DR LOVE: What about somatostatin analogs? And what about the concept of slowing disease progression, not just treating symptoms?
DR KULKE: In carcinoid tumors, I think we have a pretty good sense of the answer. There's a study called the PROMID study, in which patients with carcinoid were randomized to receive either treatment with octreotide or placebo, and there was a clear benefit in terms of time to tumor progression.
In pancreatic neuroendocrine tumors it remains an open question. One can make an assumption, but that’s a dangerous thing to do. There’s an ongoing study right now called the CLARINET study that should help answer that question in pancreatic neuroendocrine tumors.
DR LOVE: How do you approach this question, Axel, in your own practice? Do you just treat for symptoms? Or will you also add it in, either in carcinoid or in pancreatic neuroendocrine tumors?
DR GROTHEY: I mean, first of all, I really use the octreotide somatostatin analogs in patients with secretory symptoms, carcinoid symptoms. I mean, there’s no question that you would do that.
Would I use it to delay tumor progression, let’s say in the otherwise asymptomatic carcinoid patient? I’m actually more conservative here. I’d actually try to observe the clinical course for some time, kind of after diagnosis. You bring the patient back after, let’s say, 3 months, do a scan, see how rapidly progressive the tumor is or not. So I don’t use octreotide early on to delay tumor progression. I like to first get a sense of how rapidly progressive the cancer is, and if I see that the cancer is clinically progressive then I might add it to slow the progression down.
DR LOVE: Bert?
DR O'NEIL: I think there has been an overinterpretation of the PROMID study in the community, meaning that there’s now almost a feeling that there’s a mandate to have all of these patients on octreotide whether they have secretory disease or not. And I have several patients I’ve followed for 5, 7, 8 or more years with no therapy whatsoever who’ve done perfectly well. And I don’t know that those patients would have been better served by being on octreotide.
So I think we do need to pick and choose whom we put on this therapy, because it’s expensive. It does have some long-term side effects. And I don’t think we should just be starting everyone out of the gate on it.