Table 5.
Summary of expert recommendations on optimising radioligand therapy in Italy
| Definition of tumour progression prior to initiation of RLT |
| Identification of progression prior to RLT should be based on a broad (holistic) clinical assessment |
| RLT in patients with bone metastases and/or high hepatic tumour burden |
| Bone metastases of GEP origin are effectively controlled by RLT and multifocality should not represent an obstacle to the indication for this therapy |
| The fear of using RLT in patients with well-differentiated GEP-NETs and bone metastases does not seem justified, both in terms of disease control and symptom control |
| RLT is effective in patients with hepatic disease, regardless of the baseline liver disease burden, and treatment does not have effects on liver function parameters |
| It is important to assess the degree of initial liver involvement since adverse events can be related to disease progression in compromised patients |
| The optimal follow-up protocol after RLT |
| The strategy to monitor response to RLT should be defined based on the morphological and functional characteristics of the tumour, its degree of malignancy, and the patient’s general clinical profile |
| In the absence of any clinical indication, CgA evaluation and imaging are unnecessary during RLT |
| Follow-up for each patient should be defined by the MDT and tailored to the patient’s disease characteristics and therapeutic goals (e.g. survival or quality of life) |
| Follow-up timing, modulated based on prognostic parameters, could be proposed in the persistent disease setting |
| Follow-up protocols should take into account the psychological impact of monitoring on patients, as well as the financial impact on the health system |
| The timing should involve closer assessments early after RLT, becoming less frequent over time |
| Assessments involving ionising radiation (e.g. CT) should be used less often over time and replaced with safer modalities (e.g. US) |
| Organisational issues related to RLT use and managerial implications |
| Hub centres need to obtain feedback on waiting times, needs, and difficulties associated with service access (e.g. patient travel time) and provision in order to effectively provide RLT services |
| Training on RLT is needed in both hub and spoke centres, with curriculum tailored to the specific needs of each |
| A DTCP for RLT is needed to meet patients’ needs and facilitate MDT interactions, as well as to codify the service parameters for reimbursement |
| DTCP development should involve an expert panel with the contribution of Scientific Societies |
| Patient associations should be involved to reflect patient experiences and perceptions, as well as to suggest areas for improvement from a patient perspective |
| Performance indicators should be defined for the ongoing assessment of services |
| Efforts should be made to promote collaborations between small local centres and reference centres to optimise diagnosis and access to treatment, as well as to define standards in work organisation and patient management |
CgA chromogranin A, CT computed tomography, DTCP diagnostic-therapeutic care pathway, GEP gastro-entero-pancreatic, GEP-NETs gastro-entero-pancreatic neuroendocrine tumours, MDT multidisciplinary team, RLT radioligand therapy, US ultrasound