The phenomenon Foy believes is happening— an efficacy-effectiveness gap— runs rampant in cancer medicine. Some new, $200,000 a year therapy eeks out a 1.5 month PFS or OS benefit in a randomized study. What few discuss is that the patients in these randomized studies are different than the average patients in our clinic. Remember, the randomized studies supporting approval often do not support diminished doses, and don’t support starting all at the same time. The way you would verify it is to run a large randomized study, generate these subgroup specific effect sizes, and then pick a few subgroups and run the randomized study again to see how closely you predict the actual effect.