Treating institution and available pediatric neuro-oncology resources
Results from the administered survey are available Table 1 . We queried the hospital registry for new cancer diagnoses during our study periods. The INEN had 450-500 new pediatric solid and hematological cancer diagnoses per year, of which, 40-45 were CNS tumors. Between 1997-2007, there were four general pediatric oncologists who provided care to all patients with hematological and solid tumors. The total number of pediatric oncologists increased to eight during the second period at INEN. There were three neurosurgeons at INEN prior to 2008 and five general neurosurgeons during the second time period, however, none had pediatric subspecialty training. Brain and spine MRIs were not routinely obtained prior to surgery nor within 48 hours of surgery. During the first time period there was no MR imaging available at INEN, thus, MR imaging was obtained at private imaging centers, though availability, insurance issues, and the prohibitive out of pocket costs delayed imaging 2-3 months after surgery. The INEN acquired on-site MR imaging in 2008, after which, the delay in obtaining post-operative MRI in the second period decreased to approximately one month. There were ten radiologists on staff prior to 2008 which increased to fifteen radiologists after 2008. Three radiologists concentrated on CNS tumor imaging. There were ten pathologists at the INEN prior to 2008 with one trained in neuropathology, the number of both increased to 12 and two respectively after 2008. The availability of antibodies for immunohistochemistry are describe in Supplemental Table 1 . Lastly, there were one radiation oncologists dedicated to neuro-oncologic radiation therapy for children and adults. Radiation therapy was delivered via photon radiation therapy throughout these study periods, intensity-modulated radiation therapy was introduced in 2014.