Preferred Sequencing of Treatment for Neuroendocrine Tumors

Deepak Vadehra, DO Roswell Park Comprehensive Cancer Center | Tanios Bekaii-Saab, MD Mayo Clinic Arizona

Key Points

• Lutathera, a peptide receptor radionuclide therapy (PRRT), is one of the primary treatments for patients with neuroendocrine tumors (NETs).

• Second-line NET treatment includes the combination of capecitabine and temozolomide, cabozantinib, and everolimus.

• Alpha emitter agents have shown encouraging data for the treatment of NETs.

The generally favorable prognosis for patients with NETs gives clinicians time to carefully consider treatment and a more individualized approach to treatment sequencing. At the 2025 American Society of Clinical Oncology (ASCO) Annual Meeting, Deepak Vadehra, DO, of Roswell Park Comprehensive Cancer Center, spoke with Tanios Bekaii-Saab, MD, of Mayo Clinic Arizona, about his practice for patients with NETs.  

When a patient starts to show symptoms, Dr. Bekaii-Saab considers the use of lutathera, a PRRT. Four treatments is standard of care, but rechallenging beyond that may still be effective.  

After lutathera, a range of therapies is available, such as chemotherapy combinations, tyrosine kinase inhibitors (TKIs), and targeted therapies. The combination of capecitabine and temozolomide is primarily given to patients with pancreatic NETs but potentially may be used for lung NETs. Cabozantinib, a TKI, and everolimus, an agent that targets the MTOR pathway, are additional treatment options.  

Dr. Bekaii-Saab favors cabozantinib as second-line treatment for NETs. “My only exception is when patients remain very symptomatic. I may consider capecitabine and temozolomide instead because of the response rate,” he said.  

Beyond PRRT, recent research has demonstrated promising data with the use of alpha emitter agents in NETs. Moreover, alpha emitters could potentially replace PRRT, Dr. Bekaii-Saab said.