How Can Literature and Peer Review Impact an Oncology Fellow’s Career?

In an interview with CancerNetwork®, Elizabeth Thompson, MD, discussed what drew her to pediatric oncology during her training and how that interest developed alongside her radiation oncology education. She also discussed her role as the pediatric disease site lead for CURiE, walking through what the peer review process looks like, what she has learned about evaluating research quality, and what separates a strong pediatric oncology manuscript from a weaker one. Thompson closed by discussing current trends in pediatric oncology literature, including efforts to scale back treatment intensity to reduce long-term toxicity, promising research directions such as radioligand therapy, and the value she has found in taking on peer review work during residency.

Thompson is a fourth-year resident in the Department of Radiation Oncology at the University of Florida.

CancerNetwork: As the pediatrics disease site lead for CURiE, can you describe what the peer review process looks like, and how you approach manuscript evaluation?

Thompson: I review all the pediatric submissions related to pediatric radiation oncology. It’s a fairly standard process. The author submits the article they want reviewed and published, and I, along with other selected and volunteer peer reviewers, read it. There’s a portal where you can highlight sections and leave comments as you go through the manuscript. Afterward, there are questions addressing the overall theme of the paper, whether the sources are current and comprehensive, whether any major relevant literature is missing, and the general structure and quality of the paper.

I review all the pediatric submissions, along with a couple of other reviewers, and we synthesize the feedback into a final decision on whether the paper is ready to publish as is, whether it falls into a middle ground where relatively simple changes are needed before resubmission and likely publication, or whether it needs substantial additional work before it can be considered, in which case the authors still receive feedback and can resubmit. I’d say most submissions land in that middle ground. It’s rare for a paper to be accepted exactly as submitted the first time—I know that from submitting my own research—there are almost always a few changes reviewers want.

What separates a strong pediatric oncology manuscript from a weak one?

Having worked with [Danny Indelicato, MD, FASTRO, FRCR], on publishing some research myself, and through what we receive at CURiE, it’s clear that kids get far less cancer overall than adults, and their cancer types are very specific and nuanced. Compared with the adult world, smaller studies can have a much bigger impact in pediatrics because the overall data, while there are plenty of trials as kids are constantly enrolled, are more limited in terms of outcomes publications.

Even a retrospective outcomes study of 30 children with the same diagnosis, or the same stage of a diagnosis, can be quite impactful in pediatrics, even though retrospective studies are generally considered a less rigorous type of evidence in the adult world, where the gold standard is a prospective, randomized controlled trial comparing outcomes between 2 arms. In pediatrics, because the data are so limited, retrospective reviews, even with a small number of patients, can carry a lot of weight and sometimes even influence practice more than a comparable study would in adults, simply because there are less data available, overall, on children.

That’s one thing that separates a strong article: solid retrospective data with a reasonable number of patients, along with thoughtfully written manuscripts on strong subject matter. Interesting case reports are also [valuable]—we publish a lot of these at CURiE—because pediatric cases are so nuanced that almost every one could be its own case report, given how different each case and its long-term outcomes can be. Transparency around statistics is also important, along with overall clinical relevance.

What has literature review taught you about how treatment-related research gets evaluated in practice? Does it change how you think about your own treatment decisions going forward?

Definitely. Understanding practice-changing publications, whether in pediatrics or adults, is important. My residency program does a good job explaining the most important literature and different perspectives on studies, and medical school does too. This is something I’ve always been fairly familiar with; a publication comes out, and now a certain cancer type is treated a certain way because of its results. That’s typically how guidelines get updated.

But it’s always worth digging into the literature itself to make sure you agree with the conclusions. You might notice something like a study population that was overwhelmingly male with very few female participants, which could limit how applicable the findings are to female patients, or genetic nuances that weren’t accounted for. As time goes on, we’re also getting more information, in areas like genetics, that may not have been considered when older publications were written, as a lot of the large randomized controlled trials we rely on were conducted between the 1990s and 2010s, given how long it takes to collect and synthesize the data and get it published. Technology has often changed significantly since then.

Those are things worth considering when reading data that are considered practice changing. That said, I don’t think practice-changing decisions or publications are made lightly; a lot of thoughtful people are involved, so I don’t think you should go around second-guessing established guidelines. But it’s important to read the data critically. Guidelines usually don’t change until multiple sources report the same finding, which matters, but it’s worth looking closely, especially if you have the time and are treating something very specific.

Are there any trends you’re noticing in the pediatric oncology literature coming through CURiE right now?

We get a lot of case reports, which I think is somewhat more common in pediatric literature because every child’s case tends to have different outcomes or nuances to their treatment. The case reports we get cover a pretty broad range of interesting topics. I genuinely enjoy reading them; they’re specific, but they walk through an entire clinical picture, from diagnosis to treatment decisions to follow-up, which I find both interesting and helpful. They’re also a good reminder, for residents and fellows especially, of the entire process involved in treating a patient, as case reports tend to be very thoughtful about specific nuances in treatment.

Overall, it varies a lot by disease site, as pediatrics is fairly heterogeneous. But there’s a lot of interest in areas where we’re seeing good outcomes in scaling back treatment, whether through lower radiation doses or less intense chemotherapy regimens out of growing concern for long-term toxicity, which wasn’t as much of a focus historically because the priority was understandably curing the cancer. But if you can scale back treatment while maintaining strong outcomes so children experience less long-term toxicity, that’s exciting and good for everyone. That’s one trend I’ve noticed a lot. Of course, there are areas where treatment needs to be scaled up because the cancers are more aggressive, but for some of the more [treatable] pediatric cancers, there’s a lot of interest in scaling back to minimize toxicity, and long-term toxicity in general is a major focus across oncology right now.

In that same vein of reducing toxicity and new treatment advancements, has your work exposed you to treatment approaches or research directions you find particularly interesting or promising?

Oncology overall is a very promising field; it’s research dense, and there’s always something new, as everyone is working toward curing cancer. There won’t be one single cure for cancer, as it’s such a complicated disease, and once it mutates, every cancer type becomes a bit different, unless we find a way to detect it at the single-cell level.

Immunotherapy is promising and interesting. There’s also an area of radiation oncology, not currently part of the pediatric space at all: radioligand therapy, where a radioactive protein is attached to something the cancer produces, injected intravenously, and attracted to areas producing that target, such as prostate-specific antigen [PSA] in prostate cancer or somatostatin receptors in neuroendocrine tumors. There’s a lot happening there that’s promising on the radiation oncology side. Immunotherapy is more on the medical oncology side, but both are promising and meaningfully improving outcomes.

Immunotherapy has been adopted more slowly in pediatrics, partly because some long-term adverse effects are still unknown, and there’s understandable hesitancy to introduce more radical treatments to children given the potential for more significant toxicity. I’m not aware of any radioligand therapies currently used in pediatrics, but if it continues to go well in adults, I’d expect that to change. Pediatric cancers also have fewer easily targetable markers; children don’t get prostate cancer, for instance, which makes PSA such an easy target. But both of these are really exciting areas of research that should lead to better outcomes and easier treatments over time. Many pediatric cancers are curable but require intense chemotherapy or radiation with significant adverse effects. It’s usually worth it, and most children recover and do well, but it’s still a hard few months. It’s meaningful to work toward treatments that are a bit easier for patients to get through.

What value have you found in taking on peer review work at this point in your training alongside your clinical responsibilities?

I really enjoy it. Most clinicians would agree that staying up to date with the literature is important in any field, especially oncology, where there’s always significant research happening. But as a resident, it can be hard to find time for that between clinic and learning how to treat patients, let alone keeping up with new literature. In radiation oncology, specifically, it’s especially challenging, as we train across both pediatric and adult populations and every site in the body. Once you become a practicing attending, you typically focus on a few specific subsites, which makes it easier to stay current on that literature. As a resident, though, it can feel overwhelming trying to stay on top of everything.

Being a peer reviewer gives you a built-in reason to engage with new literature; you receive manuscripts by email, and while you can decline a given review, it gives you motivation to stay current. It also reinforces the skill of reading older literature critically. Having it scheduled into your day, essentially being required to read certain articles, is a good practice, and the more you read, the less daunting it becomes to go back and read older or larger, more significant papers. I really enjoy it, and it’s a great thing to take on. When you come across something particularly interesting or applicable, it’s fun to bring it up in clinic with attendings and hear their perspective, whether on a new treatment approach or an unusual case from a case report. It can make for an engaging and educational discussion.