Best Practices for the Management of Neuroendocrine Tumors - Episode 2

Practice Pearl #1 Active Surveillance vs Treatment in Patients with NETs

March 10, 2021

Megan May, PharmD, BCOP, and Daneng Li, MD, discuss when patients with NETs should be considered for active surveillance vs treatment.

Daneng Li, MD: I want to move back to you, Megan. Patients with NETs [neuroendocrine tumors] often come to us, and we have the target therapies like somatostatin analogs and PRRT [peptide receptor radionuclide therapy] that Cecilia mentioned briefly, and we’ll definitely get into more detail discussing these 2 types of treatments that specifically target the neuroendocrine tumor. Still, for some patients with NETS, we may not recommend treatment. Can you give us a little sense as to why we might not recommend treatment from the very beginning for some of these patients?

Megan May, PharmD, BCOP: Active surveillance could be recommended when a patient is diagnosed with low-grade NETs or they have asymptomatic or nonfunctional metastatic neuroendocrine tumors. These tumors are growing more slowly, and they might not cause any problems for the patients for months to years. We would not start the active treatment until the tumor really starts showing signs of progression or until the patient becomes more symptomatic.

There really is not a clear decision that I am aware of when it comes to the timing of the initiation of our SSAs [somatostatin analogs] or octreotide and lanreotide in patients with a neuroendocrine tumor. Either immediate treatment initiation or deferring initiation until evidence of progression are both seen as appropriate in these selective patient populations.

Daneng Li, MD: That is very well said. I would like to emphasize that, at times, this is a difficult conversation for patients because patients are diagnosed with a malignant tumor, and often, for other diagnoses, they are recommended immediate treatment. What we know, as you have highlighted, is that there are these low-grade neuroendocrine tumors from certain primary tracks, such as small bowel neuroendocrine tumors, that tend to be very low grade and relatively indolent.

For patients who have relatively low-volume disease, we might not need treatment. One of the things we will definitely treat is for those patients who have excess hormonal secretion, just because we are trying to control the release of hormones from the neuroendocrine tumor rather than control the overall tumor bulk. As you mentioned, however, for many of these patients who have nonfunctional neuroendocrine tumors, relatively indolent active surveillance is certainly justified, and you really emphasized that key point: We really do not have data regarding early initiation of somatostatin analogs vs later initiation of somatostatin analogs in these patients in terms of potentially deriving an overall survival benefit, which at the end of the day is the gold standard in oncology.