Earlier PRRT in Neuroendocrine Tumors Puts Pharmacists at the Center of Coordination

Peptide receptor radionuclide therapy (PRRT) belongs earlier in the treatment discussion for selected patients with neuroendocrine tumors (NETs), but translating that opportunity into care requires coordination well before an infusion. For pharmacists, access to supportive medications and communication with local oncology teams can shape whether treatment proceeds as planned.

In an interview with Pharmacy Times in recognition of NET Cancer Day, Thomas Hope, MD, professor of radiology and director of theranostics at the University of California, San Francisco, discussed how patient selection intersects with the practical demands of delivering PRRT.

Bringing PRRT Into the Discussion Earlier

The phase 3 NETTER-2 trial (NCT03972488) evaluated first-line lutetium Lu 177 dotatate (Lutathera; Novartis) plus long-acting octreotide (Sandostatin LAR; Novartis) in newly diagnosed, advanced, well-differentiated gastroenteropancreatic NETs with a Ki-67 index of approximately 10% to 55%. Median progression-free survival reached about 22.8 months compared with 8.5 months with high-dose long-acting octreotide alone (HR, 0.276; 95% CI, 0.182-0.418).¹

For Hope, the findings expand when clinicians should consider PRRT without making it the immediate choice for every patient. He described symptomatic patients with higher-volume disease as one group in whom earlier treatment may warrant consideration. Understanding how quickly disease is progressing remains central to that decision.

“I think the broader importance of NETTER-2 is that it brings PRRT earlier into the treatment discussion, particularly among community oncologists who may be less familiar with neuroendocrine tumors,” Hope explained. “That doesn't necessarily mean we should start every patient on PRRT immediately. Rather, it means we should be thinking about it earlier instead of waiting until a patient has gone through numerous lines of therapy, when it may be too late.”

Somatostatin receptor imaging also informs selection. Hope explained that lesions with low receptor uptake may not receive sufficient radiation, complicating treatment when other lesions demonstrate strong uptake. In selected circumstances, he said, a low-uptake liver lesion might be addressed with liver-directed therapy while PRRT treats the remaining receptor-avid disease.

Preparing for Treatment Day

Hope identified access to kidney-protective amino acid infusions as an important pharmacy responsibility. He recalled substantial nausea and vomiting with an older multi–amino acid formulation and described working with pharmacists to obtain a compounded alternative.

“We worked closely with our pharmacists to get a manufacturer qualified to compound amino acids, which helped our patients dramatically,” he said.

The prescribing information for lutetium Lu 177 dotatate specifies an infusion containing L-lysine and L-arginine, beginning 30 minutes before treatment and continuing during treatment and for at least 3 hours afterward. Antiemetics precede the amino acid infusion.²

Scheduling somatostatin analogs requires equal attention. Long-acting agents must be withheld for at least 4 weeks before each dose; short-acting octreotide must be withheld for at least 24 hours. Long-acting octreotide 30 mg is administered 4 to 24 hours after each Lutathera dose.²

Radiopharmaceutical delivery adds another constraint. Hope emphasized that radioactive decay limits the administration window, making transportation disruptions consequential for patients and treatment centers. He advocated for redundant supply chains and geographically distributed manufacturing capacity.

Maintaining Oversight Between Centers

Pharmacy involvement extends beyond the treatment appointment. Hope described checking blood counts between cycles to assess recovery and determine whether additional testing or a treatment delay is necessary.

“Ultimately, monitoring these changes between cycles is critical to determining whether a patient can safely proceed with their next dose,” he said.

The prescribing information calls for monitoring blood counts and renal function, with dose modifications based on toxicity severity. Follow-up must also account for delayed risks: secondary myelodysplastic syndrome and acute leukemia have been reported months to years after treatment.²

When patients return to local oncology care, Hope emphasized assigning responsibility for follow-up and clarifying whether and when somatostatin analog therapy should continue. Shared laboratory results help both teams understand the patient's recovery and ongoing needs.

“The treating physician or nurse should communicate the patient's treatment plan, laboratory results and follow-up needs to the local provider to ensure continuity of care,” he said.

Hope also pointed to a workforce need as radiopharmaceutical treatment and imaging expand, highlighting radiopharmacists’ contributions to preparation and production. “It's a critical role and we need to encourage people to join the field.”

REFERENCES

1. Singh S, Halperin D, Myrehaug S, et al. [177Lu]Lu-DOTA-TATE plus long-acting octreotide versus high‑dose long-acting octreotide for the treatment of newly diagnosed, advanced grade 2-3, well-differentiated, gastroenteropancreatic neuroendocrine tumours (NETTER-2): an open-label, randomised, phase 3 study. Lancet. 2024;403(10446):2807-2817. doi:10.1016/S0140-6736(24)00701-3

2. Lutathera. Prescribing information. Novartis Pharmaceuticals Corporation; October 2024. Accessed November 13, 2026. https://www.novartis.com/us-en/sites/novartis_us/files/lutathera.pdf