Published online Feb 28, 2015. doi: 10.3748/wjg.v21.i8.2450
Peer-review started: March 26, 2014
First decision: March 29, 2014
Revised: July 31, 2014
Accepted: October 21, 2014
Article in press: October 21, 2014
Published online: February 28, 2015
AIM: To evaluate systemic treatment choices in unresectable metastatic well-differentiated pancreatic neuroendocrine tumors (PNETs) and provide consensus treatment recommendations.
METHODS: Systemic treatment options for pancreatic neuroendocrine tumors have expanded in recent years to include somatostatin analogs, angiogenesis inhibitors, inhibitors of mammalian target of rapamycin and cytotoxic agents. At this time, there is little data to guide treatment selection and sequence. We therefore assembled a panel of expert physicians to evaluate systemic treatment choices and provide consensus treatment recommendations. Treatment appropriateness ratings were collected using the RAND/UCLA modified Delphi process. After studying the literature, a multidisciplinary panel of 10 physicians assessed the appropriateness of various medical treatment scenarios on a 1-9 scale. Ratings were done both before and after an extended discussion of the evidence. Quantitative measurements of agreement were made and consensus statements developed from the second round ratings.
RESULTS: Specialties represented were medical and surgical oncology, interventional radiology, and gastroenterology. Panelists had practiced for a mean of 15.5 years (range: 6-33). Among 202 rated scenarios, disagreement decreased from 13.2% (26 scenarios) before the face-to-face discussion of evidence to 1% (2) after. In the final ratings, 46.5% (94 scenarios) were rated inappropriate, 21.8% (44) were uncertain, and 30.7% (62) were appropriate. Consensus statements from the scenarios included: (1) it is appropriate to use somatostatin analogs as first line therapy in patients with hormonally functional tumors and may be appropriate in patients who are asymptomatic; (2) it is appropriate to use everolimus, sunitinib, or cytotoxic chemotherapy therapy as first line therapy in patients with symptomatic or progressive tumors; and (3) beyond first line, these same agents can be used. In patients with uncontrolled secretory symptoms, octreotide LAR doses can be titrated up to 60 mg every 4 wk or up to 40 mg every 3 or 4 wk.
CONCLUSION: Using the Delphi process allowed physician experts to systematically obtain a consensus on the appropriateness of a variety of medical therapies in patients with PNETs.
Core tip: Using the RAND/UCLA modified Delphi process, physician experts obtained consensus on the appropriateness of various medical therapies in unresectable metastatic well-differentiated pancreatic neuroendocrine tumors. Consensus statements were: (1) it is appropriate to use somatostatin analogs as first-line therapy in patients with hormonally-functional tumors and may be appropriate in asymptomatic patients; (2) it is appropriate to use everolimus, sunitinib, or cytotoxic chemotherapy as first-line therapy in patients with symptomatic or progressive tumors; and (3) beyond first-line, these same agents can be used. In patients with uncontrolled secretory symptoms, octreotide-LAR can be titrated up to 60 mg/4 wk or up to 40 mg/3 or 4 wk.