Treatment Sequencing and Positioning of Cabozantinib

The panel discusses where cabozantinib fits within the treatment sequence based on its current second-line label across pancreatic and extra-pancreatic neuroendocrine tumors. Faculty share varied real-world positioning, with several favoring its use in lung, higher-grade, and pancreatic tumors. One panelist reports increasingly using cabozantinib before capecitabine plus temozolomide in pancreatic disease, citing strong responses, durable benefit, and patient preference for a single daily pill over a more complex chemotherapy schedule. For grade 1 tumors, faculty generally favor somatostatin analogs or observation, reserving systemic escalation for symptomatic or progressing disease. The discussion emphasizes individualized, shared decision-making rather than rigid algorithms, weighing radioligand therapy, everolimus, and cabozantinib according to tumor biology and comorbidities. Faculty also identify clinical situations favoring avoidance of cabozantinib, including significant liver dysfunction, uncontrolled hypertension, fistula or partial bowel obstruction limiting absorption, severe renal impairment, and symptomatic heart failure given the risk of cardiovascular toxicity.