Practice Pearl 1 How NETs Treatment Landscape Has Evolved

EP: 1.Practice Pearl #1 Introduction, Definition and Diagnosis of Neuroendocrine Tumors

EP: 2.Practice Pearl #1 Active Surveillance vs Treatment in Patients with NETs

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EP: 3.Practice Pearl 1 How NETs Treatment Landscape Has Evolved

EP: 4.Practice Pearl 2: Efficacy of the Somatostatin Analogues for NETs

EP: 5.Practice Pearl 2: Indications and Safety Data of the Somatostatin Analogues for NETs

EP: 6.Practice Pearl 2: Differences Among the Somatostatin Analogues for NETs

EP: 7.Practice Pearl 2: Choosing 1 Agent Over Another in the Management of NETs

EP: 8.Practice Pearl 2: Pharmacists’ Role in Managing Treatment for Patient With NETs

EP: 9.Practice Pearl 2: Various Preparations and Delivery Systems of Somatostatin Analogues for NETs

EP: 10.Practice Pearl 2: Home Injection Programs for the Treatment of NETs

EP: 11.Practice Pearl 2: Efficacy and Safety Data of Everolimus for NETs

EP: 12.Practice Pearl 2: Management of Stomatitis When Using Everolimus for NETs

EP: 13.Practice Pearl 2: The Role of Peptide Receptor Radionuclide Therapy for NETs

EP: 14.Practice Pearl 3: Challenges for Obtaining Therapeutic Agents on Formulary for NETs

EP: 15.Practice Pearl 3 Challenges in Obtaining Authorization for the Treatments for NETs

EP: 16.Practice Pearl 3 Challenges in the Management Among the Various Sites of NETs

EP: 17.Practice Pearl 3 Unmet Needs in the Treatment of Neuroendocrine Tumors

Daneng Li, MD: Cecilia, how has the overall treatment landscape for neuroendocrine tumors evolved over time?

Cecilia Lau, RPh, BCOP, APh: Historically, surgery was the primary management modality, even in patients with advanced diseases due to the lack of good systemic options. Nowadays, however, we do have a number of options, but what we still lack are guidelines regarding the optimal sequencing of the treatment options. Generally speaking, for patients with a somatostatin receptor—positive disease, the frontline treatment would be somatostatin analogs, or SSAs. Of course, the determination of whether the patient has a somatostatin receptor–positive disease is based on functional imaging, as we discussed a few minutes ago.

Upon progression on SSAs or for patients who have receptor-negative disease, we have the tyrosine kinase inhibitors [TKIs], as well as PRRT [peptide receptor radionuclide therapy] in the form of Lutetium Lu 177 dotatate. In select cases, especially for patients with very aggressive diseases, chemotherapy may be indicated instead or in addition to somatostatin analogs.

Daneng Li, MD: That that sounds amazing. We certainly have evolved in the various types of treatments for neuroendocrine tumors, and we definitely have more treatments these days for patients, and that is certainly welcoming to the community of providers, as well as patients. One of the issues that has come up is how do we potentially sequence these treatments. I do not know if you want to comment on that or if Megan can comment on it a little, but how do we determine the potentially optimal sequence of treatment for these patients now that we have so many treatment options?

Megan May, PharmD, BCOP: As Cecilia said, it is still up in the air as to what the sequence is that we should use. Where I practice [Baptist Health Lexington], if it is more localized, we will still go for the surgery. Using the SSAs has shown great improvement for our patients’ symptoms, so it is also improving their quality of life. That has been something that we have been using more and more of too.

Another modality we have not mentioned is the neuroendocrine tumor that has spread to the liver, or the liver-directed therapies. Those are also options that we have. The radio frequency ablations, the hepatic artery embolisms, and the radio embolization are also all options that we can use for our patients if the disease has spread to the liver.

Daneng Li, MD: Absolutely. I completely agree with that point. This really highlights what you described a little earlier, that the optimal management for many of these patients requires a multidisciplinary team in which you have nuclear medicine physicians who might be able to help with administration of Lutathera [Lutetium Lu 177 dotatate], and medical oncologists with somatostatin analog therapies, the oral targeted agents, and oral chemotherapy. Teams can also have interventional radiologists or radiologists who are paramount in terms of doing these liver-directed therapies. We have always really said that the liver is 1 of the most important organs in these patients because if we can get control of the liver, certainly you can potentially help that patient in terms of survival. That is so critical.

I do also agree with your comment in the sense that we do not really know what the optimal sequence is, and we are still trying to figure that out with various clinical trials that are in development right now. These are comparing PRRT with oral targeted agents like everolimus or even PRRT with somatostatin analogs for frontline treatment of patients who might have slightly more aggressive neuroendocrine tumors. There is going to be a lot of answers that might eventually come to us as we go over time doing some of these trials.