Best Practices for the Management of Neuroendocrine Tumors - Episode 16

Practice Pearl 3 Challenges in the Management Among the Various Sites of NETs

April 6, 2021

A panel of experts in neuroendocrine tumors review the challenges in the management of patients based on the site of the tumor.

Daneng Li, MD: One of the other things that is a key challenge is that management might be slightly different depending on where the primary tumor is rising, whether it is from the GI [gastrointestinal] tract, the pancreas, or the lungs.

Cecilia, have you noticed any challenges in the management between the various sites of neuroendocrine tumors as well?

Cecilia Lau, RPh, BCOP, APh: As you said, the disease characteristics can be different depending on the site of disease. Some sites are more prone to be functional [compared with] others and [to treat] indolent disease vs the more aggressive disease. Even in the most aggressive cases or patients with very bulky disease, they may need chemotherapy either during or even before somatostatin analogues are started. Chemotherapy regimens are oftentimes tailored after the small cell cancer regimens, so we have to consider whether patients can tolerate those regimens, and we also need to work with insurance to make sure they are properly authorized.

Daneng Li, MD: Have there been any issues from your experience? We can take the example of something like a pancreatic neuroendocrine tumor where we might use oral chemotherapy with some of the alkylating agents. Have there been any issues in terms of getting oral chemotherapy as first-line treatment compared with traditionally somatostatin analogue therapy as first-line treatment for those types of neuroendocrine tumors?

Cecilia Lau, RPh, BCOP, APh: Personally, I have not had too much difficulty [at City of Hope]. For the most part, most insurance requires an authorization, but it is fairly straightforward. It is more of a co-pay issue. For 1 of the more commonly used regimens, capecitabine and temozolomide, those drugs are generic. If the patient has a high co-pay, there may not be as much patient assistance available, unlike for some of our branded drugs, where the drug company has co-pay cards to help offset the patient’s portion of the drug charges. For generic drugs, that avenue is quite limited, so that can be a little difficult for our patients.

Daneng Li, MD: Megan, similarly in terms of lung neuroendocrine tumors, there are less data on neuroendocrine tumors even with the use of agents like somatostatin analogues. There have not necessarily been large studies looking at somatostatin analogues and lung neuroendocrine tumors. Taking lung neuroendocrine tumors, have you had any difficulty in accessing any types of treatments that we use for other neuroendocrine tumors, specifically for lung neuroendocrine tumors given the limited data that are available?

Megan May, PharmD, BCOP: Yeah. That is a great question because you are right: We are extrapolating some data from the small cell lung cancer data that is out there. For us [at Baptist Health Lexington], we have had some denials, but we were able to either do a peer-to-peer with the insurance and get it approved or also write appeal letters. In the end, we have been able to treat our patients with what we wanted by providing the data that are available, looking at national guidelines, and submitting that to the insurance. We are then able to get it approved in order to treat the patient.

Daneng Li, MD: That is absolutely wonderful. These are going to be continued challenges as more treatment options become available for patients with neuroendocrine tumors. It is good to highlight some of the challenges that we might already encounter for the current treatments that are available because that is going to help us in terms of how we plan for further treatments as they become available.