JM, Ibrahim JG, Sosman JA et al. High-dose interferon alfa-2b significantly prolongs relapse-free and overall survival compared with the GM2-KLH/QS-21 vaccine in patients with resected stage IIB-III melanoma: results of intergroup trial E1694/S9512/C509801. J Clin Oncol 2001; 19(9):2370-80.
  10. Sondak VK, Liu PY, Tuthill RJ et al. Adjuvant immunotherapy of resected, intermediate-thickness, node-negative melanoma with an allogeneic tumor vaccine: overall results of a randomized trial of the Southwest Oncology Group. J Clin Oncol 2002; 20(8):2058-66.
  11. Hersey P, Coates AS, McCarthy WH et al. Adjuvant immunotherapy of patients with high-risk melanoma using vaccinia viral lysates of melanoma: results of a randomized trial. J Clin Oncol 2002; 20(20):4181-90.
  12. Morton Dl, Mozzillo N, Thompson JF et al. An international, randomized phase III trial of bacillus Calmette-Guerin (BCG) plus allogeneic melanoma vaccine (MCV) or placebo after complete resection of melanoma metastatic to regional or distant sites. J Clin Oncol 2007; 25(18S):8508.
  13. Mitchell MS, Abrams J, Thompson JA et al. Randomized trial of an allogeneic melanoma lysate vaccine with low-dose interferon Alfa-2b compared with high-dose interferon Alfa-2b for Resected stage III cutaneous melanoma. J Clin Oncol 2007; 25(15):2078-85.
  14. Testori A, Richards J, Whitman E et al. Phase III comparison of vitespen, an autologous tumor-derived heat shock protein gp96 peptide complex vaccine, with physician's choice of treatment for stage IV melanoma: the C-100-21 Study Group. J Clin Oncol 2008; 26(6):955-62.
  15. Schwartzentruber DJ, Lawson D, Richards J et al. A Phase III multi-institutions randomized study of immunization with the gp100.209-217 (210M) peptide followed by high-dose IL-2 compared with high-dose IL-2 alone in patients with metastatic melanoma. 2009 ASCO Annual Meeting 2009.
  16. Schadendorf D, Ugurel S, Schuler-Thurner B et al. Dacarbazine (DTIC) versus vaccination with autologous peptide-pulsed dendritic cells (DC) in first-line treatment of patients with metastatic melanoma: a randomized phase III trial of the DC study group of the DeCOG. Ann Oncol 2006; 17(4):563-70.
  17. Hodi FS, O'Day SJ, McDermott DF et al. Improved survival with ipilimumab in patients with metastatic melanoma. N Engl J Med 2010; 363(8):711-23.
  18. Schwartzentruber DJ, Lawson DH, Richards JM et al. gp100 peptide vaccine and interleukin-2 in patients with advanced melanoma. N Engl J Med 2011; 364(22):2119-27.
  19. Chi M, Dudek AZ. Vaccine therapy for metastatic melanoma: systematic review and meta-analysis of clinical trials. Melanoma Res 2011; 21(3):165-74.
  20. Garbe C, Eigentler TK, Keilholz U et al. Systematic review of medical treatment in melanoma: current status and future prospects. Oncologist 2011; 16(1):5-24.
  21. Chapman PB. Melanoma vaccines. Semin Oncol 2007; 34(6):516-23.
  22. Gajewski TF. Molecular profiling of melanoma and the evolution of patient-specific therapy. Semin Oncol 2011; 38(2):236-42.
  23. National Comprehensive Cancer Network. Clinical Practice Guidelines in Oncology, Melanoma (v2.2013). Available online at: http://www.nccn.org/professionals/physician_gls/pdf/melanoma.pdf.

 

  

Codes

Number

Description

CPT  86849 Unlisted immunology procedure 
ICD-9 Procedure  99.28 Immunotherapy, antineoplastic
ICD-9 Diagnosis    Investigational for all codes
HCPCS No code  
ICD-10-CM (effective 10/1/14)    Investigational for all diagnoses
  C43.0-C43.9 Malignant melanoma of skin code range
ICD-10-PCS (effective 10/1/14)   ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for the initiation of this therapy.
  3E01305 Administration, physiological system, introduction, subcutaneous tissue, percutaneous, antineoplastic, other antineoplastic
  3E02305 Administration, physiological system, introduction, muscle, percutaneous, antineoplastic, other antineoplastic
   3E03305 Administration, physiological system, introduction, peripheral vein, percutaneous, antineoplastic, other antineoplastic
  3E033WK, 3E033WL Administration, physiological system, introduction, peripheral vein, immunotherapeutic, code by qualifier (immunostimulator or immunosuppressive)
  3E043WK, 3E043WL, 3E053WK, 3E053WL, 3E063WK, 3E063WL, Administration, physiological system, introduction, immunotherapeutic, code by body part (central vein, peripheral artery, or central artery) and qualifier (immunostimulator or immunosuppressive)
Type of Service  Oncology
Place of Service  Outpatient

 


Index

Melanoma Vaccine
Vaccine, Tumor
Vaccine, Melanoma

 


Policy History

Date Action Reason
04/01/98 Add to Oncology subsection of Medicine section New Policy
05/15/02 Replace Policy Policy updated with reference to 2001 TEC Special Report; policy retitled to reflect focus on melanoma vaccines.
10/09/03 Replace Policy Policy updated with literature search; policy statement unchanged
03/15/05 Replace Policy Policy updated with literature search; policy statement unchanged
12/14/05 Replace Policy Policy updated with literature search; policy statement unchanged. Reference 5 added
06/14/07 Replace Policy Policy updated with literature search; policy statement unchanged. Reference numbers 6-11 added. Added brief explanation regarding link provided in reference number 5.
07/10/08 Replace Policy Policy extensively rewritten with literature search; references completely revised. No change in policy statement
07/09/09 Replace policy Policy updated with literature search; references 15 and 16 added. Policy statement remains unchanged
6/9/11 Replace policy Policy revised with literature search; description and rationale sections revised extensively. References 1-4, 6,7, 17, 19 added; no change to policy statement
06/14/12 Replace policy Policy updated with literature search; references 17-19 added; no change to policy statement.
05/09/13 Replace policy Policy updated with literature search through March 2013; reference 23 added; no change to policy statement.