Toxicity reporting that travels: a resource-adaptive framework for pediatric solid tumors

Toxicity reporting in pediatric oncology remains dominated by the maximum Common Terminology Criteria for Adverse Events (CTCAE) grade, which compresses a multidimensional clinical experience into a single value and inadequately captures duration, recurrence, cumulative burden, treatment disruption, functional consequences, or the child’s own experience. These limitations are particularly consequential in pediatric solid tumors, where multimodal therapy can include intensive chemotherapy, major surgery, radiotherapy, targeted agents, immunotherapy, and cellular therapies, and where treatment-related morbidity can extend across decades of survivorship. Recent work in hematological malignancies has called for toxicity assessment to move beyond maximum grade toward longitudinal, patient-centered evaluation. I argue that pediatric solid tumors provide a compelling setting in which to extend this framework, and that any such framework must remain deliverable in the low-resource settings where most children with cancer are treated. I propose that conventional CTCAE reporting be complemented by five dimensions-severity, duration, recurrence, treatment consequence, and patient impact-integrated longitudinally from treatment through survivorship using pediatric patient-reported outcomes, healthcare utilization, functional measures, and selectively validated digital biomarkers. Rather than increasing data collection indiscriminately, future trials should identify a candidate minimum clinically meaningful toxicity dataset that is deliverable without continuous connectivity and linked to predefined actions and outcomes. The objective is not to replace maximum grade, but to place it within the trajectory of a child’s treatment and subsequent life, wherever that child is treated.