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Emerging Developments in NETs, Liver Cancer

Chelsea LoCascio
Published: Tuesday, Nov 21, 2017

Scott Paulson, MD
Scott Paulson, MD
Rapid advancements in understanding the biology of neuroendocrine tumors (NETs) has made this a thrilling time to be an oncologist in this field, according to Scott Paulson, MD.

In an interview during the meeting, Paulson highlighted developments with NETs and liver cancer that community oncologists should keep in mind moving forward.

OncLive: Can you provide an overview of your presentation on NETs?

Paulson: There have been quite a few drug approvals coming through and a lot of positive trials. It’s starting to change the landscape about how we think about this as, classically, a very surgical, interventional radiology (IR)-based disease.

There’s an increasing number of drugs that are coming into it, as well. The other thing, too, that I didn’t even go into in that talk is that medical oncology, surgical techniques, and IR-directed techniques are getting a lot better.

What are the most exciting regimens that we have seen approval of recently. Are there others in the pipeline that have practice-changing potential?

The improved understanding of somatostatin analogs is very helpful. This includes where to use them, how to use them, and how best to pick out patients who need to start therapy. A challenging aspect of this disease is that if patients have a NET…perhaps they have a [malignant] cancer, [or] maybe it’s…benign and you say, "Oh, even though it’s a cancer, we're not going to do anything about it. We're just going to watch you for a while." That can be very deeply unsettling for a patient. Trying to be able to pick the people who need aggressive therapy upfront versus those who can sit back and be followed very closely is what has changed some of the landscape.

We are getting some of that information out of those trials that have been done with drugs that we've been using for a while. That’s an exciting thing when you take the clinical data. The other exciting data have been from Gallium-68 DOTATATE imaging, which has changed how we work these patients up. It has changed management decisions. I have certainly seen it directly change in the clinic; a number of times it has changed what we would have done with somebody. It’s changed how we look at their disease as more or less aggressive, and very much changed the way we would sequence therapy—so that has been exceptionally exciting.

The final and most exciting piece in all of this is the advent of peptide receptor radionuclide therapy (PRRT), which is going to change how we treat these patients. We don't know where that's going to fit into this grand sequence of how we treat them, but it certainly changed the outlook on people who have nonsurgical, very advanced disease. It has offered quite a bit of hope. The early data are extremely appealing. There are a lot of historical data to support its use. It’s going to be interesting to see how it fits when it comes into the clinic, which we expected to do once the FDA has looked at it and moved forward with it.

What are some current unmet needs in this space?

One of the things I didn't talk about at all is symptom control. This happens when about 20% of these patients who have tumors that make a lot of hormone—because these are funky tumors, they make a lot of chemicals—can have a very high symptom burden. These patients, if they're not really aggressively treated, can have a pretty poor quality of life.

We've seen quite a few new therapies work their way in that have started to help. Telotristat ethyl (Xermelo) was approved because it helps reduce the burden of serotonin production for patients with carcinoid syndrome. Patients who have refractory carcinoid syndrome have a lot of diarrhea and flushing. If you can get those symptoms under control, you can really change somebody's day today. 

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