This weekend's Nivo-Ipi results chemo CheckMate 8HW looked pretty impressive.

@ArndtVogel summarised it pretty succinctly -

BUT - something isn't quite right... so I've taken a bit of a dive... can anyone explain what I'm missing?  🧵👇

https://twitter.com/ArndtVogel/status/1748866761251082490?s=20

Firstly @SuyogCancer picks up on a couple of things:

https://twitter.com/SuyogCancer/status/1748770203033575438?s=20

Do we need 2 IO drugs?  Wouldn't it be sensible to test Nivo alone?  Oh hang on... CheckMate 8HW did EXACTLY that - but hasn't reported the Nivo alone arm?

There are treatment related deaths - so overtreating is a concern.  So of course is additional cost.

And infact the control arm is outdated - SoC would be pembrolizumab now.  We could maybe assume nivo was similar to pembro... if we had the curve...

So I've had a bit of an attempt to do what everyone says you should NEVER do - compare 2 trials. I've taken the graph from most recent Keynote data for Pembrolizumab🔵. At first glance -you might think this is performing much worse than NivoIpi -the gap between curves is small

Using some rather clever #rstats tools I crudely extracted some estimated curve data. I'm not an expert at this but the curves look about right so I don't think I've made too much of a mess. Its a manual process so not perfectly reproducible. 🔵+🔴 Keynote 🟠+⚫ Keynote

The issue to me isn't NivoIpi vs Pembro - the difference there certainly isn't massive on my attempts.  We should certainly want to see single agent Nivo.

But the *real question* is why the control arm in CheckMate faired SO poorly?

My method is far from perfect.  But my 🔔😧 is upsetting me.

Can anyone tell me if I missed something really obvious (other than never compare trials!)

Just in case I was being completely stupid, I checked my homework by taking both graphs into a drawing package - stretching the scales to match and overlayed them.

You can read the unrolled version of this thread here: https://typefully.com/ShinyBlackShoe/NRQcET4

Analysis of NivoIpi Results and Concerns

I'm not quite sure how this @DTB_BMJ #podcast crossed my timeline.

I don't think it was @Lauraangus3 's tweet but it may have been.

https://twitter.com/Lauraangus3/status/1718222410401394885

As a hater of all things cast I thought I should share some thoughts...

So let's address my distaste for podcasts. I generally find they last too long. They are self promotion or even worse they bring on another podcaster and they each spend half the time patting each other on the back for how great each others 🎙️ is..

If you don't know @DTB_BMJ it is a evidence review that aims to be impartial. We aren't talking #Prasad evangelical. Just impartial.

I haven't read a copy in years. It's mostly focussed on primary care issues from my past experience.

Anyway a 🎙️ from DtB will be impartial won't it? Read on and get my judgement later. (I was tempted to say listen to my podcast to find out!!)

There were topics of at least passing interest to me. Changes for the BNF. Coroner's reports and genomics. Maybe I miss judged them for being too primary care?

The BNF in fact isn't changing, but the NHS is no longer to buy hard copies...

The DtB feel this is the right move and I haven't found a good arguement against it. So?

Am I liking the podcast because it aligns with my own views? Or because it's balanced?

For those in panic - NHS will continue to subscribe to BNF app and online.

DtB also discussed coroners section 28 reports. A staggering number of which involve medicines. But they aren't reported in easily collated way. Which makes finding themes a challenge.


If their aim is to help change, surely they should update. Why do I fear a 🧑‍⚖️ changing things is even slower than the NHs changing stuff?

From my perspective it would be VERY useful to be able to see all s28 letters for #OncoPharm drugs for instance...

Then they moved on to genomics.

Now genomics is a situation where #OncoPharm is ahead of the curve. We've been testing DPYD for 3 years and pharmacy are the gatekeeper.

DtB go on to talk about clopidogrel. This could be PGx first big outing.  It's primary care so probably not exciting for most of my followers

BUT it should be. Not because it's clopidogrel. But because it's primary care. There is ZERO chance this can be successfully delivered with PDF results shared by email which is the current PGx shambles.

I only hope @NICEComms have a plan to instruct a decent IT solution

So what is my conclusion about 🎙️.

Well, it's probably fair to say this isn't your average sell how great I am, sell my guests being great podcast. In effect, it's the editorial for DtB.

It's only 20 mins. It's not 🇺🇸 used. It seemed balanced.

I'm probably going to listen to another.

I'd say a lot of podcast editors might do well to listen to it's style.

BUT - am I just buying into my prejudices? I'm sure there are people who think GBNews is a breath of fresh air...

Can't imagine October's issue on IV vitamin infusions is going to upset my prejudices or August's on NICE redaction.

Mmmm... 🙈🙉🙊

My Thoughts on Podcasts

This #BOPA2023 poster, aside from its interesting (& concerning) findings, originally began as a data analysis exercise. @chloewaterson88 had the goal of learning some #rstats, & while I have a fondness for 🐧 + 🚗, I was eager to work with actual data. Check out the thread 👇🧵

I thought we might be able to do something building on my guest blog with the @BennettOxford about High Dose Dexamethasone: https://www.bennett.ox.ac.uk/blog/2019/11/high-dose-dexamethasone/ (BTW: it seems blogging about this might result in product discontinuation!)

We quickly spotted there wasn't an easy way to pick all the drugs we might want, and exclude the ones we didn't want from @openprescribing.

Instead we needed to build a list of drug codes.  💡 another @BenGoldacre #opensource project: OpenCodeLists.org

For example, you could pick all cytotoxics, but that isn't just cancer treatment.  We didn't want to see data for methotrexate for instance.

To ensure we didn't miss anything, we required a decent drug classification. Sadly, the BNF Chapter Numbers from 📖 @PharmPress don't work well for #chemotherapy/#SACT.

So, we turned to the Anatomical Therapeutic Classifications from the @WHO. https://www.whocc.no/atc_ddd_index/?code=L&showdescription=yes

We did briefly toy with the idea that we might ask #ChatGPT to write the #rstats code.  It tried... It failed.



Getting the #data into :R: in this way was definitely not beginner level coding.  But the actual analysis was mostly straightforward #tidyverse.

This entire project was testament to the success of Open Data & the Freedom of Information Act.

I'm sure we all in the #NHS have moments where we wonder why #FOIA exists..

..the answer is so the public can look at data and question things - like why £1m of #SACT in Primary Care

Without #FOIA @NHSBSA would likely not release the data that @bengoldacre and @BennettOxford use to create @openprescribing.

Why is there no Secondary Care SACT data equivalent? @theosanderson has crafted a mini app to try: https://x.com/theosanderson/status/1704265751891239024?s=20


I'm keen to play more with the dataset he used and see what more we could create.

Open to collaboration if people want to build a bit of an :R: project...?

& lets not forget @NHSOpenSource #OpenSoftware too.  Analysis was performed in #Rstudio from @posit_pbc (@posit@fostodon.org) using @hadleywickham's (@hadleywickham@fostodon.org) fantastic #tidyverse.

Don't understand what I'm talking about? - come & ask...  or check out @NHSrCommunity on twitter or @NHSrCommunity@fostodon.org

So anyway... what did @chloewaterson88  find on her #BOPA2023 #poster?



- £𝟏𝐦 𝐨𝐟 𝐞𝐱𝐩𝐞𝐧𝐝𝐢𝐭𝐮𝐫𝐞 𝐨𝐧 𝐜𝐚𝐧𝐜𝐞𝐫 𝐭𝐫𝐞𝐚𝐭𝐦𝐞𝐧𝐭𝐬
- 𝐆𝐞𝐨𝐠𝐫𝐚𝐩𝐡𝐢𝐜 𝐯𝐚𝐫𝐢𝐚𝐭𝐢𝐨𝐧
- 𝐋𝐢𝐤𝐞𝐥𝐲 17% 𝐞𝐦𝐞𝐫𝐠𝐞𝐧𝐜𝐲 𝐬𝐮𝐩𝐩𝐥𝐲

Do you know why?  Are you a PCN pharmacist in one of the dark areas on the map?  Did you know this happens in your patch? @pcpa_org

Speaking of the #map - this is another example of the #FOIA in action. The map boundaries come courtesy of @ONS and @OrdnanceSurvey - all released under an #OpenGov License thanks to the #FOIA.

If we return to @chloewaterson88's findings - there are two concerns:


💠Is it EVER clinically appropriate to be making these supplies?  Does a 1 tablet emergency supply  of #palbociclib make sense?


💠The price paid is (a) for a full pack (b) not at NICE discount

#BOPA2023

If emergency supply is appropriate, we need to find better ways to handle them. But maybe we need some national guidance from @BOPACommittee to help? #OncoPharm #PharmRx

@msonetwork do you find this worrying?

Want to do your own number crunching in #rstats? :R:



Our code is all released on @github https://github.com/Chlo115/Primary-care-SACT-use the code list is on OpenCodeList. (Links on the poster.)



@chloewaterson88 will probably tell you its a bit of a steep learning curve 📈though.

You can read the unrolled version of this thread here: https://typefully.com/ShinyBlackShoe/un3I6EL

Background to discovering £1m of possibly inappropriate chemotherapy prescriptions by GPs and other prescribers in Primary Care #BOPA2023

Retrying the post from earlier. (X is broken!)

Can you help @BOPACommittee form an opinion about mixing 💉#Calcium_Folinate #Leucovorin with #Oxaliplatin/#Irinotecan?

📅 ONLINE MEETING: 7pm Tue 26th Sep

Registration link: https://forms.office.com/e/N1fxvCymex

Brief Background:
Oxaliplatin is given with folinic acid(leucovorin). Usually through the same line.

A new (cheaper) brand contains an excipient that is reported incompatible with Oxaliplatin

We hope to hear some data from @Sunnybrook that might make us more relaxed about it.

But need to agree if there is a risk and if it needs mitigating and how.

And of course... there may be insufficient stock of the version without the excipient... hence we cant just ignore it.

So lets see if we can produce some consistent guidance.


Would be great to have input from doctors, nurses (@UKONS), pharmacists (@RPharmS), pharmacy technicians (@APTUK) with an interest.

And not just @BOPACommittee pharmacy folk.  We need technical folk, @msonetwork folk, @NHS_SPS folk. The more diverse the better really.

You can read the unrolled version of this thread here: https://typefully.com/ShinyBlackShoe/qtmpuXg