In a setting such as this one has to adjust the expectations to those of the patient. SCT would be most appropriate but if the patient does not want that then the best option is investigational (if able to get to ABL001). If not, I would go with a TKI aiming for some control acknowledging that we will not achieve the deepest response. I am assuming that imatinib, dasatinib, nilotinib, bostuinib and ponatinib have all been tried (dasatinib, ponatinib are specifically mentioned in the narrative). I would continue the best tolerated agent. It has been shown that some control is better than hydroxyurea only, and that even a minor cytogenetic response confers a survival benefit compared to no cytogenetic response; not as good as complete cytogenetic response of course, but better than what you can expect with hydroxyurea only. Omacetaxine is a good option if available. This is the kind of scenario where it is worth trying as you can get some patients to respond. Otherwise, I am no fan of chemotherapy.