Should all pediatric CNS cases be referred to a proton center?

I hope there will be a substantial amount of debate on this question, and so I have invited several pediatric radiation oncologists treating patients at institutions where protons are and are not utilized.

The weight of the building data on this topic in the literature is mounting such that more and more cases are being referred to or are being treated at new proton therapy centers as it’s very clear that under most contexts protons will offer not only potential for a better late effect profile, but also an improved acute toxicity profile sometimes in CTCAE domains that are not well appreciated. That being said there are plenty of cases that many will agree are not appropriate for referral based on a variety of reasons. It’s impossible to s...

Thank you for your very insightful comments, @Dr. First Last I agree with you on all points. Will just add that for children with CNS tumors that have poor prognosis [e.g. DIPG, or diffuse pediatric-type HGG H3-wt IDH-wt (classified as glioblastoma in earlier WHO CNS classifications)], clinical advantage of proton beam therapy is likely marginal as these children are, sadly, unlikely to live long enough to experience debilitating late sequelae of cranial RT. On the other hand, if these patients with poor prognosis do choose to get proton therapy, it can actually be disadvantageous for them if protons can't be started in a timely fashion (for a variety of reasons, e.g. access to proton center, need to travel to another city/state, financial ...

I wouldn’t say all but quite a few. Denial is not just a river in Egypt. Obtain comparative dosimetry and, if protons are better, use them. That said, some who don’t have protons tend to devalue them. [Do what you would do for your child (or grandchild)]!

This is a terrific question and Dr. @Dr. First Last has provided an excellent and thoughtful answer. It is interesting to look back at the progressive adoption of protons in the COG CNS protocols (I believe first allowed in 2000 for infant medulloblastoma, then 2003 for ependymoma, 2004 for all medulloblastoma, 2005 for low grade glioma, and now all CNS trials based on 2012 NCI guidelines) and to acknowledge the importance of the Pediatric Proton Consortium Registry which allowed for the creation of a comprehensive database of pediatric patients treated with protons in the US with a major goal of accruing data regarding the acute and late effects of protons in these children. It is appropriate to always think of protons when considering irr...