Dr Dasari on Sequencing RLT, Cabozantinib, and Everolimus in NETs

Arvind Dasari, MD, MS, discusses how to sequence radioligand therapy (RLT) alongside other targeted therapies in well-differentiated neuroendocrine tumors (NETs). In this interview from the 2026 North American Neuroendocrine Tumor Society (NANETS) Symposium, he also outlines the tumor- and patient-specific factors that can guide that decision when no randomized data are available.

Dasari, a professor in the Department of Gastrointestinal Medical Oncology at The University of Texas MD Anderson Cancer Center, notes that the treatment conversation extends beyond RLT. Everolimus (Afinitor) and cabozantinib (Cabometyx) are both FDA approved across primary tumor sites. The question is therefore not only how to sequence radioligand therapies, but also how to sequence them among these other available options. He describes this as an area of debate, with no randomized data to provide a definitive answer, and says the decision needs to be tailored to each patient's context.

As a simple starting point, Dasari points to somatostatin receptor status. If a patient's tumor is not somatostatin receptor avid on a DOTATATE PET scan, RLT is not an option, and treatment moves on to targeted therapies. If the tumor is positive, that is when the sequencing question comes into play.

For patients with somatostatin receptor–positive disease, Dasari outlines several considerations: tumor bulk, Ki-67, how the tumor has behaved over time up to that point, and the need for a radiographic response. Comorbidities also factor into the choice. Cabozantinib may cause hypertension and everolimus may cause diabetes, so existing conditions can influence which agent is the better fit for a given patient.

Patient preference is the final piece. Dasari raises practical questions about whether patients are able to take time away for RLT and to be in isolation, away from their family, for 2 or 3 days. All of these factors, he explains, go into making sequencing decisions.

When a radiographic response is needed, Dasari says RLT would probably make more sense. He cautions, however, that the therapy takes about 4 to 6 months to complete. He emphasizes making sure there is enough time to deliver the full course of treatment and for patients to receive its benefit.