Individual physicians see individual patients, and they make decisions. They’re not choosing for 500 patients or 5000. It is even possible that they see only one or two of the patients you’re most interested in, in any given year.

Consider how dehumanising the Kaplan Meier plot can be. At the top of these curves, in an oncologist’s practice, a decision will be made, discussed, negotiated. Whichever treatment choice they make, the patient with breast cancer might die in a week. Whichever treatment choice they make, the patient with breast cancer might not die in 5 years. Yet too many pharma companies would shout ‘but look at the data! It is clear which product has the best efficacy!’

Those circles were real people, with real lives. Certainly you or I could look at a plot like this and hope that a patient might have ‘the right kind’ of cancer, and we might know that the chances for a woman taking trastuzumab are better in the early months and years. But for any one patient, you might never know. Even with a plot like this, you might never know, for that one person.

Pharma tends to talk to physicians as if this is literally the only thing they or their patients should care about. ‘Ignore the costs, ignore the visits to the physician, ignore the side effects. Look at the efficacy! Look at that median!’ All other things being equal, we’d expect them to go with the treatment with the best evidence, especially if it has head to head evidence. However, it is arrogant for pharma to believe that it knows what ‘all things being equal’ might mean to that physician, and that patient.

Often, of course, there is no head to head. Often, there will be no guide to managing side effects (are they transient, or treatment-limiting?). Often, there will be issues not just of cost, but hassle in getting a drug approved by payers.

You can’t start your positioning just by trying to benefit ladder 8 months of median OS. No physician in practice will ever see ‘overall survival’ - it is a study metric. No physician has a ‘median’ patient. You trivialise the differences treatment might make to a patient if you assume it is only about time, whatever the cost in impact on daily life and financially.

You might think a decision at the top of a curve like this is obvious. But real people do make different decisions. If you think they’re wrong to do so, you might need to check your understanding of their lives.