Therapy Sequencing Considerations in Advanced pNETs

Patients with well-differentiated pancreatic neuroendocrine tumors (NETs) typically receive a somatostatin analog, such as octreotide or lanreotide, as frontline therapy, says Jonathan R. Strosberg, MD. It is unclear whether continuation, beyond first disease progression, is beneficial when these agents are used for their antiproliferative effect.

Following progression, Strosberg often uses the combination of capecitabine and temozolomide for patients with relatively fast growing pancreatic NETs, and everolimus or sunitinib in slower growing tumors. Other approaches that may be integrated into treatment include liver-directed therapy, such as hepatic artery embolization.

Tumor burden and aggressiveness may help identify the type of treatment patients should receive, comments James C. Yao, MD. Individuals with low-tumor burden and more stable disease are typically given a somatostatin analog, while those with high tumor burden and symptomatic disease that is progressing rapidly may receive cytotoxic chemotherapy.

There are currently no studies that have established a standard sequence of therapies, says Matthew H. Kulke, MD. The choice of therapy often depends on the presence of symptoms, the patient’s preference, and goals of treatment, notes Kulke.