Clinical Perspectives on the Treatment of Neuroendocrine Tumors - Episode 5
Neuroendocrine Tumors: Second-Line Treatment Options
Panelists discuss how peptide receptor radionuclide therapy (PRRT) has traditionally been the go-to second-line treatment after somatostatin analog progression, though there’s hesitancy due to it being a “one-shot deal,” and growing interest in moving PRRT to earlier lines for patients with high disease burden.
Second-Line Treatment Options and Progression Management
When patients progress after first-line somatostatin analog therapy, treatment selection requires careful assessment of progression patterns, disease bulk, symptoms, and quality of life considerations. Since no treatments for neuroendocrine tumors are curative, the primary goal involves altering disease natural history while maintaining or improving quality of life. Local progression confined to the liver may warrant regional approaches like debulking surgery or embolization rather than immediate systemic therapy.
PRRT has emerged as a common second-line choice, though some hesitancy exists regarding optimal timing since it represents a “one-shot” opportunity with 4 treatments followed by transition to other therapies. Patient factors significantly influence timing, with some clinicians favoring PRRT for patients with significant disease bulk requiring tumor response. The decision involves balancing immediate treatment needs against preserving this valuable option for future use.
Targeted oral therapies including mTOR inhibitors and tyrosine kinase inhibitors offer alternative approaches but require careful consideration of patient comorbidities. mTOR inhibitors may exacerbate diabetes, while tyrosine kinase inhibitors can cause hypotension and vascular effects alongside fatigue and diarrhea. The choice between chronic daily oral therapy effects vs episodic treatment-related toxicity involves individualized patient discussions weighing symptom burden against treatment impact.
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