Treatment Landscape in Neuroendocrine Tumors

Sequencing Challenges and Treatment Selection Strategies

Treatment sequencing in NETs remains complex due to limited head-to-head comparative data and the influence of crossover effects on overall survival end points. Current practice patterns typically involve progression from somatostatin analogs to peptide receptor radionuclide therapy (PRRT), followed by consideration of targeted oral agents. However, optimal sequencing lacks definitive evidence, making patient and tumor factors equally important in decision-making alongside shared decision-making approaches.

Concerns about PRRT include the 2% to 3% leukemia risk, though the specific patient population at highest risk remains unclear, with some reports suggesting older patients with aging bone marrow may be more susceptible. Renal toxicity, while manageable with amino acid protection in healthy patients, raises questions about long-term kidney function impact in patients with baseline renal impairment, potentially affecting future treatment options.

The decision between PRRT and oral targeted agents often involves patient preference discussions, with some patients expressing preferences based on treatment-specific factors they consider important. Real-world data and ongoing studies may provide insights into optimal sequencing strategies, but current practice requires individualized approaches considering both disease characteristics and patient factors rather than following rigid algorithmic approaches.