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Gallbladder cancer starts in the small bile-storing sac under the liver and is one of the biliary tract cancers. Most cases are found late, or by chance when a gallbladder is removed for gallstones. It is rare in the UK, with about 1,300 cases a year, and much commoner in Chile, Bolivia and northern India. Found early, an operation can cure it.
The gallbladder is a pear-shaped pouch about 8 cm long under the right lobe of the liver that concentrates and stores bile; it is not essential and people digest normally without it (CRUK, what is gallbladder cancer). Cancer here is grouped with cholangiocarcinoma as biliary tract cancer, and most systemic-therapy evidence comes from mixed biliary trials, but gallbladder cancer differs in its causes (gallstones and chronic inflammation rather than liver fluke or primary sclerosing cholangitis), its geography, the way it is found (often incidentally in a cholecystectomy specimen), its staging (a separate AJCC chapter with the T2a and T2b split) and its molecular profile (HER2 alterations more often than FGFR2 fusions or IDH1 mutations). Hundal and Shaffer describe it as the commonest biliary tract cancer, 80 to 95 percent of biliary tract cancers in their review, and Roa and colleagues note that most cases are discovered incidentally after cholecystectomy for symptomatic stones.
World: the IARC gallbladder fact sheet, served today with the GLOBOCAN 2024 estimates, gives 126,384 new cases (22nd commonest cancer, age-standardised rate 1.2 per 100,000) and 92,029 deaths (20th, 0.82 per 100,000) a year, with 72.4 percent of cases in Asia, 10.0 percent in Europe, 8.8 percent in Latin America and the Caribbean and 4.3 percent in Northern America. The highest national age-standardised incidence on the sheet is Bolivia (6.7 per 100,000, both sexes; 6.0 in men) and Chile (7.6 per 100,000 in women); the highest regions are South Central Asia, South America and Eastern Asia. Earlier GLOBOCAN rounds gave lower counts, so the version matters when figures are compared. Randi and colleagues (2006) recorded the highest registry rates in women in Delhi (21.5 per 100,000), South Karachi (13.8) and Quito (12.9), high rates in Korea, Japan and parts of central and eastern Europe, and a female to male ratio of about 3. In the United States about 3,700 people a year were diagnosed in 2007 to 2011 (1.13 per 100,000) and 2,000 died (0.62 per 100,000), two thirds of them women, with rates three times higher in American Indian and Alaska Native people (Henley 2015); a 2026 meta-analysis found 3 to 3.5-fold higher incidence in Native American people nationally and 6 to 8.5-fold in the Southwest and Alaska (Kosuru 2026). SEER incidence fell by 1.65 percent a year from 1973 but has been flat since 2002 (Low 2022). In India a Tata Memorial registry of 1,950 patients (2019 to 2022) found 84.6 percent came from, or had migrated from, the Gangetic belt, and 60 percent had metastatic disease at presentation (Patkar 2025); in Pakistan a prospective series of 233 cases was 77 percent women with a mean age of 55 (Malik 2003).
United Kingdom (Cancer Research UK, drawing on the national registries): 1,288 new cases a year (2019 and 2021 to 2022 average, ICD-10 C23), around 900 in females and 380 in males, under 1 percent of all cancers; 54 percent are diagnosed at 75 or over and rates peak at ages 85 to 89, which account for 13 percent of cases. Incidence rates have risen by 79 percent since the early 1990s and by 33 percent in the last decade, and are projected to rise a further 43 percent by 2038 to 2040 to about 3,100 cases a year. Rates are higher in the Asian and Black ethnic groups than the White group in England (2013 to 2017). There are about 810 deaths a year (2022 to 2024), 60 percent at 75 or over; it is the 23rd commonest cause of cancer death (20th in women). Mortality rates are 28 percent lower than in the early 1970s but 29 percent higher than a decade ago. Lifetime risk is about 1 in 210 for females and 1 in 670 for males born in 1961. A UK primary-care cohort found biliary tract cancer incidence rising 4 percent a year in 2000 to 2010 and higher in the most deprived quintile (Keane 2014). Half of cases in England (2019) were diagnosed after an emergency presentation and 17 percent through an urgent suspected cancer referral; in Northern Ireland 24 percent of staged cases were stage I or II (2015 to 2019); in England in 2022, 21 percent of patients had surgery, 22 percent systemic therapy and 2 percent radiotherapy as part of primary treatment (CRUK main statistics page). National Disease Registration Service tables could not be read directly for this record (the site blocks automated readers); the CRUK figures above are derived from registry data.
Risk factors, with the evidence: gallstones are the strongest (pooled relative risk 4.9 for a history of benign gallbladder disease, Randi 2006; odds ratio 7.26 for gallbladder cancer in a 2021 meta-analysis of 30 studies, Huang; hazard ratio 7.35 for gallbladder cancer death in 396,720 Koreans followed by ultrasound, Ryu 2016), and larger stones carry more risk (odds ratio 2.4 for stones 2.0 to 2.9 cm and 10.1 for 3 cm or larger versus under 1 cm, Diehl 1983). Yet gallstones are very common and this cancer very rare, so most people with stones never develop it (CRUK). Porcelain gallbladder: about eight times the risk (CRUK, citing Schnelldorfer), but the 2013 systematic review found cancer in only 6 percent of calcified gallbladders in studies without selection bias against 1 percent in matched controls, and a 2018 cohort observed 90 patients for a mean 3.2 years without a cancer (DesJardins). Gallbladder polyps: about 8 percent of polyps of 10 mm or more are malignant and about 4 percent of polyps reach that size (CRUK, citing Elmasry 2016, whose review found 0.57 percent of 5,482 ultrasound-detected polyps were malignant). Primary sclerosing cholangitis: 37 percent of explanted gallbladders showed dysplasia and 14 percent adenocarcinoma in one transplant series (Lewis 2007); polyps were seen in 16 percent of 453 patients and the cancer rate among those with a polyp was 8.8 per 1,000 person-years (van Erp 2020). Chronic Salmonella Typhi carriage: summary relative risk 4.6 for anti-Vi antibodies and 5.0 for bile or stool culture across more than 1,000 cases (Koshiol 2016; pooled 4.8 in Randi 2006). Anomalous pancreaticobiliary junction: about seven times the risk in a meta-analysis of case-control studies (CRUK, citing Deng 2011); in a 2025 MRCP series the anomaly was present in 0.44 percent of benign cholecystectomies but 16 percent of gallbladder cancers, an estimated 38-fold higher incidence (Shirai 2025). Obesity: 20 percent of UK cases are attributed to overweight and obesity; risk is 22 to 29 percent higher in overweight women and 68 to 78 percent higher in obese women, and 43 to 54 percent higher in obese men (CRUK risk page; relative risk 1.69 for obesity across 14 cohorts, Liu 2016). Sex and age: 71 percent of UK patients are women and risk climbs steeply after 75 (CRUK). Aflatoxin: exposure markers were found in 32 percent of Shanghai gallbladder cancer patients against 15 percent of gallstone controls, odds ratio 7.61 for the top exposure quartile and a population attributable fraction of 20 percent (Koshiol 2017), with a parallel signal in Chile (Nogueira 2015). Genetics: a family history raises risk about five-fold (CRUK); the Indian genome-wide association study found risk variants at 7q21.12 spanning the bile phospholipid transporter genes ABCB1 and ABCB4 (per-allele odds ratios 1.47 to 1.61) and estimated a sibling relative risk of 3.15 from common variation (Mhatre 2017); in Chile each 1 percent rise in Mapuche ancestry raised risk by about 0.8 percent in a Mendelian randomisation analysis, partly through gallstones (Zollner 2023; Lorenzo Bermejo 2017). Also on the CRUK list: type 2 diabetes (44 to 49 percent higher), smoking (19 percent higher in current smokers), heavy alcohol (about three times at 50 g or more a day), choledochal cysts and ionising radiation. About 20 percent of UK cases are judged preventable.
Presentation takes two forms. A large share is found by the pathologist after a cholecystectomy for presumed gallstone disease: 0.25 to 0.89 percent of all cholecystectomy specimens in the series reviewed by Soreide (2019), 0.29 percent of 9,698 in a Danish department (0.08 percent under 60, 0.67 percent over 60; Lerche-Jorgensen 2025). The rest present with symptoms that are vague until late: pain or a dragging feeling in the right upper abdomen, feeling or being sick, loss of appetite and weight, fever, a lump in the abdomen, a swollen abdomen, and jaundice with itching, dark urine and pale stools (NHS). In the Pakistani series pain was the presenting symptom in 89 percent, weight loss in 42 percent, jaundice in 33 percent and a palpable mass in a quarter (Malik 2003). Jaundice usually means the tumour has reached the bile duct or hilar nodes: even among patients without distant spread who were operated on, five-year survival was 21.9 percent with jaundice against 68.3 percent without (Chaudhary 2021, Langenbecks Arch Surg, doi 10.1007/s00423-020-02075-8). The NHS asks people to seek urgent help for jaundice or for vomiting lasting more than two days, and NICE NG12 (1.2.10) tells GPs to consider an urgent direct-access ultrasound for an upper abdominal mass consistent with an enlarged gallbladder.
Diagnosis: ultrasound is the first test for a gallbladder mass, wall thickening or polyp, and the joint European polyp guideline keeps it as the primary investigation, with contrast-enhanced or endoscopic ultrasound reserved for expert centres in difficult cases (Foley 2022). Contrast CT of chest, abdomen and pelvis stages the tumour and judges resectability (pooled sensitivity 99 percent, specificity 76 percent for resectability; Li 2013); MRI with MRCP maps the bile ducts and liver invasion. Both are weak at finding involved lymph nodes: CT sensitivity ranged from 25 to 93 percent across studies and MRI pooled sensitivity was 75 percent (de Savornin Lohman 2019). FDG PET-CT is accurate for the primary (sensitivity 96 percent) and for distant metastases (95 percent) but less so for nodes (75 percent), and changes management in a meaningful share of patients (Parida 2021); gallbladder cancers are PET-avid, and PET can spare a futile re-resection (Soreide 2019). Blood tests include liver function and the tumour markers CA 19-9 and CEA, which are raised more often in cancer than in benign disease but cannot make or exclude the diagnosis and did not predict survival in a 200-patient Indian series (Sinha 2022); 58 percent of the Pakistani series had a raised CEA (Malik 2003). The AHPBA consensus sets the minimum staging as contrast cross-sectional imaging plus diagnostic laparoscopy (Aloia 2015). When imaging shows a resectable mass, UK hepatobiliary teams generally do not biopsy through the tumour beforehand: the Liverpool MDT relied on the surgeon's intraoperative assessment with frozen section, which matched final histology in every case but doubled operating time (Chan 2022), and an Imperial College unit runs a single-stage operation in which frozen section decides whether to extend a cholecystectomy to a radical resection (Banh 2024). Biopsy is used when the disease is clearly unresectable and systemic treatment is planned, or to confirm metastases (NHS tests page lists biopsy, laparoscopy and ERCP among the possible tests).
Pathology: about 90 percent are adenocarcinomas, which Cancer Research UK divides into non-papillary, papillary and mucinous; squamous cell carcinoma makes up about 5 percent, and adenosquamous carcinoma, small cell (neuroendocrine) carcinoma, sarcoma, neuroendocrine tumours and lymphoma are rare (CRUK types page). The WHO Classification of Tumours of the Digestive System, 5th edition (2019; summarised by Nagtegaal 2020), is the reference classification for the gallbladder and extrahepatic bile ducts; it also names the precursor lesions, flat biliary intraepithelial neoplasia and the polypoid intracholecystic papillary neoplasm (Adsay 2012; Akita 2019). Mucinous carcinoma is defined by extracellular mucin in more than half of the tumour and was 2.5 percent of 606 carcinomas (Dursun 2012); adenosquamous carcinoma needs a squamous component above 25 percent and was 5 percent of adenocarcinoma-plus-adenosquamous cases in the National Cancer Database (Murimwa 2021; Gasparello 2026); neuroendocrine carcinoma was 31 of 636 cancers, under 5 percent, in a pathology cohort and 1.6 percent of gallbladder carcinomas in SEER (Reid 2026; Cai 2022). Grade runs from 1 (well differentiated) to 3 (poorly differentiated) (CRUK stages and grades). Early cancers are often invisible to the naked eye: 60 percent of 190 Tis, T1a and T1b tumours were not apparent on gross examination, which is why the AHPBA asks for at least three sections and the cystic duct margin from every routine specimen in high-incidence areas (Roa 2013; Aloia 2015). Each subtype has its own page below.
Staging follows the AJCC and UICC TNM 8th edition (2017), described in plain words by Cancer Research UK. Tis: cancer cells confined to the lining. T1a: into the connective tissue under the lining; T1b: into the muscle layer. T2: through the muscle into the connective tissue beyond it, still within the gallbladder, split into T2a on the peritoneal side (the free side facing the abdominal cavity) and T2b on the hepatic side (the side against the liver). T3: through the outer wall, or into the liver or one adjacent organ. T4: into the main portal vein or hepatic artery, or into two or more organs outside the liver. N1: one to three regional nodes; N2: four or more (the count replaced the 7th edition's anatomical grouping after series such as Shirai 2012 showed 0, 1 to 3 and 4 or more nodes stratified survival). M1: distant spread. Stage groups: I is T1 N0, II is T2 N0, IIIA is T3 N0, IIIB is T1 to T3 with N1, IVA is T4 with N0 or N1, and IVB is any N2 or any M1. What each means for surgery: Tis and T1a are cured by the cholecystectomy already done in almost all cases (five-year survival up to 100 percent after cholecystectomy alone, Soreide 2019); from T1b upwards guidelines recommend radical (extended) cholecystectomy with resection of the liver bed and portal lymphadenectomy, though the T1b benefit is contested (meta-analysis of 26 cohorts: better overall survival with extended surgery, hazard ratio 0.48, but no difference in disease-specific survival, Cho 2026; no survival difference in 950 National Cancer Database patients, Rhodin 2024); T2b tumours carry more vascular invasion (51 versus 19 percent), perineural invasion (33 versus 8 percent) and nodal spread (40 versus 17 percent) than T2a and roughly twice the hazard of death (Shindoh 2015; Alrawashdeh 2022 meta-analysis of 2,531 patients), so liver resection matters most on the hepatic side; T3 disease is resectable when one adjacent organ can be taken en bloc; T4 disease and N2 nodes, or para-aortic node involvement, rarely benefit from resection and are directed to systemic treatment (Aloia 2015). The 8th edition N split did not improve prognostic performance over the 7th in a 7,743-patient validation (Giannis 2021), and a Korean series found the N category discriminated only when six or more nodes had been examined (Sung 2020), the count the AHPBA asks surgeons to aim for.
Screening and prevention: there is no screening programme for gallbladder cancer in the UK because no test picks it up reliably at an early stage (CRUK screening page), and none exists anywhere at population level, even in Chile or northern India (open problem). Prevention rests on managing the precursors. Polyps: the 2022 ESGAR, EAES, EFISDS and ESGE guideline recommends cholecystectomy for polyps of 10 mm or more; for 6 to 9 mm polyps with a risk factor (age over 60, primary sclerosing cholangitis, Asian ethnicity, or a sessile polyp including focal wall thickening over 4 mm); ultrasound at 6 months, 1 year and 2 years for 6 to 9 mm polyps without risk factors or 5 mm or smaller polyps with one, stopping after 2 years if there is no growth; no follow-up for polyps of 5 mm or less with no risk factors; cholecystectomy if a polyp reaches 10 mm, and discussion if it grows 2 mm or more (Foley 2022). Cancer Research UK lists anomalous pancreaticobiliary junction and choledochal cysts among the congenital risk factors, and the 38-fold incidence estimated with the maljunction (Shirai 2025) is the argument for removing the gallbladder once it is found. Prophylactic cholecystectomy has traditionally been advised for porcelain gallbladder (the CRUK patient page says a doctor may suggest it); that advice is now debated because the cancer risk in unselected calcified gallbladders is far lower than once thought and observation caused no cancers in a 90-patient cohort (Schnelldorfer 2013; DesJardins 2018). Weight, alcohol and smoking are the modifiable factors the NHS names.
Incidental cancer is the commonest route to cure. About half of incidental tumours are pT2 and a third pT1 (Soreide 2019). For T1b or deeper disease the patient should be referred to a hepatobiliary centre for re-resection, ideally 4 to 8 weeks after the first operation (median survival 40.4 months, against 17.4 months for under 4 weeks and 22.4 months for over 8 weeks in 207 US patients, Ethun 2017), with cross-sectional imaging and often PET-CT in the interval. Port-site metastases fell from 18.6 percent before 2000 to 10.3 percent since (Berger-Richardson 2017), and routine excision of port sites has no effect on survival (Soreide 2019). A Dutch study found only 53.9 percent of patients eligible for re-resection were referred to a tertiary centre (van Dooren 2024), a gap the UK pathway pages take up.
Averages across everyone diagnosed, often years ago. A median is the middle of a group: half the people counted lived longer than the figure shown, and some lived far longer. Your stage, subtype, age, fitness and the treatment you receive matter more than the average, and the numbers are improving quickly.
Around 1,300 people a year in the UK, seven in ten of them women and more than half aged 75 or over; rare here, but common where gallstones are common, above all Bolivia, Chile, northern India and Pakistan (Cancer Research UK; GLOBOCAN).
Most pancreatic cancers arise in the head next to the bile duct, which is why jaundice is the presenting sign; bile duct cancers are named by where along the tree they sit.
Same organ: Glucagonoma, VIPoma, Somatostatinoma, Pancreatic ductal adenocarcinoma, Biliary tract cancer (cholangiocarcinoma), Intrahepatic cholangiocarcinoma, Extrahepatic cholangiocarcinoma (perihilar and distal), Biliary tract cancer (all types), Neuroendocrine tumours, Pancreatic neuroendocrine tumours, Grade 3 well-differentiated neuroendocrine tumour, Extrapulmonary neuroendocrine carcinoma, Gallbladder adenocarcinoma, Papillary carcinoma of the gallbladder, Mucinous carcinoma of the gallbladder, Adenosquamous and squamous carcinoma of the gallbladder, Neuroendocrine carcinoma of the gallbladder, Incidental gallbladder cancer (found after cholecystectomy), Carcinoma in situ and dysplasia of the gallbladder, Cystic duct carcinoma, Ampullary cancer (ampulla of Vater), Resectable pancreatic ductal adenocarcinoma, Borderline resectable pancreatic ductal adenocarcinoma, Locally advanced unresectable pancreatic ductal adenocarcinoma, Metastatic pancreatic ductal adenocarcinoma, KRAS G12C-mutant pancreatic ductal adenocarcinoma, KRAS wild-type pancreatic ductal adenocarcinoma, BRCA or PALB2-mutant pancreatic ductal adenocarcinoma, Mismatch repair deficient (MSI-high) pancreatic ductal adenocarcinoma, Pancreatic acinar cell carcinoma, Intraductal papillary mucinous neoplasm and other pancreatic cystic precursors, Pancreatoblastoma, Adenosquamous carcinoma of the pancreas, Colloid (mucinous non-cystic) carcinoma of the pancreas, Undifferentiated carcinoma of the pancreas with osteoclast-like giant cells, Invasive carcinoma arising in an intraductal papillary mucinous neoplasm (IPMN-associated carcinoma), Mucinous cystic neoplasm of the pancreas with associated invasive carcinoma (MCN-associated carcinoma), Solid pseudopapillary neoplasm of the pancreas
How this cancer shows itself, how the diagnosis is confirmed, and the biomarkers clinicians test for.
Urgent direct-access ultrasound for an upper abdominal mass consistent with an enlarged gallbladder (NICE NG12 1.2.10); urgent referral for jaundice; the UK pathway page carries the detail.
Ultrasound, contrast CT, MRI with MRCP, FDG PET-CT before radical surgery, staging laparoscopy; frozen section rather than needle biopsy when the mass is resectable.
No further surgery when the cystic duct margin is clear; the simple cholecystectomy is curative in almost all cases.
Radical (extended) cholecystectomy: resection of the liver bed (wedge or segments IVb and V) with portal lymphadenectomy, bile duct resection only when the cystic duct margin is positive; re-resection 4 to 8 weeks after an incidental diagnosis; port sites not routinely excised.
Adjuvant capecitabine for six months (BILCAP, a UK trial in a mixed biliary population that required muscle-invasive gallbladder cancer for entry); the BILCAP record carries the figures, and the UK CAPBIL cohort saw no matched benefit, so ACTICCA-1 is awaited.
Gemcitabine and cisplatin with durvalumab (TOPAZ-1, in which 25 percent of patients had gallbladder cancer; NICE TA944) or with pembrolizumab (KEYNOTE-966; not appraised by NICE), with molecular profiling including HER2 at diagnosis and biliary drainage first if jaundiced. Second-line, HER2-directed and other targeted options follow in the rows below.
Cholecystectomy for polyps of 10 mm or more, or 6 to 9 mm with a risk factor; ultrasound surveillance at 6, 12 and 24 months otherwise; no follow-up for polyps of 5 mm or less without risk factors (ESGAR, EAES, EFISDS and ESGE 2022).
A stent placed by ERCP, or through the skin (PTC), is the usual way to relieve jaundice; metal stents stay open longer than plastic and are used when surgery to remove the cancer is not planned; a surgical bypass (joining the bile duct above the blockage to the small bowel) is reserved for people already having an operation or when a stent cannot be placed. Jaundice must be relieved before chemotherapy can be given safely.
HER2 testing (immunohistochemistry and in situ hybridisation) and a tumour gene panel at diagnosis of advanced disease: about one in ten gallbladder cancers is HER2-positive on staining and about one in seven carries a HER2 gene change, and zanidatamab is licensed (MHRA, February 2026) and NICE-recommended (TA1153, May 2026) for HER2-positive biliary cancer after chemotherapy; mismatch repair, BRAF V600E and NTRK results open tumour-agnostic options. On the NHS the hospital team requests the test through the Genomic Medicine Service on tissue already taken.
At every stage a trial can be a reasonable choice beside standard treatment: ask what the comparison arm is, whether a placebo is used (in KEYNOTE-966 the control arm had chemotherapy plus placebo, never placebo alone), what extra visits are involved, and that you can leave at any time. AMMF lists biliary trials open in the UK; HERIZON-BTC-302 is the first-line HER2 trial.
Gemcitabine and cisplatin with durvalumab as for metastatic disease; consider chemoradiotherapy or stereotactic radiotherapy within a trial (UK ABC-07; India POLCAGB, RUGB) and reassess for conversion surgery.
Zanidatamab (HERIZON-BTC-01: 41 percent response, 53 percent gallbladder cancer; FDA 2024, EU 2025, MHRA February 2026, NICE TA1153 May 2026) or trastuzumab deruxtecan for IHC 3+ (DESTINY-PanTumor02 biliary cohort 45 percent response; FDA tumour-agnostic 2024, not NICE-appraised); trastuzumab with pertuzumab through the UK DETERMINE platform; first-line zanidatamab within HERIZON-BTC-302 and SAFIR-ABC10.
BRAF V600E: dabrafenib with trametinib (ROAR biliary cohort 51 percent response; FDA tumour-agnostic 2022). Mismatch-repair deficiency or high tumour mutational burden: pembrolizumab (KEYNOTE-158). NTRK fusion: larotrectinib or entrectinib. KRAS G12C: sotorasib or adagrasib off-label or in trials. FGFR2 fusions (pemigatinib, futibatinib) and IDH1 mutations (ivosidenib) are intrahepatic features; the licences and NICE appraisals (TA722, TA1005, TA948) cover cholangiocarcinoma and the trials enrolled almost no gallbladder cancer.
FOLFOX with active symptom control (ABC-06, UK: overall survival 6.2 versus 5.3 months; gallbladder cancer eligible); liposomal irinotecan with fluorouracil is an NCCN option on NIFTY but was negative in NALIRICC and is not commissioned in the UK; trials preferred (SEVILLA ivonescimab versus FOLFOX at UCL; ComboMATCH for MAPK-mutant disease).
Biliary drainage by ERCP metal stent, percutaneous transhepatic drainage for hilar block or failed ERCP, or EUS-guided drainage (non-inferior to ERCP with fewer complications in a 125-patient randomised trial); duodenal stent or gastrojejunostomy for gastric outlet obstruction by expected survival (SUSTENT); opioids with coeliac plexus block for visceral pain; paracentesis or tunnelled catheter for ascites; early integrated palliative care.
Trials recruiting now, the landmark trials, the trials held by this cancer's subtypes, the key papers and what they mean, the latest literature, and the milestones year by year.
The molecular landscape: the targets and how often each appears, the pathways, the mechanics stages and the preclinical models.
Cases by country, the UK and NHS pathway and other country lenses, the expert centres with trials on record, and the centres named on this cancer's subtypes.
The decisions you may face, the aids that walk through them, the warnings on record, the first sixty days and the questions to ask.
Everything in development, the medicines held by this cancer's subtypes, the open problems and what is being done about them, the roadmaps, and what changed on this record.
Every connected record, the notes, the JSON, Markdown and RDF twins, and where the record came from and when it was checked.