Therapeutic Reciprocity in Precision Neuro-Oncology: An Ethical Threshold for Molecular Stratification in Low- and Middle-Income Countries.

Central nervous system (CNS) tumours are one of the most important entities in neurosurgery. The recent changes in the framework of the World Health Organization (WHO) classification of tumours reshape the diagnostic paradigm from morphological assessment to molecular characterization. This has elevated the standards of diagnostic precision, as well as in tailoring targeted regimes for CNS tumour management. The problem, however, lies in its limited applicability in low- and middle-income countries (LMICs) as opposed to high-income countries (HICs), where greater diagnostic precision is more likely to translate into improved patient outcomes through access to appropriate targeted therapies. Collectively, these challenges have led to the emergence of the concept of "therapeutic reciprocity." This principle emphasizes that improvements in diagnostic precision do not necessarily translate into equitable access to targeted therapies, particularly in LMICs. Consequently, without a realistic prospect of improving treatment availability, patient outcomes, or follow-up care, these out-of-pocket and non-actionable tests raise ethical and clinical-value concerns in LMIC settings. However, diagnostic precision upholds its own independent value for prognostication, avoidance of unnecessary toxicities, medication selection, surgical planning, and eligibility for clinical trials. LMICs play a huge role in collecting genomic datasets through sample donations and collaborations, yet remain underprivileged in therapeutic innovations reaching their population. Therefore, this editorial highlights these concerns while proposing strategies to bridge the gap in diagnostic precision and therapeutic innovations between LMICs and HICs.