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About This Activity

Activity Description and Learning Objectives

In this activity, experts in gastrointestinal oncology discuss the diagnosis and treatment of gastroenteropancreatic neuroendocrine tumours (GEP-NETs).

This activity has been jointly provided by Oakstone and touchIME. Oakstone Publishing is accredited by the ACCME to provide continuing medical education to physicians.

After watching this activity, participants should be better able to:

Target Audience

This activity is designed to meet the educational needs of gastrointestinal oncologists, gastroenterologists, gastrointestinal surgeons, radiologists, pathologists and nuclear medicine specialists involved in the diagnosis and management of patients with GEP-NETs.

Disclosures

Oakstone Publishing has assessed conflict of interest with its faculty, authors, editors, and any individuals who were in a position to control the content of this CME activity. Any identified relevant conflicts of interest were resolved for fair balance and scientific objectivity of studies utilized in this activity. Oakstone Publishing’s planners, content reviewers, and editorial staff disclose no relevant commercial interests.

Dr Daniel Halperin discloses: Grants/research support from Advanced Accelerator Applications, Genentech, Incyte, Lexicon Pharmaceuticals, Tarveda Therapeutics and Thermo Fisher Scientific. Consultant/Advisory Boards for Advanced Accelerator Applications, Curium Pharma, Ipsen and Lexicon Pharmaceuticals

Prof. Valerie Lewington discloses: Consultant/Advisory Boards for Advanced Accelerator Applications, Ipsen. Speakers Bureau for Advanced Accelerator Applications and Ipsen

Dr Pamela Kunz discloses: Grants/Research support from Advanced Accelerator Applications, Brahms, Ipsen, Lexicon Pharmaceuticals and Xencor. Consultant/Advisory Boards for Advanced Accelerator Applications and Lexicon Pharmaceuticals

Content Reviewer

Walter Murray Yarbrough, MD has no financial interests/relationships or affiliations in relation to this activity.

Touch Medical Director

Paul Taylor has no financial interests/relationships or affiliations in relation to this activity.

Requirements for Successful Completion

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of Oakstone Publishing and touchIME. Oakstone Publishing is accredited by the ACCME to provide continuing medical education for physicians.

Oakstone Publishing designates this enduring material for a maximum of 0.5 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

In order to receive credit for this activity, participants must review and complete the post-test and evaluation form. A score of 70% or higher is needed to obtain CME credit. Statements of credit are awarded upon successful completion of the post-test and evaluation form.

The European Union of Medical Specialists (UEMS) – European Accreditation Council for Continuing Medical Education (EACCME) has an agreement of mutual recognition of continuing medical education (CME) credit with the American Medical Association (AME). European physicians interested in converting AMA PRA Category 1 Credit™ into European CME credit (ECMEC) should contact the UEMS (www.uems.eu).

Date of original release: June 22, 2020. Date credits expire: June 22, 2021.

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Q1. Which of the following statements is true regarding quality of life in patients receiving treatment for GEP-NETs?

  1. A. Quality of life is a vitally important criterion to assess when evaluating the overall benefit of new treatments
  2. B. Patients with GEP-NETs have low scores on anxiety and depression scales
  3. C. Disease-related worries are not common in those with non-functioning tumours

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A comparison of health-related quality of life, anxiety, depression, and impulsivity scores in patients advanced GEP-NETs reported high scores on the anxiety and depression scale.1 Additionally, the same study reported that patients without carcinoid syndrome had more disease-related worries.1 Significant meaningful improvements in global quality of life have been observed in patients with durable response to their treatment.2

GEP-NETS gastroenteropancreatic neuroendocrine tumours.

References

  1. Lewis AR, et al. World J Gastroenterol. 2018;24:671–9.
  2. Pavel M, et al. Ann Oncol. 2020;31:Article in press.

Q2. What is recommended in the follow-up of metastatic GEP-NETs?

  1. A. Follow-up of metastatic grade 1–2 GEP-NETs should initially be performed every 12 months for 2 years
  2. B. Morphological imaging follow-up of grade 1–2 small intestine GEP-NETs should be carried out every month
  3. C. Tumours with the same primary site and Ki-67 index always show the same clinical evolution, and follow-up should be the same in all patients
  4. D. For grade 1–2 GEP-NETs showing rapid growth, re-biopsy should be considered

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A 2018 consensus document on the progression and treatment response criteria in GEP-NETs made the following recommendations:1

  • Follow-up of metastatic grade 1–2 GEP-NETs should initially be performed every 3 months for 2 years; in case of stable disease, assessment every 6 months is recommended. Once disease progression appears, going back to a 3-month follow-up schedule is recommended
  • Morphological imaging follow-up of grade 1–2 small intestine GEP-NETs should be carried out every 3–6 months; in case of stable disease, the follow-up schedule could be extended to 6–12 months. Once progressive disease appears, going back to 3–6-month follow-up is recommended. In case of clinical or biochemical progression, molecular imaging should be also considered
  • As GEP-NETs are very heterogeneous and tumours with the same characteristics (primary site and Ki-67 index) may show different clinical evolution, careful follow-up should be initially performed in certain patients
  • In the case of grade 1–2 GEP-NETs showing rapid growth it is recommended to consider re-biopsy.

GEP-NETS gastroenteropancreatic neuroendocrine tumours.

References

  1. Merino-Casabiel X, et al. Clin Transl Oncol. 2018;20:1522–8.

Q3. According to the WHO 2010 classification, grade 2 GEP-NETs are characterized by:

  1. A. Mitotic count <2 per 10 HPF and Ki-67 LI of <2%
  2. B. Mitotic count 2-20 per 10 HPF and Ki-67 LI of 2–20%
  3. C. Mitotic count >20 per 10 HPF and Ki-67 LI of >20%

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Grade 1 GEP-NETs have a mitotic count <2 per 10 HPF and Ki-67 LI of ≤2% and grade 3 GEP-NETs have a mitotic count >20 per 10 HPF and Ki-67 LI of >20%.1

GEP-NETS gastroenteropancreatic neuroendocrine tumours; HPF, high-power fields; LI, labelling index; WHO, World Health Organization.

References

  1. Kizilgul M, Delibasi T. Transl Gastrointest Cancer. 2014:4:1

Q4. The NETTER-1 trial of 177Lu-Dotatate, plus best supportive care, compared with octreotide alone in patients with well-differentiated, metastatic midgut neuroendocrine tumours, reported that:

  1. A. The difference in progression-free survival between treatment arms was not significant
  2. B. The difference in response rate between treatment arms was not significant
  3. C. Fewer deaths were reported in the 177Lu-Dotatate arm
  4. D. No grade 3 or 4 neutropenia, thrombocytopenia and lymphopenia were reported in either treatment arm

Please try again

In the primary analysis of the NETTER-1 trial, the estimated rate of PFS at month 20 was 65.2% (95% CI, 50.0 to 76.8) in the 177Lu-Dotatate group and 10.8% (95% CI, 3.5 to 23.0) in the control group. The response rate was 18% in the 177Lu-Dotatate group versus 3% in the control group (p<0.001). In the planned interim analysis of overall survival, 14 deaths occurred in the 177Lu-Dotatate group and 26 in the control group (p=0.004). Grade 3 or 4 neutropenia, thrombocytopenia, and lymphopenia occurred in 1%, 2%, and 9%, respectively, of patients in the 177Lu-Dotatate group, compared with no patients in the control group, with no evidence of renal toxic effects during the observed time frame.1

An update reported that median OS was 27.4 months in control group and still not reached in 177Lu-Dotatate arm. PFS at this date showed 30 events in the 177Lu-Dotatate arm and 78 in the control group (HR 0.21; CI: 0.14 0.33; p < 0.0001). Health-related quality of life time to deterioration was significantly longer in the 177Lu-Dotatate arm vs. control arm for global health status (HR 0.406; p = 0.0006), physical functioning (HR 0.518; p = 0.0147), role functioning (HR 0.580; p = 0.0298), fatigue (HR 0.621; p = 0.0297), pain (HR 0.566; p = 0.0247), diarrhea (HR 0.473; p = 0.0107), disease-related worries (HR 0.572; p = 0.0176) and body image (HR 0.425; p = 0.0058).

CI, confidence interval; HR, hazard ratio; OS, overall survival; PFS, progression-free survival.

References

  1. Strosberg J, et al. N Engl J Med. 2017;376:125–35.
  2. Strosberg J, et al. J Clin Oncol. 2018;36:4099.
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touchEXPERT OPINIONS

Individualizing care for gastroenteropancreatic neuroendocrine tumours

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Introduction

Watch leading experts involved in the care of patients with gastroenteropancreatic neuroendocrine tumours (GEP-NETs) discuss how recent advances have driven the personalization of treatment options.

This activity is intended for gastrointestinal oncologists, gastroenterologists, gastrointestinal surgeons, radiologists, pathologists and nuclear medicine specialists involved in the diagnosis and management of patients with GEP-NETs.

Learning Objectives

After watching this touchEXPERT OPINIONS, you should be able to:

  • Apply the criteria for the diagnosis of GEP-NETs
  • Evaluate the current and emerging treatment sequencing options for patients with GEP-NETs
  • Summarize why quality of life is important in patients with GEP-NETs and the role of the multidisciplinary team