On collegiality and role models


  • Fadlo R. Khuri MD

    Editor-in-Chief, Cancer, Corresponding author
    1. Winship Cancer Institute/Emory University, 1365 Clifton Rd, NE, Bldg C-3094, Atlanta, GA 30322
    • Winship Cancer Institute/Emory University, 1365 Clifton Rd, NE, Bldg C-3094, Atlanta, GA 30322
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  • This perspective is dedicated to Waun Ki Hong, MD, FACP, DMSc, recipient of the 2012 American Cancer Society Medal of Honor for Clinical Research, in humble recognition of his continued inspirational mentorship.


In this editorial, Dr. Fadlo Khuri discusses the process of peer reviewing submissions to Cancer.

Illustration  .

“Perhaps the laws of physics cease to exist on your stove.” Vincent LaGuardia Gambini, Esq, My Cousin Vinny, 1992

An angry but expressive appeal of a recent editorial rejection took me by surprise, despite the extent of my experience with both the peer-review process and, unfortunately, with rejection itself. In the letter, the author eloquently and humorously (I hope) accused me of drastically setting back the field of his cancer of interest by several decades, and even of rendering it an orphan disease! While the author did not quite quote the memorable cinematic character above, and the appeal was unsuccessful, the letter certainly triggered a reaction, and this process provoked several questions in my mind about the editorial process as a whole, and several of the challenges we face. The first of these is, how do we best express our concerns when our work, be it our original research manuscripts, reviews or perspectives, grants through which we sustain our research, or even our opinions, is summarily dismissed without what we believe to be an adequate, or even a fair, review? I do not pretend to know all the answers, but I would like to start by attempting to frame the questions. My goal in doing so is not to insult or inflame opinions that are firmly held by distinguished colleagues in the community who have worked hard, often in extraordinarily difficult circumstances, to advance the cause of the study and treatment of diseases that matter greatly to them–in some cases, diseases they have worked on their whole lives.

Physicians and scientists are passionate in these circumstances because they care, and precisely because they want to make a difference. These are commendable qualities as opposed to regrettable ones. As I occasionally remind our outstanding section editors and editorial board at Cancer, I take no offense at even the angriest and most strident comments from individuals who feel that their work has not received the proper review. We at Cancer, like other journals, either live and thrive or fail by the basic concept of peer review.

How does one define high-quality peer review in an increasingly specialized world? Who are our peers? What qualities do they bring to bear on the reviews of our work? How do we establish fairness, thoroughness, depth of understanding, and equipoise in these crucial areas? Finally, what do we at Cancer do to ensure that manuscripts are fairly reviewed? These are difficult questions, and I will attempt to answer them over the course of this editorial.

First, Cancer is a journal dedicated to publishing the very best available work on the diagnosis, prevention, epidemiology, and therapy of the various diseases defined as malignant diseases. While we have occasionally published what we presume to be high-impact articles on premalignancy, a key part of the process that ultimately leads to the disease, much of our focus is on the evaluation of the biology, epidemiology, prevention, and therapeutics of adult and pediatric cancers. As such, we attempt to attract the very best authors and convince them to submit their best work, recognizing that as we move toward a thinner, more selective journal this year, with a target acceptance rate of 16% and a goal of publishing 18–20 articles per issue, we will unfortunately miss the opportunity to publish much outstanding work from many exceptional investigators. It is our goal to continue to attract the best work of individuals, but given our rejection rate at the editorial level of approximately 60% of submitted manuscripts, many of these individuals will inevitably feel, on some level, hard done by in the review of their work. To attract this quality of submissions, we recruit and retain some of the very best experts in our field to serve as reviewers, hopefully on a repeat basis.

So how does editorial rejection occur? How can we, over a short time frame, decline to publish work that has taken many months, and in some cases many years, of hard work, honestly done, with results that do not always satisfy either the principal investigator or ourselves? The first thing I can definitively state is that we are not looking for uniformly positive results so as to further buttress our reputation as the treasure trove of much of our scientific history as a community. While we would certainly aspire to publish highly positive, landmark controlled trials, both clinical and epidemiological, as well as fundamental biological discoveries, important negative data are also something we do publish, if they are believed likely to have a substantial and meaningful impact on the field.

Please allow me to elaborate. For something to be considered to have a substantial impact on the field, the work will need to be considered by myself, and our section editors and editorial board, to be work likely of enduring impact. Science is replete with examples of magnificent discoveries that were soon overturned (and there are far too many to cite here). Among other qualities, we look for strong, steady work that is adequately powered, clearly novel in its inception, and not simply an incremental advance on the authors' previous work. We attempt to review all work previously published by the author or group of authors to ascertain that this is indeed novel work to begin with. Furthermore, we consider every review we receive carefully and do not limit the number of appeals we receive from each individual author. Cancer, like other top journals, is not the National Football League, in which teams are limited to 2 to 3 appeals per game. Rather, I handle the appeals of editorial decisions in collaboration with relevant section editors or our editorial board, and I make the final decision in each of these cases with regard to whether the appeal moves forward. We take very seriously the hard work authors put into their manuscripts, even those that we do not send out for review. However, there are 2 important sides to this story that are worth describing.

To begin with, my section editors and I do not send out for review any paper that we believe does not have a strong chance of ultimately being accepted. In other words, of the 40% of manuscripts that we send out for review, we anticipate that a total of 16%, or 40% of the aforementioned 40%, will ultimately be accepted for publication in Cancer. We repeatedly examine and consistently ascertain that we have deep and adequate expertise represented across the multiple subspecialties of cancer on which we publish, both among our section editors and our editorial board, which I have recently expanded. Here, I must emphasize that our section editors represent some of the best and brightest people in their fields and, equally important, some of the most dedicated. Many of them oversee multiple manuscript reviews at one time, in an era in which there has been a proliferation of journals and a dramatic increase in the number of requests to review that naturally follows this proliferation of journals. We keep a carefully annotated electronic log of the performance of our reviewers, as do other top journals, with regard to their timeliness, depth of review, responsiveness to reviews, and even-handedness.

Importantly, we strongly consider requests for specific reviewers by authors with respect to their manuscript in the submission process. However, it must be said that submitting names of referees who turn out to be long-time collaborators of the authors substantially detracts from our likelihood of considering the material. In other words, submitting top-quality reviewer names as alternatives when submitting an article to the journal is commendable, as long as they are not long-standing collaborators. It is difficult for me to consider that the National Institutes of Health, which for years has excluded recent coauthors as viable reviewers, got this one wrong (http://public.csr.nih.gov/Pages/default.aspx). Conflicts of interest are a real and present challenge to our peer-review system.

We hope that the spirit of transparency, fairness, and willingness to have your best work reviewed by the people you most respect and admire in the field continues to pervade the process by which our finest grants, manuscripts, and scientific work are reviewed and accepted. We also hope that we have shared the transparent processes and opportunities that Cancer provides authors to publish their very finest work, even those who have felt hard done by as a result of an expedited review. Remember that as physicians and scientists, we are role models to the young people who will change our future and the future of not only the diseases we study and treat, but indeed of mankind itself.