When should a patient consider a clinical trial if they relapse?

When should a patient consider a clinical trial if they relapse? When should a patient consider a clinical trial? As a clinical trialist, my answer would be at the very beginning. The reason is this. Say the so-called standard of care for a patient that is fit for chemotherapy is 3 plus 7. For a patient who are quote unquote unfit for chemotherapy would be say a hypometallic agent plus phenotoclax. But even with these, your best-case scenario remission rate is possible over 70 percent or so. If we really look deeper in terms of elimination of minimal residual disease, etc., that percentage drops further. So now we are talking about 40-50 percent of the patients we are getting a reasonably good response in the best-case scenario. But that's not good enough. We need to possibly push the envelope a little more. So then the question is that why not use the backbone and add things either that are available like for instance an FLT3 inhibitor or IDH inhibitor and say for hypometallic agent and phenotoclax, why not make it a triplet combination? And we and others are doing it. At least the initial data looks very promising. Whether they really translate into extended survival, we'll have to wait and see. But the early data looks very promising. For the context of FLT3, for patients who can tolerate chemotherapy, the 3 plus 7-1 nitro is added to myelostorin, which is an FLT3 inhibitor. It definitely improved the outcome. And we have similar analogies in the field of acute lymphoblastic leukemia. Particularly for the Philadelphia-positive acute lymphoblastic leukemia, we have added tyrosine kinase inhibitors either, you know, Dsatinib or Ponatinib. And the results are kind of night and day, where from 30% of long-term remission, now you're talking about 70-80% long-term remission. So just by adding one agent, right. So and that's why it's important to explore clinical trials at the very beginning. Now, the access can be a problem. And hope that we all do a better job in networking with community-based practices or organizations so that we can extend the network and then take it to even the remote parts of the country. Now, with less intensive regimens, that is becoming a more reality, right. With very intensive regimens, it's difficult to do it. But with less intensive regimens, it's becoming more and more of the reality. So, I mean, my answer as a clinical trialist would be that the earliest possible time a patient should consider a clinical trial. Now, if you're remission, but say if you have a relatively higher risk of relapse, why not think about a maintenance program, maybe on a clinical trial, right. Particularly, if the disease comes back, if it's a relapse refractory disease, then I would definitely advocate for a clinical trial because in that space very little approved drugs are there unless you're targeting a particular mutation, say IGH or FLT3 mutation. Beyond that, there is not much available. And so for 60, 70 percent of the patients when they relapse, you don't have a targetable mutation. So I would really encourage a clinical trial as an option.