I find this an interesting subject and one I have pondered over much of my career. As I already mentioned, I can easily see both sides of it Recognizing your position, I want to steel-man the other side, for sake of discussion I will argue that the ideal should be, even in 2026, that *all* cancer patients should be on a clinical trial. And I am solely going to focus on therapeutic intervention here. There are other interventions (like imaging, surveillance etc). But that is not the focus of my point here. For sake of discussion lets put aside greed, corruption, incompetence, poor trial design, as well as practical issues like access. These are of course normal aspects of human behavior and daily life, but for an aspirational goal, we can be idealistic. This is a goal, not a reality. One must recognize that what we consider “successful” treatment in oncology leaves much to be desired. For most “curable” cancers, treatment may require disfiguring surgery, difficult and sometimes lengthy courses of medical therapy (chemo, immune and other) and occasionally radiation, among other things. And what do we get for this? At best, roughly 90-95% cure rates for the most curable cancers. Even stage I lung cancer is sitting at 70-80% cure rates. Cure rates only go down from there for more advanced tumors We do not settle for 95% success in treating pneumonia, appendicitis, or many other diseases. We should not be resting on our laurels in oncology. We pay a high price for at best modest success rates. There is ample room for improvement and we will not see any improvement without clinical trials at every stage of these diseases. There is as much work to be done in improving cure rates, as reducing toxicity. It is a bit unfair to point to “evidence” as to whether or not one should consider a clinical trial. By definition, no data exists. That is the reason for the clinical trial. So how can one say that a “clinical trial” is “better” than standard of care as an aspirational goal, when no data exist? One thing to understand is that for a clinical trial to be approved and ethical, there must be equipoise (ideally determined by an impartial judge). Equipoise is a funny thing. It implies ~equivalence~ that a person should be equally happy to be assigned to ether side of a randomized trial. And yet … in most clinical trials, equipoise is acknowledged with a wink and a nod. No one, from the pharmaceutical company and their scientists, to the clinical investigator, to the patient enrolling in the trial, really thinks there is equipoise. They WANT and HOPE the exciting new drug will work. And yet, the majority of new drugs do not eventually get approved. So how do we square this? To me, equipoise means that statistically the experimental intervention is reasonably likely to be at least equivalent, and toxicity is within an acceptable range. I am glossing over a large amount of uncertainty here, but this uncertainty is the price that must be paid for progress. I justify that by pointing out my original contention, which is that success in oncology is still rather mediocre. So how could participation in a clinical trial be ~better~ for a given patient than simply moving forward with standard of care, when the drug may or may not work, and might add toxicity? To quote Rumsfeld, there are known unknowns and unknown unknowns. Standard of care is not a “known” but a “known unknown” Embarking on standard therapy means accepting a certain statistical chance of success. The individual patient still does not know whether the given treatment will work ~for them~. Only that they will have a 50, or 75 or 95% chance of success. A clinical trial on the other hand introduces a wild card. If you accept that equipoise has been deemed to be present, the person enrolling in a clinical trial has the baseline odds of success *plus* the wild card addition of the experimental drug. Maybe they will get the drug, maybe not. Maybe the new drug will work, maybe it won’t. Maybe it will add toxicity in excess of any benefit. But from the birds eye view, the person embarking on a clinical trial accrues more ~potential~ benefit than the one accepting standard of care. They get the standard odds, plus the wildcard. Even acknowledging that sometimes the experimental drug is a dud, or even net harmful, at large the individual is better off on a clinical trial than not (provided that equipoise has been deemed to be present, by an unbiased third party) because they had the additional *chance* to do better. To now, I have refrained from pointing to a community benefit, because that can be a slippery slope. But that is baked in too. Many patients facing a cancer diagnosis have a genuine desire to help other people in similar circumstance, and a thoughtful patient will realize that the only way we improve care for future cancer patients is for present cancer patients to enroll in clinical trials. As others have noted, generally only about 5% of cancer patients enroll in clinical trials, and if we could double that, or 10X that, we would make much faster progress. Considering that with AI, I anticipate a deluge of potential new drugs to emerge, we are going to have to dramatically ramp up clinical trials to accommodate all these potential new agents So from both an individual, and a community perspective, it is fair to say that enrolling in a clinical trial offers the best care a cancer patient can potentially receive