Response to Karajannis et al.

We were pleased to see the letter regarding our debate paper from Drs Karajannis, Souweidane, and Dunkel. Weighing molecular targeted therapy against conventional chemotherapy for low-grade glioma is a complicated, ubiquitous challenge our pediatric neuro-oncology community faces. We want to reinforce the authors’ additional considerations for real-life decision making.

Indeed, our faux clinical scenario presented us with histologic and molecular diagnostic information, obviating the need for debate about surgery. We cannot assume the histology and molecular profile of any given sporadic pediatric optic pathway glioma. To that extent, we restrict our consideration of targeted therapy only to scenarios such as the one provided, in which the tumor’s driver mutation is known. When is biopsy warranted for optic pathway glioma? When does surgical benefit outweigh risk? The answers are not universal, but rather nuanced for any given patient, to be reached through iterative multidisciplinary consensus depending on each patient`s clinical status and in discussion with the respective caregivers.

We appreciate the emphasis raised toward financial cost. As stated in our initial paper, the survival for pediatric optic pathway glioma is excellent.¹ Nowadays, increasing cancer care costs as well as patient cost sharing may further our survivors’ risk for financial hardship. Although the majority of adult oncologists agree that access to effective treatment should not be influenced by cost, they also agree on their responsibility in discussing out-of-pocket costs of cancer care.² We would argue the same responsibilities hold for pediatric neuro-oncologists, regardless of treatment chosen.

The indications for targeted therapy over conventional chemotherapy in pediatric low-grade glioma are far from agreed on, but will hopefully become clear through the completion of well-designed clinical trials with appropriate and consistent end points. Until a singular answer arrives, our clinical community will continue to engage in thoughtful discussions. We recognize the reality is always more complicated than practice debate.