This is a noncoverage policy for the chemosensitivity and chemoresistance
assays (CSRAs).

**CSRAs  
** In order to avoid ineffective chemotherapy toxicity, the intent of CSRAs is
to assist oncologists with the selection of chemotherapy drugs at initial
diagnosis and tumor recurrence.  
  
 **Chemosensitivity Assays**  
A chemotherapy sensitivity assay determines if a tumor growth is inhibited by
a known chemotherapy drug or drug combination. Thus, the intent of the
chemosensitivity assay is to assist the oncologist with effective chemotherapy
agent selection.  
  
Other names for chemosenstitivity assays include non-clonogenic or clonogenic
cytotoxic drug resistance assays, tumor stem cell assays, human tumor stem
cell drug sensitivity assays and differential staining cytotoxic assays. The
available chemosensitivity assays listed in this policy isolate tumor cells,
incubate the cells with drugs, and evaluate and interpret cell survival. The
difference in these assays is determined by the processing method.  
  
Chemosensitivity assays include, but are not limited to, the following:

  * DiSC assay (Differential staining cytotoxicity assay) - an _in vitro_ study for hematologic malignancies. Malignant mononuclear cells are incubated with specific chemotherapeutic agents for 4 days, and then exposed to vital stain to prevent dead/dying cells from counterstaining with hematoxylin and eosin. Slides are prepared and examined by light microscopy for percent cell kill compared to untreated controls.
  * ATP (Adenosine Triphosphate) assay - involves seeding known concentrations of tumor cells into microplate wells with single and combination chemotherapeutic agents. The ATP content of each well is measured after multiple days of incubation followed by addition of luciferin-luciferase to an aliquot of lysed cells in a luminometer. Luminescence measurements are directly related to ATP levels. These measurements allow determination of percent inhibition compared to controls.
  * MTT (Methyl Thiazolyl Tetrazolium) assay - determines the ability of viable cells to convert a soluble tetrazolium salt (MTT) into an insoluble formazan precipitate. Drug-induced cell death and loss of enzymatic activity generate the formazan product from the MTT.
  * HDRA (AntiCancer Inc) Assay - a semi-automated histoculture drug response assay utilizing the MTT stain to assess drug sensitivity.
  * EVA-PCD (Rational Therapeutics) assay - a non-proliferative assay that provides a measure of drug-induced cell death _in vivo_.

  
**Chemoresistance Assays**  
A chemoresistance assay determines "extreme drug resistance" when tumor cell
cultures are exposed to high concentrations of selected agent(s) for long
exposure times. A chemoresistance assay is used to deselect potentially
ineffective therapeutic agents. A single chemoresistance assay is addressed in
this policy:

  * Oncotech EDR (Exiqon Diagnostics) - an _in vivo_ assay designed to predict the sensitivity and resistance of solid tumor cultures to a variety of increasing doses of selected chemotherapy agents. Fresh viable tumor tissue is minced and enzyme digested to disaggregate the tumor cells. The tumor cells are plated in soft agar. The cells are exposed to tumor type-specific anti-neoplastic agents for 5 days. Drug exposures in excess of the maximum clinically tolerated are used (5 to 80 times greater than _in vivo_ ). Tritiated thymidine is added during the last 2 days of culture as a measure of cell proliferation. Treated cells are compared to untreated controls. If malignant cells proliferate _in vitro_ under extreme chemotherapeutic exposure, then _in vivo_ exposures will be ineffective. Results are reported as low (LDR), intermediate (IDR) and extreme drug resistance (EDR). The live cells remaining post-treatment are enumerated microscopically and the resulting cell counts are compared to controls to generate a dose-response curve for each tested agent. The response curve is used to score a tumor's response.

  
**Studies**  
The Blue Cross and Blue Shield Association (BCBSA) performed an extensive
literature review that will not be cited in this policy on CSRAs. Their
findings, published as a Tec Assessment in 2002, indicated that there was
insufficient data to determine whether assay-directed chemotherapy improves
health outcomes compared to empiric chemotherapy. In summary, the authors
stated that well-designed trials were needed to determine whether assay-
directed chemotherapy actually improves health outcomes.  
  
Two years later, the American Society of Clinical Oncology (ASCO) collaborated
with BCBSA to assess the scientific literature in support of CSRA assays.
Absent new evidence of clinical utility, ASCO recommended that CSRAs should
not be used outside of the clinical trial setting. A second BCBSA assessment
noted a higher response rate for assay-guided therapy. However, they
questioned if difference was attributed to bias and confounding.  
  
A retrospective study suggested improved progression free (PFS) and overall
survival (OS) in 50 consecutive platinum-sensitive ovarian cancer patients who
received EDR assay-guided therapy. Study flaws include absence of blinding or
randomization, small study size, and performance bias and selection.
Therefore, the study does NOT establish the relative effectiveness of assay-
guided treatment over empiric treatment. The authors acknowledged the study
lacked adequate power for hypothesis testing and was intended for "exploratory
purposes" to generate a hypothesis worthy of further study.  
  
Additional studies after the BCBSA's and ASCO's assessments included a
prospective blinded study on 48 patients with recurrent malignant glioma.
While shortened time to progression and OS were noted, the findings were not
statistically significant. The authors recommended future studies.  
  
Using an ATP-based assay (not EDR), 147 platinum resistant patients with
ovarian cancer were randomized between assay-directed chemotherapy vs
physician's choice of therapy. While improved PFS response rates were noted,
there was no difference in OS between the groups. These authors recommended a
larger trial.  
  
In another study, the EDR assay results were available for 189 non-small cell
lung cancer patients for the oncologist's consideration for assay-directed
therapy. In 59 of 189 patients who received post-op or adjuvant therapy,
Eastern Cooperative Oncology Group (ECOG) standard or the oncologist's
preference determined the therapy. The selected therapy was "not
individualized to each patient with respect to assay results". Forty-five
patients were assessed. Patients with tumors that exhibited LDR to platinum
(27 patients) were compared with patients with tumors that exhibited IDR/EDR
to platinum (18 patients). In summary, 18 of 27 patients (67%) with LDR are
alive; 9 of 18 patients (50%) with IDR/EDR are alive at publication. This
study demonstrates a significant flaw, because therapy was not chosen or based
on assay results. The authors recommended a phase III randomized clinical
trial to test whether EDR assay is associated with improved survival compared
with empiric chemotherapy.  
  
Another article demonstrates EDR is common after prior exposure to paclitaxel,
but does not correlate EDR assay results with clinical outcomes (clinical
utility).  
  
A prospective study of 43 patients with ovarian cancer received 6-9 cycles of
platinum and taxane. PFS and OS among patients with and without EDR to
platinum were not clinically significant. The authors recommended a
prospective trial to select first- and second-line chemotherapy to define the
clinical efficacy of the assay.  
  
More recently, a retrospective review of 377 primary ovarian cancer patients
demonstrated EDR assay results do not independently predict or alter the
outcomes of patients treated with current standard of primary cytoreductive
surgery followed by platinum and taxane combination chemotherapy.7 Study flaws
are discussed in the letters to the editor. However, the authors of the
letters to the editor admit a prospective registration trial controlling
various factors will be necessary to determine the ability of an _in vitro_
assay to truly predict response, time to progression and OS.  
  
Two 2009 retrospective studies provide conflicting insight into the clinical
utility of the EDR assay. In the first study, EDR was assessed in 253 ovarian
cancer patients. Dual-resistance was defined as at least one EDR in the
primary and secondary treatment groups. The authors concluded that the
presence of EDR to multiple agents was not associated with OS in advanced
stage epithelial ovarian, fallopian and primary peritoneal cancers. In the
second study, 58 of 173 patients who underwent optimal primary cytoreduction
with ovarian tumor LDR to both platinum and taxane demonstrated statistically
improved PFS and OS compared with the 115 patients who demonstrated IDR or EDR
to these agents.  
  
It is noteworthy, the 2009 National Comprehensive Cancer Network (NCCN)
guidelines noted that _in vitro_ CSRAs should not be recommended due to the
lack of demonstrable efficacy for choosing a chemotherapy regimen. In 2010
without supporting clinical trials, NCCN notated that CSRAs are used in some
NCCN Centers. However, NCCN indicated that the current level of evidence is
not sufficient to supplant standard of care chemotherapy.  
  
July 25, 2011, The American Society of Clinical Oncology Clinical Practice
Guideline updated the guidelines on the use of CSRA and posted on
<https://ascopubs.org/doi/full/10.1200/JCO.2011.36.0354> ahead of print.
"Review of the literature does _not_ identify any CSRAs for which the evidence
base is sufficient to support use in oncology practice."

Level of Evidence

Quality - Moderate  
Strength - Strong  
Weight - Moderate

CSRAs are considered investigational and not a covered Medicare benefit.