 Češtje. Češtje za svoje interakcije, in je mi. Češtje, da bomo tudi o Miloma, vsak tudi več na vsega vsega barja. In svoje interakcije je zelo, Miloma se zelo zelo in več vsega vsega zelo, da je več več komplikativ in zelo začnega vzivno zelo. V Australija, če je nekaj z Hungaryi, in v hematologijke centrače, nekaj 10% od vsojnih, ima Miloma, in 90% od vsojnih, nekaj je dobrozna, v tem hematologijke nature. Kaj je, nekaj nekaj nekaj nekaj, nekaj nekaj dve, nekaj nekaj zelo. in je koristit na Milovo, ki reprezensuje 10% z vsebih hematologijkej doličnjih. To je vsebih problem. Vesetno je vsebih problem v čem način boh, da je bolj nekaj nekaj nekaj nečariko, v senterljski v Europi. Vsi je tudi izgleda v Hangari, Pomečno in Polje je vseč nespešno vseča, Ček, Republik in Slobaki je nekaj nekaj nekihme, tako mnogo videli svoji problem. Prezumim, da jaz so vsečje predpravila hongerejne sveče in zelo, da je pričo po te delo njihovo kraje. Kaj je najpravj eštečne barije? granted some of the exes barrier, which we experience in Hangar そう比 kdo flash. For instance we have the treat for my lymphoma for off the table therapy. So in Europe this is an important problem, which is much less problem in the US. In the US the label is one thing in the tryst for doctors that can use a lot of text of table. v njenih njegovih kraju, je slabnj, njegovih ne možeš vzupit parlj, in v Hungarji, hranjnješko in značno, ne bo verjenje vzupit nišelji, nekaj nešelj, ali ne možeš značnja se način nekaj zelo. Nisem, in se je vzupit, ki bilo se doljez, ne bo vzupit, ne bo vzupit, ne bo no način na način. Tako, to je bilo všeč veliko problem. Svečo, to je svoje svoje držav. Tako, držav je EME režistirati. Tako, je zelo vzgleda, ali ne zelo vzgleda, ker je zelo vzgleda. Vzgleda je zelo vzgleda, da nekaj zelo vzgleda nekaj zelo vzgleda, da nekaj zelo vzgleda, There are a few patients in Hungary have supplemental health coverage. But that seems to be insufficient for cancer care. So this is also a problem that the government doesn't pay and the supplemental health insurance doesn't pay. And the excess barrier is the presence of rate ingles. I don't know in your country but in Hungary we have rate ingles for transplantation. Some patients do progress while on the rating list. To je problem, da ne potrebujemo potraviti patičnih, kaj smo počutili, ker smo počutili počutil v potraviti uniti. Tako počutelj, potraviti patičnji je na listu kratkih. Normalno medikalačnih smo sveti, da počutijo počutelje, je dobro, da počutilo počutelje, in počutilo potraviti patičnje. To je optimale. ...zapravljno se zbizila 3-4 raznega v Hungaryi, da je to taj transplantacija. V Hungaryi ne znam o vso kraju, ... ...zapravljno se je zbizila in zelo in zelo in zelo in zelo in zelo in zelo. Zelo je doktor, da se vse, da je optimale terapije, ... ...zelo in zelo, da je zelo in zelo, ... ...zelo in zelo in zelo in zelo in zelo, ... zelo zelo se vstajamo, da je to izvončen. Vizumim, da je to izvončen, da je to izvončen in na odličenje od 1-2 mnami zelo se izvončen, se, kaj je občin in čudovito izvončen je. Zato je to več najš potem vrči. Zato očenje, da je odličen skazanje, kaj je izvončen in izvončen je nekaj nekaj nekaj nekaj. zato to bi je odličeno. Dobro, se na prvnoj teropij, da je izveč. Zelo se je izveč, kako je zelo zelo zelo zelo zelo zelo zelo zelo. Zelo je, da je v tebej Evropijanih kraju, zelo zelo zelo je vsega. V Angriju, prizelo zelo zelo zelo zelo zelo zelo zelo 90%. Tako je zelo več zelo zelo. Tako je zelo zelo zelo, zelo je nekaj nezelo. Prejvjeli, konstrat je zelo vzelo, ali smo unfoljati počutiti. Vtečne in Bothezomi je nirmje, da je tudi tukaj z tukaj, in je vse zelo vse. Zato smo iznočili, da inakcijne regimenje izjela tukaj, potenja tukaj, asa je še zdojila bydovčen. Vtečne in Bothezomi se obježivali v Saikofosamide otečne in talidomi dotečne talidomidexametazone in maybe in certain situations, especially in the case of extra medjural disease, it could be anticyclins, like at the British protocol. And in some situations when the patient refuses to have parenteral therapy, you can use cyclophosamide, talidomidexametazone, and that is also available, because now Sergine offers talidomide really cheap in Hungary. We had to buy the drug from India, but now we can have a legal talidomide in Hungary, and it is done cheap. So we have good options, and I think there is no excess value because of the generic program. And stem cell mobilization is usually again without problem, Pre myself isn't doing well, we have a problem about the long term storage of stem cells. The so called tank problem. The stans in which the stem cells are sitting in liquid nitrogen, these have some cost and the resupply of liquid nitrogen is expensive. Especially if you start to think that you want to store the stem cells to 5 to 10 years, maybe longer. Tukaj je bilo spes, však je bilo učin, da je vse zelo vse zelo, da da je vse, da je želimo, da je zelo, da je zelo. V spremsega autologičnega transmittacije, ki sem vidim v mojej vsega, mora je vsega glada, bo je to v mistih kraju. Vsega glada je, Se vse zelo za hljubi, ker je zelo začetne, ali ne zelo začetne, kako je delat in začetne, ali se ne zelo začetne, in se ne zelo začetne, zelo začetne, zelo začetne. In se je to zelo, ker je zelo začetne, v vsej toksizati. In nekaj v Hungaryi, nekaj in glist, je zelo v Miloma patičnih. To je razilj, da linfoma patičnih je pravdi, ker na linfoma patičnih, kaj je zelo na glistih, nekaj je opcijnje v salvičnih. Zelo je, da na Miloma, nekaj je nekaj opcijnje v salvičnih, nekaj je nekaj problem na glistih. Miloma patičnih nekaj je nekaj opcijnje v glistih, nekaj je nekaj patičnih, da je identikalne. Zelo je, da je medicarizm, kaj je začetil, nekaj je nekaj. Zelo je, da je nekaj malo malo malo malo malo malo. Zelo je problem, ker nekaj nekaj nekaj nekaj vzelo v zelo v zelo v zelo v zelo. Zelo je, da težite stem pas v in nekaj drug darbe bo inčen, ki jazem čekaj, nabijem točnjo zelo, tako je probel. In druga je zelo, odlično Evropiji Unijan, z Vrkutima, na kako jazem daj dobro druga in na Evropiji marketu je ni veliko, in zelo, da nekaj druga nelične zelo od Indija. Tisto je probel, in tism je izdenštrovna vrkutina, V svoj halj, nekaj malo malo, ali so začeliti na metotek sejt. Ko je vzgledati in da nekaj, ki je bilo druga. In tudi nekaj ne, da je vzgledati na tereski vse market, in na še ne vemo 5-4 uroja, ko je druga fora kolonkeselja. Zato je, da neč nekaj, neč nekaj dobro v svoju zelo, ki neč nekaj, ki je začelizav, in kako je zelo, in je nekaj držav, tako to je konsequencije v generijku programu, da priječenje držav je tako ljude, da vših kompaničnih zelo prišli. Tako to je problem. To je problem in to je neko, da je zelo početno izgledat. Tako, in konsolidacije in izgledanje, da imam tako veliko izgledanje, o zelo v ideju. Zato imamo izgleden izgleden zelo. Zelo je to , da je zelo našem label in alidomaj, potrebno je zelo, ali v angriju, da sem bilo poživljati, ker je bilo zelo poživljati. V nekaj nekaj nekaj mnogo, da je bilo poživljati kaj je začela načo povačenje, zelo je zelo tako zelo izgleda. Všeč nekaj je tudi otev, ako je bilo povajčen povačenje in nekaj je malo država v ročneh izgleda. Je to načo inošnje vrv, ker nekaj drugi, ki smo vzivali način, ne vzivali način in to je vspe tudi o povajčenjih terapri. ozvoričenje terapije. Zato v tem, ki ne zelo vziv, ne zelo vziv, da vzivem, da bi včešel vziv, da je to zelo vziv, da je to zelo vziv, ali da je to zelo vziv, ne je bilo vziv, in da je bilo vziv, je bilo vziv. Vzivem, da ne zelo vziv, ne zelo vziv. We have a problem for access to minimal resilience monitoring because it needs a special center whose has a good flow cytometry laboratory where few patients have access to such center tako Centra, zelo Tervol in nekaj problemov. MRD monitorično je zelo v tem, da je zelo v tem, da je zelo v univerzitičnih, in maybe všeč na hospitali, in nekaj zelo vsi, da ne zelo v MRD monitoričnih, zelo v logističnih in finančnih različnih različnih. OK. So the problems are many, with respect to the patients who are eligible for transplantation, but there are problems for patients not eligible for transplantation. Again, as botazomib is generic, melfalan, prednisalon, botazomib, MPV combination, no problem. I mean, sometimes oral melfalan is also a problem to get, because sometimes oral melfalan is not available on the market, at least in Hungary. It's not registered, so it's a little problem, because it's off-label, melfalan, and melfalan's label comes from MPV, Valkid label. So, I mean, legally it's borderline, but since the drug is cheap, then although the price of melfalan has gone up approximately three times in the last couple of years, but it's still cheap, so it's a problem, it's marginal at this point, and we have access to MPT and CTD combinations for those patients who need all oral therapy, so who do not want to get subcontinuous injections of botazomib. Okay, with Lenaridomide and Dexamethasone first line, I think in Hungary the insurance company said that it's hopeless, because they normally finance Lenaridomide for four months and then you have to show partial response or better and then you get additional financing for one year, and that's for relapse disease, but for newly diagnosed elderly patients to give 18 months of therapy or maybe continuous, as Dr. Zvigman said, this seems to be, again, beyond financial control, it is at least not covered by Hungarian insurance. But you know, Lenaridomidexamethasone has been superseded at least in the US with botazomib-Lenaridomidexamethasone, it has been shown in a clinical trial that it is superior. Again, this is not label, although botazomib would be cheap, but Lenaridomide botazomib, again, goes to the expensive problem, so, since it's of labor, it's easy to refuse and we have a financing problem again with Lenaridomide, first line. In those cases, where we have pre-existing neuropathy due to diabetes or alcoholism, I mean, this is a problem, but we have generic bentomastin in Hungary and probably in your countries as well, and generic bentomastin is on label and financed. So, I think this is a good option at this point for these patients who have neurotoxicity due to myeloma, diabetes or alcoholism. So, I think the problems are here mostly related to first line Lenaridomidexamethasone. Now, relapse. Okay. I would start in the middle. I think that you as a physician or you as a patient, you want the best available therapy and the insurance provider wants you to get the cheapest therapy and these usually do not coincide. That's a problem, because at least in Hungary insurance providers prefer repeat as many times a botazomib based therapy as possible because it's cheap and effective as far as all of you know that botazomib has a long-term problem of neurotoxicity, especially hand and feet, sensory neuropathy. Now, if prior response was good and the side effects were few, then I have a smiley face. I have no problem medically to repeat it. I mean, there are these patients, maybe one-third of the patients had few side effects and very good response problem. Repeat MPV, repeat VTD, no problem. Class switch would be required in those cases when you have neuropathy or other toxicity and then the problem is that the insurance company may want you to use teledomide because again it's cheap, much cheaper than nanolidomide but the problem is that teledomide is toxic, especially it's neurotoxicity long term and usually not very reversible. So it's a problem. And in this case you may get access to nanolidomide but usually the problem is that at least in Hungary they give a quota to each department and if your quota is filled then you have to turn in individual claims and then it becomes really difficult to get access to the drug. Second line. Third line is usually easier because in the third line the insurance company cannot really argue effectively against the use of nanolidomide. Unfortunately we do know from clinical studies that nanolidomide works better in second line than in third line but the insurance company thinks the opposite way that if you give it third line it works less effectively that's better because they have to provide it for a shorter period of time. You see. I always say that they sit on the horse and hold in the tail. So they want to delay providing the best drug because delay means fewer months of therapy and that's better for them for financing viewpoint. Okay. So triple combinations. If the patient is fit you want to use three drugs instead of two because three is better than two. Four may be not better than three but in certain situations maybe but three is optimal. So if a patient is fit you want to use. But two expensive drugs in one line of therapy it's very difficult. Again the insurance companies at least in developed countries may want you to use the cheapest available therapy and at least the reality in Hungary is that you could use bortezomib in combination with steroid, benizolone, or dexametazone and a cheap cytostatic drug like cykelfossomide, malphalan, or doxorubicin. So this is triple therapy effective and good but the problem is bortezomib toxicity. Telidomide containing regiments are again available and in this case they are off-label like CTD but usually in Hungary finance because the situation is interesting that something may be off-label but cheap then who cares about being off-label something is off-label and expensive then it becomes really important then it is off-label. And the new drugs, carfilzomib exazomib and daratumumab usually to get access in second line is problematic but as we heard from Dr. Siegman it's also a problem in the Netherlands whose per capita GDP is a couple of times higher than Hungary so the problem is really maybe universal at this point so to get the best therapy may be without not without any problems yeah, that's a problem and it's difficult to handle and I think patient advocacy groups are really important to tailor this kind of problems to show to the lawmakers that best available therapy is the best option for the patient ok savage transplantation so we are talking about transplantation done second or maybe third time because now there are data emerging that autologous transplantation could be done even three times not just two I mean two is now standard of care but now we start to talk about three no, so at least in Hungary patients who responded well at least maybe minimum two but better than three is for autologous transplantation you can give good induction therapy and then do a second autologous transplantation and it is normally approved by the finance transplantation committee and it's done quite regularly but not frequently but the problem is availability of stem cells because there is not really universal capacity to collect stem cells sufficient for two or maybe three transplantation because it takes a lot of financial resources to maintain these banks because these are kind of cell banks because they sooner or later they will cover buildings because there are so many patients and so many bags of stem cells so it's really problematic because of material and human resources because you have to maintain them properly there was a question about possibility of recollection and our result was 19 out of 20 so it is possible to re-collect stem cells but platix of four excess is critical without platix of four maybe only one third of these patients could be effectively immobilized so it's very important that at least in Hungary platix of four is available so we have no problem with this and the rating list is a problem because for second autologous transplantation the rating list is more of a problem than in the case of the first in these patients you really want to have the transplantation done in the optimal period otherwise the advantage of the second transplantation may be lost because you need to give another salvage therapy and I think this is an interesting situation that autologous stem cell transplantation in myeloma at present is one of the cheapest therapies available I think this is only a couple of months of lendardidomai treatment or maybe two months of daratumumup treatment so it's really dirt cheap as compared to the novel drugs and this has been the totally opposite maybe ten years ago and this is it made a very interesting situation because the transplant budget is increased to cover all these additional necessary transplantations and I think again this needs to have the low makers and the financial decision makers to become aware of this problem that we need to have more access to autologous transplantation and on the long run it saves money for the country because this is a cheap therapy nowadays and this is a special expensive therapy but in the case of myeloma this is not true anymore ok and how about the situation of refractory myeloma refractory myeloma are considered patients who do not respond to therapy or those who progress immediately upon stopping it this means that patients may respond well to a therapy but when you decide to terminate therapy they immediately progress that means a problem because they have probably a resistant clone that emers during the therapy and usually you remedy it by class switch so if the patient receive botasomy based therapy then you switch to lenalidomide based therapy or maybe pomalidomide if available in your country but lenalidomide may have more difficulty because if they receive first line botasomy second line lenalidomide they may have pre-existing neuropathy from first line therapy so you cannot easily switch back to botasomy so you really want to give them something better less toxic but at least in Hungary this is a situation where the insurance company says that oh we have toxic alternative which is very cheap you should provide that but the problem is that using third, fourth, fifth line it's kind of palliative therapy in my experience in this situation works as long as you provide it and immediately the patient progresses when you stop but the insurance company says that again you can give six cycles for six months and then we can renegotiate in six months so, and professionally in this situation of lenalidomide refactory patient with neuropathy I would like to give my patients carfilizomib or dilatumumab but it is a difficult application to get approval for I don't know about your country but we'll be happy to hear your experience and there is a situation of multi refactory myeloma I mean this is a real tough job Patients in this category do not respond to multiple attempts so I mean to try this and that and that and then the patient still progresses and usually there are very few things that can turn bad with a patient who respond to therapy and a lot of things who can turn bad for the patient who is refactory to the therapy because you get all the toxicity of the therapy and all the problems of progressive myeloma so in this patient's condition is usually deteriorating, you need to be quick and individual applications tend not to be quick and especially if the patient exhausted the good options of botazomib and lenalidomide based combinations and this case usually a multi agent combination like PDT pace is used in Hungary sometimes we give them 50 milligram of high beam alpha and that's also a good option in certain situations and can work for a couple of months and give you time enough to negotiate with the insurance company to get something better sometimes it gets approval sometimes not and in this situations access to novel agents in clinical studies is really important and we are really keen on enrolling refactory patients to clinical trials because usually that's the only way to get access to novel therapies quickly enough maybe daratumumab is a good option but the problem is that it works only one in four patients so four patients you take for three in this situation it won't work only one out of four you will get an effective therapy and we have seen the results of pomalidomide that it works only 40% but if you have POMP cyclone then it goes up to 50% so it's a really problem and the barriers are numerous and in this situation and really I consider the central eastern Europe but our problems are our problems together with the patients we strive to jump above the barriers and hopefully solve the situation and I'm ready for questions and discussions anyone has a question should be many questions we are talking about barriers to access and in this particular context you have mentioned I have seen that whatever therapeutic treatments you administer are more or less valid for all countries within eastern Europe you have mentioned that professionally it is preferable to use curfee, XA, DARA, etc but you said that access is problematic could you define that could you give us some details what do you mean problematic is do you have to do you have to ask the companies to make donations for the patients do you have to ask your own agency for medication to consider a particular case and if that's the case who's having the final the final word let's say the doctor because a doctor will have 10 problematic cases and probably will have to submit only a list of 5 I mean what is the role of the doctor in this circumstance but please define what does it mean problematic I completely understand the problem and your questions problem as well I mean the situation is that it is very difficult to get donations from pharmaceutical companies outside of certainly existing individual named patient programs that are few in between but we had one for exasomy and one for nivolumab so they do exist but few in between I mean in Western Europe there are more but the general access situation in Hungary is that you have to turn in an advance claim request individually each patient one by one not a list you have to argue with the insurance company in writing why do you think your patient should get this or that drug and why not the other and if your claim is accepted then you will get a couple of months of financing of the drug and then you have to turn in a second claim to show that it was effective and so on and so on usually normally done every three months you have to write a claim so the finance national agency of education yes to our insurance but who makes the final decision are the hidden experts of the insurance company whose name is secret so they won't tell you so the medical expert of the insurance company who may be a good hematologist or who may be a poor hematologist I mean it cannot be influenced and maybe he's a good hematologist but he has given the command to kill all applications this year maybe discuss next year but this year we have no money left and then they will refuse your applications or they may give you no response for a couple of months then comes January and they may accept it if your patient is still alive I mean normally normally what I do is I administer the best available therapy at the same time I turn in my claim for the best theoretically available therapy and then because usually these patients who have progressive resistant myeloma they need to get some form of therapy so I decide what to choose from the available and I make some decision sometimes it's only palliative care but sometimes some sort of a combination that what I said that sometimes we use VDT paste sometimes we use high dose stem cells and this way we may get a few months of time to do all the correspondence with the insurance because normally it takes one to two months I mean this is not fast and the patient may pass away during this period so this If it doesn't work this way because we have time remaining we have several cases like that it was a post transplant autologous transplant the person didn't require among other things the farmer refused for some reasons to go operate and the individual was quite young for this something I mean and of course there may exist a black market for certain drugs but that's that is part of the patients problem I mean some patients do get drugs illegally I mean I cannot officially talk about it but that does exist a black market you were talking about waiting lists for the patients but what about a lack or a shortage of stem cell donors as we in Holland meet you need more stem cell donors for allergenic transplantation Yes I mean this is a problem but less of a problem at least in European countries Caucasian population usually have a really good chance to get a proper donor I think in Hungary we have a problem of gypsies because they do not normally have a donor available because of the different agele constitution and I think the same situation about the Basque people here in France and Spain because they have a different agele composition than rest of European population but most of the Caucasian people in Europe tend to be similar so maybe one mismatch donor could be found for more than 80% if sibling is not available siblings have few and fewer unfortunately because the families tend to shrink I don't know my father was 11th child and I was 2nd child so I mean the families are decreasing as generations are passing and I think in Hungary normally most families have only one child I don't know in your countries but probably 10 is similar so siblings are much fewer but usually the young people who are the university students many of them apply to become stem cell donors so I mean they constitute a large number of health individuals and maybe 80% of the patients have chance to have a good donor but definitely for certain subpopulations it's a problem but I see less of a problem for the main population I have also a question the problem is according to me and lots of people lawyers also that states or insurance companies living on a different pattern living on a different level than patients because you told already that the best cure is triple combination it needs lots of money for free drugs not only one and it make the life longer three or four times I had the article from professor Hayek who wrote that we sell land using this triple combination but not before now it's not very hard to find people living 20 or 25 years so it will cost really a lot I mean the situation from the viewpoint of the insurance providers is a little bit more complicated than that because they tend to calculate quality adjusted life year gain and how much money that costs and then let's say if your therapy increases your life expectancy by one year and it cost 50,000 euros then they may decide that this could be financed but if it cost 100,000 euros they may decide that this will not be financed because your country cannot afford it even the quality is perfect the quality of life is perfect after this triple combination sometimes not usually yes but sometimes not so it's difficult situation because these drugs tend to be really expensive and more than human life and like definitely mention human life when I was a medical student the life expectancy for Miloma was one and a half year and maybe five years with transplantation and now average is beyond the eight years maybe 20 something years I practice medicine good news for us bad news for insurance I would like to tell something more especially for these patients have to provide those retirement funds and so on they cost a lot of money for the states we have the sentence and try to imagine that we were talking about the data it's a novel medicine you told that it's 25% of success when you use it but I don't if you know that for the producer of data the center central and the old communist countries are all together 2% of income 2% of their global income they don't even know where is Hungary Poland, Romania I was told it's kind of rounding 2% they will not give any donation because it's too small market it's sad but I was really shocked they see countries or they see group of countries where the income is more than 10% it's a normal in big corporation normal thinking GE or Ford or something like that 10% is a serious market below, no sad so in powering myeloma advocacy across Europe must be created on the level of governments before the elections and all this kind of things because we cannot really think that the donation is a way I think so I mean and also access to more clinical trials because if you are a patient in a clinical trial or a patient is volunteering to participate then usually can have access to the new drugs for free free for the patient and free for the government insurance so I mean this is really important that the government insurance companies should strive to develop more centers of excellence to have more clinical trial participation but also it's not really understood because this should be part of the long term thinking of the insurance providers to motivate the system towards clinical trials and maybe some more country based clinical trials should be there I have one more question but wait I have a role of chairman sorry I speak as a retired the person from a company and I want to give you some hints I completely agree with you about clinical trials because these give the company some more let's say easy way to give drugs but and I remember we discussed a lot with Viorica in the past what the community and also the doctor community should do is to raise the level sometimes in some countries of the centers because the clinical trials should follow very strict rule of quality so-called good clinical practice and we faced when I was working in Novartis the fact that in some country the level is increasing because of ESMO, because of EHA because of training but this is one point, help as a community to have center of excellence to do clinical trials. Second donation I said also yesterday companies are not charities and I speak from former companies that for example in CML organize one of the most important donation project for Gliwek in all under developed countries so the companies that are aware of that try to find a way but is very difficult to even legally even if a company and I faced that because I was working as responsible for patient groups and I received a request for donation even willing to do that from the legal point of view the fiscal point of view sometimes is really difficult even if a company would like to so I want to not to defend but I want to explain some situation so it's not so easy to do donation even if you want make an example from Italy where I live if a company make a donation they should pay VAT on that that is crazy if you wanted so I want to just to explain some situation from companies and the companies try to when is possible to do it but it's not easy also and again if you start with a donation then you think that the company should do donation we are companies are not charities I think your comments are much appreciated there is some roles to avoid the VAT payment the last question it is the last question I know Susana thank you very much for your input the problem is that the main responsibility goes to the state particularly when the patients are taxpayers or have been taxpayers for all their life so the primary responsibility is the state and not the company and I fully agree with you that they are not charity one and I have not heard anything about with cytogenetics one way to establish the treatment, the stages and so on and so forth my question is again in relation to the responsibility of the state does your state have cytogenetic laboratories? I know that private laboratories exist as well as in Romania but are there any places where Hungarian people can go to the cytogenetic laboratories governed by the state fortunately yes there are six good cytogenetic laboratories state state so it's free for the patient so this is organized yes for cytogenetic but we have a problem with minimal residual disease monitoring that's a problem this is still ahead of us to solve it but cytogenetics yes it has been fortunately solved so it's free for the patient ok thank you thank you doctor I would like to tell that we finished in time so it's a good success