Establish intent of treatment

• Curative
• Anti-cancer therapy to improve quality of life and/or longevity without expectation of cure
• Symptom palliation

Surgery: The surgical procedure undertaken will depend on the location(s) of the NET and treatment intent. Surgery may be curative, de-bulking for symptom control or palliative.

No treatment / active surveillance (watch and wait): No treatment may be suitable for some NET patients if the NET is not causing symptoms or problems, there is little disease, the disease is stable or the tumour is low grade (G1).

Localised radiation therapy: Patients with oligometastatic disease, a dominant or critically strategic site of progression or highly symptomatic metastases may benefit from radiation therapy.

Peptide receptor radionuclide therapy (PRRT): Patients with metastatic disease who have progressed following first-line somatostatin analogues (SSAs) may benefit from systemic radionuclide therapy (or PRRT).

Systemic therapy:

• SSAs are the most common first-line treatment of G1/G2 NETs. They have antisecretory and antiproliferative effects.
• Oral targeted therapy: Molecular targeted therapy for mTOR and multitargeted pathways.
• Chemotherapy is an option for NET patients with pancreatic, bronchial or high-grade (G2/G3) NETs. It can be used in combination with PRRT and adjuvant to surgery.

Liver-directed therapy: Targeted therapy with radiation or chemotherapy directly to liver metastases may be indicated for some patients.

Immunotherapy is investigational for NETs and is an emerging therapy.

Clinical trials: Many emerging therapies are only available by participating in clinical trials.

Palliative care: Early referral to palliative care can improve quality of life and in some cases survival. Referral should be based on need, not prognosis. For more, visit the Palliative Care Australia website <www.palliativecare.org.au>.

Communication

The lead clinician and team’s responsibilities include:

• discussing treatment options with the patient and/or carer including the intent of treatment as well as risks and benefits
• discussing advance care planning with the patient and/or carer where appropriate
• communicating the treatment plan to the patient’s GP
• helping patients to find appropriate support for programs where appropriate to improve treatment outcomes.

Checklist

• Intent of treatment established
• Risks and benefits of treatments discussed with the patient and/or carer
• Treatment plan discussed with the patient and/or carer
• Treatment plan provided to the patient’s GP
• Treating specialist has adequate qualifications, experience and expertise
• Supportive care needs assessment completed and recorded, and referrals to allied health services actioned as required
• Early referral to palliative care considered
• Advance care planning discussed with the patient and/or carer

Timeframe

Surgery: Timeframe for surgery will be based on investigation and staging of the NET and surgery intent.

Localised radiation therapy: Treatment should start as soon as possible for symptomatic patients.

PRRT: When PRRT is necessary, treatment should start as soon as possible.

Systemic therapy: When active treatment is necessary, treatment should start within 4 weeks.

Liver directed therapy: When active treatment is necessary, treatment should start within 4 weeks.