INSIGHTS FROM: ZOZO GREENHOLZ, RN; ANDREW E. HENDIFAR, MD; ERIC LIU, MD, FACS; MARIAH MAHOTZ, RN, BSN, OCN
Tuesday, January 07, 2020
Eric Liu, MD, FACS: The management of neuroendocrine tumors has changed a lot in the past few years, and it’s actually a wonderful improvement. Basically, what we’ve done is increase the number of tools in our toolbox. In the past we had surgery. Of course, that was very important. And of course, we had shots we would give—synthetic hormones. But in the past few years, we’ve seen a lot of new innovation. This includes medicines, which we can use to help slow down growth. We have new chemotherapeutic agents that help. We also have some new agents that can help patients with their symptoms. For example, people who have very severe diarrhea can have other medications that can help.
But the really new medication that we’ve tried, that we’ve included in the toolbox, is something called PRRT, or peptide receptor radionuclide therapy. This is a new type of treatment that combines the hormone with radiation. Now you can get liquid radiation therapy from the inside out. All these treatments that were available outside the US [United States] previously are now available here. So it’s given our patients many more options to hopefully have a better quality of life and quantity of life.
With these new tools that we have, it actually becomes more complicated. Remember, neuroendocrine is a different type of a disease. It’s a different kind of cancer. It’s a chronic cancer. In general, these tumors tend to grow very slowly. There are versions that grow very fast and can be very deadly, which is a different type of thing.
But with our more well-differentiated or slower-growing neuroendocrine cancers, we have to think of it differently. We have to think of it as a marathon and not a sprint. Again, the great thing is we have lots of tools in the toolbox. Some innovations that we’ve seen have been in imaging, for example, where we have this new scan called a gallium Ga68-DOTATATE PET [positron emission tomography] or CT [computed tomography] scan. That has changed the way we take care of patients because now we can see the disease much more clearly. We now have a true and very accurate evaluation of where the disease is.
But once you know what you’re dealing with, which is absolutely important to start out with, you have to decide what you want to do. We have so many tools in the toolbox, and every individual person is so different that you want to make sure you provide the right care, know what’s needed, and sequence it. There’s a lot of thinking that’s involved with taking care of a neuroendocrine patient.
For example, sometimes patients really have a lot of symptoms. Their stomach hurts. Maybe their bowel is obstructed. In that case, the patient needs surgery. Sometimes they have tumors that can be removed surgically, and that’s great. So we try to do as much surgery up front. But sometimes the disease has spread very, very far and they need more systemic therapy. In those cases, we would want to make sure their whole body is treated. Our first line is always a somatostatin analogue, which is a synthetic hormone that we use.
But then there are other treatments that we can add—different medicines. Of course, in certain cases you may want to give this PRRT liquid radiation therapy sooner rather than later. There’s a lot of thought that goes into it. Sometimes if the disease is just in the liver, you can even do different types of embolization to the liver, which is more of what we call a local-regional therapy. Then you can just treat the liver. The problem with neuroendocrine is it’s very complicated and there’s no pathway for treatment. It’s more of a web of treatment. So seeing a neuroendocrine specialist is very, very important to help make those crucial decisions.