Talk:Cancer pain/GA2

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GA Review[edit]

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Reviewer: Allens (talk · contribs) 12:50, 30 March 2012 (UTC)

On initial scan-through, no quick-fail problems seen. A few comments:

  • Formatting (I may go in and fix some of these myself; most are not requirements for good-article status):
  • In terms of images, it's generally preferable if they are alternating sides. Nice use of "Fig. #" references and {{anchor}} templates - I will keep this in mind for my editing of other articles.
  • Image captions should not have periods unless they are full sentences.
  • I generally see "side-effects" without the hyphen (it's hyphenated in the article); it's possible both ways are correct.
  • Instead of "free membership required" as part of a citation's title, I advise using the {{registration required}} template after the citation.
  • I would group together the lead's second and third paragraphs into one paragraph.
  • On the other hand, I would put the material on cingulotomy in its own separate paragraph.
  • There are a few duplicate links, which I'll fix myself shortly.
  • A stylistic matter (not a requirement): I suggest putting Epidemiology at the start of the article, as a subheader under "Pain", and moving the corresponding paragraph in the lead. Allens (talk | contribs) 14:17, 30 March 2012 (UTC)
  • Some of the references contain multiple citations of the same book (e.g., the Fitzgibbon text) but different pages; it would be nice if these were put into a Works Cited section with {{sfn}} references to them. I'm not sure how to do this with vcite, however. Allens (talk | contribs) 14:17, 30 March 2012 (UTC) I think Fitzgibbon & Loeser was the only culprit. --Anthonyhcole (talk) 13:11, 5 June 2012 (UTC)
  • I only see information about UK laws regarding pain management and the potential hastening of death. What about laws elsewhere? There are also a few minor wording changes preferable there which I may do myself ("one philosophical justification" instead of "a philosophical justification" and "this legal approach" instead of "this approach", unless pain management professionals are philosophers in their spare time - possible...).
Can't find anything wrt US or other legal position on this. Should I remove the UK position until I've found some more national positions? I've incidentally added something about the obligation to treat pain adequately.

Countries are oblighed by international human rights law to make pain treatment available to those within their borders as a duty under the right to health, and failure to take reasonable measures to relieve the suffering of those in pain may be seen as failure to protect against cruel, inhuman and degrading treatment. The right to pain relief is affirmed in U.S. law in the Supreme Court case of Vacco v. Quill, in statute law such as California Business and Professional Code22, and in case law precedents.

which I came across in my search.

  • Something about pain's impacts on patient likelihood of recovery from the cancer itself, as opposed to overall functioning, would be nice. Allens (talk | contribs) 13:09, 30 March 2012 (UTC)
I haven't encountered this yet in my reading.
  • Tramadol is unusual also in typically not causing sedation; on the other hand, it also can interfere with some anti-nausea drugs. If you could find references for these two pieces of information (possibly in the tramadol article? I haven't checked, I will admit...), including them would be nice. Allens (talk | contribs) 13:22, 30 March 2012 (UTC)
I found a source for reduced sedation ( and respiratory depression) but nothing for interfering with anti-nausea treatment so have added

...with the possible exception of tramadol due to its low sedative properties and reduced potential for respiratory depression

--Anthonyhcole (talk) 13:11, 5 June 2012 (UTC)

  • Is a "mild" chemotherapy sometimes used similarly to radiation therapy in treating pain? Allens (talk | contribs) 13:22, 30 March 2012 (UTC)
I haven't encountered that in my reading. --Anthonyhcole (talk) 13:11, 5 June 2012 (UTC)
@ Allens and Anthonyhcole => in my specialty, lung cancer, it is getting VERY common, and in fact in many places, is fairly standard practice, that "reduced-dose intensity" chemotherapy (with or without radiation) regimens ARE used in many palliative situations, particularly to reduce pain, increase patient performance status, and to address certain "oncologic emergencies". Examples include impending bone fracture from mets in the appendicular skeleton, spinal mets with cord compression or impending vertebral fracture, in patients with superior vena cava compression, or with involvement of the brachial plexus from Pancoast tumors (in the lung apex), and in other palliative situations, just as "off the top of my head" examples.
Some patients will respond very well (but usually transiently) to fairly low doses of chemo and/or radiation. Platinum-based drugs cisplatin (appx. 25 to 50 mg/m2, instead of 75-125 mg/m2 - but HARD to tolerate) or carboplatin (AUC=2 instead of full-dose AUC=6, and MUCH easier to tolerate) are the typical "reduced dose intensity chemo" used, and with radiation doses used on the order of 3 to 12 Grays, at 1-2 Grays per fraction, for 3 to 6 fractions, as opposed to a "full-course, curative intent-type" dose to the tumor mass in the chest and regional nodes of 45 to 60+ Grays.— Preceding unsigned comment added by Uploadvirus (talkcontribs) 9:15, 8 June 2012
That's great. Thanks, Uploadvirus. I'll check it out. --Anthonyhcole (talk) 19:50, 8 June 2012 (UTC)
I've searched Google Scholar and PubMed for "reduced dose chemotherapy" and "reduced dose intensity chemotherapy" and found some results addressing therapeutic use but none addressing palliation. Perhaps it's early days. We can't put anything in the article, though, until we see some science behind it. If anybody hears of something I'd appreciate a nudge. --Anthonyhcole (talk) 07:32, 9 June 2012 (UTC)
  • It might be a good idea (only if you can find a reference pointing this out) to mention that anti-nausea drugs may be needed anyway for side effects of chemo, etc. Allens (talk | contribs) 13:22, 30 March 2012 (UTC)
I'm not sure that's pertinent to this article. --Anthonyhcole (talk) 13:11, 5 June 2012 (UTC)
  • Referencing overall appears good, with the minor exception noted above. I'll do a check on a few randomly-chosen examples.
  • Disambiguation links found: Hypogastric plexus; spinal nerve roots. Allens (talk | contribs) 13:09, 30 March 2012 (UTC)
  • Current status summary:
GA review (see here for what the criteria are, and here for what they are not)

See above for other comments.

  1. It is reasonably well written.
    a (prose): b (MoS for lead, layout, word choice, fiction, and lists):
    No problems.
  2. It is factually accurate and verifiable.
    a (references): b (citations to reliable sources): c (OR):
    Check looks OK.
  3. It is broad in its coverage.
    a (major aspects): b (focused):
    Some mention of non-UK laws/practice is needed; aside from that, appears good.
  4. It follows the neutral point of view policy.
    Fair representation without bias:
    No problems noted (I'm not aware of there being other viewpoints from professionals in the field...).
  5. It is stable.
    No edit wars, etc.:
  6. It is illustrated by images, where possible and appropriate.
    a (images are tagged and non-free images have fair use rationales): b (appropriate use with suitable captions):
    No problem except as noted above regarding alternating sides, periods.
  7. Overall:
    Looks like a pass!
  • Allens (talk | contribs) 12:50, 30 March 2012 (UTC)
    • Thanks for your advice, Allens. I've moved the epidemiology data up per your suggestion. (Not sure if I'm meant to strike that point above, I've never followed a GA review.) All of your points are pertinent and I'll address each carefully when I can get to the library, in the next few days hopefully. --Anthonyhcole (talk) 08:21, 31 March 2012 (UTC)
  • Quite welcome. Either striking the point out or putting  Done by it is fine. Allens (talk | contribs) 13:14, 31 March 2012 (UTC)
  • Allens, thank you again for the effort you put in here. Something's come up, though, and I have to take an indefinite Wikibreak. I'm not sure if the GA template needs adjusting or anything. Hopefully, if your good points haven't been addressed by then, I'll be able to get back to this at some point. Sorry if I've let you down. --Anthonyhcole (talk) 04:08, 10 April 2012 (UTC)
I understand completely - stuff does happen... You haven't let me down, don't worry! I may try to find some/all of the needed references, et cetera myself. Allens (talk | contribs) 05:13, 10 April 2012 (UTC)
I've done what I can here and made notes above. --Anthonyhcole (talk) 13:11, 5 June 2012 (UTC)
Thanks! It looks pretty good to me; I have asked DocJames to take a look since he was spotting some things that I wasn't. Allens (talk | contribs) 13:19, 5 June 2012 (UTC)
I'll be looking over it later today (it's currently 1:20 AM here) and coming to a conclusion. Looks good on first glance, including correcting what DocJames had spotted. Allens (talk | contribs) 05:21, 9 June 2012 (UTC)
I apologize for the delay; things came up... I see no reason that this shouldn't pass; the epidemiology section is pretty "meaty" now, for instance. Now let me remember how to declare a GA pass... Allens (talk | contribs) 11:09, 11 June 2012 (UTC)
Thanks Allen, and everybody else. --Anthonyhcole (talk) 12:14, 11 June 2012 (UTC)


  1. This topic has a lot of recent literature. I am not sure why primary references are still be used? Or references more than 5-8 years old? Such as this 1993 primary research [1].

    That study was cited in Twycross & Bennett (2008), the source for that paragraph. We don't need to cite the source of their description, but I see no harm in doing so.

  2. We should use people or person rather than patient.

    I was fairly careful to only use "patient" when the source was discussing patients.

  3. We do not typically state the study design as done here "A 2003 review comparing studies of patients" we typically simple state the conclusions as all refs should be secondary sources.

    That seems to have been removed now.

  4. There are a number of one sentence paragraphs / sections. These need to be addressed.

    I allow the thoughts contained in them, rather than the number of sentences used, to determine my paragraph breaks. Feel free to make changes if you think it will make the ideas expressed clearer.

  5. Images should be placed in the section to which they apply not above it.Doc James (talk · contribs · email) 13:20, 15 April 2012 (UTC)

    That seems to have been attended to.

Thanks, James! That all looks like good advice. I'll act on it in the fullness of time. --Anthonyhcole (talk) 13:56, 15 April 2012 (UTC)
  1. I corrected your link. Editors are allowed to WP:USEPRIMARY sources, but I agree that whenever possible, it would be preferable to use more current and more comprehensive sources. In this case, I'm not too worried about it, though, because the information all seems to be correct, even though the citation behind it isn't ideal. I worry far more about poor sourcing when it results in bad information getting to the reader.
  2. It's not unreasonable to use "patients" here, because there are far more people with cancer than there are patients with cancer. (The difference is whether the person has been diagnosed/is seeking care for cancer. After all, 80% of 80-year-old men are "people with prostate cancer", but only about a tenth of them are "patients with prostate cancer".)
  3. That's generally true for reviews, but MEDRS recommends this style for primary studies, and it's not inappropriate to identify the reviews when you're contrasting studies of significantly different quality.
  4. There's no rule against single-sentence paragraphs.
  5. I've fixed the image locations. This technically isn't in the Good article criteria, but I like to have WP:ACCESS compliance anyway. Perfection in image placement would also require moving the right-justified images so that they appear in the middle of multi-paragraph sections, because WP:IMAGES discourages having images appear where the reader expects to find the first word of the new section. But again, this is not something that an article can be failed over, because the GA requirements do not include this detail. WhatamIdoing (talk) 15:04, 15 April 2012 (UTC)
We are writing for a general audience. There is guidance on this point at "common pitfalls" in our manual of style Wikipedia:Manual_of_Style/Medicine-related_articles#Common_pitfalls. For medical content primary sources are not ideal per WP:MEDRS and this is consensus opinion. Thus I see this as a 2(b) issue in the GA criteria. Doc James (talk · contribs · email) 00:21, 16 April 2012 (UTC)
I don't think that using "patients" when justified necessarily connotes not writing for a general audience. How would you prefer to get around the problem that WhatamIdoing has pointed out regarding people with cancer vs patients with cancer?
Secondary references instead of primary references, when the primary references are old enough to be included in secondary references, are certainly preferable. Any suggestions for such - ideally freely available? Allens (talk | contribs) 01:11, 16 April 2012 (UTC)
All the patients with prostate cancer are people with prostate cancer. Thus I do not see a problem to get around. Just because you have not seen a doctor does not mean you do not have the disease. I have contributed to many GAs and only used the term once.
There are many secondary sources. A few
  1. Induru, RR (2011 Jul). "Managing cancer pain: frequently asked questions.". Cleveland Clinic journal of medicine. 78 (7): 449–64. PMID 21724928.  Unknown parameter |coauthors= ignored (|author= suggested) (help); Check date values in: |date= (help)
  2. Portenoy, RK (2011 Jun 25). "Treatment of cancer pain.". Lancet. 377 (9784): 2236–47. PMID 21704873.  Check date values in: |date= (help)
  3. Marcus, DA (2011 Aug). "Epidemiology of cancer pain.". Current pain and headache reports. 15 (4): 231–4. PMID 21556709.  Check date values in: |date= (help)
  4. Porter, LS (2011 Aug). "Psychosocial issues in cancer pain.". Current pain and headache reports. 15 (4): 263–70. PMID 21400251.  Unknown parameter |coauthors= ignored (|author= suggested) (help); Check date values in: |date= (help)
  5. Sheinfeld Gorin, S (2012 Feb 10). "Meta-analysis of psychosocial interventions to reduce pain in patients with cancer.". Journal of clinical oncology : official journal of the American Society of Clinical Oncology. 30 (5): 539–47. PMID 22253460.  Unknown parameter |coauthors= ignored (|author= suggested) (help); Check date values in: |date= (help)
I am happy to help with access.Doc James (talk · contribs · email) 01:33, 16 April 2012 (UTC)
Also would be good to follow the outline of WP:MEDMOS more closely as is done in the main article on pain. Doc James (talk · contribs · email) 01:39, 16 April 2012 (UTC)

What's the status of this review? No comments in about three weeks. Wizardman Operation Big Bear 04:28, 5 May 2012 (UTC)

I'm being distracted by RL and Wikidramas. I'll attend to the above in a few days. --Anthonyhcole (talk) 09:02, 5 May 2012 (UTC)
It's been another three weeks. Can this review be wrapped up soon? BlueMoonset (talk) 04:06, 26 May 2012 (UTC)
I've placed it on hold. Allens (talk | contribs) 09:26, 26 May 2012 (UTC)
A standard hold is one week, and we're now past that. I put a note on Anthony's talk page a week ago, after you started the hold, and he said he'd get to it after Thursday. It's Monday again; he's been editing, just not here. I didn't think to leave anything for Doc James; his last edits to the article were May 7. The article's been under review for over two months at this point; perhaps it's time to give a final deadline for the outstanding issues to be addressed, if not close the review altogether. BlueMoonset (talk) 01:10, 5 June 2012 (UTC)
OK. Deadline: This Friday, 8 June 2012. Allens (talk | contribs) 01:20, 5 June 2012 (UTC)

Thanks everybody. I think I've addressed what I can of Allens' observations, and I've responded to James' comments above. If anyone wants to collapse single sentence paragraphs into multi-sentence paragraphs, go ahead. I won't because I think it's clearer this way. As far as I know the only really old sources are there because they were cited in a much later review or textbook chapter (which I cite at the end of the sentence or paragraph) and I thought readers might like to know which study they were referring to. If someone wants to remove those citations, go ahead. I won't, because I think they're useful. Thanks again for your patience and advice. --Anthonyhcole (talk) 13:40, 5 June 2012 (UTC)

Regarding old sources: I just noticed I'm citing Melzack R & Casey KL. Sensory, motivational and central control determinants of chronic pain: A new conceptual model. In: Kenshalo DR. The skin senses: Proceedings of the first International Symposium on the Skin Senses, held at the Florida State University in Tallahassee, Florida. Springfield: Charles C. Thomas; 1968. p. 423–443. for the following

The sensation of pain is distinct from the unpleasantness associated with it. For example, it is possible in some cases, through psychosurgery or drug treatment, to remove the unpleasantness from pain without affecting its intensity, and suggestion, as in hypnosis and placebo, can sometimes temporarily reduce pain's unpleasantness but leave its intensity unchanged. Some drug therapies and other interventions can remove both the sensation of pain and its unpleasantness, and certain emotional states, such as the excitement of sport or war, can produce the same effect.

I could probably find a recent iteration of that but Melzack and Casey is the seminal statement of this three-way distinction - sensory, affective and cognitive (suggestion), so I'd prefer to cite the source. It's a bit like Newton's Principia or Copernicus' De revolutionibus orbium coelestium, an oldie but a goodie. --Anthonyhcole (talk) 03:35, 6 June 2012 (UTC)


This source says 15% of those with non metastatic Ca have pain. A discussion of how much pain occurs with different procedures would also be useful Doc James (talk · contribs · email) 19:03, 7 May 2012 (UTC)

Those are some great stats in those links. From memory, there was more interesting information in the sources I used for the epidemiology section too, that I didn't (for concision I think) include. If you don't have a problem with a meaty epidemiology section, I don't. But I can't do focussed work like this for a few days. Feel free to have your way with anything, if you want, James. --Anthonyhcole (talk) 19:32, 7 May 2012 (UTC)
No worries regarding time limits. Here there is no time limit :-) I am away on holidays for the next few weeks. Doc James (talk · contribs · email) 19:43, 7 May 2012 (UTC)
Great. By the way, above you mention I'm citing old study reports. I'm pretty sure I only cited them when the review that I cite for the whole sentence or section cites them, that is, when the best way to convey the conclusions of a review includes mentioning a couple of studies. --Anthonyhcole (talk) 19:50, 7 May 2012 (UTC)
Yes, but once again that's 15% of patients having pain, not 15% of people having pain. WP:MEDMOS#Not using careful language warns about exactly this mistake: "Do not confuse patient-group prevalence figures with those for the whole population that have a certain condition. For example: "One third of XYZ patients" is not always the same as "One third of people with XYZ", since many people with XYZ may not be seeking medical care." WhatamIdoing (talk) 19:55, 7 May 2012 (UTC)
I think I attended to that in the article. It's very late here, so I'll check in the morning. --Anthonyhcole (talk) 20:10, 7 May 2012 (UTC)
Couldn't sleep. I checked, and I haven't conflated patients and people. I think you're right, WhatamIdoing, we need to keep the distinction clear. --Anthonyhcole (talk) 20:18, 7 May 2012 (UTC)
It is probably me she is referring to.Doc James (talk · contribs · email) 20:21, 7 May 2012 (UTC)
Ah. OK. Right. The rewording of the epidemiology section should maintain that distinction. Fair enough. --Anthonyhcole (talk) 20:25, 7 May 2012 (UTC)

I haven't addressed the epidemiology. I agree, James, that it could and should be expanded per your suggestion. I don't know when I'll be well enough to confront it though. Do you think that is sufficient to disqualify the article from GA status? --Anthonyhcole (talk) 13:45, 5 June 2012 (UTC)

It would be nice to see this section improved. I will leave the final call up to the main reviewer. Hope you are feeling well soon and thus back to Wikipedia full time :-) Doc James (talk · contribs · email) 04:23, 6 June 2012 (UTC)
I'm actually in a teaching hospital at the moment, with an awesome library, so may be able to do this. We'll see. --Anthonyhcole (talk) 07:30, 6 June 2012 (UTC)
The "15% of those with non metastatic Ca have pain" claim from your first link cites a 1982 review. More recent reviews don't use the class "pain associated with metastases" because it's not possible yet to distinguish that from pain associated with advanced cancer/terminal cancer in the studies. I've added a list of the more painful cancers, and the procedures mentioned in the second book you linked to. How am I doing? --Anthonyhcole (talk) 10:39, 6 June 2012 (UTC)


Other than the image of the PCA pump I am not sure the others are sufficiently relevant to the text at hand to keep in this article. Doc James (talk · contribs · email) 04:12, 6 June 2012 (UTC)

I'd prefer to keep the anatomical illustrations, as they do make quite a bit of obscure text clearer, but I'm unconcerned about the rest. --Anthonyhcole (talk) 07:33, 6 June 2012 (UTC)