Treatment Sequencing in Neuroendocrine Tumors

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Treatment Sequencing and Clinical Pearls

Key Themes:

• Treatment Sequencing Considerations:
• Limited data on optimal sequencing

• More important that patients receive all available treatments than the specific sequence

• An Alliance trial on pancreatic NETs comparing peptide receptor radionuclide therapy with capecitabine/temozolomide closed due to poor accrual
• Recommended Positioning of Cabozantinib:
• For pancreatic NETs: Typically, third line after somatostatin analogues plus 1 additional FDA-approved therapy

• For small bowel NETs: Third line after somatostatin analogues and radioligand therapy

• For lung NETs: May consider second line due to limited effective treatments
• Management Pearls:
• Monitor for common adverse effects: hypertension, liver function abnormalities, skin rash, diarrhea

• Manage hypertension aggressively with antihypertensives

• Most oncologists familiar with cabozantinib from its use in renal cell carcinoma, thyroid cancer, or liver cancer

Notable Insights:

Dr Halfdanarson emphasized that while cabozantinib was not tested as second-line therapy, there might be situations where this approach would be reasonable, particularly for lung NETs, where treatment options are more limited.