Margetuximab-cmkb (Margenza)

Number: 0985

Table Of Contents

Policy
Applicable CPT / HCPCS / ICD-10 Codes
Background
References


Policy

Scope of Policy

This Clinical Policy Bulletin addresses margetuximab-cmkb (Margenza) for commercial medical plans. For Medicare criteria, see Medicare Part B Criteria.

Note: Requires Precertification:

Precertification of margetuximab-cmkb (Margenza) is required of all Aetna participating providers and members in applicable plan designs. For precertification of margetuximab-cmkb (Margenza), call (866) 752-7021, or fax (888) 267-3277. For Statement of Medical Necessity (SMN) precertification forms, see Specialty Pharmacy Precertification

  1. Criteria for Initial Approval

    Breast Cancer

    Aetna considers margetuximab-cmkb (Margenza) medically necessary for treatment of HER2-positive breast cancer with no response to preoperative systemic therapy or HER2-positive recurrent unresectable or metastatic breast cancer, in combination with chemotherapy, for members who have received two or more prior regimens.

    Aetna considers all other indications as experimental and investigational. 

  2. Continuation of Therapy

    Aetna considers continuation of margetuximab-cmkb (Margenza) therapy medically necessary in members requesting reauthorization for breast cancer when there is no evidence of unacceptable toxicity or disease progression while on the current regimen.

Dosage and Administration

Margetuximab-cmkb is available as Margenza 250 mg/10 mL (25 mg/mL) in a single-dose vial.

For intravenous infusion only. Do not administer as an intravenous push or bolus.

Breast Cancer

The recommended dose of Margenza is 15 mg/kg, administered as an intravenous infusion every 3 weeks (21-day cycle) until disease progression or unacceptable toxicity.

Administer Margenza as an intravenous infusion at 15 mg/kg over 120 minutes for the initial dose, then over a minimum of 30 minutes every 3 weeks for all subsequent doses.

On days when both Margenza and chemotherapy are to be administered, Margenza may be administered immediately after chemotherapy completion.

Source: MacroGenics, Inc., 2020b.


Table:

CPT Codes / HCPCS Codes / ICD-10 Codes

Code Code Description

Information in the [brackets] below has been added for clarification purposes.   Codes requiring a 7th character are represented by "+" :

Other CPT codes related to the CPB:

96413-96417 Chemotherapy administration, intravenous infusion technique

HCPCS codes covered if selection criteria are met:

J9353 Injection, margetuximab-cmkb, 5 mg

Other HCPCS codes related to the CPB:

J9000-J9999 Chemotherapy drugs

ICD-10 codes covered if selection criteria are met:

C50.011-C50.929 Malignant neoplasm of a breast [HER2-positive metastatic][recurrent or unresectable disease]

Background

U.S. Food and Drug Administration (FDA)-Approved Indications

  • Margenza is indicated, in combination with chemotherapy, for the treatment of adult patients with human epidermal growth factor receptor 2 (HER2)-positive metastatic breast cancer who have received two or more prior anti-HER2 regimens, at least one of which was for metastatic disease.

Compendial Uses

  • Breast cancer

Margetuximab-cmkb (Margenza) is a HER2/neu receptor antagonist indicated, in combination with chemotherapy, for the treatment of adult patients with metastatic HER2­ positive breast cancer who have received two or more prior anti-HER2 regimens, at least one of which was for metastatic disease. Margenza (margetuximab-cmkb), a HER2/neu receptor antagonist, is a chimeric Fc-engineered IgG1 kappa monoclonal antibody. Margetuximab-cmkb is produced by recombinant DNA technology in a mammalian cell (Chinese Hamster Ovary) culture.

Margenza binds to the extracellular domain of the human epidermal growth factor receptor 2 protein (HER2). Upon binding to HER2-expressing tumor cells, margetuximab-cmkb inhibits tumor cell proliferation, reduces shedding of the HER2 extracellular domain and mediates antibody-dependent cellular cytotoxicity (ADCC).

Margenza carries a black box warning to include left ventricular dysfunction and embryo-fetal toxicity (MacroGenics, Inc.; 2020b). Margenza may lead to reductions in left ventricular ejection fraction (LVEF). Evaluate cardiac function prior to and during treatment. Discontinue Margenza treatment for a confirmed clinically significant decrease in left ventricular function. Exposure to Margenza during pregnancy can cause embryo-fetal harm. Advise patients of the risk and need for effective contraception.

Margetuximab-cmkb (Margenza) carries additional warnings and precautions that include infusion-related reactions (IRRS) (MacroGenics, Inc.; 2020b). Monitor for signs and symptoms. If a significant infusion-associated reaction occurs, slow or interrupt the infusion and administer appropriate medical therapies.

Per the prescribing information (MacroGenics, Inc.; 2020b), the most common adverse drug reactions geater than 10% with margetuximab-cmkb in combination with chemotherapy include fatigue/asthenia, nausea, diarrhea, vomiting, constipation, headache, pyrexia, alopecia, abdominal pain, peripheral neuropathy, arthralgia/myalgia, cough, decreased appetite, dyspnea, infusion-related reactions, palmar-plantar erythrodysesthesia, and extremity pain.

Breast Cancer

Human epidermal growth factor receptor 2 (HER2) is a protein that is found on the surface of some cancer cells that promotes growth and is associated with aggressive disease and poor prognosis. The incidence of HER-2 positive breast cancer cases is estimated to be 15-20%. Monoclonal antibodies targeting HER2 have greatly improved outcomes; however, a significant number of patients progress to later lines of therapy. There continues and remains to be an unmet need for effective treatments for metastatic HER2-positive breast cancer (MacroGenics, 2020a).

On December 16, 2020, the FDA approved margetuximab-cmkb in combination with chemotherapy, for the treatment of adult patients with metastatic HER2-positive breast cancer who have received two or more prior anti-HER2 regimens, at least one of which was for metastatic disease. The approval for Margenza was established on data from the SOPHIA, a randomized Phase 3 clinical trial.

In this study, Rugo et al. (2021) compared the clinical efficacy of margetuximab versus trastuzumab, each with chemotherapy, in patients with pretreated ERBB2 (formerly HER2)-positive advanced breast cancer (ABC). All study patients had previously received trastuzumab, all but one patient had previously received pertuzumab, and 91% had previously received ado-trastuzumab emtansine, or T-DM1. This international, randomized, open-label, phase 3 clinical trial was comprised by a total of 536 patients who were randomized to receive margetuximab (n=266) or trastuzumab (n=270). The primary endpoints of the study were sequentially-assessed progression-free survival (PFS), determined by blinded, centrally-reviewed radiological review, followed by overall survival (OS). Additional key secondary endpoints were PFS by investigator assessment, objective response rate (ORR) and duration of response. The investigators determined that margetuximab improved primary PFS evidenced by a statistically significant 24% reduction in the risk of disease progression or death in margetuximab plus chemotherapy compared with trastuzumab plus chemotherapy (hazard ratio [HR] = 0.76; 95% CI, 0.59-0.98; p=0.033; median PFS 5.8 vs 4.9 months). Following the second planned interim analysis of 270 deaths, the median OS was 21.6 months with margetuximab versus 19.8 months with trastuzumab (HR, 0.89; 95% CI, 0.69-1.13; p=0.33). Furthermore, margetuximab improved objective response rate over trastuzumab: 22% and 16% (p=0.06; October 10, 2018), and 25% vs 14% (p<0.001; September 10, 2019). The results of final OS analysis is anticipated in the second half of 2021. There was a greater incidence of infusion-related reactions with margetuximab (35 [13.3%] versus 9 [3.4%]); otherwise, safety was comparable. In conclusion, margetuximab with chemotherapy demonstrated acceptable safety with a statistically significant improvement in PFS compared with trastuzumab plus chemotherapy in ERBB2-positive ABC following progression on 2 or more prior anti-ERBB2 therapies.


References

The above policy is based on the following references:

  1. Kreutzfeldt J, Rozeboom B, Dey N, De P. The trastuzumab era: current and upcoming targeted HER2+ breast cancer therapies. Am J Cancer Res. 2020;10(4):1045-1067.
  2. MacroGenics Inc. MacroGenics announces FDA approval of Margenza for patients with pretreated metastatic HER-2 positive breast cancer. Press Release. Rockville, MD: MacroGenics; December 16, 2020a.
  3. MacroGenics, Inc.Margenza (margetuximab-cmkb) injection, for intravenous use. Prescribing Information. Rockville, MD: MacroGenics; revised December 2020b.
  4. MacroGenics, Inc. Margetuximab plus chemotherapy vs trastuzumab plus chemotherapy in the treatment of HER2+ metastatic breast cancer (SOPHIA). ClinicalTrials.gov Identifier: NCT02492711. Bethesda, MD: National Library of Medicine; updated December 19, 2020c.
  5. McAndrew NP. Updates on targeting human epidermal growth factor receptor 2-positive breast cancer: What's to know in 2021. Curr Opin Obstet Gynecol. 2022;34(1):41-45.
  6. National Comprehensive Cancer Network (NCCN). Margetuximab-cmkb. NCCN Drugs and Biologics Compendium. Plymouth Meeting, PA: NCCN; December 2022.
  7. Royce M, Osgood CL, Amatya AK, et al. FDA approval summary: Margetuximab plus chemotherapy for advanced or metastatic HER2-positive breast cancer. Clin Cancer Res. 2022;28(8):1487-1492.
  8. Rugo HS, Im SA, Cardoso F, et al. Efficacy of margetuximab vs trastuzumab in patients with pretreated ERBB2-positive advanced breast cancer: A phase 3 randomized clinical trial. JAMA Oncol. 2021.
  9. Tarantino P, Curigliano G, Parsons HA, et al. Aiming at a tailored cure for ERBB2-positive metastatic breast cancer: A review. JAMA Oncol. 2022;8(4):629-635.
  10. U.S. Food and Drug Administration (FDA). FDA approves margetuximab for metastatic HER2-positive breast cancer. Silver Spring, MD: FDA; December 17, 2020.