Hi, everyone. My name is Alejandro Rohein. I'm an associate professor in the Department of GYN Oncology at MD Anderson Cancer Center. In addition to that, I'm an associate editor for Gynecologic Oncology. Thank you so much for the opportunity to be here and allow me to discuss or present how to get a manuscript published. So really the goal of this lecture is to go step-by-step about how I think when I'm preparing a manuscript. I would say that this talk is probably more targeted to residents and fellows or junior faculty that are starting. You are a more seasoned investigator, many of the things that I'll be discussing might be fairly basic. The other part is that this is really how I do it. There are tons of different ways of how to think about writing manuscripts or prepare research projects, but this is how I like to think about it. It just really serves as a framework whenever I'm preparing a manuscript. So again, this is how I do it. You might have a different style. You might pick some of the tips that I'm going to give, but this is just some suggestions. And it's not like I do this every time, but again, it just really serves as a framework of how to think about it. Now, one of the most important things that I'm going to be highlighting is that it's very important to think about the journal. So whenever you're thinking about your research project, you have to start thinking about what journal you want to target. Do you want to target a journal that is more subspecialized like the International Journal or Chihuahuan Oncology? Do you want something a little more broader like the Green Journal or the Grey Journal? Do you want to go a higher tier and look at a cancer journal such as JCO, JAMA Oncology, or are you really going to go to high top tier journals such as the New England Journal of Medicine, Lancet, or JAMA? So it really depends on the question that you're trying to answer, the quality of the data, and the quality of the study, and whether your study is really changing practice or not. So the most important thing whenever you're thinking about writing a manuscript is how to think about a research project, and you want to have a project that it's new, it's novel, and potentially can really change the standard of care or move the needle in the management of patients with GYN cancer. You have to have a very clear research question. So we prefer when authors in their manuscripts have a very clear hypothesis of what they were intending to do when they were thinking about the project. So whenever I see in a manuscript that there's a hypothesis, that's something that the authors were thinking even before writing the manuscript, what was the hypothesis? And I see that like our hypothesis was such and such and such, I think that to me gives it a much higher quality because I can understand that, or at least signifies that the authors were really thinking about hypothesis generating research. Very, very important, like whenever I'm thinking of an idea and I'm trying to think about how we're going to analyze, I go through a literature review. First of all, I want to make sure that what I'm thinking about has not been published before, and also the literature review really puts a framework into whatever we're trying to do. I would say that one of the things that I've learned by writing manuscripts is that it's always a good idea to go broad, and what I mean with that is that sometimes we tend to focus only on GYN cancers, but I think when you want to think about something novel, innovative, it's always good to think about outside and more broadly like all cancer types, so go to general cancer journals, or even outside of oncology and looking at other specialties and how they're thinking about it, how they're resolving problems. And also, even if you want to take it even a notch higher, like outside of medicine, how economists might be thinking about issues, how biologists might be thinking about issues, and perhaps implement some of those techniques or methodologies into research projects. Whenever you're thinking about the manuscript, it's very important to think about the audience, so what is the target audience? So again, and I'm going to keep going back, is what is the journal, right? The question that the data that you have is very specific, it's a very GYN oncologist specific topic, you know, perhaps you want to do a subspecialty journal, is it like a perhaps a broader audience, like perhaps your study is looking at oncofertility and some, you know, maybe OB-GYNs or infertility specialists might benefit from your research, so perhaps you want to think about a general OB-GYN journal. And then the last thing about the initial, kind of when I think about it, the initial steps, I try to create an outline, so what are the, what is the main message or a couple of messages that I want to give whenever I'm writing? And you know, it has to be one main message, but then maybe you want to have like two or three sub-bullets, bullet points of things that you really want to stress when you are writing your manuscript. So I think it's always a good idea before you start designing your study and thinking about the manuscript to seek statistical advice. I understand that not every institution might have a statistician available or might be hard to get advice from a statistician, so I recognize that might be a limitation, but if, you know, you work in an institution or have friends who's a statistician or you can access a statistician, I think it's always a good idea to at least discuss a project with them because they might have a very different perspective. And also, it's important because you don't want to start getting the data or writing the manuscript and suddenly realize that your statistics are fairly weak. This might sound fairly obvious, but you want to use the right study design. So there's always a place for a core study, a case control study, doing a survey analysis, doing a randomized control trial. So really, the question that you want to answer, the data that you have available is going to dictate what kind of, what is the right study design. So there are some questions that are very hard to answer with a randomized control trial. So in those situations, we use cohort studies, and cohort studies you can have access to national databases, but perhaps it's hard to get that and you may have to use your own institution's database or you can collaborate with different institutions and get enough data from a particular disease site of a question that you want to answer. So really, the question that you are trying to answer, the availability of the data is really going to dictate your study design. And one of the things is that there might be questions that are hard to answer with the data that you have. So you might be able to produce some pilot data, but you may have to do a larger study or think about creative ways of trying to answer the question. Keep an open mind about other sources of data and really think about biases. And I'll talk about biases in a little while because I think that is, especially for retrospective observational studies, that's a significant part, that's a significant thing of what I evaluate when I'm reviewing a manuscript. It's always a good idea to discuss before you do anything about authorship, so you have a mentor or a principal investigator, it's important to discuss before you start doing anything about authorship. And that might be tricky, but I don't think you're ever going to regret having that discussion early on, especially the first author and the last author, because the last thing that you want is you've done all the work, almost completed the manuscript, and suddenly realize that authorship has not been discussed and you're going to be a second author or a middle author. So again, I think it's one of those things that might not make you feel good to go to your mentor or a principal investigator and talk about authorship. But I think it's something that, at least now that I serve as a principal investigator and I mentor our fellows, I think it's something that I think is very important for them to discuss before they embark on any research projects. And also, at the same time, just talk about who are going to be the authors and what other potential collaborators you may have in the research project. So once I have all the data, and I'm, you know, I'm not really focusing on all the steps of how to create a research project. I'm really talking about the manuscript. So I first write a draft, and the first draft is always, you know, that's, first of all, it's always the hardest because it takes, you know, some momentum to start writing. And there's important, very, very important, you don't have to do it perfectly the first time. I think it's important to follow your outline and then just put things in the paper. And then little by little, you can edit the different paragraphs, but you just have to write that first draft. And that is going to create kind of this framework where you can then work on and then edit. So I always write this first draft, it's very rough. If you see all the first drafts, most of my first drafts, most of the times don't make sense because sometimes there's just ideas or lines of trying to construct this piece, like this, these different puzzles, put them together. But just write some and just put it on, you know, what ideas, and again, it's a rough sketch of what you're trying to accomplish. The second draft that I write is really looking at the instructions from the journal that I'm trying to, where I want to send the manuscript. Like different journals have different instructions and how they like things to be framed. Some are more flexible than others, and some are very strict on how they want the manuscripts to be structured. So, and you know, there's limits and so forth. So I would say that when I'm really doing the second draft that I really put in more effort editing and so forth, that's when I look at the instructions and try to follow those instructions to make sure that I don't have a lot of editing in the back end. Once I have the second draft, I usually solicit feedback from all the co-authors. If you have a mentor, I think it's a good idea to start showing that even, you know, talking to your mentors or, you know, or people who are overseeing the study, even the first or second draft. And then once you have a good second draft, and whoever's the principal investigator or other main collaborators feel comfortable, then at that point might be a good idea to start getting feedback from other collaborators. So this is just a general road. Again, you write your first draft, first, you know, first formal draft. You ask your peers, collaborators to give you feedback. You know, it's good and it's important to get feedback from collaborators. You might encounter collaborators that are going to be more involved than others, but really try to get feedback. The more feedback you get in this stage, the better. And to be honest, like when I wrote my first manuscripts, I used to get a lot of revisions from my mentors. And I do prefer, and you know, it's painful and it was hard to see all of these edits and changes and suggestions, and it just made you, you know, I remember it used to make me feel awful that I didn't know how to write, but that's exactly what you want. You want someone who really takes the time and goes through the manuscript and really provides good feedback. That's exactly what you want. You want your manuscript to almost look instead of all black, all red with all of these comments, so you can make it better. So then after that, you submit it to journal for consideration, again, very important to think about what is the proper journal. And if you don't know what is the proper journal, just ask to your mentors, the principal investigators or your peers, where they think it would be a good place for the manuscript. And again, there's a lot of reasons why you should send it to different journals. And I mentioned some of them previously. So the sections of the manuscript are in abstract. There's always word limits depending on the journal. So always keep that in mind. Introduction, to me, I usually think the introduction should be around two paragraphs, maximum three paragraphs. And it should be, what is the problem that you're trying to address? A brief overview of the existing data, okay? Why your study is important. It's important to really explain to whoever's reading why this study is important. And then also try to really, really, very clearly put what is your objective or what is the hypothesis that you're trying to prove. But it should not be more than three paragraphs. Then is the method section. When I do the methods, I first try to describe where the data came from, what is the inclusion exclusion criteria? And I tried to do a good job of really varying it in a lot of detail, describing the statistics of the project. And then the results, the text, the tables and the figures. Tables and figures are very, very important and really spend a lot of time making sure that the tables look fine. What I mean with that is make sure that the numbers in the tables are corresponding to whatever you put in the manuscript, okay? Make sure that the tables look nice. Like when we see this, reviewers notice when someone has put the F word in the tables and they look nice. And make sure that the words are complete or if there's like abbreviations that you're saying that in the tables. And I would just look like top tier journals to show how they present the tables and just replicate that. You want your tables to look pristine. Figures are also very, very important. And again, this is one of those things that I don't think a lot of people think about it. But when you look at a manuscript that you get to review and you see that someone put a lot of effort into the figures and you see these nice figures that really can tell a story about what the investigators are trying to prove. That gives a lot of weight, especially if the figures look nice and pretty. So if you have access to be able to include nice figures, or whatever you're trying to show, you really spend time making sure that they look nice. And more important that actually provide important data that it's easy for people to read and understand and exemplify what you're trying to prove with your study. And then the discussion should be around five or six paragraphs, no more than that. I always like to include a limitations paragraph. What are the limitations of the study and how you try to overcome those limitations? And then for a lot of journals, you have to put a concluding paragraph. And I think that's a nice way to kind of put everything together. And then references, just make sure that the references are the proper references. Some people, some reviewers actually look through all the references and make sure that they look fine. So just spend good time and making sure that everything looks adequate. So what are the common causes of rejection? And this is things that as a reviewer or as an editor, that I pay attention to. So I think the number one is that the study is not novel enough or is not addressing an important question. So if we get a manuscript that it's just showing the same thing that has been shown in randomized trials, in prospective studies, in large cohort studies, and now it's a small study from a single institution study, that probably is not novel enough, right? It's been published before and now a single institution study is probably not gonna change dramatically how we treat patients. So again, I think the novelty, how creative, whether it's a new data source, a new way of looking at a specific question, that is important. And it's important to stress that in the introduction so reviewers and editors know that this is a different way of looking at a specific question. And the important thing is that you wanna address an important clinical question. We really want to move the needle in the care of patients with GYN cancers. So the second common cause of rejection is methodology. So if I don't see what are the inclusion or exclusion criteria, I think that to me is a big red flag. Insufficient sample size, obviously that is a big issue. Perhaps it's a small sample size, it's a prospective randomized pilot study, obviously that is important, right? But if it's, again, a question that has been addressed in randomized trials, and now you're presenting a retrospective single institution study with 20 patients, that probably is not enough. So again, just think about what is the question. If it's novel, perhaps you might get away with small sample size, but if it's something that it's more common that has been addressed before, you might wanna show like a larger sample size. It's very, very important to be very clear about what is the treatment intervention, what we call exposure. And sometimes it's actually hard to assess when you're reading manuscripts, what is actually the intervention that the authors are trying to look at. So just make sure that you are very clear about, this is our exposure, and how you assess that in the data that you have. Not only mentioning what it is, but also explain where, how you define that, super important. So value of measures not demonstrated. So if you, for example, if you're using surveys and so forth, make sure that they are validated surveys, or if you are looking at certain outcomes that are not hard outcomes, but they are like composite outcomes, make sure that other studies have shown that that data is reliable, and those are good outcomes to measure. And finally, if there are statistics concerns, I would say that to me, I like to have a whole paragraph, at least really putting in a lot of detail, what are the statistics. And not only for, you have to be explicit. For example, if you're talking about logistic regression, to me, it's very important, or a Cox regression model, saying what are the variables that were included in the models? And what was the rationale for those variables that you include in the models? And if you had different models in, and you were looking at different things, why were you looking at, you create a different model? So be very explicit about the decisions that you made when you were doing the statistics of your study. So in terms of the results, I think sometimes results are confusing, or they are not in an order that it's easy to understand. So I would say that what it's important is that the manuscript has to have a flow. You're trying to tell a story. So sometimes you read some of these manuscripts, some manuscripts and results are all confusing, and it's hard to tell. So you wanna make sure that everything's clear, and whoever's reading the manuscript is not having to think a lot about the stuff, but you wanna make it easier for the readers. A very, very, very important thing, it's considering confounding and selection bias, especially for retrospective observational studies. So all of these, every retrospective study, every observational study is gonna have confounding and potentially selection bias. So, and you are not gonna be able to assess for all the confoundings that you have. There's a lot of unmeasured confounding, and there are different strategies to address unmeasured confounding. But if you don't use those strategies, at least saying in the limitations, there's an unmeasured confounding that could explain our results, and mention what is the potential measure confounding you're thinking about, and just saying this is a limitation. But just keep in mind that there is now methodologies that you can use, they're not hard to use, to at least assess for unmeasured confounding. The same goes for selection bias. There are ways, there are strategies, the statistics that you can use to address for selection bias. For example, propensity score matching might be way, one way you can use instrumental variables. There's like newer research methodologies like quasi-experimental designs that may address all of these issues. So again, try to think creatively and new ways of looking at the data. And finally, in the interpretation of the problems, a big, big red flag is when we see someone who's being very overly speculative, or they do not discuss implications, right? But more times, like when you see that the results are inflated, some authors try to claim that this, such new therapy should become standard of care based on retrospective data. So just, I would say, be concrete in the results, and also understand what are the limitations of your data. And finally, there are stylistic issues. And I would say that you wanna be very concrete when you write, specific. If English is not your primary language, I would say that there are ways to come around. There's editing services out there that can help. And that has an important, right? I mean, you wanna make sure that the readers, and whereas the reviewers are able to understand what you're trying to say. So the style that you use in the manuscript is very, very, very, very important. It's not the most important thing. I think the data is the most important thing, but really style and how the manuscript reads can give you extra points with reviewers. So this is all data about some of the reasons why some manuscripts were not accepted. And as you can see, poorly written was the most common thing. So again, spend time making sure that your manuscript has a nice flow, and it's easier for the readers to understand. So I mentioned some of these things, but these are the key elements. So in terms of the topic, I mentioned that you wanna have something that is relevant for the field, a new way of looking at, some innovation or creative way of looking at the data. Think about the journal. Again, some questions are more appropriate for subspecialty journals, others for top tier journals, others for like general OB-GYN or general cancer journals. So really try to match the topic with the journal. And if sometimes, if you're a resident or a fellow, this is something that I think your faculty or mentors can really help you try to think about what is the proper, the adequate journal where to submit your manuscript. And really, really, really like think about the quality, how the manuscript reads, how the tables are structured, how the figures look. Those things, stylistic things give you extra points. And really, I do think that have an impact in how reviewers might look at your manuscript. So I think that's about it. So if anyone has any questions about this talk, I'm happy to talk anytime. Feel free to contact me. My email is J-A-R-A-U-H at indianason.org. Thank you very much.

manuscript publishing

choosing the right journal

clear research question

literature review

study designs

statistical advice