Best Practices for the Management of Neuroendocrine Tumors - Episode 13

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

A panel of experts in the management of NETs discuss the role of peptide receptor radionuclide therapy for NETs.

Daneng Li, MD: The newest treatment is something that all these patients are excited about, and it is obviously the role of peptide receptor nucleotide therapy [PRRT]. Many of our patients were flying to Europe previously to get this treatment when we did not have the treatment in the United States, but now we have the treatment in the United States. Megan, if you can comment on the role of PRRT in terms of its impact for patients with neuroendocrine tumors, that will help our colleagues understand it better.

Megan May, PharmD, BCOP: PRRT is a combination of the radioisotope, an SSA [somatostatin analogue], and a biting chelator. Lutetium Lu 177 was evaluated in the NETTER-1 trial, and this was a prospective, randomized trial in patients who had progressive, metastatic midgut neuroendocrine tumors. It showed a median progression-free survival of about 28 months after PRRT was compared with high-dose octreotide, which had a median progression-free survival of about 8 months.

These could be good options for patients who have inoperable or metastatic disease, and they have been associated with a significant reduction in tumor size. The tumor was rendered operable after receiving this. One thing we also want to be aware of is the cost of medication, so making sure we get it through the insurance for approval. We also need to do education on safe handling and precautions with these medications.

Daneng Li, MD: That is an exciting treatment. As you have mentioned, it has good data in terms of antitumor activity.

For all our colleagues and our audience, 1 of the key things to know is that this is a treatment that encompasses a multidisciplinary team. You need a potential medical oncologist who understands the disease and a nuclear medicine physician who might be ordering or administering this treatment with a radiopharmacist. To all our pharmacy colleagues, you might be asked to help with the medications that go along with the PRRT, such as amino acid formulations that are used to help protect the kidneys, as well as hydration orders and prophylactic medications to help the patient get the treatment such as antinausea medications that we would traditionally use with chemotherapy or less than chemotherapy.

This is a team effort. Nobody would say that 1 team could do this, so it is good to become familiar with this new treatment moving forward because more and more patients are going to keep asking for it based on the fact that it is relatively new, and there is a lot of excitement surrounding it. I do not think it necessarily replaces any of the treatments we already have, but it is an additional treatment that we did not have before. That is always going to be welcome for this patient population.

Cecilia Lau, RPh, BCOP, APh: I also want to comment that, as pharmacists, we need to be aware that a lot of these patients are also on somatostatin analogues, and there is an issue of timing for patients who are undergoing PRRT treatment. The recommendation is that long-acting somatostatin analogues should not be administered within 4 weeks prior to a PRRT dose, and then they can be resumed between 4 and 24 hours afterward. At the same time, short-acting somatostatin analogues should also be stopped 24 hours prior to a PRRT dose because of the potential competition at the somatostatin receptor site.

Daneng Li, MD: Absolutely. That is a good pearl for our entire team and for all our pharmacy colleagues to know, because it is always good to remind your patients. Sometimes patients forget that they are so used to being on somatostatin analogue therapy that they get into a routine schedule. When you are doing PRRT, you have to potentially adjust that schedule as you mentioned. That is a great pearl to highlight for them.