what is a peer reviewed research paper

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Articles: Finding (and Identifying) Peer-Reviewed Articles: What is Peer Review?

• What is Peer Review?
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Peer Review in 3 Minutes

What is "Peer-Review"?

What are they.

Scholarly articles are papers that describe a research study. 

Why are scholarly articles useful?

They report original research projects that have been reviewed by other experts before they are accepted for publication, so you can reasonably be assured that they contain valid information. 

How do you identify scholarly or peer-reviewed articles?

• They are usually fairly lengthy - most likely at least 7-10 pages
• The authors and their credentials should be identified, at least the company or university where the author is employed
• There is usually a list of References or Works Cited at the end of the paper, listing the sources that the authors used in their research

How do you find them? 

Some of the library's databases contain scholarly articles, either exclusively or in combination with other types of articles. 

Google Scholar is another option for searching for scholarly articles. 

Know the Difference Between Scholarly and Popular Journals/Magazines

Peer reviewed articles are found in scholarly journals.  The checklist below can help you determine if what you are looking at is peer reviewed or scholarly.

• Both kinds of journals and magazines can be useful sources of information.
• Popular magazines and newspapers are good for overviews, recent news, first-person accounts, and opinions about a topic.
• Scholarly journals, often called scientific or peer-reviewed journals, are good sources of actual studies or research conducted about a particular topic. They go through a process of review by experts, so the information is usually highly reliable.

• Next: Finding Peer Reviewed Articles >>
• Last Updated: May 21, 2024 8:45 AM
• URL: https://libguides.usu.edu/peer-review

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License

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Understanding Peer Review in Science

Peer review is an essential element of the scientific publishing process that helps ensure that research articles are evaluated, critiqued, and improved before release into the academic community. Take a look at the significance of peer review in scientific publications, the typical steps of the process, and and how to approach peer review if you are asked to assess a manuscript.

What Is Peer Review?

Peer review is the evaluation of work by peers, who are people with comparable experience and competency. Peers assess each others’ work in educational settings, in professional settings, and in the publishing world. The goal of peer review is improving quality, defining and maintaining standards, and helping people learn from one another.

In the context of scientific publication, peer review helps editors determine which submissions merit publication and improves the quality of manuscripts prior to their final release.

Types of Peer Review for Manuscripts

There are three main types of peer review:

• Single-blind review: The reviewers know the identities of the authors, but the authors do not know the identities of the reviewers.
• Double-blind review: Both the authors and reviewers remain anonymous to each other.
• Open peer review: The identities of both the authors and reviewers are disclosed, promoting transparency and collaboration.

There are advantages and disadvantages of each method. Anonymous reviews reduce bias but reduce collaboration, while open reviews are more transparent, but increase bias.

Key Elements of Peer Review

Proper selection of a peer group improves the outcome of the process:

• Expertise : Reviewers should possess adequate knowledge and experience in the relevant field to provide constructive feedback.
• Objectivity : Reviewers assess the manuscript impartially and without personal bias.
• Confidentiality : The peer review process maintains confidentiality to protect intellectual property and encourage honest feedback.
• Timeliness : Reviewers provide feedback within a reasonable timeframe to ensure timely publication.

Steps of the Peer Review Process

The typical peer review process for scientific publications involves the following steps:

• Submission : Authors submit their manuscript to a journal that aligns with their research topic.
• Editorial assessment : The journal editor examines the manuscript and determines whether or not it is suitable for publication. If it is not, the manuscript is rejected.
• Peer review : If it is suitable, the editor sends the article to peer reviewers who are experts in the relevant field.
• Reviewer feedback : Reviewers provide feedback, critique, and suggestions for improvement.
• Revision and resubmission : Authors address the feedback and make necessary revisions before resubmitting the manuscript.
• Final decision : The editor makes a final decision on whether to accept or reject the manuscript based on the revised version and reviewer comments.
• Publication : If accepted, the manuscript undergoes copyediting and formatting before being published in the journal.

Pros and Cons

While the goal of peer review is improving the quality of published research, the process isn’t without its drawbacks.

• Quality assurance : Peer review helps ensure the quality and reliability of published research.
• Error detection : The process identifies errors and flaws that the authors may have overlooked.
• Credibility : The scientific community generally considers peer-reviewed articles to be more credible.
• Professional development : Reviewers can learn from the work of others and enhance their own knowledge and understanding.
• Time-consuming : The peer review process can be lengthy, delaying the publication of potentially valuable research.
• Bias : Personal biases of reviews impact their evaluation of the manuscript.
• Inconsistency : Different reviewers may provide conflicting feedback, making it challenging for authors to address all concerns.
• Limited effectiveness : Peer review does not always detect significant errors or misconduct.
• Poaching : Some reviewers take an idea from a submission and gain publication before the authors of the original research.

Steps for Conducting Peer Review of an Article

Generally, an editor provides guidance when you are asked to provide peer review of a manuscript. Here are typical steps of the process.

• Accept the right assignment: Accept invitations to review articles that align with your area of expertise to ensure you can provide well-informed feedback.
• Manage your time: Allocate sufficient time to thoroughly read and evaluate the manuscript, while adhering to the journal’s deadline for providing feedback.
• Read the manuscript multiple times: First, read the manuscript for an overall understanding of the research. Then, read it more closely to assess the details, methodology, results, and conclusions.
• Evaluate the structure and organization: Check if the manuscript follows the journal’s guidelines and is structured logically, with clear headings, subheadings, and a coherent flow of information.
• Assess the quality of the research: Evaluate the research question, study design, methodology, data collection, analysis, and interpretation. Consider whether the methods are appropriate, the results are valid, and the conclusions are supported by the data.
• Examine the originality and relevance: Determine if the research offers new insights, builds on existing knowledge, and is relevant to the field.
• Check for clarity and consistency: Review the manuscript for clarity of writing, consistent terminology, and proper formatting of figures, tables, and references.
• Identify ethical issues: Look for potential ethical concerns, such as plagiarism, data fabrication, or conflicts of interest.
• Provide constructive feedback: Offer specific, actionable, and objective suggestions for improvement, highlighting both the strengths and weaknesses of the manuscript. Don’t be mean.
• Organize your review: Structure your review with an overview of your evaluation, followed by detailed comments and suggestions organized by section (e.g., introduction, methods, results, discussion, and conclusion).
• Be professional and respectful: Maintain a respectful tone in your feedback, avoiding personal criticism or derogatory language.
• Proofread your review: Before submitting your review, proofread it for typos, grammar, and clarity.
• Couzin-Frankel J (September 2013). “Biomedical publishing. Secretive and subjective, peer review proves resistant to study”. Science . 341 (6152): 1331. doi: 10.1126/science.341.6152.1331
• Lee, Carole J.; Sugimoto, Cassidy R.; Zhang, Guo; Cronin, Blaise (2013). “Bias in peer review”. Journal of the American Society for Information Science and Technology. 64 (1): 2–17. doi: 10.1002/asi.22784
• Slavov, Nikolai (2015). “Making the most of peer review”. eLife . 4: e12708. doi: 10.7554/eLife.12708
• Spier, Ray (2002). “The history of the peer-review process”. Trends in Biotechnology . 20 (8): 357–8. doi: 10.1016/S0167-7799(02)01985-6
• Squazzoni, Flaminio; Brezis, Elise; Marušić, Ana (2017). “Scientometrics of peer review”. Scientometrics . 113 (1): 501–502. doi: 10.1007/s11192-017-2518-4

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What is peer review.

Peer review is ‘a process where scientists (“peers”) evaluate the quality of other scientists’ work. By doing this, they aim to ensure the work is rigorous, coherent, uses past research and adds to what we already know.’ You can learn more in this explainer from the Social Science Space.  

Peer review brings academic research to publication in the following ways:

• Evaluation – Peer review is an effective form of research evaluation to help select the highest quality articles for publication.
• Integrity – Peer review ensures the integrity of the publishing process and the scholarly record. Reviewers are independent of journal publications and the research being conducted.
• Quality – The filtering process and revision advice improve the quality of the final research article as well as offering the author new insights into their research methods and the results that they have compiled. Peer review gives authors access to the opinions of experts in the field who can provide support and insight.

Types of peer review

• Single-anonymized  – the name of the reviewer is hidden from the author.
• Double-anonymized  – names are hidden from both reviewers and the authors.
• Triple-anonymized  – names are hidden from authors, reviewers, and the editor.
• Open peer review comes in many forms . At Sage we offer a form of open peer review on some journals via our Transparent Peer Review program , whereby the reviews are published alongside the article. The names of the reviewers may also be published, depending on the reviewers’ preference.
• Post publication peer review can offer useful interaction and a discussion forum for the research community. This form of peer review is not usual or appropriate in all fields.

To learn more about the different types of peer review, see page 14 of ‘ The Nuts and Bolts of Peer Review ’ from Sense about Science.

Please double check the manuscript submission guidelines of the journal you are reviewing in order to ensure that you understand the method of peer review being used.

• Journal Author Gateway
• Journal Editor Gateway
• Transparent Peer Review
• How to Review Articles
• Using Sage Track
• Peer Review Ethics
• Resources for Reviewers
• Reviewer Rewards
• Ethics & Responsibility
• Sage editorial policies
• Publication Ethics Policies
• Sage Chinese Author Gateway 中国作者资源

Explainer: what is peer review?

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We’ve all heard the phrase “peer review” as giving credence to research and scholarly papers, but what does it actually mean? How does it work?

Peer review is one of the gold standards of science. It’s a process where scientists (“peers”) evaluate the quality of other scientists’ work. By doing this, they aim to ensure the work is rigorous, coherent, uses past research and adds to what we already knew.

Most scientific journals, conferences and grant applications have some sort of peer review system. In most cases it is “double blind” peer review. This means evaluators do not know the author(s), and the author(s) do not know the identity of the evaluators. The intention behind this system is to ensure evaluation is not biased.

The more prestigious the journal, conference, or grant, the more demanding will be the review process, and the more likely the rejection. This prestige is why these papers tend to be more read and more cited.

The process in details

The peer review process for journals involves at least three stages.

1. The desk evaluation stage

When a paper is submitted to a journal, it receives an initial evaluation by the chief editor, or an associate editor with relevant expertise.

At this stage, either can “desk reject” the paper: that is, reject the paper without sending it to blind referees. Generally, papers are desk rejected if the paper doesn’t fit the scope of the journal or there is a fundamental flaw which makes it unfit for publication.

In this case, the rejecting editors might write a letter summarising his or her concerns. Some journals, such as the British Medical Journal , desk reject up to two-thirds or more of the papers.

2. The blind review

If the editorial team judges there are no fundamental flaws, they send it for review to blind referees. The number of reviewers depends on the field: in finance there might be only one reviewer, while journals in other fields of social sciences might ask up to four reviewers. Those reviewers are selected by the editor on the basis of their expert knowledge and their absence of a link with the authors.

Reviewers will decide whether to reject the paper, to accept it as it is (which rarely happens) or to ask for the paper to be revised. This means the author needs to change the paper in line with the reviewers’ concerns.

Usually the reviews deal with the validity and rigour of the empirical method, and the importance and originality of the findings (what is called the “contribution” to the existing literature). The editor collects those comments, weights them, takes a decision, and writes a letter summarising the reviewers’ and his or her own concerns.

It can therefore happen that despite hostility on the part of the reviewers, the editor could offer the paper a subsequent round of revision. In the best journals in the social sciences, 10% to 20% of the papers are offered a “revise-and-resubmit” after the first round.

3. The revisions – if you are lucky enough

If the paper has not been rejected after this first round of review, it is sent back to the author(s) for a revision. The process is repeated as many times as necessary for the editor to reach a consensus point on whether to accept or reject the paper. In some cases this can last for several years.

Ultimately, less than 10% of the submitted papers are accepted in the best journals in the social sciences. The renowned journal Nature publishes around 7% of the submitted papers.

Strengths and weaknesses of the peer review process

The peer review process is seen as the gold standard in science because it ensures the rigour, novelty, and consistency of academic outputs. Typically, through rounds of review, flawed ideas are eliminated and good ideas are strengthened and improved. Peer reviewing also ensures that science is relatively independent.

Because scientific ideas are judged by other scientists, the crucial yardstick is scientific standards. If other people from outside of the field were involved in judging ideas, other criteria such as political or economic gain might be used to select ideas. Peer reviewing is also seen as a crucial way of removing personalities and bias from the process of judging knowledge.

Despite the undoubted strengths, the peer review process as we know it has been criticised . It involves a number of social interactions that might create biases – for example, authors might be identified by reviewers if they are in the same field, and desk rejections are not blind.

It might also favour incremental (adding to past research) rather than innovative (new) research. Finally, reviewers are human after all and can make mistakes, misunderstand elements, or miss errors.

Are there any alternatives?

Defenders of the peer review system say although there are flaws, we’re yet to find a better system to evaluate research. However, a number of innovations have been introduced in the academic review system to improve its objectivity and efficiency.

Some new open-access journals (such as PLOS ONE ) publish papers with very little evaluation (they check the work is not deeply flawed methodologically). The focus there is on the post-publication peer review system: all readers can comment and criticise the paper.

Some journals such as Nature, have made part of the review process public (“open” review), offering a hybrid system in which peer review plays a role of primary gate keepers, but the public community of scholars judge in parallel (or afterwards in some other journals) the value of the research.

Another idea is to have a set of reviewers rating the paper each time it is revised. In this case, authors will be able to choose whether they want to invest more time in a revision to obtain a better rating, and get their work publicly recognised.

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• What Is Peer Review? | Types & Examples

What Is Peer Review? | Types & Examples

Published on 6 May 2022 by Tegan George . Revised on 2 September 2022.

Peer review, sometimes referred to as refereeing , is the process of evaluating submissions to an academic journal. Using strict criteria, a panel of reviewers in the same subject area decides whether to accept each submission for publication.

Peer-reviewed articles are considered a highly credible source due to the stringent process they go through before publication.

There are various types of peer review. The main difference between them is to what extent the authors, reviewers, and editors know each other’s identities. The most common types are:

• Single-blind review
• Double-blind review
• Triple-blind review

Collaborative review

Open review.

Relatedly, peer assessment is a process where your peers provide you with feedback on something you’ve written, based on a set of criteria or benchmarks from an instructor. They then give constructive feedback, compliments, or guidance to help you improve your draft.

Table of contents

What is the purpose of peer review, types of peer review, the peer review process, providing feedback to your peers, peer review example, advantages of peer review, criticisms of peer review, frequently asked questions about peer review.

Many academic fields use peer review, largely to determine whether a manuscript is suitable for publication. Peer review enhances the credibility of the manuscript. For this reason, academic journals are among the most credible sources you can refer to.

However, peer review is also common in non-academic settings. The United Nations, the European Union, and many individual nations use peer review to evaluate grant applications. It is also widely used in medical and health-related fields as a teaching or quality-of-care measure.

Peer assessment is often used in the classroom as a pedagogical tool. Both receiving feedback and providing it are thought to enhance the learning process, helping students think critically and collaboratively.

Prevent plagiarism, run a free check.

Depending on the journal, there are several types of peer review.

Single-blind peer review

The most common type of peer review is single-blind (or single anonymised) review . Here, the names of the reviewers are not known by the author.

While this gives the reviewers the ability to give feedback without the possibility of interference from the author, there has been substantial criticism of this method in the last few years. Many argue that single-blind reviewing can lead to poaching or intellectual theft or that anonymised comments cause reviewers to be too harsh.

Double-blind peer review

In double-blind (or double anonymised) review , both the author and the reviewers are anonymous.

Arguments for double-blind review highlight that this mitigates any risk of prejudice on the side of the reviewer, while protecting the nature of the process. In theory, it also leads to manuscripts being published on merit rather than on the reputation of the author.

Triple-blind peer review

While triple-blind (or triple anonymised) review – where the identities of the author, reviewers, and editors are all anonymised – does exist, it is difficult to carry out in practice.

Proponents of adopting triple-blind review for journal submissions argue that it minimises potential conflicts of interest and biases. However, ensuring anonymity is logistically challenging, and current editing software is not always able to fully anonymise everyone involved in the process.

In collaborative review , authors and reviewers interact with each other directly throughout the process. However, the identity of the reviewer is not known to the author. This gives all parties the opportunity to resolve any inconsistencies or contradictions in real time, and provides them a rich forum for discussion. It can mitigate the need for multiple rounds of editing and minimise back-and-forth.

Collaborative review can be time- and resource-intensive for the journal, however. For these collaborations to occur, there has to be a set system in place, often a technological platform, with staff monitoring and fixing any bugs or glitches.

Lastly, in open review , all parties know each other’s identities throughout the process. Often, open review can also include feedback from a larger audience, such as an online forum, or reviewer feedback included as part of the final published product.

While many argue that greater transparency prevents plagiarism or unnecessary harshness, there is also concern about the quality of future scholarship if reviewers feel they have to censor their comments.

In general, the peer review process includes the following steps:

• First, the author submits the manuscript to the editor.
• Reject the manuscript and send it back to the author, or
• Send it onward to the selected peer reviewer(s)
• Next, the peer review process occurs. The reviewer provides feedback, addressing any major or minor issues with the manuscript, and gives their advice regarding what edits should be made.
• Lastly, the edited manuscript is sent back to the author. They input the edits and resubmit it to the editor for publication.

In an effort to be transparent, many journals are now disclosing who reviewed each article in the published product. There are also increasing opportunities for collaboration and feedback, with some journals allowing open communication between reviewers and authors.

It can seem daunting at first to conduct a peer review or peer assessment. If you’re not sure where to start, there are several best practices you can use.

Summarise the argument in your own words

Summarising the main argument helps the author see how their argument is interpreted by readers, and gives you a jumping-off point for providing feedback. If you’re having trouble doing this, it’s a sign that the argument needs to be clearer, more concise, or worded differently.

If the author sees that you’ve interpreted their argument differently than they intended, they have an opportunity to address any misunderstandings when they get the manuscript back.

Separate your feedback into major and minor issues

It can be challenging to keep feedback organised. One strategy is to start out with any major issues and then flow into the more minor points. It’s often helpful to keep your feedback in a numbered list, so the author has concrete points to refer back to.

Major issues typically consist of any problems with the style, flow, or key points of the manuscript. Minor issues include spelling errors, citation errors, or other smaller, easy-to-apply feedback.

The best feedback you can provide is anything that helps them strengthen their argument or resolve major stylistic issues.

Give the type of feedback that you would like to receive

No one likes being criticised, and it can be difficult to give honest feedback without sounding overly harsh or critical. One strategy you can use here is the ‘compliment sandwich’, where you ‘sandwich’ your constructive criticism between two compliments.

Be sure you are giving concrete, actionable feedback that will help the author submit a successful final draft. While you shouldn’t tell them exactly what they should do, your feedback should help them resolve any issues they may have overlooked.

As a rule of thumb, your feedback should be:

• Easy to understand
• Constructive

Below is a brief annotated research example. You can view examples of peer feedback by hovering over the highlighted sections.

Influence of phone use on sleep

Studies show that teens from the US are getting less sleep than they were a decade ago (Johnson, 2019) . On average, teens only slept for 6 hours a night in 2021, compared to 8 hours a night in 2011. Johnson mentions several potential causes, such as increased anxiety, changed diets, and increased phone use.

The current study focuses on the effect phone use before bedtime has on the number of hours of sleep teens are getting.

For this study, a sample of 300 teens was recruited using social media, such as Facebook, Instagram, and Snapchat. The first week, all teens were allowed to use their phone the way they normally would, in order to obtain a baseline.

The sample was then divided into 3 groups:

• Group 1 was not allowed to use their phone before bedtime.
• Group 2 used their phone for 1 hour before bedtime.
• Group 3 used their phone for 3 hours before bedtime.

All participants were asked to go to sleep around 10 p.m. to control for variation in bedtime . In the morning, their Fitbit showed the number of hours they’d slept. They kept track of these numbers themselves for 1 week.

Two independent t tests were used in order to compare Group 1 and Group 2, and Group 1 and Group 3. The first t test showed no significant difference ( p > .05) between the number of hours for Group 1 ( M = 7.8, SD = 0.6) and Group 2 ( M = 7.0, SD = 0.8). The second t test showed a significant difference ( p < .01) between the average difference for Group 1 ( M = 7.8, SD = 0.6) and Group 3 ( M = 6.1, SD = 1.5).

This shows that teens sleep fewer hours a night if they use their phone for over an hour before bedtime, compared to teens who use their phone for 0 to 1 hours.

Peer review is an established and hallowed process in academia, dating back hundreds of years. It provides various fields of study with metrics, expectations, and guidance to ensure published work is consistent with predetermined standards.

• Protects the quality of published research

Peer review can stop obviously problematic, falsified, or otherwise untrustworthy research from being published. Any content that raises red flags for reviewers can be closely examined in the review stage, preventing plagiarised or duplicated research from being published.

• Gives you access to feedback from experts in your field

Peer review represents an excellent opportunity to get feedback from renowned experts in your field and to improve your writing through their feedback and guidance. Experts with knowledge about your subject matter can give you feedback on both style and content, and they may also suggest avenues for further research that you hadn’t yet considered.

• Helps you identify any weaknesses in your argument

Peer review acts as a first defence, helping you ensure your argument is clear and that there are no gaps, vague terms, or unanswered questions for readers who weren’t involved in the research process. This way, you’ll end up with a more robust, more cohesive article.

While peer review is a widely accepted metric for credibility, it’s not without its drawbacks.

• Reviewer bias

The more transparent double-blind system is not yet very common, which can lead to bias in reviewing. A common criticism is that an excellent paper by a new researcher may be declined, while an objectively lower-quality submission by an established researcher would be accepted.

• Delays in publication

The thoroughness of the peer review process can lead to significant delays in publishing time. Research that was current at the time of submission may not be as current by the time it’s published.

• Risk of human error

By its very nature, peer review carries a risk of human error. In particular, falsification often cannot be detected, given that reviewers would have to replicate entire experiments to ensure the validity of results.

Peer review is a process of evaluating submissions to an academic journal. Utilising rigorous criteria, a panel of reviewers in the same subject area decide whether to accept each submission for publication.

For this reason, academic journals are often considered among the most credible sources you can use in a research project – provided that the journal itself is trustworthy and well regarded.

Peer review can stop obviously problematic, falsified, or otherwise untrustworthy research from being published. It also represents an excellent opportunity to get feedback from renowned experts in your field.

It acts as a first defence, helping you ensure your argument is clear and that there are no gaps, vague terms, or unanswered questions for readers who weren’t involved in the research process.

Peer-reviewed articles are considered a highly credible source due to this stringent process they go through before publication.

In general, the peer review process follows the following steps:

• Reject the manuscript and send it back to author, or
• Lastly, the edited manuscript is sent back to the author. They input the edits, and resubmit it to the editor for publication.

Many academic fields use peer review , largely to determine whether a manuscript is suitable for publication. Peer review enhances the credibility of the published manuscript.

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What is peer review?

From a publisher’s perspective, peer review functions as a filter for content, directing better quality articles to better quality journals and so creating journal brands.

Running articles through the process of peer review adds value to them. For this reason publishers need to make sure that peer review is robust.

Editor Feedback

"Pointing out the specifics about flaws in the paper’s structure is paramount. Are methods valid, is data clearly presented, and are conclusions supported by data?” (Editor feedback)

“If an editor can read your comments and understand clearly the basis for your recommendation, then you have written a helpful review.” (Editor feedback)

Peer Review at Its Best

What peer review does best is improve the quality of published papers by motivating authors to submit good quality work – and helping to improve that work through the peer review process. 

In fact, 90% of researchers feel that peer review improves the quality of their published paper (University of Tennessee and CIBER Research Ltd, 2013).

What the Critics Say

The peer review system is not without criticism. Studies show that even after peer review, some articles still contain inaccuracies and demonstrate that most rejected papers will go on to be published somewhere else.

However, these criticisms should be understood within the context of peer review as a human activity. The occasional errors of peer review are not reasons for abandoning the process altogether – the mistakes would be worse without it.

Improving Effectiveness

Some of the ways in which Wiley is seeking to improve the efficiency of the process, include:

• Reducing the amount of repeat reviewing by innovating around transferable peer review
• Providing training and best practice guidance to peer reviewers
• Improving recognition of the contribution made by reviewers

Visit our Peer Review Process and Types of Peer Review pages for additional detailed information on peer review.

Transparency in Peer Review

Wiley is committed to increasing transparency in peer review, increasing accountability for the peer review process and giving recognition to the work of peer reviewers and editors. We are also actively exploring other peer review models to give researchers the options that suit them and their communities.

Special Issues

Special Issues are subject to extensive review, during which journal Editors or Editorial Board input is solicited for each proposal. Our approval process includes an assessment of the rationale and scope of the proposed topic(s), and the expertise of Guest Editors, if any are involved. Special Issue articles must follow the same policies as described in the journal's Author Guidelines.

Editor/Editorial Board papers

Papers authored by Editors or Editorial Board members of the title are sent to Editors that are unaffiliated with the author or institution and monitored carefully to ensure there is no peer review bias.

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• CAREER COLUMN
• 08 October 2018

How to write a thorough peer review

• Mathew Stiller-Reeve 0

Mathew Stiller-Reeve is a climate researcher at NORCE/Bjerknes Centre for Climate Research in Bergen, Norway, the leader of SciSnack.com, and a thematic editor at Geoscience Communication .

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Scientists do not receive enough peer-review training. To improve this situation, a small group of editors and I developed a peer-review workflow to guide reviewers in delivering useful and thorough analyses that can really help authors to improve their papers.

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doi: https://doi.org/10.1038/d41586-018-06991-0

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What is the Purpose of Peer Review?

What makes a good peer reviewer, how do you decide whether to review a paper, how do you complete a peer review, limitations of peer review, conclusions, research methods: how to perform an effective peer review.

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Elise Peterson Lu , Brett G. Fischer , Melissa A. Plesac , Andrew P.J. Olson; Research Methods: How to Perform an Effective Peer Review. Hosp Pediatr November 2022; 12 (11): e409–e413. https://doi.org/10.1542/hpeds.2022-006764

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Scientific peer review has existed for centuries and is a cornerstone of the scientific publication process. Because the number of scientific publications has rapidly increased over the past decades, so has the number of peer reviews and peer reviewers. In this paper, drawing on the relevant medical literature and our collective experience as peer reviewers, we provide a user guide to the peer review process, including discussion of the purpose and limitations of peer review, the qualities of a good peer reviewer, and a step-by-step process of how to conduct an effective peer review.

Peer review has been a part of scientific publications since 1665, when the Philosophical Transactions of the Royal Society became the first publication to formalize a system of expert review. 1 , 2   It became an institutionalized part of science in the latter half of the 20 th century and is now the standard in scientific research publications. 3   In 2012, there were more than 28 000 scholarly peer-reviewed journals and more than 3 million peer reviewed articles are now published annually. 3 , 4   However, even with this volume, most peer reviewers learn to review “on the (unpaid) job” and no standard training system exists to ensure quality and consistency. 5   Expectations and format vary between journals and most, but not all, provide basic instructions for reviewers. In this paper, we provide a general introduction to the peer review process and identify common strategies for success as well as pitfalls to avoid.

Modern peer review serves 2 primary purposes: (1) as “a screen before the diffusion of new knowledge” 6   and (2) as a method to improve the quality of published work. 1 , 5  

As screeners, peer reviewers evaluate the quality, validity, relevance, and significance of research before publication to maintain the credibility of the publications they serve and their fields of study. 1 , 2 , 7   Although peer reviewers are not the final decision makers on publication (that role belongs to the editor), their recommendations affect editorial decisions and thoughtful comments influence an article’s fate. 6 , 8  

As advisors and evaluators of manuscripts, reviewers have an opportunity and responsibility to give authors an outside expert’s perspective on their work. 9   They provide feedback that can improve methodology, enhance rigor, improve clarity, and redefine the scope of articles. 5 , 8 , 10   This often happens even if a paper is not ultimately accepted at the reviewer’s journal because peer reviewers’ comments are incorporated into revised drafts that are submitted to another journal. In a 2019 survey of authors, reviewers, and editors, 83% said that peer review helps science communication and 90% of authors reported that peer review improved their last paper. 11  

Expertise: Peer reviewers should be up to date with current literature, practice guidelines, and methodology within their subject area. However, academic rank and seniority do not define expertise and are not actually correlated with performance in peer review. 13  

Professionalism: Reviewers should be reliable and objective, aware of their own biases, and respectful of the confidentiality of the peer review process.

Critical skill : Reviewers should be organized, thorough, and detailed in their critique with the goal of improving the manuscript under their review, regardless of disposition. They should provide constructive comments that are specific and addressable, referencing literature when possible. A peer reviewer should leave a paper better than he or she found it.

Is the manuscript within your area of expertise? Generally, if you are asked to review a paper, it is because an editor felt that you were a qualified expert. In a 2019 survey, 74% of requested reviews were within the reviewer’s area of expertise. 11   This, of course, does not mean that you must be widely published in the area, only that you have enough expertise and comfort with the topic to critique and add to the paper.

Do you have any biases that may affect your review? Are there elements of the methodology, content area, or theory with which you disagree? Some disagreements between authors and reviewers are common, expected, and even helpful. However, if a reviewer fundamentally disagrees with an author’s premise such that he or she cannot be constructive, the review invitation should be declined.

Do you have the time? The average review for a clinical journal takes 5 to 6 hours, though many take longer depending on the complexity of the research and the experience of the reviewer. 1 , 14   Journals vary on the requested timeline for return of reviews, though it is usually 1 to 4 weeks. Peer review is often the longest part of the publication process and delays contribute to slower dissemination of important work and decreased author satisfaction. 15   Be mindful of your schedule and only accept a review invitation if you can reasonably return the review in the requested time.

Once you have determined that you are the right person and decided to take on the review, reply to the inviting e-mail or click the associated link to accept (or decline) the invitation. Journal editors invite a limited number of reviewers at a time and wait for responses before inviting others. A common complaint among journal editors surveyed was that reviewers would often take days to weeks to respond to requests, or not respond at all, making it difficult to find appropriate reviewers and prolonging an already long process. 5  

Now that you have decided to take on the review, it is best of have a systematic way of both evaluating the manuscript and writing the review. Various suggestions exist in the literature, but we will describe our standard procedure for review, incorporating specific do’s and don’ts summarized in Table 1 .

Dos and Don’ts of Peer Review

First, read the manuscript once without making notes or forming opinions to get a sense of the paper as whole. Assess the overall tone and flow and define what the authors identify as the main point of their work. Does the work overall make sense? Do the authors tell the story effectively?

Next, read the manuscript again with an eye toward review, taking notes and formulating thoughts on strengths and weaknesses. Consider the methodology and identify the specific type of research described. Refer to the corresponding reporting guideline if applicable (CONSORT for randomized control trials, STROBE for observational studies, PRISMA for systematic reviews). Reporting guidelines often include a checklist, flow diagram, or structured text giving a minimum list of information needed in a manuscript based on the type of research done. 16   This allows the reviewer to formulate a more nuanced and specific assessment of the manuscript.

Next, review the main findings, the significance of the work, and what contribution it makes to the field. Examine the presentation and flow of the manuscript but do not copy edit the text. At this point, you should start to write your review. Some journals provide a format for their reviews, but often it is up to the reviewer. In surveys of journal editors and reviewers, a review organized by manuscript section was the most favored, 5 , 6   so that is what we will describe here.

As you write your review, consider starting with a brief summary of the work that identifies the main topic, explains the basic approach, and describes the findings and conclusions. 12 , 17   Though not universally included in all reviews, we have found this step to be helpful in ensuring that the work is conveyed clearly enough for the reviewer to summarize it. Include brief notes on the significance of the work and what it adds to current knowledge. Critique the presentation of the work: is it clearly written? Is its length appropriate? List any major concerns with the work overall, such as major methodological flaws or inaccurate conclusions that should disqualify it from publication, though do not comment directly on disposition. Then perform your review by section:

Abstract : Is it consistent with the rest of the paper? Does it adequately describe the major points?

Introduction : This section should provide adequate background to explain the need for the study. Generally, classic or highly relevant studies should be cited, but citations do not have to be exhaustive. The research question and hypothesis should be clearly stated.

Methods: Evaluate both the methods themselves and the way in which they are explained. Does the methodology used meet the needs of the questions proposed? Is there sufficient detail to explain what the authors did and, if not, what needs to be added? For clinical research, examine the inclusion/exclusion criteria, control populations, and possible sources of bias. Reporting guidelines can be particularly helpful in determining the appropriateness of the methods and how they are reported.

Some journals will expect an evaluation of the statistics used, whereas others will have a separate statistician evaluate, and the reviewers are generally not expected to have an exhaustive knowledge of statistical methods. Clarify expectations if needed and, if you do not feel qualified to evaluate the statistics, make this clear in your review.

Results: Evaluate the presentation of the results. Is information given in sufficient detail to assess credibility? Are the results consistent with the methodology reported? Are the figures and tables consistent with the text, easy to interpret, and relevant to the work? Make note of data that could be better detailed in figures or tables, rather than included in the text. Make note of inappropriate interpretation in the results section (this should be in discussion) or rehashing of methods.

Discussion: Evaluate the authors’ interpretation of their results, how they address limitations, and the implications of their work. How does the work contribute to the field, and do the authors adequately describe those contributions? Make note of overinterpretation or conclusions not supported by the data.

The length of your review often correlates with your opinion of the quality of the work. If an article has major flaws that you think preclude publication, write a brief review that focuses on the big picture. Articles that may not be accepted but still represent quality work merit longer reviews aimed at helping the author improve the work for resubmission elsewhere.

Generally, do not include your recommendation on disposition in the body of the review itself. Acceptance or rejection is ultimately determined by the editor and including your recommendation in your comments to the authors can be confusing. A journal editor’s decision on acceptance or rejection may depend on more factors than just the quality of the work, including the subject area, journal priorities, other contemporaneous submissions, and page constraints.

Many submission sites include a separate question asking whether to accept, accept with major revision, or reject. If this specific format is not included, then add your recommendation in the “confidential notes to the editor.” Your recommendation should be consistent with the content of your review: don’t give a glowing review but recommend rejection or harshly criticize a manuscript but recommend publication. Last, regardless of your ultimate recommendation on disposition, it is imperative to use respectful and professional language and tone in your written review.

Although peer review is often described as the “gatekeeper” of science and characterized as a quality control measure, peer review is not ideally designed to detect fundamental errors, plagiarism, or fraud. In multiple studies, peer reviewers detected only 20% to 33% of intentionally inserted errors in scientific manuscripts. 18 , 19   Plagiarism similarly is not detected in peer review, largely because of the huge volume of literature available to plagiarize. Most journals now use computer software to identify plagiarism before a manuscript goes to peer review. Finally, outright fraud often goes undetected in peer review. Reviewers start from a position of respect for the authors and trust the data they are given barring obvious inconsistencies. Ultimately, reviewers are “gatekeepers, not detectives.” 7  

Peer review is also limited by bias. Even with the best of intentions, reviewers bring biases including but not limited to prestige bias, affiliation bias, nationality bias, language bias, gender bias, content bias, confirmation bias, bias against interdisciplinary research, publication bias, conservatism, and bias of conflict of interest. 3 , 4 , 6   For example, peer reviewers score methodology higher and are more likely to recommend publication when prestigious author names or institutions are visible. 20   Although bias can be mitigated both by the reviewer and by the journal, it cannot be eliminated. Reviewers should be mindful of their own biases while performing reviews and work to actively mitigate them. For example, if English language editing is necessary, state this with specific examples rather than suggesting the authors seek editing by a “native English speaker.”

Peer review is an essential, though imperfect, part of the forward movement of science. Peer review can function as both a gatekeeper to protect the published record of science and a mechanism to improve research at the level of individual manuscripts. Here, we have described our strategy, summarized in Table 2 , for performing a thorough peer review, with a focus on organization, objectivity, and constructiveness. By using a systematized strategy to evaluate manuscripts and an organized format for writing reviews, you can provide a relatively objective perspective in editorial decision-making. By providing specific and constructive feedback to authors, you contribute to the quality of the published literature.

Take-home Points

FUNDING: No external funding.

CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no potential conflicts of interest to disclose.

Dr Lu performed the literature review and wrote the manuscript. Dr Fischer assisted in the literature review and reviewed and edited the manuscript. Dr Plesac provided background information on the process of peer review, reviewed and edited the manuscript, and completed revisions. Dr Olson provided background information and practical advice, critically reviewed and revised the manuscript, and approved the final manuscript.

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Evaluating Resources: Peer Review

What is peer review.

The term peer review can be confusing, since in some of your courses you may be asked to review the work of your peers. When we talk about peer-reviewed journal articles, this has nothing to do with your peers!

Peer-reviewed journals, also called refereed journals, are journals that use a specific scholarly review process to try to ensure the accuracy and reliability of published articles. When an article is submitted to a peer-reviewed journal for publication, the journal sends the article to other scholars/experts in that field and has them review the article for accuracy and reliability.

Find out more about peer review with our Peer Review Guide:

• Peer Review Guide

Types of peer review

Single blind.

In this process, the names of the reviewers are not known to the author(s). The reviewers do know the name of the author(s).

Double blind

Here, neither reviewers or authors know each other's names.

In the open review process, both reviewers and authors know each other's names.

What about editorial review?

Journals also use an editorial review process. This is not the same as peer review. In an editorial review process an article is evaluated for style guidelines and for clarity. Reviewers here do not look at technical accuracy or errors in data or methodology, but instead look at grammar, style, and whether an article is well written.

What is the difference between scholarly and peer review?

Not all scholarly journals are peer reviewed, but all peer-reviewed journals are scholarly.

• Things that are written for a scholarly or academic audience are considered scholarly writing.
• Peer-reviewed journals are a part of the larger category of scholarly writing.
• Scholarly writing includes many resources that are not peer reviewed, such as books, textbooks, and dissertations.

Scholarly writing does not come with a label that says scholarly . You will need to evaluate the resource to see if it is

• aimed at a scholarly audience
• reporting research, theories or other types of information important to scholars
• documenting and citing sources used to help authenticate the research done

The standard peer review process only applies to journals. While scholarly writing has certainly been edited and reviewed, peer review is a specific process only used by peer-reviewed journals. Books and dissertations may be scholarly, but are not considered peer reviewed.

Check out Select the Right Source for help with what kinds of resources are appropriate for discussion posts, assignments, projects, and more:

• Select the Right Source

How do I locate or verify peer-reviewed articles?

The peer review process is initiated by the journal publisher before an article is even published. Nowhere in the article will it tell you whether or not the article has gone through a peer review process.

You can locate peer-reviewed articles in the Library databases, typically by checking a limiter box.

• Quick Answer: How do I find scholarly, peer reviewed journal articles?

You can verify whether a journal uses a peer review process by using Ulrich's Periodicals Directory.

• Quick Answer: How do I verify that my article is peer reviewed?

What about resources that are not peer-reviewed?

Limiting your search to peer review is a way that you can ensure that you're looking at scholarly journal articles, and not popular or trade publications. Because peer-reviewed articles have been vetted by experts in the field, they are viewed as being held to a higher standard, and therefore are considered to be a high quality source. Professors often prefer peer-reviewed articles because they are considered to be of higher quality.

There are times, though, when the information you need may not be available in a peer-reviewed article.

• You may need to find original work on a theory that was first published in a book.
• You may need to find very current statistical data that comes from a government website.
• You may need background information that comes from a scholarly encyclopedia.

You will want to evaluate these resources to make sure that they are the best source for the information you need.

Note: If you are required for an assignment to find information from a peer-reviewed journal, then you will not be able to use non-peer-reviewed sources such as books, dissertations, or government websites. It's always best to clarify any questions over assignments with your professor.

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Finding Journal Articles 101

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What Does "Peer-reviewed" or "Refereed" Mean?

Peer review is a process that journals use to ensure the articles they publish represent the best scholarship currently available. When an article is submitted to a peer reviewed journal, the editors send it out to other scholars in the same field (the author's peers) to get their opinion on the quality of the scholarship, its relevance to the field, its appropriateness for the journal, etc.

Publications that don't use peer review (Time, Cosmo, Salon) just rely on the judgment of the editors whether an article is up to snuff or not. That's why you can't count on them for solid, scientific scholarship.

Note:This is an entirely different concept from " Review Articles ."

How do I know if a journal publishes peer-reviewed articles?

Usually, you can tell just by looking. A scholarly journal is visibly different from other magazines, but occasionally it can be hard to tell, or you just want to be extra-certain. In that case, you turn to Ulrich's Periodical Directory Online . Just type the journal's title into the text box, hit "submit," and you'll get back a report that will tell you (among other things) whether the journal contains articles that are peer reviewed, or, as Ulrich's calls it, Refereed.

Remember, even journals that use peer review may have some content that does not undergo peer review. The ultimate determination must be made on an article-by-article basis.

For example, the journal  Science  publishes  a mix  of peer-reviewed and non-peer-reviewed content. Here are two articles from the same issue of  Science . 

This one is not peer-reviewed:  https://science-sciencemag-org.ezproxy.lib.utexas.edu/content/303/5655/154.1  This one is a peer-reviewed research article:  https://science-sciencemag-org.ezproxy.lib.utexas.edu/content/303/5655/226

That is consistent with the Ulrichsweb  description of  Science , which states, "Provides news of recent international developments and research in all fields of science. Publishes original research results, reviews and short features."

Test these periodicals in Ulrichs :

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Finding Scholarly Articles: Home

What's a Scholarly Article?

Your professor has specified that you are to use scholarly (or primary research or peer-reviewed or refereed or academic) articles only in your paper. What does that mean?

Scholarly or primary research articles are peer-reviewed , which means that they have gone through the process of being read by reviewers or referees  before being accepted for publication. When a scholar submits an article to a scholarly journal, the manuscript is sent to experts in that field to read and decide if the research is valid and the article should be published. Typically the reviewers indicate to the journal editors whether they think the article should be accepted, sent back for revisions, or rejected.

To decide whether an article is a primary research article, look for the following:

• The author’s (or authors') credentials and academic affiliation(s) should be given;
• There should be an abstract summarizing the research;
• The methods and materials used should be given, often in a separate section;
• There are citations within the text or footnotes referencing sources used;
• Results of the research are given;
• There should be discussion   and  conclusion ;
• With a bibliography or list of references at the end.

Caution: even though a journal may be peer-reviewed, not all the items in it will be. For instance, there might be editorials, book reviews, news reports, etc. Check for the parts of the article to be sure.   

You can limit your search results to primary research, peer-reviewed or refereed articles in many databases. To search for scholarly articles in  HOLLIS , type your keywords in the box at the top, and select  Catalog&Articles  from the choices that appear next.   On the search results screen, look for the  Show Only section on the right and click on  Peer-reviewed articles . (Make sure to  login in with your HarvardKey to get full-text of the articles that Harvard has purchased.)

Many of the databases that Harvard offers have similar features to limit to peer-reviewed or scholarly articles.  For example in Academic Search Premier , click on the box for Scholarly (Peer Reviewed) Journals  on the search screen.

Review articles are another great way to find scholarly primary research articles.   Review articles are not considered "primary research", but they pull together primary research articles on a topic, summarize and analyze them.  In Google Scholar , click on Review Articles  at the left of the search results screen. Ask your professor whether review articles can be cited for an assignment.

A note about Google searching.  A regular Google search turns up a broad variety of results, which can include scholarly articles but Google results also contain commercial and popular sources which may be misleading, outdated, etc.  Use Google Scholar  through the Harvard Library instead.

About Wikipedia .  W ikipedia is not considered scholarly, and should not be cited, but it frequently includes references to scholarly articles. Before using those references for an assignment, double check by finding them in Hollis or a more specific subject  database .

Still not sure about a source? Consult the course syllabus for guidance, contact your professor or teaching fellow, or use the Ask A Librarian service.

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The Peer Review Process

So you need to use scholarly, peer-reviewed articles for an assignment...what does that mean? 

Peer review  is a process for evaluating research studies before they are published by an academic journal. These studies typically communicate  original research  or analysis for other researchers. 

The Peer Review Process at a Glance:

Looking for peer-reviewed articles?  Try searching in OneSearch or a library database  and look for options to limit your results to scholarly/peer-reviewed or academic journals. Check out this brief tutorial to show you how:   How to Locate a Scholarly (Peer Reviewed) Article

Part 1: Watch the Video

Part 1: watch the video all about peer review (3 min.) and reflect on discussion questions..

Discussion Questions

After watching the video, reflect on the following questions:

• According to the video, what are some of the pros and cons of the peer review process?
• Why is the peer review process important to scholarship?
• Do you think peer reviewers should be paid for their work? Why or why not?

Part 2: Practice

Part 2: take an interactive tutorial on reading a research article for your major..

Includes a certification of completion to download and upload to Canvas.

Social Sciences

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(e.g. Visual & Media Arts, Cultural Studies, Literature, History)

Click on the handout to view in a new tab, download, or print.

For Instructors

• Teaching Peer Review for Instructors

In class or for homework, watch the video “All About Peer Review” (3 min.) .

Video discussion questions:

• According to the video, what are some of the pros and cons of the peer review process

Assignment Ideas

• Ask students to conduct their own peer review of an important journal article in your field. Ask them to reflect on the process. What was hard to critique?
• Have students examine a journals’ web page with information for authors. What information is given to the author about the peer review process for this journal?
• Assign this reading by CSUDH faculty member Terry McGlynn, "Should journals pay for manuscript reviews?" What is the author's argument? Who profits the most from published research? You could also hold a debate with one side for paying reviewers and the other side against.
• Search a database like Cabell’s for information on the journal submission process for a particular title or subject. How long does peer review take for a particular title? Is it is a blind review? How many reviewers are solicited? What is their acceptance rate?
• Assign short readings that address peer review models. We recommend this issue of Nature on peer review debate and open review and this Chronicle of Higher Education article on open review in Shakespeare Quarterly .

Proof of Completion

Mix and match this suite of instructional materials for your course needs!

Questions about integrating a graded online component into your class, contact the Online Learning Librarian, Rebecca Nowicki ( [email protected] ).

Example of a certificate of completion:

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How to Write a Peer Review

When you write a peer review for a manuscript, what should you include in your comments? What should you leave out? And how should the review be formatted?

This guide provides quick tips for writing and organizing your reviewer report.

Review Outline

Use an outline for your reviewer report so it’s easy for the editors and author to follow. This will also help you keep your comments organized.

Think about structuring your review like an inverted pyramid. Put the most important information at the top, followed by details and examples in the center, and any additional points at the very bottom.

Here’s how your outline might look:

1. Summary of the research and your overall impression

In your own words, summarize what the manuscript claims to report. This shows the editor how you interpreted the manuscript and will highlight any major differences in perspective between you and the other reviewers. Give an overview of the manuscript’s strengths and weaknesses. Think about this as your “take-home” message for the editors. End this section with your recommended course of action.

2. Discussion of specific areas for improvement

It’s helpful to divide this section into two parts: one for major issues and one for minor issues. Within each section, you can talk about the biggest issues first or go systematically figure-by-figure or claim-by-claim. Number each item so that your points are easy to follow (this will also make it easier for the authors to respond to each point). Refer to specific lines, pages, sections, or figure and table numbers so the authors (and editors) know exactly what you’re talking about.

Major vs. minor issues

What’s the difference between a major and minor issue? Major issues should consist of the essential points the authors need to address before the manuscript can proceed. Make sure you focus on what is  fundamental for the current study . In other words, it’s not helpful to recommend additional work that would be considered the “next step” in the study. Minor issues are still important but typically will not affect the overall conclusions of the manuscript. Here are some examples of what would might go in the “minor” category:

• Missing references (but depending on what is missing, this could also be a major issue)
• Technical clarifications (e.g., the authors should clarify how a reagent works)
• Data presentation (e.g., the authors should present p-values differently)
• Typos, spelling, grammar, and phrasing issues

3. Any other points

Confidential comments for the editors.

Some journals have a space for reviewers to enter confidential comments about the manuscript. Use this space to mention concerns about the submission that you’d want the editors to consider before sharing your feedback with the authors, such as concerns about ethical guidelines or language quality. Any serious issues should be raised directly and immediately with the journal as well.

This section is also where you will disclose any potentially competing interests, and mention whether you’re willing to look at a revised version of the manuscript.

Do not use this space to critique the manuscript, since comments entered here will not be passed along to the authors.  If you’re not sure what should go in the confidential comments, read the reviewer instructions or check with the journal first before submitting your review. If you are reviewing for a journal that does not offer a space for confidential comments, consider writing to the editorial office directly with your concerns.

Get this outline in a template

Giving Feedback

Giving feedback is hard. Giving effective feedback can be even more challenging. Remember that your ultimate goal is to discuss what the authors would need to do in order to qualify for publication. The point is not to nitpick every piece of the manuscript. Your focus should be on providing constructive and critical feedback that the authors can use to improve their study.

If you’ve ever had your own work reviewed, you already know that it’s not always easy to receive feedback. Follow the golden rule: Write the type of review you’d want to receive if you were the author. Even if you decide not to identify yourself in the review, you should write comments that you would be comfortable signing your name to.

In your comments, use phrases like “ the authors’ discussion of X” instead of “ your discussion of X .” This will depersonalize the feedback and keep the focus on the manuscript instead of the authors.

General guidelines for effective feedback

• Justify your recommendation with concrete evidence and specific examples.
• Be specific so the authors know what they need to do to improve.
• Be thorough. This might be the only time you read the manuscript.
• Be professional and respectful. The authors will be reading these comments too.
• Remember to say what you liked about the manuscript!

Don’t

• Recommend additional experiments or  unnecessary elements that are out of scope for the study or for the journal criteria.
• Tell the authors exactly how to revise their manuscript—you don’t need to do their work for them.
• Use the review to promote your own research or hypotheses.
• Focus on typos and grammar. If the manuscript needs significant editing for language and writing quality, just mention this in your comments.
• Submit your review without proofreading it and checking everything one more time.

Before and After: Sample Reviewer Comments

Keeping in mind the guidelines above, how do you put your thoughts into words? Here are some sample “before” and “after” reviewer comments

✗ Before

“The authors appear to have no idea what they are talking about. I don’t think they have read any of the literature on this topic.”

✓ After

“The study fails to address how the findings relate to previous research in this area. The authors should rewrite their Introduction and Discussion to reference the related literature, especially recently published work such as Darwin et al.”

“The writing is so bad, it is practically unreadable. I could barely bring myself to finish it.”

“While the study appears to be sound, the language is unclear, making it difficult to follow. I advise the authors work with a writing coach or copyeditor to improve the flow and readability of the text.”

“It’s obvious that this type of experiment should have been included. I have no idea why the authors didn’t use it. This is a big mistake.”

“The authors are off to a good start, however, this study requires additional experiments, particularly [type of experiment]. Alternatively, the authors should include more information that clarifies and justifies their choice of methods.”

Suggested Language for Tricky Situations

You might find yourself in a situation where you’re not sure how to explain the problem or provide feedback in a constructive and respectful way. Here is some suggested language for common issues you might experience.

What you think : The manuscript is fatally flawed. What you could say: “The study does not appear to be sound” or “the authors have missed something crucial”.

What you think : You don’t completely understand the manuscript. What you could say : “The authors should clarify the following sections to avoid confusion…”

What you think : The technical details don’t make sense. What you could say : “The technical details should be expanded and clarified to ensure that readers understand exactly what the researchers studied.”

What you think: The writing is terrible. What you could say : “The authors should revise the language to improve readability.”

What you think : The authors have over-interpreted the findings. What you could say : “The authors aim to demonstrate [XYZ], however, the data does not fully support this conclusion. Specifically…”

What does a good review look like?

Check out the peer review examples at F1000 Research to see how other reviewers write up their reports and give constructive feedback to authors.

Time to Submit the Review!

Be sure you turn in your report on time. Need an extension? Tell the journal so that they know what to expect. If you need a lot of extra time, the journal might need to contact other reviewers or notify the author about the delay.

Tip: Building a relationship with an editor

You’ll be more likely to be asked to review again if you provide high-quality feedback and if you turn in the review on time. Especially if it’s your first review for a journal, it’s important to show that you are reliable. Prove yourself once and you’ll get asked to review again!

• Getting started as a reviewer
• Responding to an invitation
• Reading a manuscript
• Writing a peer review

The contents of the Peer Review Center are also available as a live, interactive training session, complete with slides, talking points, and activities. …

The contents of the Writing Center are also available as a live, interactive training session, complete with slides, talking points, and activities. …

There’s a lot to consider when deciding where to submit your work. Learn how to choose a journal that will help your study reach its audience, while reflecting your values as a researcher…

How to Write and Publish a Research Paper for a Peer-Reviewed Journal

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• Published: 30 April 2020
• Volume 36 , pages 909–913, ( 2021 )

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• Ella August   ORCID: orcid.org/0000-0001-5151-1036 1 , 2  

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Communicating research findings is an essential step in the research process. Often, peer-reviewed journals are the forum for such communication, yet many researchers are never taught how to write a publishable scientific paper. In this article, we explain the basic structure of a scientific paper and describe the information that should be included in each section. We also identify common pitfalls for each section and recommend strategies to avoid them. Further, we give advice about target journal selection and authorship. In the online resource 1 , we provide an example of a high-quality scientific paper, with annotations identifying the elements we describe in this article.

Similar content being viewed by others

How to Choose the Right Journal

The Point Is…to Publish?

Writing and publishing a scientific paper

Avoid common mistakes on your manuscript.

Introduction

Writing a scientific paper is an important component of the research process, yet researchers often receive little formal training in scientific writing. This is especially true in low-resource settings. In this article, we explain why choosing a target journal is important, give advice about authorship, provide a basic structure for writing each section of a scientific paper, and describe common pitfalls and recommendations for each section. In the online resource 1 , we also include an annotated journal article that identifies the key elements and writing approaches that we detail here. Before you begin your research, make sure you have ethical clearance from all relevant ethical review boards.

Select a Target Journal Early in the Writing Process

We recommend that you select a “target journal” early in the writing process; a “target journal” is the journal to which you plan to submit your paper. Each journal has a set of core readers and you should tailor your writing to this readership. For example, if you plan to submit a manuscript about vaping during pregnancy to a pregnancy-focused journal, you will need to explain what vaping is because readers of this journal may not have a background in this topic. However, if you were to submit that same article to a tobacco journal, you would not need to provide as much background information about vaping.

Information about a journal’s core readership can be found on its website, usually in a section called “About this journal” or something similar. For example, the Journal of Cancer Education presents such information on the “Aims and Scope” page of its website, which can be found here: https://www.springer.com/journal/13187/aims-and-scope .

Peer reviewer guidelines from your target journal are an additional resource that can help you tailor your writing to the journal and provide additional advice about crafting an effective article [ 1 ]. These are not always available, but it is worth a quick web search to find out.

Identify Author Roles Early in the Process

Early in the writing process, identify authors, determine the order of authors, and discuss the responsibilities of each author. Standard author responsibilities have been identified by The International Committee of Medical Journal Editors (ICMJE) [ 2 ]. To set clear expectations about each team member’s responsibilities and prevent errors in communication, we also suggest outlining more detailed roles, such as who will draft each section of the manuscript, write the abstract, submit the paper electronically, serve as corresponding author, and write the cover letter. It is best to formalize this agreement in writing after discussing it, circulating the document to the author team for approval. We suggest creating a title page on which all authors are listed in the agreed-upon order. It may be necessary to adjust authorship roles and order during the development of the paper. If a new author order is agreed upon, be sure to update the title page in the manuscript draft.

In the case where multiple papers will result from a single study, authors should discuss who will author each paper. Additionally, authors should agree on a deadline for each paper and the lead author should take responsibility for producing an initial draft by this deadline.

Structure of the Introduction Section

The introduction section should be approximately three to five paragraphs in length. Look at examples from your target journal to decide the appropriate length. This section should include the elements shown in Fig.  1 . Begin with a general context, narrowing to the specific focus of the paper. Include five main elements: why your research is important, what is already known about the topic, the “gap” or what is not yet known about the topic, why it is important to learn the new information that your research adds, and the specific research aim(s) that your paper addresses. Your research aim should address the gap you identified. Be sure to add enough background information to enable readers to understand your study. Table 1 provides common introduction section pitfalls and recommendations for addressing them.

The main elements of the introduction section of an original research article. Often, the elements overlap

Methods Section

The purpose of the methods section is twofold: to explain how the study was done in enough detail to enable its replication and to provide enough contextual detail to enable readers to understand and interpret the results. In general, the essential elements of a methods section are the following: a description of the setting and participants, the study design and timing, the recruitment and sampling, the data collection process, the dataset, the dependent and independent variables, the covariates, the analytic approach for each research objective, and the ethical approval. The hallmark of an exemplary methods section is the justification of why each method was used. Table 2 provides common methods section pitfalls and recommendations for addressing them.

Results Section

The focus of the results section should be associations, or lack thereof, rather than statistical tests. Two considerations should guide your writing here. First, the results should present answers to each part of the research aim. Second, return to the methods section to ensure that the analysis and variables for each result have been explained.

Begin the results section by describing the number of participants in the final sample and details such as the number who were approached to participate, the proportion who were eligible and who enrolled, and the number of participants who dropped out. The next part of the results should describe the participant characteristics. After that, you may organize your results by the aim or by putting the most exciting results first. Do not forget to report your non-significant associations. These are still findings.

Tables and figures capture the reader’s attention and efficiently communicate your main findings [ 3 ]. Each table and figure should have a clear message and should complement, rather than repeat, the text. Tables and figures should communicate all salient details necessary for a reader to understand the findings without consulting the text. Include information on comparisons and tests, as well as information about the sample and timing of the study in the title, legend, or in a footnote. Note that figures are often more visually interesting than tables, so if it is feasible to make a figure, make a figure. To avoid confusing the reader, either avoid abbreviations in tables and figures, or define them in a footnote. Note that there should not be citations in the results section and you should not interpret results here. Table 3 provides common results section pitfalls and recommendations for addressing them.

Discussion Section

Opposite the introduction section, the discussion should take the form of a right-side-up triangle beginning with interpretation of your results and moving to general implications (Fig.  2 ). This section typically begins with a restatement of the main findings, which can usually be accomplished with a few carefully-crafted sentences.

Major elements of the discussion section of an original research article. Often, the elements overlap

Next, interpret the meaning or explain the significance of your results, lifting the reader’s gaze from the study’s specific findings to more general applications. Then, compare these study findings with other research. Are these findings in agreement or disagreement with those from other studies? Does this study impart additional nuance to well-accepted theories? Situate your findings within the broader context of scientific literature, then explain the pathways or mechanisms that might give rise to, or explain, the results.

Journals vary in their approach to strengths and limitations sections: some are embedded paragraphs within the discussion section, while some mandate separate section headings. Keep in mind that every study has strengths and limitations. Candidly reporting yours helps readers to correctly interpret your research findings.

The next element of the discussion is a summary of the potential impacts and applications of the research. Should these results be used to optimally design an intervention? Does the work have implications for clinical protocols or public policy? These considerations will help the reader to further grasp the possible impacts of the presented work.

Finally, the discussion should conclude with specific suggestions for future work. Here, you have an opportunity to illuminate specific gaps in the literature that compel further study. Avoid the phrase “future research is necessary” because the recommendation is too general to be helpful to readers. Instead, provide substantive and specific recommendations for future studies. Table 4 provides common discussion section pitfalls and recommendations for addressing them.

Follow the Journal’s Author Guidelines

After you select a target journal, identify the journal’s author guidelines to guide the formatting of your manuscript and references. Author guidelines will often (but not always) include instructions for titles, cover letters, and other components of a manuscript submission. Read the guidelines carefully. If you do not follow the guidelines, your article will be sent back to you.

Finally, do not submit your paper to more than one journal at a time. Even if this is not explicitly stated in the author guidelines of your target journal, it is considered inappropriate and unprofessional.

Your title should invite readers to continue reading beyond the first page [ 4 , 5 ]. It should be informative and interesting. Consider describing the independent and dependent variables, the population and setting, the study design, the timing, and even the main result in your title. Because the focus of the paper can change as you write and revise, we recommend you wait until you have finished writing your paper before composing the title.

Be sure that the title is useful for potential readers searching for your topic. The keywords you select should complement those in your title to maximize the likelihood that a researcher will find your paper through a database search. Avoid using abbreviations in your title unless they are very well known, such as SNP, because it is more likely that someone will use a complete word rather than an abbreviation as a search term to help readers find your paper.

After you have written a complete draft, use the checklist (Fig. 3 ) below to guide your revisions and editing. Additional resources are available on writing the abstract and citing references [ 5 ]. When you feel that your work is ready, ask a trusted colleague or two to read the work and provide informal feedback. The box below provides a checklist that summarizes the key points offered in this article.

Checklist for manuscript quality

Data Availability

Michalek AM (2014) Down the rabbit hole…advice to reviewers. J Cancer Educ 29:4–5

Article   Google Scholar  

International Committee of Medical Journal Editors. Defining the role of authors and contributors: who is an author? http://www.icmje.org/recommendations/browse/roles-and-responsibilities/defining-the-role-of-authosrs-and-contributors.html . Accessed 15 January, 2020

Vetto JT (2014) Short and sweet: a short course on concise medical writing. J Cancer Educ 29(1):194–195

Brett M, Kording K (2017) Ten simple rules for structuring papers. PLoS ComputBiol. https://doi.org/10.1371/journal.pcbi.1005619

Lang TA (2017) Writing a better research article. J Public Health Emerg. https://doi.org/10.21037/jphe.2017.11.06

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Acknowledgments

Ella August is grateful to the Sustainable Sciences Institute for mentoring her in training researchers on writing and publishing their research.

Code Availability

Not applicable.

Author information

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Clara Busse & Ella August

Department of Epidemiology, University of Michigan School of Public Health, 1415 Washington Heights, Ann Arbor, MI, 48109-2029, USA

Ella August

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Correspondence to Ella August .

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Busse, C., August, E. How to Write and Publish a Research Paper for a Peer-Reviewed Journal. J Canc Educ 36 , 909–913 (2021). https://doi.org/10.1007/s13187-020-01751-z

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How to Write and Publish a Research Paper for a Peer-Reviewed Journal

Clara busse.

1 Department of Maternal and Child Health, University of North Carolina Gillings School of Global Public Health, 135 Dauer Dr, 27599 Chapel Hill, NC USA

Ella August

2 Department of Epidemiology, University of Michigan School of Public Health, 1415 Washington Heights, Ann Arbor, MI 48109-2029 USA

Associated Data

Communicating research findings is an essential step in the research process. Often, peer-reviewed journals are the forum for such communication, yet many researchers are never taught how to write a publishable scientific paper. In this article, we explain the basic structure of a scientific paper and describe the information that should be included in each section. We also identify common pitfalls for each section and recommend strategies to avoid them. Further, we give advice about target journal selection and authorship. In the online resource 1 , we provide an example of a high-quality scientific paper, with annotations identifying the elements we describe in this article.

Electronic supplementary material

The online version of this article (10.1007/s13187-020-01751-z) contains supplementary material, which is available to authorized users.

Introduction

Writing a scientific paper is an important component of the research process, yet researchers often receive little formal training in scientific writing. This is especially true in low-resource settings. In this article, we explain why choosing a target journal is important, give advice about authorship, provide a basic structure for writing each section of a scientific paper, and describe common pitfalls and recommendations for each section. In the online resource 1 , we also include an annotated journal article that identifies the key elements and writing approaches that we detail here. Before you begin your research, make sure you have ethical clearance from all relevant ethical review boards.

Select a Target Journal Early in the Writing Process

We recommend that you select a “target journal” early in the writing process; a “target journal” is the journal to which you plan to submit your paper. Each journal has a set of core readers and you should tailor your writing to this readership. For example, if you plan to submit a manuscript about vaping during pregnancy to a pregnancy-focused journal, you will need to explain what vaping is because readers of this journal may not have a background in this topic. However, if you were to submit that same article to a tobacco journal, you would not need to provide as much background information about vaping.

Information about a journal’s core readership can be found on its website, usually in a section called “About this journal” or something similar. For example, the Journal of Cancer Education presents such information on the “Aims and Scope” page of its website, which can be found here: https://www.springer.com/journal/13187/aims-and-scope .

Peer reviewer guidelines from your target journal are an additional resource that can help you tailor your writing to the journal and provide additional advice about crafting an effective article [ 1 ]. These are not always available, but it is worth a quick web search to find out.

Identify Author Roles Early in the Process

Early in the writing process, identify authors, determine the order of authors, and discuss the responsibilities of each author. Standard author responsibilities have been identified by The International Committee of Medical Journal Editors (ICMJE) [ 2 ]. To set clear expectations about each team member’s responsibilities and prevent errors in communication, we also suggest outlining more detailed roles, such as who will draft each section of the manuscript, write the abstract, submit the paper electronically, serve as corresponding author, and write the cover letter. It is best to formalize this agreement in writing after discussing it, circulating the document to the author team for approval. We suggest creating a title page on which all authors are listed in the agreed-upon order. It may be necessary to adjust authorship roles and order during the development of the paper. If a new author order is agreed upon, be sure to update the title page in the manuscript draft.

In the case where multiple papers will result from a single study, authors should discuss who will author each paper. Additionally, authors should agree on a deadline for each paper and the lead author should take responsibility for producing an initial draft by this deadline.

Structure of the Introduction Section

The introduction section should be approximately three to five paragraphs in length. Look at examples from your target journal to decide the appropriate length. This section should include the elements shown in Fig.  1 . Begin with a general context, narrowing to the specific focus of the paper. Include five main elements: why your research is important, what is already known about the topic, the “gap” or what is not yet known about the topic, why it is important to learn the new information that your research adds, and the specific research aim(s) that your paper addresses. Your research aim should address the gap you identified. Be sure to add enough background information to enable readers to understand your study. Table ​ Table1 1 provides common introduction section pitfalls and recommendations for addressing them.

The main elements of the introduction section of an original research article. Often, the elements overlap

Common introduction section pitfalls and recommendations

Methods Section

The purpose of the methods section is twofold: to explain how the study was done in enough detail to enable its replication and to provide enough contextual detail to enable readers to understand and interpret the results. In general, the essential elements of a methods section are the following: a description of the setting and participants, the study design and timing, the recruitment and sampling, the data collection process, the dataset, the dependent and independent variables, the covariates, the analytic approach for each research objective, and the ethical approval. The hallmark of an exemplary methods section is the justification of why each method was used. Table ​ Table2 2 provides common methods section pitfalls and recommendations for addressing them.

Common methods section pitfalls and recommendations

Results Section

The focus of the results section should be associations, or lack thereof, rather than statistical tests. Two considerations should guide your writing here. First, the results should present answers to each part of the research aim. Second, return to the methods section to ensure that the analysis and variables for each result have been explained.

Begin the results section by describing the number of participants in the final sample and details such as the number who were approached to participate, the proportion who were eligible and who enrolled, and the number of participants who dropped out. The next part of the results should describe the participant characteristics. After that, you may organize your results by the aim or by putting the most exciting results first. Do not forget to report your non-significant associations. These are still findings.

Tables and figures capture the reader’s attention and efficiently communicate your main findings [ 3 ]. Each table and figure should have a clear message and should complement, rather than repeat, the text. Tables and figures should communicate all salient details necessary for a reader to understand the findings without consulting the text. Include information on comparisons and tests, as well as information about the sample and timing of the study in the title, legend, or in a footnote. Note that figures are often more visually interesting than tables, so if it is feasible to make a figure, make a figure. To avoid confusing the reader, either avoid abbreviations in tables and figures, or define them in a footnote. Note that there should not be citations in the results section and you should not interpret results here. Table ​ Table3 3 provides common results section pitfalls and recommendations for addressing them.

Common results section pitfalls and recommendations

Discussion Section

Opposite the introduction section, the discussion should take the form of a right-side-up triangle beginning with interpretation of your results and moving to general implications (Fig.  2 ). This section typically begins with a restatement of the main findings, which can usually be accomplished with a few carefully-crafted sentences.

Major elements of the discussion section of an original research article. Often, the elements overlap

Next, interpret the meaning or explain the significance of your results, lifting the reader’s gaze from the study’s specific findings to more general applications. Then, compare these study findings with other research. Are these findings in agreement or disagreement with those from other studies? Does this study impart additional nuance to well-accepted theories? Situate your findings within the broader context of scientific literature, then explain the pathways or mechanisms that might give rise to, or explain, the results.

Journals vary in their approach to strengths and limitations sections: some are embedded paragraphs within the discussion section, while some mandate separate section headings. Keep in mind that every study has strengths and limitations. Candidly reporting yours helps readers to correctly interpret your research findings.

The next element of the discussion is a summary of the potential impacts and applications of the research. Should these results be used to optimally design an intervention? Does the work have implications for clinical protocols or public policy? These considerations will help the reader to further grasp the possible impacts of the presented work.

Finally, the discussion should conclude with specific suggestions for future work. Here, you have an opportunity to illuminate specific gaps in the literature that compel further study. Avoid the phrase “future research is necessary” because the recommendation is too general to be helpful to readers. Instead, provide substantive and specific recommendations for future studies. Table ​ Table4 4 provides common discussion section pitfalls and recommendations for addressing them.

Common discussion section pitfalls and recommendations

Follow the Journal’s Author Guidelines

After you select a target journal, identify the journal’s author guidelines to guide the formatting of your manuscript and references. Author guidelines will often (but not always) include instructions for titles, cover letters, and other components of a manuscript submission. Read the guidelines carefully. If you do not follow the guidelines, your article will be sent back to you.

Finally, do not submit your paper to more than one journal at a time. Even if this is not explicitly stated in the author guidelines of your target journal, it is considered inappropriate and unprofessional.

Your title should invite readers to continue reading beyond the first page [ 4 , 5 ]. It should be informative and interesting. Consider describing the independent and dependent variables, the population and setting, the study design, the timing, and even the main result in your title. Because the focus of the paper can change as you write and revise, we recommend you wait until you have finished writing your paper before composing the title.

Be sure that the title is useful for potential readers searching for your topic. The keywords you select should complement those in your title to maximize the likelihood that a researcher will find your paper through a database search. Avoid using abbreviations in your title unless they are very well known, such as SNP, because it is more likely that someone will use a complete word rather than an abbreviation as a search term to help readers find your paper.

After you have written a complete draft, use the checklist (Fig. ​ (Fig.3) 3 ) below to guide your revisions and editing. Additional resources are available on writing the abstract and citing references [ 5 ]. When you feel that your work is ready, ask a trusted colleague or two to read the work and provide informal feedback. The box below provides a checklist that summarizes the key points offered in this article.

Checklist for manuscript quality

(PDF 362 kb)

Acknowledgments

Ella August is grateful to the Sustainable Sciences Institute for mentoring her in training researchers on writing and publishing their research.

Code Availability

Not applicable.

Data Availability

Compliance with ethical standards.

The authors declare that they have no conflict of interest.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

• Introduction
• Conclusions
• Article Information

Error bars indicate SDs.

Other includes American Indian or Alaska Native, Middle Eastern or North African, Native Hawaiian or other Pacific Islander, or none of these categories can fully describe the participant. Multiple races correspond to those who self-identified as more than 1 race and ethnicity category. All trends were statistically significant at P  < .05. Error bars indicate 95% CIs.

All trends were statistically significant at P  < .05. Error bars indicate 95% CIs.

The exploratory mediation analysis estimated that 46% (95% CI, 35%-61%) of the temporal trend in age at menarche was explained by BMI at menarche. Total effect represents the overall change in age at menarche per 10-year lapse in birth year, direct effect represents the proportion of this change that is independent of BMI z score at menarche, and indirect effect represents the proportion of this change mediated through BMI z score at menarche. Error bars indicate 95% CIs.

eMethods. Detailed Exclusion of Individuals With Potentially Inaccurate Time to Regularity Information

eFigure 1. Conceptual Model of the Research Question and Potential Mechanisms

eFigure 2. Flowchart of Participants in This Study

eFigure 3. Percentage of Participants in Each Time to Cycle Regularity by Age at Menarche

eFigure 4. Percentage of Participants With Predicted Time to Cycle Regularity Across Birth Year Categories, With Age at Menarche Fixed at the Mean (12.2 Years of Age)

eFigure 5. Temporal Trends of Time to Cycle Regularity by Birth Year Category, Stratified by Race/Ethnicity

eFigure 6. Temporal Trends of Time to Cycle Regularity by Birth Year Category, Stratified by Socioeconomic Status (SES)

eFigure 7. Temporal Trends of BMI Across Age Categories, Based on BMI z Scores and Percentiles Using the CDC Growth Chart (N = 9865)

eFigure 8. Predicted Mean Age at Menarche Across Birth Years by Race/Ethnicity, When Adjusted for BMI at Menarche

eTable 1. Characteristics of the Subset of 9865 AWHS Participants Who Provided Self-Recalled Weight and Height at Menarche, Overall and by Birth Year Category

eTable 2. Age at Menarche and Time to Cycle Regularity Measures by Birth Year Groups, Stratified by Race/Ethnicity

eTable 3. Age at Menarche and Time to Cycle Regularity Measures by Birth Year Groups, Stratified by Socioeconomic Status

eTable 4. Effect Estimates for the Temporal Trend in Age at Menarche, Mutually Adjusted for Race/Ethnicity and Socioeconomic Status

eTable 5. Age at Menarche and Time to Cycle Regularity Measures by Birth Year Groups, Stratified by Geographical Region

eTable 6. Effect Estimates for the Temporal Trend in Age at Menarche and Time to Regularity, Accounting for BMI at Menarche

eTable 7. Causal Mediation Analysis for the Temporal Trends in Time to Regularity Measures Among 8752 Participants With BMI z-Score at Menarche (Mediator)

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Wang Z , Asokan G , Onnela J, et al. Menarche and Time to Cycle Regularity Among Individuals Born Between 1950 and 2005 in the US. JAMA Netw Open. 2024;7(5):e2412854. doi:10.1001/jamanetworkopen.2024.12854

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Menarche and Time to Cycle Regularity Among Individuals Born Between 1950 and 2005 in the US

• 1 Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
• 2 Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
• 3 Epidemiology Branch, Division of Intramural Research, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, Durham, North Carolina
• 4 Health, Apple Inc, Cupertino, California
• 5 Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
• Invited Commentary Menstruation as the Next Vital Sign Lauren C. Houghton, PhD JAMA Network Open

Question   In the US, what are the temporal trends in age at menarche and time from menarche to cycle regularity?

Findings   This cohort study of 71 341 US female individuals born between 1950 and 2005 found significant trends toward earlier menarche and longer time to regularity over time, and these trends were more pronounced among those who were non-Hispanic Black, Asian, or of other or multiple races (compared with non-Hispanic White individuals) and among low socioeconomic status groups. Body mass index at menarche partially mediated the trend for menarche.

Meaning   These findings suggest that early-life menstrual characteristics have been trending in directions that indicate higher risk of later adverse health outcomes, which may contribute to health disparities.

Importance   Early menarche is associated with adverse health outcomes. Trends toward earlier menarche have been observed in the US, but data remain limited on differences by sociodemographic factors and body mass index (BMI). Time from menarche to cycle regularity is another understudied early-life characteristic with health implications.

Objectives   To evaluate the temporal trends and disparities in menarche and time to regularity and explore early-life BMI as a mediator.

Design, Setting, and Participants   This ongoing cohort study enrolled participants from an ongoing mobile application–based US cohort from November 14, 2019, to March 20, 2023.

Exposures   Birth year (categorized as 1950-1969, 1970-1979, 1980-1989, 1990-1999, and 2000-2005).

Main Outcomes and Measures   Main outcomes were age at menarche and time to regularity, which were self-recalled at enrollment. In addition, early (aged <11 years), very early (aged <9 years), and late (aged ≥16 years) age at menarche was assessed.

Results   Among the 71 341 female individuals who were analyzed (mean [SD] age at menarche, 12.2 [1.6] years; 2228 [3.1%] Asian, 3665 [5.1%] non-Hispanic Black, 4918 [6.9%] Hispanic, 49 518 [69.4%] non-Hispanic White, and 8461 [11.9%] other or multiple races or ethnicities), 5223 were born in 1950 to 1969, 12 226 in 1970 to 1979, 22 086 in 1980 to 1989, 23 894 in 1990 to 1999, and 7912 in 2000 to 2005. The mean (SD) age at menarche decreased from 12.5 (1.6) years in 1950 to 1969 to 11.9 (1.5) years in 2000 to 2005. The number of individuals experiencing early menarche increased from 449 (8.6%) to 1223 (15.5%), the number of individuals experiencing very early menarche increased from 31 (0.6%) to 110 (1.4%), and the number of individuals experiencing late menarche decreased from 286 (5.5%) to 137 (1.7%). For 61 932 participants with reported time to regularity, the number reaching regularity within 2 years decreased from 3463 (76.3%) to 4075 (56.0%), and the number not yet in regular cycles increased from 153 (3.4%) to 1375 (18.9%). The magnitude of the trend toward earlier menarche was greater among participants who self-identified as Asian, non-Hispanic Black, or other or multiple races (vs non-Hispanic White) ( P  = .003 for interaction) and among participants self-rated with low (vs high) socioeconomic status ( P  < .001 for interaction). Within a subset of 9865 participants with data on BMI at menarche, exploratory mediation analysis estimated that 46% (95% CI, 35%-61%) of the temporal trend in age at menarche was explained by BMI.

Conclusions and Relevance   In this cohort study of 71 341 individuals in the US, as birth year increased, mean age at menarche decreased and time to regularity increased. The trends were stronger among racial and ethnic minority groups and individuals of low self-rated socioeconomic status. These trends may contribute to the increase in adverse health outcomes and disparities in the US.

Menarche is the culmination of a complex sequence of events involving the maturation of the reproductive axis. 1 , 2 Early menarche is associated with increased risk of adverse health outcomes, such as cardiovascular diseases, cancers, spontaneous abortion, and premature death, 3 - 9 whereas late menarche is associated with increased risk of fractures. 10 , 11 Studies have found trends toward earlier menarche during the past 5 to 10 decades in the US as well as globally. 12 - 19 In the US, studies have additionally evaluated whether this trend varied by sociodemographic factors. 13 , 20 - 26 Some of them 13 , 21 - 23 , 25 showed significant racial and ethnic differences, whereas others 20 , 24 , 26 did not, and most 13 , 20 , 22 , 24 were limited to non-Hispanic Black vs White comparisons. Furthermore, most studies 20 , 21 , 23 , 24 , 26 focused on mean age at menarche, with the frequency of early or late menarche rarely evaluated. Notably, obesity is a risk factor for early-onset puberty, 27 - 31 and the prevalence of childhood obesity has increased in the US, 32 , 33 leading to hypotheses on the potential role of obesity in the trends toward earlier menarche. However, whether obesity is the primary factor underlying the trends in menarche remains debatable. 34 Whether and to what extent the trend in menarche is attributable to changes in early-life body mass index (BMI) remains to be determined. 28

The menstrual cycle is a vital sign. 35 The maturation of the reproductive axis, measured as the time from menarche to established cycle regularity, is another important but understudied hallmark of early-life menstrual health. Within 1 to 2 years after menarche, irregular cycles are considered a normal process of pubertal transition. 36 , 37 Full maturation of the reproductive axis leads to more regular menstrual function. 38 Longer time to regularity has been associated with lower fecundability, longer menstrual cycles, and increased risk of metabolic conditions and all-cause mortality. 39 - 42 Whereas the trends in time to regularity (influenced by environmental pollutants) 43 , 44 were evaluated in Japanese 14 and French 45 cohorts, it is not known whether it has also changed during the past several decades in the US.

In this study, we used data from a large, mobile application–based cohort of adults in the US to evaluate temporal trends in menarche and time to regularity among members of a racially and ethnically diverse study population born between 1950 and 2005. We analyzed overall temporal trends and whether observed trends differ by sociodemographic factors. Additionally, we explored whether BMI at menarche might mediate the observed temporal trends.

The Apple Women’s Health Study is a prospective digital cohort study in the US. Users of the Apple Research app on their iPhone were eligible if they had ever menstruated at least once in life, live in the US, were at least 18 years old (19 years in Alabama and Nebraska and 21 years in Puerto Rico), and were able to communicate in English. Eligibility also required sole use of an iCloud account and an iPhone. Enrollment began on November 14, 2019, and is ongoing. Participants provided written informed consent at enrollment. This study was approved by the institutional review board at Advarra. Details were described previously. 46 On enrollment, participants were asked to complete surveys of demographics as well as reproductive and medical history. For this analysis, we included participants who reported female sex assigned at birth, who were enrolled until March 20, 2023, and who provided age at menarche information. We excluded those born in 1931 to 1949 due to potential survival bias and too few individuals representing this group. A conceptual model is shown in eFigure 1 in Supplement 1 . The final study population included 71 341 participants; data analysis was limited to subsets who answered the relevant questions (eFigure 2 in Supplement 1 ). This study followed the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) guideline.

We grouped self-reported year of birth as 1950 to 1969 (n = 5223), 1970 to 1979 (n = 12 226), 1980 to 1989 (n = 22 086), 1990 to 1999 (n = 23 894), and 2000 to 2005 (n = 7912). Participants were asked the question, “ At what age did you have your first menstrual period? It’s okay to estimate,” with the following response options: “7 years old or younger,” integer options between 8 and 15 years old, “16 years old or older,” “I don’t know,” or “I prefer not to answer.” Those who indicated they did not know or preferred not to answer or did not respond were excluded. We derived the following measures: (1) age at menarche (in years) (we assigned the value of 7 to those aged ≤7 years [196 (0.3%)] and the value of 16 to those aged ≥16 years [2447 (3.4%)]); (2) early menarche (yes/no) (age at menarche <11 years 47 ); (3) very early menarche (yes/no) (age at menarche <9 years 48 ); and (4) late menarche (yes/no) (age at menarche ≥16 years). 49

Participants were asked, “After your first menstrual cycle, how long did it take for your cycle to become regular?” with the following response options: “less than 1 year,” “1-2 years,” “3-4 years,” “more than 5 years,” “after using hormones (eg, birth control pills),” “They’re not yet regular,” “I don’t know,” or “I prefer not to answer.” Those who indicated don’t know or prefer not to answer or who did not respond were considered missing. We further excluded 224 individuals with potentially inaccurate time-to-regularity information (eMethods in Supplement 1 ). For the remaining 61 932 participants, we categorized time to regularity as 2 years or less, 3 to 4 years, more than 5 years, not yet regular, or regular after using hormones.

We considered the following self-reported variables to evaluate whether the temporal trends in age at menarche or time to regularity differ by sociodemographic factors: (1) self-identified race and ethnicity (Asian, Hispanic, non-Hispanic Black, non-Hispanic White, and other and multiple races (including American Indian or Alaska Native, Middle Eastern or North African, Native Hawaiian or other Pacific Islander, “None of these fully describe me,” and self-identified with >1 option) 50 ; (2) subjective socioeconomic status (SES) at enrollment based on the MacArthur Scale of Subjective Social Status 51 (categorized as 0-3 [low], 4-5 [medium], and 6-9 [high]), which was used as a surrogate for premenarche SES; and (3) geographic location (based on state of residence and categorized as Northeast, Midwest, South, and West).

In addition, among a subset of 9865 participants (13.8%) who retrospectively reported weight and height at menarche, we derived BMI (calculated as weight in kilograms divided by height in meters squared) for age z scores, percentiles, and categories at menarche using the Centers for Disease Control and Prevention Growth Chart. 52 - 54 We considered BMI at menarche as a potential mediator of temporal trends in age at menarche or time to regularity.

We calculated means (SDs) for continuous variables and reported numbers (percentages) for binary or categorical variables, overall and stratified by birth year categories (χ 2 tests were performed to identify differences in time to regularity by birth year categories). We summarized the percentages of time to regularity by age at menarche. We used generalized linear regression (gaussian or binomial distributions for continuous or binary categorical variables), with birth year as the exposure variable to generate P values for temporal trends.

To understand how temporal trends differ by sociodemographic factors, we performed analyses stratified by each covariate. A test of trend was performed within each level of the covariate by including birth year as the exposure variable in regression models. We also tested whether the slope of trends differed by covariates by including an interaction term between each covariate and birth year in the regression models and performing a type 3 test for significance.

We evaluated trends over time in the subset of 9865 participants with data on BMI at menarche. We performed an exploratory causal mediation analysis 55 , 56 with nonparametric bootstrap (500 simulations) to quantify the proportions (95% CIs) of temporal trends in menarche or time to regularity mediated by BMI z score at menarche. We evaluated these temporal trends as a secondary analysis after stratifying by BMI categories at menarche or adjusting for BMI at menarche z scores.

To evaluate the robustness of our results, we performed sensitivity analyses, including evaluating the temporal trends in time to regularity when further adjusted for age at menarche, using models that mutually adjusted for race and ethnicity and SES and using multinomial logistic models for the categorical time-to-regularity variable, with 2 years or less as the referent group. Analyses were conducted in Python, version 3.6 (Python Software Foundation) and R, version 4.1.2 (R Project for Statistical Computing). All statistical tests were 2-sided with 95% CIs. P  < .05 was considered statistically significant.

The Table shows the characteristics of the 71 341 participants. Among them, 2228 (3.1%) self-identified as Asian, 4918 (6.9%) as Hispanic, 3665 (5.1%) as non-Hispanic Black, 49 518 (69.4%) as non-Hispanic White, and 8461 (11.9%) as other or multiple races. A total of 21 561 (30.2%) had a high subjective SES level. The mean (SD) age at menarche was 12.2 (1.6) years, and 9174 (12.9%) had early menarche (aged <11 years). A total of 38 524 (62.2%) reached regularity within 2 years after menarche, whereas 6950 (11.2%) did not establish regularity. Characteristics of the 9865 participants with weight and height information at menarche are given in eTable 1 in Supplement 1 . Compared with the full study population, these participants tend to have earlier birth years, be non-Hispanic White, and have high subjective SES.

Figure 1 shows the temporal trends of age at menarche and time to regularity. The mean (SD) age at menarche decreased from 12.5 (1.6) to 11.9 (1.5) years comparing those born in 1950 to 1969 vs 2000 to 2005 ( P < .001 for trend) ( Figure 1 A and Table ). The number of individuals experiencing early menarche increased from 449 (8.6%) to 1223 (15.5%), the number of individuals experiencing very early menarche increased from 31 (0.6%) to 110 (1.4%) for very early menarche, and the number of individuals experiencing late menarche decreased from 286 (5.5%) to 137 (1.7%) ( P < .001 for trend) ( Figure 1 B and Table ). From the 1950 to 1969 birth years to the 2000 to 2005 birth years, the number reaching regularity within 2 years decreased from 3463 (76.3%) to 4075 (56.0%), and the number not yet in regular cycles increased from 153 (3.4%) to 1375 (18.9%) ( P < .001 for trend) ( Figure 1 C and Table ). The mean (SD) time to regularity among those who spontaneously established regularity increased from 1.27 to 1.40 years ( P < .001 for trend) ( Table ). eFigure 3 in Supplement 1 shows lower percentages of time to regularity less than 2 years among those with either early or late menarche (inverse U-shaped association). Further adjusting for age at menarche resulted in similar distributions of time to regularity (eFigure 4 in Supplement 1 ).

The temporal trends stratified by race and ethnicity are presented in Figure 2 (estimates in eTable 2 in Supplement 1 ). Participants who were Asian, Hispanic, non-Hispanic Black, or of other or multiple races or ethnicities had consistently earlier mean age at menarche than non-Hispanic White participants. All racial and ethnic groups had temporal trends toward earlier menarche ( P  < .001 for trend), but when compared with non-Hispanic White participants, the magnitude of decrease in mean age at menarche across birth year categories was larger among those self-identified as non-Hispanic Black, Asian, and other or multiple races or ethnicities ( P  = .003 for interaction). All racial and ethnic groups showed a decreasing proportion of time to regularity within 2 years and an increased proportion of not establishing regularity ( P  < .001 for trend) (eFigure 5 and eTable 2 in Supplement 1 ), although there was no interaction between race and ethnicity and birth year. The temporal trends stratified by SES are presented in Figure 3 (estimates in eTable 3 in Supplement 1 ). Compared with those with high SES, those with low SES had earlier menarche, lower proportion of time to regularity within 2 years (eFigure 6 in Supplement 2 ), and larger magnitude of decrease in age at menarche. The heterogeneity by race and ethnicity for the trend toward earlier menarche remained when further adjusted for SES and vice versa (eTable 4 in Supplement 1 ). There was no interaction between geographic region and birth year when adjusting for race and ethnicity (eTable 5 in Supplement 1 ).

Overall, using multinomial logistic regressions yielded P -for-trend values of <.001 for each category of time to regularity compared with ≤2 years. Among the 9865 participants who provided weight and height at menarche, the BMI z score, percentile, and prevalence of obesity increased across birth year categories (eFigure 7 and eTable 1 in Supplement 1 ). An exploratory mediation analysis showed that the proportion of the temporal trends toward earlier menarche mediated by BMI z score at menarche was 46% (95% CI, 35%-61%) ( Figure 4 ). When stratified by BMI categories at menarche, the healthy and underweight group still showed a trend toward earlier menarche (eTable 6 in Supplement 1 ). When adjusted for BMI z scores, a trend toward earlier menarche remained (eTable 6 in Supplement 1 ), as did heterogeneity by race and ethnicity (eFigure 8 in Supplement 1 ). There was no evidence of significant mediation by BMI at menarche for the temporal trends in time to regularity (eTable 7 in Supplement 1 ).

This cohort study of 71 341 participants born between 1950 and 2005 in the US found temporal trends toward earlier menarche (earlier mean age, higher percentage of early menarche, and lower percentage of late menarche) and longer time from menarche to cycle regularity (lower percentage of time to regularity within 2 years, higher percentage of time to regularity within 3-4 years, and higher percentage of not establishing regularity). These trends remained across all sociodemographic groups but were stronger among certain non-White (specifically, Asian, non-Hispanic Black, and other or multiple races or ethnicities) and low SES groups. In an exploratory analysis, BMI at menarche may explain a significantly large proportion of the temporal trends toward earlier menarche.

Our findings of a temporal trend toward earlier menarche are consistent with some US-based studies, with similar magnitude of changes. 12 , 13 , 16 Other studies indicated that age at menarche stabilized during the past 50 years, whereas evidence that the median decreased by 2.5 to 4 months in the past 25 years remains, 20 , 57 consistent with a change from 12.2 to 11.9 years of age for those born in 1980 to 1989 vs 2000 to 2005 in our study. Despite a relatively small magnitude of change in mean age, our study is among the first to show that the percentages of early and very early menarche have also increased by almost 2-fold across birth years from 1950 to 2005, raising concerns that more individuals may be vulnerable to adverse health outcomes related to early menarche. 3 - 6 Late menarche has decreased, which may have other health implications, such as the decreasing rates of fractures. 58 , 59

We found that non-Hispanic Black participants had consistently earlier mean age at menarche than White participants, also similar to prior US-based studies. 13 , 20 - 26 We also found that non-Hispanic Black participants had a larger magnitude of change toward earlier menarche across birth year categories compared with non-Hispanic White participants. Similarly, we found other groups (Asian and other or multiple races), rarely evaluated in previous studies of menarche, also had consistently earlier mean ages and larger magnitudes of change toward earlier menarche than non-Hispanic White participants. We found similar patterns for self-rated low SES (compared with high SES). The factors driving this widening gap of disparities remain to be explored; transethnic genome-wide association studies indicated that these disparities are unlikely to be attributed to genetic variations, suggesting they may be driven by other environmental or contextual factors that may, through racism, impact different pathways, leading to earlier menarche. 60

Onset of menarche is closely related to attainment of adequate body fat via pathways such as increased insulin-like growth factor 1 and leptin that stimulate gonadotropin-releasing hormone. 61 In our exploratory analysis, we found that BMI at menarche may explain 46% of the temporal trends in menarche. This finding suggests that childhood obesity, a risk factor for earlier puberty, 27 - 30 , 62 which has increased in the US, 32 , 33 could be a contributing factor to the trend toward earlier menarche. However, the remaining 54% remain unclear. Our exploratory analysis also showed that BMI may have contributed to earlier menarche among non-Hispanic White, Black, and other or multiple races, whereas the trend among Asian and Hispanic individuals remains to be further explored. Previous studies also showed that the biggest decrease in age at menarche occurred before the obesity epidemic in the US, 34 suggesting that other factors need to be explored to explain these trends and disparities, including environmental factors (eg, endocrine-disrupting chemicals, metals, or air pollutants could impact pubertal timing, 63 - 65 with disproportionally higher exposure among certain racial and ethnic minority groups), 66 - 68 dietary patterns (eg, sugar intake via insulin-mediated pathways), 69 - 71 psychosocial stress, 72 and adverse childhood experiences. 73

Our findings of temporal trends toward longer time to regularity and higher proportion of never establishing regularity in the US have not been previously reported. Because longer time to regularity has been associated with adverse outcomes, 39 - 42 it may serve as an early-life vital sign. These temporal trends may be driven by longer time to maturation of the reproductive axis (eg, impacted by endocrine disruptors) 74 or increasing ovulation disorders 75 that impact cycle regularity. Although earlier studies suggest that regular menstruation should be established within 1 to 2 years after menarche, 37 , 38 , 76 , 77 evidence remains limited on whether delays beyond 2 years warrant clinical or lifestyle intervention. 78 In our study, the mean time to regularity among those who spontaneously established regularity was 1.2 to 1.5 years within the 2-year window. However, the proportions taking 3 to 4 years or never establishing regularity were increasing. A French cohort born between 1935 and 1950 showed a decrease from 64% to 53% for time to regularity within 1 year, but data are limited for the US. 45 We also found differences by race and ethnicity (eg, Hispanic individuals reported a higher rate of not establishing regularity compared with their non-Hispanic White peers, consistent with a study 79 showing that Hispanic individuals having the highest risk of cycle irregularity in adulthood). Our findings suggest the necessity of further studies on the postmenarche years and the need for early intervention during relevant time windows. Continued research on the association of BMI and other factors on reproductive development is needed, and findings should be conveyed to health professionals.

This study has several unique strengths. First, a large study size of 71 341 participants in a heterogeneous population allowed for sufficient statistical power to detect racial and ethnic differences, even for groups that were previously understudied. Second, we evaluated temporal trends in the percentages of early or late menarche in addition to mean age. Third, our study is the first, to our knowledge, to evaluate and report a temporal trend toward longer time to regularity, suggesting future research directions on this understudied early-life marker of menstrual health. Fourth, our study is the first, to our knowledge, to use digital observational cohort data evaluating BMI at menarche as a potential contributor to the observed temporal trends.

Our study also has limitations. First, the retrospective self-report may induce recall bias and misclassification, likely differential across birth year categories. However, previous validation studies 80 - 82 showed moderate to high correlations between recalled and original age and body size at menarche. Second, BMI at menarche was only available among a subset of participants with demographic distributions different from the full study population. Third, data are limited for additional early-life factors that may contribute to these trends. Fourth, our results may not be generalizable to all US individuals who menstruate or to other populations. Potential selection bias may arise due to self-selection into the study that may be impacted by sociodemographic characteristics.

In this US cohort study of 71 341 individuals born between 1950 and 2005, we observed temporal trends toward earlier menarche and longer time to regularity. These trends appeared across all sociodemographic groups but were stronger among certain racial and ethnic groups (Asian, non-Hispanic Black, or other and multiple races or ethnicities) and low subjective SES groups. Body mass index at menarche mediated a significantly large proportion of the trends toward earlier menarche. Further awareness among health care practitioners and researchers is needed to understand the reasons for these trends and their health implications.

Accepted for Publication: March 1, 2024.

Published: May 29, 2024. doi:10.1001/jamanetworkopen.2024.12854

Open Access: This is an open access article distributed under the terms of the CC-BY-NC-ND License . © 2024 Wang Z et al. JAMA Network Open .

Corresponding Author: Zifan Wang, PhD, MS, Department of Environmental Health, Harvard T.H. Chan School of Public Health, 665 Huntington Ave, Bldg 1, Room 1404, Boston, MA 02115 ( [email protected] ).

Author Contributions: Dr Wang and Mr Asokan had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Dr Wang and Mr Asokan contributed equally to this work.

Concept and design: Wang, Jukic, Williams, Hauser, Coull, Mahalingaiah.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Wang, Asokan, Mahalingaiah.

Critical review of the manuscript for important intellectual content: Asokan, Onnela, Baird, Jukic, Wilcox, Curry, Fischer-Colbrie, Williams, Hauser, Coull, Mahalingaiah.

Statistical analysis: Wang, Asokan, Onnela, Coull, Mahalingaiah.

Obtained funding: Curry, Williams, Hauser, Coull, Mahalingaiah.

Administrative, technical, or material support: Asokan, Jukic, Wilcox, Curry, Fischer-Colbrie, Coull, Mahalingaiah.

Supervision: Hauser, Mahalingaiah.

Conflict of Interest Disclosures: Dr Curry and Mr Fischer-Colbrie are employed by Apple Inc and report owning Apple stocks. No other disclosures were reported.

Funding/Support: This research was supported in part by award Z01ES103333 from the Intramural Research Program of the National Institutes of Health (Drs Baird, Jukic, and Wilcox). Support for Drs Baird, Jukic, and Wilcox was provided by the Intramural Research Program of the National Institute of Environmental Health Sciences, National Institutes of Health. Apple Inc is the sponsor of this study.

Role of the Funder/Sponsor: Apple Inc provided platforms and software for the collection and management of the data and participated in the review and approval of the manuscript. It played no role in the design and conduct of the study, analysis and interpretation of the data, preparation of the manuscript, or in the decision to submit the manuscript for publication.

Meeting Presentation: Preliminary findings of this work were presented at the American Society for Reproductive Medicine Scientific Congress & Expo; October 16, 2023; New Orleans, Louisiana.

Data Sharing Statement: See Supplement 2 .

Additional Contributions: Malaika Gabra, BA, Mackenzie Collyer, BS, Elizabeth Peebles, BA, Carrie Sarcione, MEd, and Ariel Scalise, MPH, Harvard T.H. Chan School of Public Health, assisted with this study and are paid staff members of the Apple Women's Health Study (AWHS), who provided support on the administrative parts of this study. The AWHS team would like to thank the study participants for consenting and contributing to the advancement of women’s health research.

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• Published: 03 June 2024

Localized Merkel cell carcinoma treatment considerations: a response to the forty-year experience at the Peter MacCallum cancer centre

• James Leigh 1 &
• Kurt Gebauer 2 , 3  

BMC Cancer volume  24 , Article number:  675 ( 2024 ) Cite this article

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The Original Article was published on 07 January 2023

Merkel cell carcinoma (MCC) is a rare but aggressive neuroendocrine tumour of the skin with poor prognosis and rising global incidence. A recently published article in BMC Cancer, titled “Merkel cell carcinoma: a forty-year experience at the Peter MacCallum Cancer Centre” (Wang et al.), provides a contemporary analysis of locoregional disease outcomes in Australia which highlights the comparative effectiveness of radiotherapy for excisions with involved margins versus wide local excision. There is a persistent lack of clear, well-defined guidelines to manage MCC in Australia despite experiencing the highest rates globally. The advanced age at onset also provides inherent challenges for optimal management and often, a case-by-case approach is necessary based on patient preferences, baseline function and fitness for surgery. This paper responds to the recently published article by Wang et al. and will expand the discourse regarding management of localized MCC. Specifically, we will discuss the surgical excision approaches; alternative treatment options for MCC including radiotherapy, Mohs micrographic surgery and novel immunotherapy agents being investigated through several clinical trials.

Peer Review reports

This journal recently published an article by Wang et al., which describes a forty-year experience at Australia’s Peter MacCallum Cancer Centre managing Merkel cell carcinoma (MCC), a highly aggressive cutaneous neuroendocrine tumor [ 1 ]. There is ongoing debate regarding management of localized MCC which we will expand upon in this article, including surgical margin considerations, immunotherapy and lessons learned from melanoma treatments.

1. Surgical margin considerations for localized MCC

Surgical margins are an important consideration in MCC management, particularly among elderly patients or those undergoing adjuvant radiotherapy (RT). Wang et al. conclude that “if treated with adjuvant radiotherapy, there is no difference in overall survival or disease-free survival with positive surgical margins” [ 1 ]. WLE has traditionally been recommended as a primary treatment modality with sentinel lymph node biopsy (SLNB) [ 2 ]; however, the findings by Wang et al. challenge this paradigm and aligns with the clinical outcomes which we have observed in our high-volume community dermatology clinic. Globally, guidelines are recognizing alternative first-line treatment modalities for localized MCC including RT, Mohs micrographic surgery and immunotherapy.

The National Comprehensive Cancer Network (NCCN) has developed revised guidelines for the management of MCC [ 3 ]. Wang et al. reference the 2021 NCCN guidelines, which recommend 1–2 cm margins as definitive treatment for localized MCC in low-risk cases with absent risk factors (larger primary tumor (> 1 cm); chronic T-cell immunosuppression, HIV, chronic lymphocytic leukemia (CLL), solid organ transplant; head/neck primary site; lymphovascular invasion (LVI) present) [ 3 ]. However, an updated version of the NCCN guidelines now exists and instead recommends that “surgical margins should be balanced with morbidity of surgery, with surgical goal of primary tissue closure to avoid undue delay to adjuvant RT” [ 4 ]. Their updated terminology signals a preference for adjuvant RT over clear surgical margins, in the event of delayed RT due to wound healing for WLE. These guidelines also include Mohs micrographic surgery as an option for primary excision, which has recently been recognized as a comparable treatment for localized MCC [ 5 ] but was not acknowledged in Wang et al.’s article. Further research is needed to identify the most effective excision technique which considers the importance of time-sensitive adjuvant radiotherapy, particularly in comorbid or surgically unfit patients more common among the elderly.

2. The role of immunotherapy in localized MCC

Immunotherapy has significantly changed the landscape of systemic treatments for metastatic cancer. Its role in localized cutaneous malignancy is also being increasingly recognized, particularly among melanoma and MCC. Since the publication of the Peter MacCallum forty-year experience managing MCC [ 1 ], the NCCN has updated their guidelines to include immunotherapy for locally recurrent N0 (local) disease if surgery and radiotherapy are not viable treatment options [ 4 ]. The specific immunotherapies include pembrolizumab and retifanlimab-dlwr which are approved for use in America, while avelumab is the approved agent in Australia. Of note, avelumab is only indicated in metastatic disease (stage IV) in Australia at the time of writing; however, the I-MAT study is investigating the efficacy of avelumab for stage I-III MCC [ 2 ]. Existing immunotherapy trials include the ADMEC-O trial (NCT02196961) which is investigating the efficacy of adjuvant nivolumab monotherapy in patients with completely resected MCC [ 6 ]. Other trials include America’s ADAM trial which investigates the efficacy of avelumab for regional disease that has spread to the lymph nodes [ 7 ], and the STAMP clinical trial which investigates the efficacy of adjuvant pembrolizumab after surgery for stage I-III disease [ 8 ].

Adjuvant immunotherapy presents a viable alternative treatment in patients who are unfit for major surgery and with logistical barriers to RT, often delivered over 20–30 separate sessions. In our experience, a sizeable cohort of MCC patients are considered unfit for major surgery due to their advanced age at diagnosis, poor mobility and comorbidities. Furthermore, several of our patients declined RT due to difficulty with transportation particularly among elderly patients with mobility difficulties. Although immunotherapy can be very costly and cause unwanted side effects, it may be an appropriate treatment option in patients with MCC who are not amenable to WLE or RT, given the rarity of this cancer and demonstrated benefit in systemic disease. Effective patient selection for immunotherapy is important to maximize benefit considering both high costs and toxicity profiles associated with treatment. This is evident in countries such as Norway where immunotherapy is not considered cost-effective [ 9 ]. Furthermore, immunotherapy may provide benefit in non-surgical patients where sentinel lymph node biopsy is not possible.

3. Lessons learned from melanoma

Melanoma treatments have rapidly advanced in the past decade, and several findings may be translatable to the management of MCC from a surgical and medical perspective. Immunotherapy provides significant patient benefits, including improved disease-free survival and overall survival. Given the high metastatic potential among patients with invasive melanoma, patients are now being considered for immunotherapy even in localized disease. Indeed, a recent study by Eggermont et al. (KEYNOTE-716) demonstrated the benefits of adjuvant pembrolizumab for preventing disease recurrence or death in stage IIa and IIb melanoma after excision [ 10 ]. As we have described, there is comparable MCC research relating to adjuvant immunotherapy through the STAMP trial which is due for completion in 2025 [ 8 ].

On a surgical front, the MelMarT-II trial is investigating the clinical outcomes of 1 cm vs. 2 cm margins for patients with localized melanoma [ 11 ]. Wide local excision has long been considered the gold-standard surgical treatment for melanoma and Merkel cell carcinoma; however, this surgical approach is being reconsidered to minimize unnecessarily wide margins and associated complications. Conducting an equivalent randomized controlled trial for the surgical management of MCC presents a challenge due to its relative rarity. However, the outcomes of MelMarT-II should be contextualized to MCC including the cost-effectiveness of WLE and patient quality of life implications after surgery.

Merkel cell carcinoma is a highly aggressive cutaneous neuroendocrine tumor. Although rare, it most commonly affects elderly patients, many of whom have comorbidities that may limit treatment options including WLE or RT. Wang et al. provide an important and contemporary description of their forty-year experience in managing MCC in Australia, a country with the highest incidence of MCC globally. WLE may not be the best treatment option for all patients, and clinicians should be aware of the various treatment options which exist for localized MCC. These include WLE and sentinel lymph node biopsy with or without adjuvant RT; Mohs surgery; isolated RT; and more recently, immunotherapy. Less invasive treatments for MCC do exist and may be favorable among patients with poor functional status or contraindications to surgery. Further prospective research which acknowledges the clinical challenges of advanced age at diagnosis, for example a randomized controlled trial, may augment the evidence for the management of localized MCC among elderly patients.

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Acknowledgements

Thank you to Associate Professor David Kok and his research team for their valuable paper titled “Merkel cell carcinoma: a forty-year experience at the Peter MacCallum Cancer Centre”. A/Prof Kok has endorsed our development and submission of this article in response to his paper.

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Leigh, J., Gebauer, K. Localized Merkel cell carcinoma treatment considerations: a response to the forty-year experience at the Peter MacCallum cancer centre. BMC Cancer 24 , 675 (2024). https://doi.org/10.1186/s12885-024-12443-y

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Received : 06 October 2023

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DOI : https://doi.org/10.1186/s12885-024-12443-y

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