Sequencing and Place of Cabozantinib in NETS Treatment Algorithm

The specialists discussed sequencing and side effect management of cabozantinib in neuroendocrine tumors (NETs), particularly in pancreatic, small bowel, and lung NETs. Dr. Shaheen highlighted that sequencing remains challenging, as most patients with SSTR-positive, grade 1–2 NETs receive PRRT upfront for convenience and efficacy. Cabozantinib is generally considered after PRRT, especially for pancreatic NETs, and may be sequenced earlier than other targeted agents due to its superior response rates. The panel emphasized that, despite multiple available therapies—including everolimus, sunitinib, and chemotherapy—patients eventually receive most treatments over their disease course, making sequencing flexible. Dr. Arshad discussed side effect management with cabozantinib, noting class-specific VEGF-related eOects such as hypertension, hand-foot syndrome, and rash. Strategies include early intervention with primary care or dermatology, dose reductions per FDA guidance, and individualized titration to balance efficacy with tolerability. Overall, careful monitoring and patient-centered management are key to optimizing outcomes with cabozantinib.