Talk:Lung cancer

Update notes

Mostly notes to self, though certainly anyone is welcome to act on them.

• Diagnosis:
  • Need to decide on images/tables that will stay.
  • Expand on initial biopsy, histology characteristics of various NSCLCs, update differential, immunostaining, name the VA SCLC system with ref, update the surgical staging paragraph.
• Treatment:
  • More on when treatment is stopped, look at paragraph on "several treatments can be provided...", update palliative care, noninvasive/lifestyle interventions.
  • Deal with images.
• Prognosis:
  • Agh, hoping to find a source that clearly says "prognosis depends on how advanced the disease is", and something that gives a clear sense of how prognosis varies over geography (now we just have a few random snippets from various countries).
  • Expand/update
• Causes, Pathogenesis, Prevention, Epi, History:
  • Update/organize throughout.
• Research:
  • [1] has some info on cell lines used in lung cancer research. Will return to it to clean up the Research section Ajpolino (talk) 17:55, 12 December 2022 (UTC)
  • [2] has detail on experimental diagnostic procedures

As mentioned at the FAR page I may be out for the next two weeks. Looking forward to getting back to updating around the New Year. Ajpolino (talk) 18:12, 12 December 2022 (UTC)

@Axl:, hello! I'm not sure what your level of available time is like, but for issues you don't have time to directly deal with, feel free to dump comments small or large here and I'll do my best to get to them. Happy editing! Ajpolino (talk) 21:41, 29 December 2022 (UTC)

Hi, Ajpolino. My availability for editing is rather irregular. I am currently on vacation so I have a little more time at the moment. Thank you for editing and improving the article. Axl ¤ [Talk] 22:00, 29 December 2022 (UTC)

Just a note to self (or anyone else) that I should include the fact that lung cancer is defined as only tumors from the respiratory epithelium (not all tumors found in the lung, as is probably generally believed). I don't want to have a two sentence section called "Definition", so maybe we can squeeze it somewhere in the Diagnosis section? Ref to use is {{sfn|Horn|Iams|2022|loc="Pathology"}} which says The World Health Organization (WHO) defines lung cancer as tumors arising from the respiratory epithelium (bronchi, bronchioles, and alveoli). Ajpolino (talk) 03:54, 18 January 2023 (UTC)

Citation cleanup

@Axl and Ajpolino: so happy to see restoration here ! When you two say you are ready, we can call in Colin, Graham Beards and Spicy for a read-through. I am happy to do grunt work, but real life has interfered badly of late. But one note: Axl, Ajpolino has upgraded the citation style to sfns, as you can see in this version, so we now have a mixed citation style, with the older citations still using cite templates. We, unfortunately (in the olden days) did not provide page numbers or specifics when citing medical literature, making verification difficult. AJpolino's edits are using a style that is less specific than page numbers, by providing the section only in the paper, which is sufficient for verification while much easier to use than adding every page number. As you add new citations, might you use that same style? We can switch the old ones over later; I am willing to help on that, but can only do so to the extent I understand the text and the paper is freely accessible. Bst, SandyGeorgia (Talk) 17:13, 4 January 2023 (UTC)

Hi all! Yes, sorry for the reference style change. Citing page numbers or sections seems to be the industry standard at FAC these days, so I figured I may as well make the change as long as I was already updating the text. Many of the references I used are online only, so I've mostly used section headings rather than page numbers. Axl, if you find the sfn formatting a hassle, don't worry about it, I can update the reference syntax relatively easily when we're done.

As a brief update, I've mostly finished the heavy lifting on the more clinical material. I still have some heavier editing/updating to do at "Pathogenesis" and below. Then everything will need a coat of polish. Also the images/tables need a refresh. But we're making good progress! Holiday travel season is over, so hopefully I can chip away at it more this week. Thanks all! Ajpolino (talk) 17:22, 4 January 2023 (UTC)

I am not sure how the sfn style is better than the "cite journal" style. If you guys are sure that sfn is better, then I shall accept that. Axl ¤ [Talk] 00:16, 5 January 2023 (UTC)

It's not better per se; it's just an easier way to overcome the need for page numbers. SandyGeorgia (Talk) 00:31, 5 January 2023 (UTC)

If anyone can supply the page numbers for Horn (2018), I can do the work of converting to sfns; you can just temporarily add the page nos to each of the seven citations using the {{rp}} template, and I will do the convert. SandyGeorgia (Talk) 13:43, 5 January 2023 (UTC)

Would you all be interested in separating journals, books as we did at J._K._Rowling#Works_cited ? I found that helpful as I work to clean up citations ... If so, I will do the work ... separating them makes it much easier to standardize format and check for consistency. SandyGeorgia (Talk) 13:46, 5 January 2023 (UTC)

Actually, there are boatloads of book sources missing page numbers; I can do all the cleanup if someone sticks in page nos with an rp template. Ditto on journals, where I can convert to sfns is section names are given. SandyGeorgia (Talk) 14:23, 5 January 2023 (UTC)

Just popping in for a second to say the Horn (2018) citations to the 20th edition of Harrison's will probably be replaced by citations to the already updated 21st edition (Horn & Iams 2022), I just haven't got to some of them yet. No opinion on the other bits yet. Ajpolino (talk) 15:18, 5 January 2023 (UTC)

Got, it, thx ... will hold off on any further work for now (as I was hit with a broken pipe in the basement anyway ... grrrrr .... ) SandyGeorgia (Talk) 19:34, 5 January 2023 (UTC)

I have 21st edition of Harrison's Principles. I shall try to update this over this weekend. Axl ¤ [Talk] 17:42, 6 January 2023 (UTC)

I have updated the Stage Group table in line with Harrison's Principles 21st. However the table in Harrison's wrong.... (IIIC is missing, and T3-4 N2 is not accounted for.) I shall update it with a correct reference. Axl ¤ [Talk] 14:44, 7 January 2023 (UTC)

I tried to update reference 1, which is currently 20th edition, but this broke many other references. :-( Axl ¤ [Talk] 15:20, 7 January 2023 (UTC)

Ha! Nothing can be easy. It broke because of the {{sfn}} references. I hope you'll forgive a brief explanation. Apologies if it repeats things you already know:

The expectation at FAC has evolved over time, and folks now expect our featured articles to have references that designate the place within a source that a fact came from. You could do this with the "classic" {{cite journal/book}} setup by repeating the whole reference each time, but changing the |pages= parameter as necessary. But that's a bit of a hassle, and leads to a bunch of extra repetitive citation text in the wikitext and the references section. Enter the now-popular {{sfn}} system, which is a second layer on top of the "classic" {{cite journal}} system. We still have the {{cite journal/book}} references to each source. But to reference different page numbers/locations within a given source, we can generate a short footnote with {{sfn|Source Author(s)|Year|location name}}. So I've been stashing the full references to each source in the Lung_cancer#Cited section at the bottom, then using {{sfn}} to generate footnotes that point to a given source and the section within the source where the information is found (added convenience when you hover your mouse over or click on an sfn footnote in the article, it should display the full source citation).

So at the bottom of the page I have a {{cite book}} reference to the Harrison's 21st chapter on lung cancer. Throughout the text I have {{sfn|Horn|Iams|2022|loc=[some section name]}} which generates a short footnote referring to the Harrison's chapter and displaying the section name the info came from. When you updated the reference to the Harrison's 20th chapter to the 21st, the {{sfn}} templates all got confused because there were now two references with authors Horn/Iams from 2022 – the one in the "Cited" section at the page bottom, and the one you'd just made. So all the {{sfn}} references to the Harrison's 21st chapter threw an error message at you.

All that to say you'll have to switch to the sfn system if you'd like to add more references to Harrison's 21st. Alternatively if you find the syntax annoying, I'm happy to do that for you. I'm assuming based on your past editing interests that you have some background in pulmonology or oncology. If that's true, one way you could be particularly valuable is if you could read through the text and let us know where you think the article currently falls short or misrepresents topics. I'm not a lungs/cancer guy, so I'm always afraid I may have misinterpreted something as I wrote. Ajpolino (talk) 17:13, 7 January 2023 (UTC)

And I am happy to do this kind of grunt work (converting them over) once you two nail down the content and sources, so Axl, don't worry too much for now. I have finally gotten carpet reinstalled and water event dealt with in my basement, so will spend the next few days getting caught up but will be available to help here next week. SandyGeorgia (Talk) 18:44, 7 January 2023 (UTC)

Thank you both for the explanation and the support. Axl ¤ [Talk] 23:17, 7 January 2023 (UTC)

The new references to Harrison's Principles don't actually have pag numbers. They just have generic descriptions like "Immunohistochemistry" and "Risk Factors". Axl ¤ [Talk] 23:30, 7 January 2023 (UTC)

I only have online access to the new edition of Harrison's. It's not separated into numbered pages (each chapter is just displayed as a long webpage) so I reference the section titles instead. For sfn you can use |p= to cite a single page, |pp= to cite a page range, and |loc= to add a text field for section name, figure name, et al. Ajpolino (talk) 15:15, 8 January 2023 (UTC)

SG FAR comments

Skipping the lead (left 'til last), and looking only at the early sections that Ajpolino has already worked on. Please feel free to revert any damage I do. SandyGeorgia (Talk) 00:16, 19 January 2023 (UTC)

• I am not fond of the layout of images and tables. We should ask Graham87 how Lung_cancer#Staging works on his screenreader. SandyGeorgia (Talk) 00:16, 19 January 2023 (UTC)
  • @SandyGeorgia: It's not a problem for me personally, but you can ask more specific questions at Wikipedia talk:Manual of Style/Accessibility and get feedback from a wider variety of users. Graham87 03:33, 19 January 2023 (UTC)

    Thanks Graham ... I did some adjusting after pinging you, so it's better now. SandyGeorgia (Talk) 03:34, 19 January 2023 (UTC)

• Tumors obstructing bloodflow to the heart can cause superior vena cava syndrome ... don't make the reader click on a link to understand the sentence ... a very brief explanation of what this syndrome is should be given for the layreader.
• Is there a way to vary the wording hear to avoid repetition? while tumors infiltrating the area around the heart can cause fluid buildup around the heart

  Thinking about this. Haven't come up with a clever idea yet. If you have a suggested rephrasing I'm all ears. Ajpolino (talk) 03:27, 20 January 2023 (UTC)

• Yikes, I need help here: Those with lung cancer also commonly experience hypokalemia due to inappropriate secretion of adrenocorticotropic hormone, as well as hyponatremia due to overproduction of antidiuretic hormone or atrial natriuretic peptide. A few more parentheticals so I don't have to click out ? (I didn't need help with hypercalcemia because dear hubby had a parathryroid tumor so I know that word, but it is also easy enough to understand, while this one loses me.)

  Do you think "hypokalemia (low potassium)... hyponatermia (low sodium)..." would suffice? The hormone names are probably a lot for the layreader to take in. Do you think it'd be clearer to remove them altogether? I could also hide the blood mineral terms behind wikilinks ([[hypokalemia|low potassium]]) if you don't think that's too Easter eggy... Ajpolino (talk) 03:27, 20 January 2023 (UTC)

  Yes ... if I have the general gist of what those things are, then the eye/brain skips the following parts it doesn't know, because the context is given. SandyGeorgia (Talk) 09:16, 20 January 2023 (UTC)

• Around a third of people with lung cancer develop nail clubbing, while up to one in ten experience hypertrophic primary osteoarthropathy. WAID is always telling us to use parallel structure for numbers ... that is, either one in three and up to one in ten, or a third and a tenth. (Later we have "Up to 1 in 12 people with lung cancer", so perhaps the third should be switched to one in three ... in fact gonna do that now.) Also, parenthetical on the big long disease :) As we get further into the article, in the more technical parts, it's OK to have terms that not all layreaders will know, buy anyone should be able to get through Symptoms.
• Not sure ... is issues redundant here cancer have paraneoplastic clotting issues? As an example of where I don't need parentheticals, the rest of that sentence (Up to one in twelve people with lung cancer have paraneoplastic clotting issues, including migratory venous thrombophlebitis, clots in the heart, and disseminated intravascular coagulation.) is understandable because the intro tells me those things are clotting issues.

Will continue after dinner, SandyGeorgia (Talk) 00:31, 19 January 2023 (UTC)

• Citation consistency:
  • Assumming Holland-Frei84 will be replaced, so not converting yet to sfn
  • Are you leaving book sources used only once inline (sample, Chakraborty, MurrayNadel52, Van Schil PE, and Lim W), or should they be converted to sfn? Also, Ost D (2015). "Chapter 110: Approach to the patient with pulmonary nodules". In Grippi MA, Elias JA, Fishman JA, Kotloff RM, Pack AI, Senior RM (eds.). Fishman's Pulmonary Diseases and Disorders (5th ed.). McGraw-Hill. p. 1685. ISBN 978-0-07-179672-9.
  • We need ISBNs on all the books; unless there are easily at hand, and unless there is more than one edition, I could look them up and add them.
    • I added ISBNs and editors but pls check my work. SandyGeorgia (Talk) 03:35, 19 January 2023 (UTC)

I'll be happy to convert these if needed, not sure if the style here is to leave those used only once as inline. SandyGeorgia (Talk) 01:04, 19 January 2023 (UTC)

Part 1 - I think I've implemented your suggestions, except for the ones I've asked for a bit of help with above. The books that aren't sfns are from before I got involved. If I keep them I'll convert to sfn. Thanks a million for your suggestions and help so far! Continuing below! Ajpolino (talk) 03:27, 20 January 2023 (UTC)

Diagnosis

• Since PET scanning cannot be used in the brain, ... huh ? What did my husband just have then ?
• to scan the brain for metastases in those with NSCLC and large tumors, NSCLC is undefined at this point in the article. This is a flow issue-- they are defined in next section (Classification -- perhaps this is why Classification is often the first section?). Oops, wrong, they are defined in the lead. SandyGeorgia (Talk) 02:22, 19 January 2023 (UTC)
• Repetitive, find a way to vary wording? When spread to lymph nodes or to a single site is suspected, the suspected metastasis is often biopsied to confirm that it is cancerous. SandyGeorgia (Talk) 01:12, 19 January 2023 (UTC)

Classification

• Do we not have wikilinks for these terms? Should they be WP:RED? Adenocarcinomas are classified as lepidic (growing along the surface of intact alveolar walls),[32] acinar and papillary, or micropapillary and solid pattern.

  Hmm I'm not sure we'd be well-served by standalone articles for each. They're mostly just terms of art that need definition. I should at least add more parentheticals to help the reader. But maybe there's a histology-related article where definitions could be discussed? Presumably this problem will come up in articles on other cancers too... Ajpolino (talk) 04:00, 20 January 2023 (UTC)

Staging

• Is potential redundant here? It is one of the factors affecting both the prognosis and the potential treatment of lung cancer.
• Now that I've read the text and the chart, I'm wondering if the "Diagrams of main features of staging" are really necessary-- they are certainly cluttering the page. Although we may be able to find a better layout, depending on what Graham87 says about the effect on screen reader. SandyGeorgia (Talk) 01:26, 19 January 2023 (UTC)
• I moved one table up which reduces the clutter, but I'm still not convinced we need the diagram gallery. Can the gallery be moved to lung cancer staging? SandyGeorgia (Talk) 01:30, 19 January 2023 (UTC)

  I've mostly left the tables and images untouched since I arrived here. I don't have much gift for visualizing what looks good and what doesn't (you should see my wardrobe). Feel free to cut whichever tables and images you don't think add much value to your reading experience. Feel free to cut as many as you'd like. We can always add different (better, more informative) images if we free up some space. Ajpolino (talk) 04:00, 20 January 2023 (UTC)

  I'd like to hear from Axl first, but I think we'd be much better off moving the Staging images in the gallery to lung cancer staging, which by the way should also have the tables. As a layreader, the text explanation and tables give me all I need ... the additional images are repetitive and distracting. SandyGeorgia (Talk) 09:20, 20 January 2023 (UTC)

I am fine with moving the staging pictures to "Lung cancer staging". Axl ¤ [Talk] 18:25, 25 January 2023 (UTC)

Screening

• Kinda vague: Some forms of population screening can allow for earlier detection
• Total seems redundant here: in those who have a total smoking history of at least 30 pack-years ... what else could 30 pack-years be but total?

Treatment

• Citing the first para should be doable; I realize it's a summary, but if you don't cite it, someone will come along and stick a tag on it anyway, so might as well.
• Should this have a time frame, or does that come later (in Prognosis)? First-line therapy causes remission in up to 80% of those who receive it; however most people relapse with chemotherapy-resistant disease. however within x years most people relapse ??

  Haven't found a timeline for that yet, but am keeping my eyes peeled. A variety of other time frames are in the Prognosis section, but not this one. The Harrison's book only has the gently vague The prognosis is especially poor for patients who relapse within the first 3 months of therapy... but gives no sense of how common that is or what a "normal" time frame might be. Ajpolino (talk) 20:07, 25 January 2023 (UTC)

• Since Stereotactic body radiation therapy is red, we need a brief parenthetical definition (or create a stub)?

  Was just about to write up a stub when I found the longtime stub Stereotactic radiation therapy which is a suitable redirect target. Ajpolino (talk) 20:07, 25 January 2023 (UTC)

• though the combination therapy comes with harsher side effects ... such as needed?
• Awkward, vary wording? People whose NSCLC is not targetable by current molecular targeted therapies
• I don't know what bronchoplasty is. Have we no links for all of these? If an airway becomes obstructed by cancer growth, options include rigid bronchoscopy, balloon bronchoplasty, stenting, and microdebridement.[58] Laser photosection involves the delivery of laser light inside the airway via a bronchoscope to remove the obstructing tumor.
• Noninvasive interventions needs update still (2011 sources).
• I believe this should be deleted: The American Society for Clinical Oncology also recommends aerobic and resistance exercise as an adjunct to treatment of any cancer at an early enough stage that the cancer could be cured.[72]

Done, looking VERY good ! Let me know if/when my help is needed to convert cite templates to sfns. SandyGeorgia (Talk) 01:54, 19 January 2023 (UTC)

Alright, did all the easy things on your list. Marked a few that I need to revisit. Also still need to reformulate the bronchoplasty paragraph, and the rest of the noninvasive interventions paragraph. Thanks a million for your thoughts! Sorry for the slow reply. Busy couple weeks in real life. Hoping things are about to quiet down and we can drag this bad boy across the finish line. Ajpolino (talk) 02:26, 26 January 2023 (UTC)

Great ... ping me when you're ready for the next look. Bst, SandyGeorgia (Talk) 02:36, 26 January 2023 (UTC)

Break for FAR comments, pt 2

I'm nearly done with a first draft of updated content – just need to look into the last couple paragraphs of the History section and deal with the images. In the meantime, SG, Colin, Graham Beards, Spicy (sorry, figured it doesn't hurt to ask again), hello. Any chance one (or more) of you has a moment to read through the text and give comments? Anything you have time for is a huge help. Also if you have ideas for images feel free to share them or make changes yourselves. I left it for last as I don't have much of a knack for visual display. Also Axl if you have a moment to read through and let me know if there's anything that rings inaccurate/incomplete to your eye/ear, that would be immensely helpful. Anyone else watching this page is also, of course, most welcome to chime in. Thanks all! Ajpolino (talk) 00:38, 24 April 2023 (UTC)

I'm reading, but not finding nits to pick; silence is golden :) SandyGeorgia (Talk) 03:11, 24 April 2023 (UTC)

Well, I see I should not have fallen asleep at the wheel :) I should be able to dig in tomorrow or the next day ... SandyGeorgia (Talk) 01:35, 25 April 2023 (UTC)

I should have time today. Graham Beards (talk) 07:06, 24 April 2023 (UTC)

Ajpolino, thank you (and the other editors) for updating the article with more recent references. Excellent work! Axl ¤ [Talk] 07:29, 26 April 2023 (UTC)

Graham

• I see straight off we go from singular to plural in the first two sentences. I think we are using the word "cancer" in two subtly different meanings: as the disease and as cases of the disease.
• We use the word "diagnoses" when perhaps "cases" is fine.
• Where in the figure legend we have "Pneumonectomy specimen" why not just say "lung"? Graham Beards (talk) 11:40, 24 April 2023 (UTC)

Thanks for the comments. Striking as I go; hope you don't mind. Ajpolino (talk) 18:05, 24 April 2023 (UTC)

Colin

I haven't read the article or any comments above. I started with the lead, because that's what our readers will do.

• Is "exacerbated" the right word (make a bad thing worse) or are they actually the cause of the genetic damage.
• Is "distant" appropriate. Wouldn't "other" be fine, as it suggests the tumours spead to your fingers and toes rather than e.g. to other organs nearby.
• Would "multiply" be better than "proliferate" as an easier word.
• I wonder if "according to" is better than "based on". And my first thought about "the cells" was confusion as surely these are "lung cells". Perhaps "type of lung cells" would clarify that we are being quite specific.
• Could classification can go later in the lead. It seems nerdy and perhaps isn't the most vital aspect for our reader and involves a lot of terminology/jargon.

  Moved down a bit. Let me know if you think it'd fit better elsewhere (or worded differently). Ajpolino (talk) 18:33, 24 April 2023 (UTC)

• Is "general respiratory problems" a thing? I'm also thinking we may try to reduce the repetition of the word "symptoms". How about "most people develop unspecific respiratory problems: coughing, shortness of breath, and/or chest pain".

  Note to self to look for other places I can replace "symptom". Ajpolino (talk) 18:33, 24 April 2023 (UTC)

• "These can be accompanied by a wide variety of symptoms depending on the location and size of the tumor" seems like a longwinded way of saying "other symptoms depend on the location and size of the tumor".
• "Many develop symptoms due to metastases". The paragraph is about symptoms, not patients, so the "many" here is jarring and it takes a bit to realise we are talking about people. What are you trying to say here? That sometimes the symptoms that prompt a diagnosis are due to metastases? If so, can be be clearer? Cause if we are merely commenting that metastases have symptoms, then that's perhaps not lead-relevant, or belongs in a prognosis.

  Mostly the latter (metastases have symptoms). Suspect you're right that it's unneeded. Folks will get the whole story in the next section. Ajpolino (talk) 18:33, 24 April 2023 (UTC)

• "typically undergo various imaging tests" does each patient undergo various imaging tests, or do they typically undergo an imaging test, of which there are various? The sentence suggests the former and I suspect the latter.

  The former. A single patient could get an X-ray (primary care, clinical suspicion), then a CT (preliminary diagnosis), then possibly image guiding for your biopsy (definitive diagnosis), then PET and maybe MRI (staging). How's "typically undergo a series of imaging tests..."? Ajpolino (talk) 18:33, 24 April 2023 (UTC)

  Yes, I had no idea you'd get so many. Is that common in developed countries, or just in the US say? Colin°^Talk 21:04, 24 April 2023 (UTC)

  We do love our imaging here, but I believe even you Brits go through the whole rigamarole in this case. Here's the relevant NHS page. Ajpolino (talk)

• "is staged based on..." The word "staged" here, as an activity, is jargon. What about "After diagnosis, the lung cancer is assessed to see what stage of the disease a patient is at."

  How about "After diagnosis, further imaging and biopsies are done to determine the cancer's stage based on how far it has spread" -- hoping to give the reader a sense of what staging entails... Ajpolino (talk) 18:33, 24 April 2023 (UTC)

  Yes. Colin°^Talk 21:04, 24 April 2023 (UTC)

• "Cancers caught at an earlier stage tend to have better prognoses" is it the cancer that has the prognosis or the patient? Maybe a very disease-focused medic would think the former but I wonder if the general reader will think the latter. If the latter, it would be "Patients whose cancer is caught at an earlier stage tend to have better prognoses".

  Yikes, good catch. Ajpolino (talk) 18:33, 24 April 2023 (UTC)

• "Treatment for early stage lung cancers includes surgery to remove the tumor" Why is "cancers" plural, especially as "tumor" is singular. Wouldn't "cancer" be fine?
• "kill remaining cancer cells" I'm tempted to insert "any" before "remaining".
• "with radiation therapy and chemotherapy alongside targeted molecular therapies and immune checkpoint inhibitors" the first two are terms folk will know (though why not "radiotherapy"?) But "molecular therapies" I have no idea what those are, and "immune checkpoint inhibitors" doesn't even link to an article on the topic. I'm guessing both of these are drugs and wondering why they aren't included as "chemotherapy" but suspect then that term is only used for certain kinds of drugs. I wonder if at this stage we'd be better just saying "with radiation therapy, chemotherapy and other drug treatments" unless you can explain to the reader easily what these fancy treatments are, and the names here certainly don't enlighten me about what they might be.

  Ah, thanks. It's hard for me to know how well medical jargon has seeps into popular understanding. How's "... and chemotherapy alongside drug treatments that target specific cancer subtypes."? They are all drugs, but folks in the field differentiate "chemotherapeutics" (technically just means drugs, but used in cancer to refer to generalist drugs that interfere with cell multiplication broadly) from "molecular therapies" (drugs that target specific mutated proteins, mostly only efficacious when you have a tumor with the particular targeted mutation). We're currently in the midst of a boom in our inventory of the latter. Apologies in advance for when you get to the treatment section. A lot has changed in the last 10 years!

  Incredible we don't have a dedicated article on immune checkpoint inhibitors, it was the subject of a 2018 Nobel prize. I'll put it on the to-do list. Even a short dedicated article would be an improvement over the current redirect target. There are loads of sources.

  From Googling "radiotherapy", it looks like the big American organizations may prefer "radiation therapy", while the big UK organizations prefer "radiotherapy"? Not a big difference to my ear. Just wanted folks to think "radiation" and not "radio". If you think one version is clearer I'm happy to switch. Ajpolino (talk) 19:02, 24 April 2023 (UTC)

  Your suggestion looks good. I can understand the idea of drugs to target the mutations and their proteins but to my ear "molecular therapies" sounds as daft as a shampoo that claims it doesn't have any "chemicals" in it. All drugs are molecules of something surely. We didn't get to choose the what they are called, but it is opaque to me.

  I don't think anyone in the UK would think "radiotherapy" involved Classic FM's "Smooth Classics at 7" calming patients down. But "radiation therapy" sounds dangerously uncontrolled to me. If that's the terminology in the US then that's what it is. -- Colin°^Talk 21:12, 24 April 2023 (UTC)

• "lung cancer is often deadly, with around 19% of people surviving five years". The first half talks about dying and the second half talks about surviving. This is jarring and adding an "only" in front of "around" would help with that transition. However, I'm rather skeptical that this 19% is a universal stat with two significant figures of accuracy. I'd rather just round to 20% and then even better just use words like "one in five" or "four in five" for survival or death figures respectively. If we put it in words like this, we don't even need to say it is often deadly because the numbers speak for themselves. "Even with treatment, only one in five people survive five years on from their diagnosis".
• "Survival is higher". It is the rate that is higher, not the survival itself. "Survival rates are higher" or similar.
• "hazardous chemicals like asbestos and radon gas" I guess I think "chemicals" are liquids, and neither of these are liquids. Google Image the word and you'll find pictures of colourful flasks and test tubes. The other problem with "chemicals" is that it suggests a chemical reaction as the cause, where certainly with radon gas it is radiation. I'm not sure how asbestos does its harm, but my mind is wondering about those fibres causing physical damage. Both issues could be fixed by saying "substances" rather than "chemicals".

  Interesting! Changed. Ajpolino (talk) 19:02, 24 April 2023 (UTC)

• Ah, we mention survival rate again here and it varies from 10 to 20%. Hmm. The global cases/deaths stats (2.2m cases; 1.8m deaths) suggest about an 80% death rate, which matches the earlier comment, though that would include untreated people too. Maybe best to not mention those "10 to 20%" stats in the lead, as they are just more numbers for the reader to take in and conflict a bit with what we already said about prognosis. We could certainly keep the comment that "incidence and outcomes vary widely". Is "with geography" the best way of putting it? It makes me think of the school subject rather than if we'd said "geographically" or "globally". Is tobacco usage the main reason for both incidence and outcome, or is the latter more to do with healthcare quality and general population health?

  The source attributes the difference in both incidence and mortality to tobacco use: "International variation in lung cancer rates and trends largely reflects the maturity of the tobacco epidemic, with patterns in mortality paralleling those in incidence because of the high fatality rate". In fact in Fig. 7 they show lung cancer, and most other cancers, have higher incidence/mortality in more developed countries rather than less. I'm left assuming that's because the global poor aren't getting lung cancer diagnoses (and the severely poor may be dying before their opportunity to get lung cancer)? But I haven't found a source that much explores it, so I don't comment on it here. Sadly, the tobacco use epidemic has moved to lower income countries. So expect this to evolve over the coming decades.

  Anyway, have changed the wording to "Cases occur throughout the world, although incidence and outcomes vary widely depending on patterns of tobacco use."

  I think the first clause is too obviously so to be worth saying. How about "Incidence and outcomes vary widely across the world, depending on ..." -- Colin°^Talk 21:16, 24 April 2023 (UTC)

  Done. Ajpolino (talk) 01:17, 25 April 2023 (UTC)

• "Over the mid-20th century" Seems a little clunky. How about "Around the middle of the 20th century"?

  Realized I'd written "20th century" twice in two sentences. How's "In the 1950s and 1960s, increasing evidence..."?

  Yes that's better. -- Colin°^Talk 21:16, 24 April 2023 (UTC)

-- Colin°^Talk 09:59, 24 April 2023 (UTC)

Thanks for your comments Colin. I hope you don't mind I struck comments as I implemented them. Happy to hear any more feedback you may have. I find I'm fairly hopeless at editing my own writing. I always know what meaning I intended. Ajpolino (talk) 21:10, 24 April 2023 (UTC)

Little pob

I have replaced the endash between the ICD-11 and ICD-11 codes with a comma within {{medical resources}}. The ICD only uses dashes in specific areas; the code range for the chapter and the code range for a specified block – relevant example here is C30-C39. Happy to discuss reasoning further here or at the template's talk page. Little pob (talk) 12:59, 24 April 2023 (UTC)

Spicy

Just some quick thoughts, sorry that I don't have the time or expertise to do more.

• Definitive diagnosis of lung cancer requires a biopsy of the suspected tumor be examined by a histologist under a microscope. In addition to recognizing cancerous cells, a histologist can classify the tumor according to the type of cells it originates from. - should this not be 'pathologist'? Unless this is some regional usage that I'm unaware of, a histologist is generally the person who does the processing, cutting and staining of the sample - not the person looking at the slide and making the diagnosis. Important distinction!
• only one in five people survives five years on from their diagnosis sounds a bit clumsy. What about "Only about 20 percent of people survive five years on..."
• In lung cancer screening studies as many as 30% of those screened appear to have a lung nodule, the majority of which turn out to be benign. - they appear to have a nodule... so they don't really have one, and it's just an imaging artifact? Or they do have one, but it's benign?

  The latter. Removed "appear to". Ajpolino (talk) 00:58, 25 April 2023 (UTC)

• Less than 10% of lung cancers are large-cell carcinomas,[3] so named because the cells are large, - I'm sure there's a better way to say this, but I can't think of one at the moment
• within the scope of a single tolerable radiotherapy field. - What does "tolerable" mean here? I don't see that word, or words to that effect, in the source.

  Ah, the two sources I leaned on most heavily for that section (the Harrison's Internal Med chapter, and the Murray & Nadel's chapter) both use "tolerable" and it must have settled into my brain. I think they mean "that the patient can safely endure", but now that you point it out I think it's clear enough without.

• The screening section only mentions the USPSTF's recommendations, do we have information on screening protocols in other countries/regions?
• I'm confused by the inline links in the image captions in the 'treatment' section - should those not just be references instead?

  Yeah, sorry I still have to replace some images. I haven't bothered with those because I know I'll replace them when I get there. Ajpolino (talk) 00:58, 25 April 2023 (UTC)

• Being overweight is associated with a lower risk of developing lung cancer, possibly due to the tendency of those who smoke cigarettes to have a lower body weight.[88] Similarly, being underweight is associated with a reduced lung cancer risk. - I don't see how that's similar - in fact, it seems rather contradictory.

  Yeah it is a bit surprising. I changed it to "However, being underweight is also..." but I suspect there's a better way to phrase this. Perhaps some review has a theory on why underweight is protective...

Thanks for your work on the article. Spicy (talk) 23:15, 24 April 2023 (UTC)

Thank you very much for your time and comments Spicy. It is, as always, a pleasure to work with you. I hope you're doing well and the new admin buttons aren't getting too much to your head :) Ajpolino (talk) 00:58, 25 April 2023 (UTC)

Hi, good to see the article being updated. I added a European Commission cancer screening report. Can someone please help me with the reference formatting? I just used the ref tool via doi. It is paraphrased info from recommendation 2 of this report, page 27 of the pdf.JenOttawa (talk) 01:27, 25 April 2023 (UTC)

I'll fix the ref to save Ajpolino the work ... SandyGeorgia (Talk) 01:37, 25 April 2023 (UTC)

Added Canada as well but ref will not be correctt for the feature article, hopefully not as botched as the EU report. Thank you for your patience with my references!!!!JenOttawa (talk) 01:38, 25 April 2023 (UTC)

I'll fix it if you're done ... but Ajpolino, why isn't screening in the Prevention section? SandyGeorgia (Talk) 01:40, 25 April 2023 (UTC)

Thanks both for your efforts! Prevention would probably be fine too. Having it under Diagnosis fit better in my head – it doesn't prevent disease, just allows for an earlier diagnosis than usual. If others think it flows better under Prevention, that's fine by me. Ajpolino (talk) 03:08, 25 April 2023 (UTC)

I came to the same conclusion in the middle of the night :) SandyGeorgia (Talk) 14:15, 25 April 2023 (UTC)

Thanks so much. I see a typo in "smoker" (smokes) from my work but was waiting as not to edit at the same time as you. In the meantime was looking for some good quality reviews on developing countries and screening. No problem to remove my contribution or move it somewhere else if not appropriate as per your above comment). Just wanted to help fill one of the identified gaps.JenOttawa (talk) 01:45, 25 April 2023 (UTC)

Thanks for waiting; an edit-conflict on that one from my iPad would have sent me running from the building :) I've converted to sfn, and will leave the rest to the master here (Ajpolino). SandyGeorgia (Talk) 02:01, 25 April 2023 (UTC)

PS, because neither of those sources had traditional vauthors, I had to define the refs as a harvid, see here. When there are actual author names, sfns are much easier. SandyGeorgia (Talk) 02:05, 25 April 2023 (UTC)

Thanks so much. Have a nice day! JenOttawa (talk) 12:06, 25 April 2023 (UTC)

Adding a few ideas for lung cancer screening in developing countries to this talk page. I have not found a high quality review yet, but did not have much time to search. Review/commentary article: [3]https://tlcr.amegroups.com/article/view/27776/21205. This one on the western pacific region meets medrs better (in my opinion after a quick scan as they did a more formal literature review, similar to a scoping review): [4]https://ascopubs.org/doi/full/10.1200/GO.22.00329. I am out of time to go through these so posting for when I return or if someone else wants to see what they can do that is great.JenOttawa (talk) 12:11, 25 April 2023 (UTC)

SG

What are Nitrosodimethylamines? Could someone stub it, or will a parenthetical suffice? SandyGeorgia (Talk) 18:02, 25 April 2023 (UTC)

Looked into it, I think it's a typo in the source. The review cites a paper about nitrosamines, which many groups have linked to cancer. N-nitrosodimethylamine is a particular nitrosamine. Other sources don't discuss a class of "nitrosodimethylamines". Ajpolino (talk) 21:56, 25 April 2023 (UTC)

One m ?? directly or indirectly by inflamming the lung SandyGeorgia (Talk) 18:10, 25 April 2023 (UTC)

The construct here is not parallel, but I am at a loss for how to fix it:

• Similarly, exposure to radon, a naturally occurring breakdown product of the Earth's uranium, is associated with increased lung cancer risk. This is particularly true in underground miners, who have the greatest exposure; but also in indoor air in residential spaces. SandyGeorgia (Talk) 18:13, 25 April 2023 (UTC)

Not sure what the problem is, but "Similarly, exposure to radon, a naturally occurring breakdown product of the Earth's radium, very variable geographically, is associated with increased lung cancer risk. This is particularly true for underground miners, who have the greatest exposure; but also for those exposed to indoor air in certain areas and types of buildings. In fact it is not uranium directly, or just uranium. See radon Johnbod (talk) 18:30, 25 April 2023 (UTC)

The non-parallelism is one part talks about people (miners), while the other part talks about places (residential spaces). SandyGeorgia (Talk) 18:38, 25 April 2023 (UTC)

Based on both of your comments, how's "Similarly, exposure to radon, a naturally occurring breakdown product of the Earth's radioactive elements, is associated with increased lung cancer risk. Radon levels vary with geography. Underground miners have the greatest exposure; however even the lower levels of radon that seep into residential spaces can increase occupants' risk of lung cancer."? Ajpolino (talk) 21:57, 25 April 2023 (UTC)

Much better, SandyGeorgia (Talk) 02:12, 26 April 2023 (UTC)

And workplaces too. Johnbod (talk) 03:58, 26 April 2023 (UTC)

Since we have previously discussed in the article that incidence varies dramatically by region and sex, can we clarify (explicitly) more about this statement:

• The incidence in men rose until the mid-1980s, and has declined since then. In women, the incidence rose until the late 1990s, and has since been stable.

That is, do we mean to say the ***worldwide*** incidence here, or is this data specific to certain regions? SandyGeorgia (Talk) 21:49, 25 April 2023 (UTC)

• It's referring to US men and women. I've just removed it. There's no statement that can be made about global trends there. A population's lung cancer incidence/deaths are dominated by the popularity of tobacco use, which seems to vary with gender, geography, et al. Hopefully we get that across in the article. The curious may enjoy entering a few countries into this graph to see how variable the trends are. Ajpolino (talk) 00:10, 26 April 2023 (UTC)

  Is that/should that be in External links? I'm out for two days now, real life just got weirder. Did what I could; great work! SandyGeorgia (Talk) 00:36, 26 April 2023 (UTC)

Aj, could you ctrl-f on "dramatically" and try to vary some of those remaining? SandyGeorgia (Talk) 22:02, 25 April 2023 (UTC)

• Oops. Removed most. Ajpolino (talk) 00:10, 26 April 2023 (UTC)

Maybe I missed it, but I can't find where CHART is mentioned or defined in the article, and yet it's in History. SandyGeorgia (Talk) 22:06, 25 April 2023 (UTC)

• Defined -- though that and the prior paragraph are the two paragraphs I haven't yet looked into. Might update some of the text and references.Ajpolino (talk) 00:10, 26 April 2023 (UTC)

I am SO happy to see the image overkill removed. I've done all I can do; hope we'll get a solid layreader in next. SandyGeorgia (Talk) 22:08, 25 April 2023 (UTC)

Ajpolino, I was going to do some more ref cleanup, but realized you might not be done ...

• Removed unused Greaves and Saunders
• Are you planning to keep the Jonas 2021 citations? If so, need to adjust them to same citation format.
• Are you keeping the Autoref33, 34, etc citations? If so, I will rename them to AuthorYear

And while I was looking at those, I realized you still have a lot of inline (hidden) comments, so I decided to stay out of the way :) SandyGeorgia (Talk) 03:18, 29 April 2023 (UTC)

I went through and sfn-ified the remaining main text references. The last old school ones are the ones used in History#Treatment, which are historical tidbits left for the curious (in the article since before I arrived). I'm still hoping to find some secondary sources to fill out that subsection, but if you've got a moment and don't mind those can be renamed to author/year. Otherwise, I think(?) I've caught up to the references. Ajpolino (talk) 15:34, 30 April 2023 (UTC)

I will do those then (just not at the moment, busy :) SandyGeorgia (Talk) 18:03, 30 April 2023 (UTC)

Ajpolino, yes, I see the problem you are having with the Treatment history; it's mostly primary source original research. So I opted to leave the refs in the old style reflist after renaming them, rather than moving them to sfn, so you will have the reminder left to deal with them as you are able. But that leaves us with an inconsistent citation style; I can go ahead and convert them to sfn if you'd like, omitting page numbers and loc=.

On Edwards, since I could read the source, I did convert it to sfn, but I am unclear if the source supports the text:

• Palliative radiotherapy has been used since the 1940s.[115] pp. 24–25

Please have a look; as I read it, the source doesn't actually state when that started (I could be reading the wrong section). Sorry I wasn't much help! I was wondering if it would be better to delete that entire para if you can't find secondary sources? SandyGeorgia (Talk) 02:28, 1 May 2023 (UTC)

Suggestion: Move History of treatment to Treatment of lung cancer#History; problem solved. SandyGeorgia (Talk) 06:02, 1 May 2023 (UTC)

Argh, just spent another hour looking for good sources on the topic and am throwing in the towel. I'll set a calendar reminder to look again in a year or two – it boggles the mind that there's nothing out there. I moved the shakiest material to Treatment_of_lung_cancer#History per your suggestion. The little voice in my head tells me the remaining paragraphlet on surgical history should go as well, but I'm not sure I have the heart to move it since I just wrote it a day or two ago. If you think it's too incomplete to live in this article, maybe you can move it to Treatment_of_lung_cancer#History; I'll avert my eyes.

I think that's my last to-do list item. Though likely I've missed something. Is anyone waiting on me to do anything? @Graham Beards and Colin: if there's anything else you wished to look through and comment on, I'm ready. Certainly I appreciate the time you've already put into this. Thanks again all. Ajpolino (talk) 15:41, 1 May 2023 (UTC)

Images

Thanks all for your comments so far. If folks have any thoughts on the current images or decent replacements please share them or boldly try some replacements. I don't have a very good eye for visual display. I'm slowly working my way down the article trying to find/make images that help with understanding, but I'm not too confident in my judgment. Ajpolino (talk) 01:55, 26 April 2023 (UTC)

And in case anyone wants to help search, I'm hoping to replace the bottom 3 images. I'd like to replace the cancer lung with an image of something related to smoking cessation/policy (maybe a sign forbidding smoking in a public place? A graphic display on a cigarette box?), the epidemiology map needs updating, and the big English infographic is a bit much. There's probably room to add another image or two elsewhere as well. Ajpolino (talk) 02:01, 26 April 2023 (UTC)

I hate dealing with images :) Colin's your guy. But a general point for future reference (although I'm not going to object after your beautiful work :)

Ideally, images would be WP:ACCESSible to all, including the color blind and understandable to those who use screenreaders. With respect to content, we are advised at MOS:COLOR never to use only color to convey information, which File:Lung diagram - tumor surgeries.png does. But everyone uses color in maps and diagrams anyway, 'cuz it's often hard to find a way around it. Look at the maps at Great Fire of London, which Guerillero kindly redid during the article's FAR, to use cross-hatching to indicate the regions that were previously shown only with color. The information there is now conveyed in two ways, so those who can't see colors can still see the information. I don't expect you to worry about fixing this because most FAs don't, and MOS:COLOR is written more specifically about tables and templates than images, which can't always be fixed, but just something to keep in mind if you do more images down the road.

I know nothing of how to write alt text for images so screenreaders can get an idea of the information conveyed-- Eubulides, one of earliest and finest medical editors, now long gone, was the expert at that-- and it would sure be nice if we had someone to replace his work on medical articles.

So happy to see this article coming together, and amazed that you took on such a big job here :) SandyGeorgia (Talk) 01:14, 27 April 2023 (UTC)

Wow, awesome (above and beyond the call of duty :) SandyGeorgia (Talk) 18:00, 28 April 2023 (UTC)

PS, include the source with the image caption? (I would do it for you but not home, iPad editing from car). SandyGeorgia (Talk) 18:02, 28 April 2023 (UTC)

Good idea, done! Ajpolino (talk) 18:33, 28 April 2023 (UTC)