NETs Treatment Landscape and Selection Factors

Pamela Kunz, MD: The treatment landscape for neuroendocrine tumors has evolved quite a bit in the past few years. We’re very fortunate to have had a number of new FDA approvals in the past 5 to 10 years, and that gives our patients many more treatment options. An unanswered question is, What is the optimal sequence of therapy?

The main principles that guide treatment selection are 2-fold. There are characteristics of treatment and characteristics of the patients or their tumor types. I’ll split those up. Characteristics of treatment include both potential adverse effects of therapy and the outcome measures. I’ll go into some detail there. In terms of adverse effects, they range considerably depending on the class of therapy and the therapy itself. For example, somatostatin analogues have a very favorable adverse-effect profile and cause very few adverse effects.

Patients tolerate them quite well and have good quality of life. Perhaps patients who are older might tolerate those better. We know that for patients who are completely asymptomatic and starting a therapy, that might be a good 1 to start with. Chemotherapies tend to have more adverse effects, so we talk about that risk-to-benefit ratio with patients. In terms of outcome measure, what is the goal of the therapy? Will the therapy shrink the cancer, or will the therapy solely control the growth and prevent further growth?

Different patients need different outcomes, depending on what symptoms they may start with or the status of their cancer when we’re thinking about therapy selection.

In addition, characteristics of the patients also guide treatment selection. They fall into 6 main categories, which include hormone status, whether a patient has a functional or nonfunctional tumor; extent and burden of disease; pace of disease growth, whether they have a well-differentiated or poorly differentiated tumor and grade; the primary site, or where the cancer started: lung, gastrointestinal tract, pancreas, or other.

The sixth is the somatostatin receptor status, which has become even more important as we’ve had the advent of the gallium-68-DOTATATE PET/CTs [positron emission tomography/computed tomography scans]. I think about all 6 of these features and try to think of answers for each as I’m selecting therapies for patients.

Transcript Edited for Clarity