Eng Outlines a Road Map for Fellows Navigating Manuscript Writing and Publication

For oncology fellows, learning to write and publish is as integral to training as clinical care itself, according to Cathy Eng, MD, FACP, FASCO.

"It's extremely important to learn how to write, and your very first time writing, you may be heavily criticized. Don't be offended—everybody has their own way that they like to approach things. You're here to learn, and the attending is here to help you," Eng, a professor of medicine in the Division of Hematology and Oncology at Vanderbilt University Medical Center, where she holds the David H. Johnson Chair in Surgical and Medical Oncology and serves as co-director of GI oncology and co-leader of the Gastrointestinal Cancer Research Program at the Vanderbilt-Ingram Cancer Center in Nashville, Tennessee, said in an interview with OncLive^®.

In the interview, Eng outlined the publication process for fellows, covering topic identification, the review process, and common obstacles that can arise.

OncLive: How should fellows go about identifying whether a research question or project is worthy of pursuing for publication?

Eng: Number one, I think the most important matter is that they should try to know the subject matter they're interested in. If they're interested in lung cancer, they should know the general basics of that field and its landscape.

A lot of my own questions arise from my experience with clinical care, and then really doing an extensive literature search to make sure it hasn't been published before. That's the most important thing—there are a lot of [similar] studies out there, and you want to differentiate yourself and make sure your subject matter of interest hasn't already been reported.

Not only that, but when I write anything, I want to make sure I know the rationale, I know the background, and my references are up to date. Even those small items really matter. And your references aren't necessarily just what's been published—you need to see what's been recently presented at the most recent meetings. For cancer care, I always look at what's been presented at the ASCO and ESMO [meetings], and then you'll do a search to see what's out there. For some meetings overseas, it's a little harder because you can't necessarily access the slides or presentations—it may just be a small press release. That's the time to reach out to the investigator.

I did that very early in my career. There was a very famous person, and I found their email address and wasn't fearful of asking my question. That actually resulted in a manuscript and a book chapter, because we connected even though we were at completely different institutions. It was also a way to establish a relationship and network with somebody you may completely admire from afar and didn't think would take the time to answer your question. You'd be surprised—a lot of people are very invested in mentorship of junior fellows and faculty members.

What are the essential components of a strong manuscript, and what information is often unnecessary or distracting?

Standard approaches to a manuscript are always background and rationale for why you're writing the paper, then methods—your statistics. Your methods and statistics are extremely important; they'll be heavily criticized by reviewers at times, whether it's a retrospective analysis, a prospective analysis, or a case study. After that, you put down your findings, your results, and then your conclusions.

Some of the things I find at fault are figures that are unreadable or too crowded—they don't make a lot of sense. Another fault I find surprising is when authors don't include the statistical value of the demographics. If you're showing a demographic table of X vs Y, you need to show whether that's statistically significant.

The one thing I'd highly recommend you not do is, if you already have data in a figure or table, don't replicate the exact same information in the text. Keep in mind, all the journals only allow you so many words, so you want to be as descriptive as possible without being redundant—just describe it briefly and refer to figure X or table X.

Another thing people tend to do is go off on subject matter they themselves think is important to the topic but that really has no relevance to what you're discussing. It's fine to reference something to provide rationale, but there's no need to elaborate on it for another paragraph or two when it doesn't pertain to the subject matter.

I also find it hard to read a manuscript when authors just list things. That drives me a little crazy, to be honest, because these are manuscripts, not book chapters. You can write an excellent review article without making it look like a book chapter. I find figures and tables extremely helpful, especially when the subject matter is broad, and you have multiple references—putting things into a figure or table helps the reader categorize and separate the topics you're trying to focus on, whether that's early-stage versus metastatic disease or treatment-naive patients. It also gives me better clarity when I revisit the manuscript. More often than not, if the tables and figures are really good, they'll be used in other people's presentations—whether it's a board review or a post-ASCO talk. If it's done well, it may be cited.

What should fellows know about selecting the right journal for their manuscript?

It's very important to run it by your attending to see what journal fits. Sometimes fellows are very ambitious and excited about their subject matter, but in fact it may not be as high-impact as they'd like. The most important thing to keep in mind is that whether it's a positive study or a negative study, you need to get it published. A lot of people don't publish their negative trials, even for a high- or lower-impact journal, and that's really important to keep in mind—as long as it's in PubMed and people can find it, because negative trials impact the design of future trials.

In regard to journals, I'd always suggest choosing at least three that you and your attending have agreed upon. It's very common to get rejected the first time around, and sometimes even when a paper is accepted with major revisions, and you complete those revisions, it's still not accepted. A lot of people get disappointed—it happens because sometimes the subject matter just isn't meant for that journal. But many top-tier journals are also associated with a lower-tier journal that can take those revisions and hand them to the next editor, which improves your chances of publication.

I've seen junior faculty members and fellows get overly ambitious about the subject matter, believing they deserve a journal with an impact factor of 20 to 30, and then get rejected and refuse to go to a journal with an impact factor of 7 because they believe they deserve a 15. At that point, you've wasted a year because you've been rejected by two journals and your data isn't as lucrative anymore.

The most important thing is to get it published. And as a fellow—I'm guilty of this too—if you've started writing something during your fellowship, get it completed before you leave. It's less likely to be completed once you move to your next position, whether that's a resident going into fellowship or a fellow becoming an attending, because life happens and you no longer have access to the data. The worst-case scenario is you hand it off to someone junior and end up as third or fourth author, but at least it gets published.

What should fellows expect after a manuscript is submitted, in terms of the review and revision process?

After it's submitted, it usually goes to the editor or section editor of that journal, who then puts in reviewers—usually between two and three per paper—and we try to identify people who are specifically familiar with that subject matter.

The problem is that journal reviewers don't get paid to review, so everyone is very overwhelmed with their current schedule. Unless it's a very high-impact journal, I've sent out review requests to sometimes 20 or 30 people as a section editor and had them rejected. So I'll often get the question, "Why is it taking so long?" I sent it to a ton of people, but they don't necessarily have the time—it also depends on the time of year you submit. If you submit right before a national meeting, it's not likely to get reviewed by anybody, because the reviewer typically only has two weeks—sometimes just one week for journals like the Lancet, though most give two weeks and sometimes an extension.

Identifying a reviewer can take several weeks because this is volunteer work, and I've noticed it's much harder to get reviewers nowadays. Part of that is that they're not compensated and everyone is busy, and part of it may be that junior faculty members don't always know the value of reviewing because they're busy building their own careers. I still review a lot of manuscripts myself, even as a section editor, because I learn from what's going on in the field—sometimes I'll be asked to review a GI cancer I don't commonly see, or a new drug in development, which is exciting because that new drug can have benefit in a malignancy you're interested in. So I try to encourage people to review, because it's harder to find reviewers nowadays.

Once you get the review back, most are major revisions, and the turnaround time varies by manuscript—some are lenient, some are very quick, and you can ask for extensions. For the high-impact journals especially, if a manuscript has gone to three reviewers who each have 10 to 15 comments, that's 50 comments easily—I've had as many as 75 or 80. The high-impact journals tend to be very stringent about formatting and presentation, which adds to your workload.

When you resubmit, most journals want a track-changes copy and a clean copy. I also do a cover letter with each reviewer point in bold and my response immediately underneath, so it's very clear to the reviewer—because as one of those reviewers, we're often asked to review the resubmission, especially with major revisions. It's much easier for me when authors address why they changed something point by point; it's more confusing when a journal doesn't include the track-changes version, because then I can't tell what was changed. A clean copy, a track-changes copy, and a cover letter with a point-by-point response are extremely important.

What are the primary takeaways fellows should know before getting involved in publishing a manuscript?

Number one, as a fellow, this is a great opportunity, and it's extremely important to learn how to write. Your very first time writing, you may be heavily criticized—you may not be familiar with the approach, or the attending you're working with may not like your formatting or your verbiage. Don't be offended; everybody has their own way of approaching things. It's very important for fellows not to get defensive and think their way is the right way—you're here to learn, and the attending is here to help you.

If you're interested in academic medicine and further publications, the more experience you have writing, the easier it becomes. Some things just become natural, and that will help with grant submissions in the future, too, because those require rationale and background and very similar concepts—what's your hypothesis, that kind of thing. It just keeps things flowing and gives you more experience, which makes it easier as your career matures.