Wikipedia:Peer review/Pancreatic cancer/archive1

Pancreatic cancer
This peer review discussion has been closed. I've listed this article for peer review because it has been extensively revised as part of WikiProject CRUK and I'd like to take it on to FAC. Thanks, Wiki CRUK John (talk) 15:28, 12 November 2014 (UTC)
 * Version at the start of the PR


 * Closing comments I'm closing this now, as it has run 3 weeks or so, and gone quiet. Very many thanks to all who contributed here, or just by editing the article, as several did. I think all points have been addressed, or by-passed by other changes, except for the image question in the last section. I'll copy that to the article talk page, and if anyone has further comments on other matters below, please continue the discussion there. I will take the article to FAC shortly. Thanks again for a great response! Wiki CRUK John (talk) 10:33, 1 December 2014 (UTC)

Comments from Axl/"109"

 * From the lead section, paragraph 3: "Other recommendations include limiting alcohol intake and eating a healthy diet." It is unclear if these measures should prevent cancer or improve outcome after cancer has occurred. These aspects are not listed with the other risk factors in paragraph 2. Axl ¤ [Talk] 13:13, 13 November 2014 (UTC)
 * Yes, indeed. Btw the current ref here is inadequate (not sure how that happened), but eg this from the ACS gives "healthy diet" advice for prevention, while admitting the evidence is slim. I think I should cut the alcohol, maybe the lot. Doing that now. Wiki CRUK John (talk) 17:04, 13 November 2014 (UTC)
 * Er, you don't seem to have changed the article's text. Axl ¤ [Talk] 21:03, 14 November 2014 (UTC)
 * Sorry, no. Got distracted before I hit save. to do. Wiki CRUK John (talk) 12:01, 17 November 2014 (UTC)
 * Now "Other recommendations include maintaining a healthy weight and avoiding red and processed meat". Ref: cite web|title=Can pancreatic cancer be prevented?|url=http://www.cancer.org/cancer/pancreaticcancer/detailedguide/pancreatic-cancer-prevention|website=American Cancer Society|accessdate=13 November 2014. Wiki CRUK John (talk) 10:33, 18 November 2014 (UTC)
 * That sort of highly restrictive advice (per Results of ) might be sensible for someone with a high genetic predisposition for a particular disease who actively wants to try to avoid it, but it just isn't a realistic or appropriate recommendation for the general population. 109.157.83.50 (talk) 12:58, 18 November 2014 (UTC)
 * Softened to "limiting consumption of red and processed meat", but it is no good reverting to a version that includes alcohol, which isn't even in the recommendations. The entire health advice sector advocates this all the time, for prevention of a whole range of diseases (and pretty much "avoiding" too), so it is at best OR to remove. Wiki CRUK John (talk) 16:36, 18 November 2014 (UTC)
 * No, lacking the time to produce the appropriate reliable medical sourcing ≠ OR! And irresponsible wording by conventional RS is not something we should follow here, imo. 109.157.83.50 (talk) 16:44, 18 November 2014 (UTC)
 * There seems to be a mismatch here. The prevention advice given by the ACS in the reference currently provided in the article (rather than the link above, which appears to be dead) is much more tentative and realistic: The best advice to possibly  [my emphasis] lower the risk of pancreatic cancer is to avoid tobacco use and stay at a healthy weight. Being physically active and following the other ACS recommendations related to a healthy diet [including, inter alia, "Limit how much processed meat and red meat you eat" and "If you drink alcohol, limit your intake." ] may also be helpful. I think the current wording  does now reflect that advice (although, arguably, there is a bit too much weight on the meat aspect for that particular source). 109.157.83.50 (talk) 17:16, 18 November 2014 (UTC)

Comments from NikosGouliaros
Congratulations to everyone who has worked for this article. For my review I will draw comparison from the most relevant featured article in Wikipedia, lung cancer. My main bibliographic reference is: Alberts, SR, and Goldberg, RM. Chapter 9: Gastrointestinal tract cancers. In: Casciato, DA, and Territo, MC (2009). Manual of clinical oncology. pp. 188-236. Lippincott Williams & Wilkins. ISBN-13: 9780781768849. Please note that when I propose changing something in the article, it doesn't mean that the way it is written is wrong; and that this is my first peer review in Wikipedia.

Lead

 * A perfect opening phrase/definition wouldn't use the word "cancer" to describe what pancreatic cancer is. An alternative: "Pancreatic cancer is a malignant tumor that develops in the pancreas" etc.
 * Yes, I think it once did, more or less. But that uses less accessible language, though avoiding the repetition. Wiki CRUK John (talk) 11:46, 17 November 2014 (UTC)
 * Changed the opening sentence accordingly. Sounds better now (atleast to me) Sohebbasharat (talk) 21:31, 17 November 2014 (UTC)
 * At least 2 others have changed this since & there is section on the talk page. Wiki CRUK John (talk) 10:38, 18 November 2014 (UTC)


 * I guess it isn't written on stone, but, the lead being a summary of the article, I would have the content of the lead follow the same order as the sections in the main body of the article. Therefore, information on classification could precede signs and symptoms. Information on the age distribution of the ailment could be mentioned right next to other epidemiology data. As an exception, I would far from disagree with mentioning causes of pancreatic cancer along with information on prevention, as these two are closely connected.
 * Yes on the last point, though others have been moving this bit to and fro. The age distribution is rather essential for diagnosis and the worried well, which is why it belongs with symptoms imo. The article has 12 main text sections which have to go into 4 lead paras, so I think that while the main sequence should be followed, one can't be too rigid, or it reads like notes. Wiki CRUK John (talk) 11:46, 17 November 2014 (UTC)
 * Since we're writing an encyclopedia article and not a public health service leaflet on the disease (I'm sure it's not just the worried well we're writing for), I still believe that signs and symptoms in the first paragraph are not at their best place; to me, classification feels better there (i.e., in the first paragraph). Moreover, I think it is a bit lacking in continuity to follow this order of information:
 * Definition. Signs and symptoms
 * (Change of paragraph) Age distribution. Predisposing factors. Classification. Diagnosis. Staging. Screening.
 * (Change of paragraph) Prevention. Management
 * (Change of paragraph) Epidemiology. Outcomes
 * How about:
 * Definition. Classification.
 * (Change of paragraph) Signs and symptoms. Diagnosis. Staging.
 * (Change of paragraph) Predisposing factors. Prevention. Screening.
 * (Change of paragraph) Management. Outcomes. (Epidemiology either here or end of previous paragraph)
 * However, as I haven't been working on the article until very recently, I feel obviously obliged to let the main editor decide on the lead. It's not bad as it is! --NikosGouliaros (talk) 15:57, 19 November 2014 (UTC)
 * I have a lot of sympathy with this, but the "classification" bit inevitably gets into more fiddly stuff than is really suitable for the 1st para I think. Anyone else? Oh well, I've done it now, giving a rather long and dense 1st para. Really it's crying out for a para 5.Wiki CRUK John (talk) 10:47, 24 November 2014 (UTC)


 * "Adenocarcinomas start within the part of the pancreas that makes digestive enzymes, known as the exocrine pancreas." An alternative link would be Pancreas. It might as well be added later.
 * added alternative link to the exocrine mention in classification section Sohebbasharat (talk) 21:31, 17 November 2014 (UTC)


 * "There are also a number of other types of pancreatic cancer." There is no need to repeat this. It has been mentioned three lines earlier; the reference [4] can be added there.
 * Done; don't think this needs more reffing here. Wiki CRUK John (talk) 10:38, 18 November 2014 (UTC)


 * "Surgery is the only treatment that can cure the disease". There's no doubt about that, but nowhere in the article have I found a citation (which isn't necessary in the lead though).
 * It is cited (after a couple more sentences) to Wolfgang etc at the start of management. Ryan (1044) and Bond-Smith (3) also have nice clear statements. Not sure if more needs adding. Wiki CRUK John (talk) 11:46, 17 November 2014 (UTC)


 * "Early palliative care is recommended even in those who are receiving treatment aimed at curing it". I would use "the disease" instead of "it".
 * Someone has changed to " Early palliative care is recommended even in those who are receiving active treatment.[7][8]" - not sure if this is clear enough. Wiki CRUK John (talk) 11:46, 17 November 2014 (UTC)
 * I don't think it is. Treatment with therapeutic intent is a very specific thing; "active treatment" is not. Your phrase was just fine, but for that "it" I didn't feel great about. --NikosGouliaros (talk) 16:00, 19 November 2014 (UTC)
 * Now changed (not by me) to:"Early palliative care is recommended even in those who are receiving treatment that aims for a cure" - ok I think. Wiki CRUK John (talk) 10:43, 20 November 2014 (UTC)

Classification

 * "the 99% of cases that occur in the exocrine (or "non-endocrine") parts of the pancreas". I know it has been explaine in the lead section, but maybe here too we should also elaborate on what exocrine pancreas means?
 * added link to exocrine. maybe if someone doesnt know they can click on it. Sohebbasharat (talk) 21:32, 17 November 2014 (UTC)


 * I've never heard the phrase "non-endocrine parts of pancreas", and it isn't mentioned in pancreas.
 * I agree. non-endocrine pancreas is no standard term. Removed.Sohebbasharat (talk) 21:32, 17 November 2014 (UTC)


 * Allow me to rephrase the first sentence: "The exocrine group is dominated by pancreatic adenocarcinoma ("invasive" or "ductal" is sometimes added to this term, without changing its meaning), which arises from the epithelial cells of the pancreatic ducts and is by far the most common type; it represents about 85% of all pancreatic cancers, although the cells from which it arises represents less than 10% of the pancreas by volume."
 * "The remaining 1% of pancreatic cancers are in the endocrine parts of the pancreas". There are also nonepithelial tumors (sarcomas and lymphomas), but they are rare.
 * I've tweaked wording to accommodate (I think) this observation. 109.157.83.50 (talk) 13:43, 22 November 2014 (UTC)


 * "although surgery offers the only possibility of curing both groups". This was just mentioned in the lead, I'm not sure it needs to be repeated in this section.
 * In general I'm in favour of repeating important points, backed up by research on how people digest information. Wiki CRUK John (talk) 11:54, 17 November 2014 (UTC)


 * Both groups mainly (but not exclusively) occur in people over 40, and are slightly more common in men, but some rare sub-types mainly occur in women or children.[15] For all types the only curative treatment is surgery, and for most sub-types the outcomes are typically poor." I'm not sure it's necessary, but why not mentioning this information in the epidemiology and outlooks sections, and only there?
 * As last. Wiki CRUK John (talk) 11:54, 17 November 2014 (UTC)


 * "invasive" and "ductal" may be added to this term". One could add "without changing its meaning" - as this isn't clear.
 * And you have. I can't decide if this helps, or risks confusing further. Wiki CRUK John (talk) 11:54, 17 November 2014 (UTC)


 * "and is covered in detail in other sections". Maybe just write "(see later)" or something, linking to pancreatic cancer?
 * I don't like internal links to other parts of the article, & I think WP:MOS agrees with me (somewhere). If I follow one myself I always feel short-changed. Wiki CRUK John (talk) 10:18, 18 November 2014 (UTC)


 * "Like "functioning" endocrine cancers..." The lay reader isn't supposed to know what this means; I can't find a suitable link to a Wikipedia article; I therefore propose the deletion of the phrase.
 * "(see next section)" added. Wiki CRUK John (talk) 11:54, 17 November 2014 (UTC)


 * One could link to signet cell
 * Done Wiki CRUK John (talk) 11:54, 17 November 2014 (UTC)

Signs and symptoms

 * I don't understand what distinguishes symptoms that are mentioned first from "other symptoms" the ones mention under heading "Other symptoms".
 * As I left it (not still true after edits by others), all the first group were reported in over 50% of cases in Table 2 in Syl de la Cruz etc, and are introduced as "common". Maybe I should explain this in a note. WP articles tend to have exhaustive and indiscriminate lists of symptoms, which I was trying to avoid. Wiki CRUK John (talk) 11:09, 18 November 2014 (UTC)
 * I totally agree with you on how ill-advised it is to just drop a list of symptoms, mixing common, rare, major and minor ones. That heading "other symptoms" still bothers me though. Maybe one could swap it with the phrase "Other, less common symptoms include:". --NikosGouliaros (talk) 16:05, 19 November 2014 (UTC)
 * I agree the issue, but I'm not sure how to handle it. For one thing metastasic symptoms must be fairly/very common but I can't source a %. The first group are now again all over 50% per source. Wiki CRUK John (talk) 11:06, 20 November 2014 (UTC)


 * I think it is necessary to explain how steatorrhea is also caused by exocrine pancreatic secretion failure. I would also mention it as a separate symptom from weight loss.
 * This has all been moved around, I'm not sure how beneficially. Wiki CRUK John (talk) 02:46, 19 November 2014 (UTC)
 * Sorted out now, I hope. Wiki CRUK John (talk) 11:06, 20 November 2014 (UTC)
 * The current version of the article has had the word "steatorrhea" completely removed. I'm reverting some of the changes that have lead to this, but I still think that steatorrhea might need to be mentioned as a separate symptom. This is a minor point though; the important is that it is mentioned! --NikosGouliaros (talk) 16:17, 19 November 2014 (UTC) (It was actually mentioned, just not by name. --NikosGouliaros (talk) 22:00, 19 November 2014 (UTC))
 * Linked from fatty stools. I think this is ok. It's not a word non-medics know at all. Wiki CRUK John (talk) 11:06, 20 November 2014 (UTC)


 * "Typically, pancreatic cancer first metastasizes to regional lymph nodes, and later to the liver or to the peritoneal cavity, large intestine or lungs; it rarely metastasizes to bone or brain." I propose removing this information from this section and mentioning it in a new subsection, Metastasis, in the diagnosis section, per Lung cancer.
 * Hmm, it would be pretty short. This article already has 2 sections more than Lung cancer. what do others think? Btw, someone has added a ref for "it rarely metastasizes to bone or brain", with a link to a PDF of the 1983 edn of the AJCC Staging Manual. No doubt still as true, but does anyone have a more recent one? .Wiki CRUK John (talk) 12:09, 17 November 2014 (UTC)
 * It's just an idea. Though as I write later it will also briefly mention pancreas as a site of metastases from other tumors. NikosGouliaros (talk) 14:01, 17 November 2014 (UTC)
 * Ok, I have now done this, adding 2ndy cancers to the pancreas, but for now kept it all in this section, under a sub-heading. Wiki CRUK John (talk) 10:06, 24 November 2014 (UTC)


 * Acute pancreatitis is an occasional first manifestation of pancreatic cancer
 * No doubt, but it isn't in any of the several main journal sources I'm using I think, so probably one for a detailed textbook. But I might alter the existing bit on signs in the diagnosis section. Wiki CRUK John (talk) 09:25, 24 November 2014 (UTC)
 * Actually we already have "A clinical history of chronic pancreatitis appears to be associated with an almost 3-fold increase in risk, and as with diabetes, new-onset pancreatitis may be a symptom of a tumor" ref Wolfgang, in .risk factors. Wiki CRUK John (talk) 14:17, 24 November 2014 (UTC)

Risk factors

 * One could also add toxic substances that increase risk for pancreatic cancer: 2-naphthylamine, benzidine, gasoline derivatives, DDT, and two DDT derivatives (ethylan and DDD).
 * I thought about this, but it is remarkable how few MEDRS reviews etc mention them. Not sure what to do. On the whole this formerly had too many factors (including coffee I think), as WP articles tend to do, & the significance of the main ones was lost. Wiki CRUK John (talk) 10:23, 18 November 2014 (UTC)

Diagnosis

 * This section sometimes gives one the impression that no "Signs and symptoms" section has preceded. Some of its contents could be moved to the "Signs and symptoms" section or be omitted (as they have already been mentioned).
 * I thought about this a lot, but decided to keep the degree of repetition. S&S concentrates on the experience of the patient, Diagnosis on the physician's interpretation, particularly with regard to the part of the pancreas where the tumor is located. "Symptoms" are generally the most common search term in relation to any disease, and I think is important that that section is kept simple and highly accessible. Wiki CRUK John (talk) 10:56, 18 November 2014 (UTC)


 * The 1st paragraph might be better suited in the "Signs and symptoms" section.
 * as above Wiki CRUK John (talk)


 * The 2nd paragraph, on pain, in my opinion belongs to the "Signs and symptoms" section too.
 * as above Wiki CRUK John (talk) 16:29, 18 November 2014 (UTC)


 * The sentence begining with "Medical imaging techniques..." is where the "Diagnosis" part really starts, in my opinion.
 * But how does the patient get to the medical imaging? That is a hospital perspective, isn't it? Wiki CRUK John (talk) 10:56, 18 November 2014 (UTC)
 * I'll be honest: I sometimes caught my self reviewing the article as if reviewing a medical textbook. However, mentioning the symptoms once more still feels a bit redundant; it's presumable and common that the patient is lead to imaging because of their symptoms! --NikosGouliaros (talk) 16:33, 19 November 2014 (UTC)


 * One could consider beginning the section with a sentence like the one it already begins with, explaining that pancreatic cancer is often diagnosed late in its course - this would need a citation though, that I cannot come up with right now. E.g.: "The various symptoms of pancreatic adenocarcinoma are neither individually distinctive to it, nor common in the early stages of disease.  Therefore it is often diagnosed late in its course.  " Then one could add subsections on imaging, blood tests, biopsy, and pathology (perhaps the last two could be included in one subsection).
 * Not sure what you saying here. The next ref (Ryan) covers all the para so far, though most of the main general ones could also be used. There are a number of diagnostic options at this point, and I think practice is both in a state of flux, and pretty variable with geography, so I think the relative lack of specificity and detail is correct. The recent MEDRS show a fair degree of variation in emphasis on this subject. Wiki CRUK John (talk) 10:56, 18 November 2014 (UTC)
 * I'm sorry about not being clear; and you can forget about the citations I called for. My idea about the section would be:
 * Start with the sentence it begins with: "Pancreatic adenocarcinoma has a number of symptoms, but none that are individually distinctive to it, or appear in the early stages of disease. "
 * A subsection on a diagnostic technique, e.g. imaging
 * A subsection on blood tests
 * A subsection on biopsy and pathology
 * And the rest go to "Signs and symptoms". Well, I'm just saying... --NikosGouliaros (talk) 16:33, 19 November 2014 (UTC)


 * I think that endoscopic retrograde cholangiopancreatography and magnetic resonance cholangiopancreatography must be mentioned too, as they might be necessary for differential diagnosis from cholangiocarcinoma - though this goes rather far from my field of expertise and I can't make a more definite contribution.
 * The second added, which sources (Bond-Smith, 3) say has normally replaced the first in diagnosis. Wiki CRUK John (talk) 14:17, 18 November 2014 (UTC)
 * No doubt about that, but endoscopic retrograde cholangiopancreatography has the benefit of simultaneously allowing palliative interventions. (No citation handy). --NikosGouliaros (talk) 16:37, 19 November 2014 (UTC)


 * a) As I said before, I consider reasonable to add another subsection on Metastasis, with information on patterns of metastatic spread of primary pancreatic cancer. b) It can also be mentioned that pancreas is a rare site of secondary malignant tumors.
 * a) discussed above, b) A more recent source would be ideal. I don't think any of the main sources mention this. Wiki CRUK John (talk) 10:56, 18 November 2014 (UTC)
 * In my humble opinion, just a phrase on metastatic tumors in pancreas is necessary. Here's a more recent reference (a riview article).
 * See above, done, using this handy recent ref. Thanks! Wiki CRUK John (talk) 10:07, 24 November 2014 (UTC)

Staging

 * "(AJCC-UICC)" might be more appealing to my eye than "so AJCC-UICC"
 * Someone else changed to "The cancer staging system used internationally for pancreatic cancer is that of the American Joint Committee on Cancer and Union for International Cancer Control (AJCC and UICC)." but the point is it is normally referred to with the dash, which perhaps needs spelling out. Wiki CRUK John (talk) 16:27, 18 November 2014 (UTC)

Mechanism

 * It might be more appropriate to either include the full name of all mentioned genes, or only the initials of all genes.
 * I've generally followed the sources, or used the WP titles. Not an area I'm at home in, but a jumble of naming styles seems usual. Wiki CRUK John (talk) 14:24, 18 November 2014 (UTC)


 * "Endocrine pancreatic tumors have been variously called islet cell tumors, pancreas endocrine tumors (PET), and pancreatic neuroendocrine tumors (PNET or PanNET)." This section might be more relevant in the Classification section. The rest of the paragraph would probably be more relevant in the Epidemiology section.
 * Moved it all up to Classification. Wiki CRUK John (talk) 14:32, 18 November 2014 (UTC)

Prevention
Balanced and direct.

Management

 * It is customary that palliative care is discussed after management options with curative intent. (I change the order in the article myself.)
 * "An abutment of the tumor": Something feels wrong with the syntax. I propose: "An abutment of the tumor and a major blood vessel, defined..." etc.
 * Changed to "An 'abutment' of the tumor is defined as the tumor touching up to 180° of a blood vessel's circumference, and may be operable..." - ok I think Wiki CRUK John (talk) 15:00, 18 November 2014 (UTC)


 * "After surgery, adjuvant chemotherapy with gemcitabine or 5-FU should be offered if the person is fit after surgery," One could rephrase: "After surgery, adjuvant chemotherapy with gemcitabine or 5-FU should be offered, provided the person is in a reasonably fit condition". One can also link to adjuvant therapy.
 * Done similar Wiki CRUK John (talk) 15:07, 18 November 2014 (UTC)


 * I wonder if the paragraph on celiac plexus block could only be mentioned in the Palliative Therapy section.
 * Done, leaving a general mention of palliative surgery. Wiki CRUK John (talk) 16:21, 18 November 2014 (UTC)


 * "This marked the first FDA approval of a chemotherapy drug primarily for a nonsurvival clinical trial endpoint." A citation is needed.
 * I know, but I've never managed to find one for this leftover from an old version. It's an interesting point, but unless anyone has one it'll have to go. Wiki CRUK John (talk) 16:21, 18 November 2014 (UTC)


 * In palliative care, a mention of biliary stents for management of biliary obstruction might be warrantied. One can link to Bile_duct.
 * Done. Wiki CRUK John (talk) 16:21, 18 November 2014 (UTC)


 * "Pancreatic adenocarcinoma and the other less common exocrine cancers have a very poor prognosis, as they are resistant to treatment and usually cause no early symptoms. Therefore they are normally diagnosed at a late stage, when the cancer is already locally advanced or has spread to other parts of the body." One could rephrase: "Pancreatic adenocarcinoma and the other less common exocrine cancers of the pancreas have a very poor prognosis, as they are usually diagnosed at a late stage, when the cancer is already locally advanced or has spread to other parts of the body, and they are resistant to treatment."
 * That reads as though they are only resistant once they are "locally advanced or has spread", which isn't really right. Wiki CRUK John (talk) 12:16, 17 November 2014 (UTC)


 * Mentioning a 5-year survival of 16% for unresectable neuroendocrine tumors in the text gives the impression that endocrine pancreatic tumors have a grim prognosis too.
 * It still says " Outcomes with pancreatic endocrine tumors, many of which are benign and completely without clinical symptoms, are much better, and even those cases not able to be treated by surgery have a 5-year survival rate of 16%,[41] although the outlook greatly varies according to the type." which seems the right balance to me. Wiki CRUK John (talk) 16:23, 18 November 2014 (UTC)

Distribution

 * As I have explained in the relative discussion in WP: MEDMOS I disagree with "Distribution" substituting "Epidemiology" as a section heading.

History

 * Excellent. I just minimally rephrased a couple of sentences myself.

Research

 * Similarly, no comments to make.

Comments from Biosthmors
I am primarily looking at the lead, but I see "One to two in every hundred cases are neuroendocrine tumors" but then "The remaining 1% of pancreatic cancers are in the endocrine parts of the pancreas" in the Classification section. Can we be consistent about whether this is 1% or 1 to 2%? And am I correct in assuming the words endocrine and neuroendocrine are synonymous when used in this way? I don't currently think we should we devote a full sentence to the endocrine prognosis in the lead. It's rare and we say "References to pancreatic cancer often refer only to [pancreatic adenocarcinoma]". It also makes me wonder how often one receives a diagnosis of "a localized and small cancerous growth (< 2 cm)". I wonder if we might be cherrypicking things to make pancreatic cancer sound better than it typically is experienced. Biosthmors (talk) pls notify me (i.e. &#123;&#123;U&#125;&#125;) while signing a reply, thx 01:57, 19 November 2014 (UTC)
 * There is a recent section Talk:Pancreatic_cancer that addresses that issue. I think we have to cover all types. That last bit has been added in one of the 200-odd edits since I started the PR; I can't see where. Not sure it's a good idea, at least there. But there must be '000s of such cases annually, I'd have thought. Wiki CRUK John (talk) 02:15, 19 November 2014 (UTC)
 * Thanks for the reply. If you don't mind, I'd like to re-make a point by rephrasing it into another question. Doesn't the article currently contradict itself by saying "One to two in every hundred cases are neuroendocrine tumors" and "The remaining 1% of pancreatic cancers are in the endocrine parts of the pancreas"? Thanks. Biosthmors (talk) pls notify me (i.e. &#123;&#123;U&#125;&#125;) while signing a reply, thx 17:28, 19 November 2014 (UTC)
 * In fact not really, but I'll check the sources & fudge somehow. Such figures (where, when) are not exact and rounding is inevitable, but we'd better not let the children guess that I suppose. Wiki CRUK John (talk) 11:09, 20 November 2014 (UTC)
 * I think what really means to say here, beyond the chatty style, is to find an editorially and scientifically appropriate solution to the wording *without* fudging. 109.157.83.50 (talk) 11:55, 20 November 2014 (UTC)
 * If you say so. Wiki CRUK John (talk) 10:15, 24 November 2014 (UTC)
 * added "or so". Wiki CRUK John (talk) 10:15, 24 November 2014 (UTC)
 * I have split up the bit added to the lead, moving the detail to "Outcomes". The source quote is a nice example of the imprecision inevitable in such things: "The highest cure rate occurs if the tumor is truly localized to the pancreas; however, this stage of disease accounts for less than 20% of cases. For patients with localized disease and small cancers (<2 cm) with no lymph node metastases and no extension beyond the capsule of the pancreas, complete surgical resection is associated with an actuarial 5-year survival rate of 18% to 24%", from the NCI . This also gives the % you asked about above, so there should be well over 50,000 such cases pa globally (and one hopes this figure will continue to rise). Wiki CRUK John (talk) 10:36, 24 November 2014 (UTC)

Comments from an ip

 * Re pancreatic neuroendocrine tumors: I'm uncomfortable with using the MeSH vocabulary tree (primarily used for indexing/calaloguing/search purposes) as a principal source for clinical/biological classification. Some sources that imo are more appropriate are already being cited, and I think we should be referring to them. 109.157.83.50 (talk) 18:07, 21 November 2014 (UTC)
 * I've acted on this observation myself. The "MeSH paragraph" now has a primarily historical focus. The MeSH terminology pertinent to PanNETs listed/linked in a footnote with WP links. (Of course this raises the question of how to keep Wikipedia articles abreast of relevant changes in clinical classification and terminology - MeSH/ICD are not a fully aprropriate guide to this, imo.) 109.157.83.50 (talk) 10:40, 23 November 2014 (UTC)
 * Epidemiological information for PanNETs is currently in the final paragraph of the Classification section rather than under Distribution. Presumably this is an oversight? (Though classification considerations are highly relevant to the numbers.) 109.157.83.50 (talk) 18:07, 21 November 2014 (UTC)
 * I've now moved this content to the Distribution section. 109.157.83.50 (talk) 10:40, 23 November 2014 (UTC)
 * No, it wasn't an "oversight"! I think it, or most of it should probably be moved back. The definitional & detection issues seem to belong together. Wiki CRUK John (talk) 09:18, 24 November 2014 (UTC)
 * I'm afraid I don't follow you there, John. The content I moved has nothing to with "Classification" as such, and everything to do with "Epidemiology"/"Distribution". While I fully concur with you that appropriate contextualization is important for readers (see my rationale below for maybe adopting "Types" as a heading), I really can't see how arbitrarily including a whole paragraph of frequency considerations (i.e. "Epidemiology"/"Distribution") is helpful. It also seems strange to artificially confer undue weight to the neuroendocrine subgroup that – as noted in the opening sentence of the subsection – comprises only a very small minority of all pancreatic cancers (the "Endocrine" subsection has gone from being about half as long again  as that of the statistically predominant "Exocrine" types to being – appropriately, imo – at least slightly shorter ). 109.157.83.50 (talk) 10:09, 24 November 2014 (UTC)
 * Adding: Hum, maybe you're alluding to the clinical issues regarding those small tumors found at screening, or as incidental findings, that are of doubtful clinical relevance? Maybe a few well-chosen words here could be relevant (along with appropriate mentions in other sections, including "Diagnosis", "Epidemiology" and, perhaps, "Prevention" and "Treatment" etc). 109.157.83.50 (talk) 11:21, 24 November 2014 (UTC)


 * Not currently contemplated by medmos, but would a simpler heading like ==Types== be more helpful for our general readership than ==Classification==? Imo, this would be in keeping with some of the more general introductory considerations that it seems sensible to refer to in this section (as pointed out by above ). 109.157.83.50 (talk) 16:01, 23 November 2014 (UTC)
 * Probably, & you've raised that at WP:MEDMOS, but not a point for here. Wiki CRUK John (talk) 10:50, 24 November 2014 (UTC)
 * erm, why not? If it proves uncontroversial at WT:MEDMOS, and we feel it's more reader-friendly here... 109.157.83.50 (talk) 18:36, 24 November 2014 (UTC)
 * If... 12:52, 26 November 2014 (UTC)


 * Different parts of the page abbreviate "pancreatic neuroendocrine tumors" differently. Which do we want to use: PanNETs or PNETS? Whichever... 109.157.83.50 (talk) 11:09, 24 November 2014 (UTC)
 * From memory, PanNETs seems more common I think. Wiki CRUK John (talk) 11:12, 24 November 2014 (UTC)
 * Fine by me. 109.157.83.50 (talk) 11:38, 24 November 2014 (UTC)
 * Done Wiki CRUK John (talk) 12:52, 26 November 2014 (UTC)
 * It was confirmed to me that PanNET is better - not least because PNET also = something else, I think (as per a disam page) Primitive neuroectodermal tumor. Wiki CRUK John (talk) 13:20, 27 November 2014 (UTC)

Image error
I just noticed that the first image in the signs & symptoms section (File:1820 The Pancreas.jpg) erroneously shows pancreatic hormones flowing from the pancreas into the splenic artery (even in the wrong direction, against the bloodflow). The correct image should show hormones flowing into the splenic vein and the pancreaticoduodenal veins, which then drain into the portal vein. --WS (talk) 20:06, 23 November 2014 (UTC)
 * Damm! There doesn't seem to be another image as good. Can anyone else confirm this, though I'm sure WS is correct? Wiki CRUK John (talk) 09:05, 24 November 2014 (UTC)
 * Wouterstomp is right. The blood vessel below the splenic artery appears to be the splenic vein&mdash;at least it is in the right position, just behind the upper part of the pancreas. By anatomical convention, the splenic vein, like other systemic veins, is often coloured blue on diagrams. Axl ¤ [Talk] 12:26, 27 November 2014 (UTC)
 * Thanks. Oh well, it will have to go. Maybe the producers can correct it. Unfortunately the Commons images are not well categorized at all, but I can't see a decent substitute. Wiki CRUK John (talk) 13:22, 27 November 2014 (UTC).
 * How about this one? A wider scope, and less detail, but the best I can see for now. There is also room for this (COI declared), with more detail on the ducts. Wiki CRUK John (talk) 18:53, 30 November 2014 (UTC)