Patterns of Care Among Real-World Patients with Metastatic Neuroendocrine Tumors

Abstract

Background Although recent pivotal trials (PROMID, CLARINET) have established somatostatin analogs (SSAs) as first‐line agents for neuroendocrine tumors (NETs), their use in clinical practice is largely unknown. We aimed to understand real‐world management and treatment of gastroenteropancreatic (GEP) NETs. Materials and Methods Patients with metastatic GEP‐NETs treated with SSAs, lanreotide depot or octreotide long‐acting release (LAR), between January 1, 2015, and December 31, 2015, were identified from a U.S. claims database supplemented with chart review for a subset of patients. Descriptive statistics summarized patients’ demographics, clinical characteristics, treatment patterns, and healthcare resource use. Univariate and multivariate comparisons were made across SSA groups. Results Among 548 patients treated with an SSA for metastatic GEP‐NET (lanreotide = 108; octreotide = 440), demographic and clinical characteristics were similar across groups, except more patients with pancreatic NETs were treated with lanreotide (38.7% vs. 6.3%, p < .01). More octreotide patients had a diagnosis of carcinoid syndrome compared with lanreotide patients (19.8% vs. 11.1%, p = .02). Approximately 1.1% of patients received lanreotide (>120 mg every 4 weeks [Q4W]) at a dose above label compared with 12.7% of octreotide patients (>30 mg Q4W; p < .01). At 1.5 years after SSA initiation, 85.7% (95% confidence interval, 74.3%–92.3%) were still on index SSA as reported by the physician. Variances between chart review and claims data were significant. Conclusion SSAs were common in first‐line systemic intervention, but dose escalations and dosing deviations outside of label were noted. Variances between claims and chart review warrant additional research to compare methodologies. With an increasing focus on value‐based care in oncology, it is critical to understand the use of, and outcomes with, these agents in community practices. Implications for Practice The aim of this study was to enhance understanding of real‐world management and treatment of metastatic neuroendocrine tumors (NETs), with particular focus on systemic therapy with a somatostatin analog (SSA). As per published guidelines, SSAs are common in first‐line systemic intervention, but dose escalations and dosing deviations outside of the label are noted for symptom control. Nevertheless, oncologists must weigh the implications of the use of above‐label dosing of SSAs to manage and treat patients with metastatic NET within a value‐based care framework.

Opportunities to Improve Symptom Control with Somatostatin Congeners in GEP-NETs: A Review of Key Issues

“…11 In addition, conservative management is often recommended for elderly patients or those with significant comorbidities and lesions ≤2 cm. 17,18 Beyond surgical intervention, the somatostatin congeners (more commonly known as analogues) octreotide acetate and lanreotide have had the most profound effect on NET management. 13,19 Somatostatin analogues (SSAs) are standard first-line therapies for functional NETs, according to the NCCN, ESMO and NANETS, and they are generally used to control tumor growth and associated clinical symptoms.…”

“…20 In a recent retrospective administration claims analysis of almost 3000 patients with NETs, >80% were prescribed octreotide LAR, due in part to its dosing convenience over the IR formulation. 18,29,30 Current Use Cases for Octreotide IR…”

“…39 In current clinical practice, 13-30% of patients receive above-standard LAR doses in an effort to adequately control symptoms or suppress tumor progression. 18,40 Similar responses to dose escalation are often discussed with lanreotide therapy in cases of symptomatic and radiologic progression. 35 Often the circulating octreotide drug levels produced by LAR doses 10, 20, or 30 mg/month do not completely saturate SSTR2 receptors in all patients.…”

“…In pre-pandemic studies, patients with NETs averaged 25.7 outpatient visits and 5.6 inpatient visits annually, with the most common being visits to oncologist offices. 18,53 In response to governmental regulations and individual health concerns, oncology patient visits dropped dramatically in 2020 and, despite the lifting of stay-at-home orders, oncology service utilization continues to lag behind 2019 levels. 54 In an observational multi-center study, up to 40% of patients interrupted their therapy over the past year, due in part to the pandemic's impact on in-office visits.…”

“…However, more than 80% of patients present with advanced, nonresectable disease [ 11 ]. In addition, conservative management is often recommended for elderly patients or those with significant comorbidities and lesions ≤2 cm [ 17 , 18 ]. Beyond surgical intervention, the somatostatin congeners (more commonly known as analogs) octreotide acetate and lanreotide have had the most profound effect on NET management [ 13 , 19 ].…”