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How to Write a Literature Review | Guide, Examples, & Templates

How to Write a Literature Review | Guide, Examples, & Templates

Published on January 2, 2023 by Shona McCombes . Revised on September 11, 2023.

What is a literature review? A literature review is a survey of scholarly sources on a specific topic. It provides an overview of current knowledge, allowing you to identify relevant theories, methods, and gaps in the existing research that you can later apply to your paper, thesis, or dissertation topic .

There are five key steps to writing a literature review:

Search for relevant literature
Evaluate sources
Identify themes, debates, and gaps
Outline the structure
Write your literature review

A good literature review doesn’t just summarize sources—it analyzes, synthesizes , and critically evaluates to give a clear picture of the state of knowledge on the subject.

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What is the purpose of a literature review, examples of literature reviews, step 1 – search for relevant literature, step 2 – evaluate and select sources, step 3 – identify themes, debates, and gaps, step 4 – outline your literature review’s structure, step 5 – write your literature review, free lecture slides, other interesting articles, frequently asked questions, introduction.

Quick Run-through
Step 1 & 2

When you write a thesis , dissertation , or research paper , you will likely have to conduct a literature review to situate your research within existing knowledge. The literature review gives you a chance to:

Demonstrate your familiarity with the topic and its scholarly context
Develop a theoretical framework and methodology for your research
Position your work in relation to other researchers and theorists
Show how your research addresses a gap or contributes to a debate
Evaluate the current state of research and demonstrate your knowledge of the scholarly debates around your topic.

Writing literature reviews is a particularly important skill if you want to apply for graduate school or pursue a career in research. We’ve written a step-by-step guide that you can follow below.

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Writing literature reviews can be quite challenging! A good starting point could be to look at some examples, depending on what kind of literature review you’d like to write.

Example literature review #1: “Why Do People Migrate? A Review of the Theoretical Literature” ( Theoretical literature review about the development of economic migration theory from the 1950s to today.)
Example literature review #2: “Literature review as a research methodology: An overview and guidelines” ( Methodological literature review about interdisciplinary knowledge acquisition and production.)
Example literature review #3: “The Use of Technology in English Language Learning: A Literature Review” ( Thematic literature review about the effects of technology on language acquisition.)
Example literature review #4: “Learners’ Listening Comprehension Difficulties in English Language Learning: A Literature Review” ( Chronological literature review about how the concept of listening skills has changed over time.)

You can also check out our templates with literature review examples and sample outlines at the links below.

Download Word doc Download Google doc

Before you begin searching for literature, you need a clearly defined topic .

If you are writing the literature review section of a dissertation or research paper, you will search for literature related to your research problem and questions .

Make a list of keywords

Start by creating a list of keywords related to your research question. Include each of the key concepts or variables you’re interested in, and list any synonyms and related terms. You can add to this list as you discover new keywords in the process of your literature search.

Social media, Facebook, Instagram, Twitter, Snapchat, TikTok
Body image, self-perception, self-esteem, mental health
Generation Z, teenagers, adolescents, youth

Search for relevant sources

Use your keywords to begin searching for sources. Some useful databases to search for journals and articles include:

Your university’s library catalogue
Google Scholar
Project Muse (humanities and social sciences)
Medline (life sciences and biomedicine)
EconLit (economics)
Inspec (physics, engineering and computer science)

You can also use boolean operators to help narrow down your search.

Make sure to read the abstract to find out whether an article is relevant to your question. When you find a useful book or article, you can check the bibliography to find other relevant sources.

You likely won’t be able to read absolutely everything that has been written on your topic, so it will be necessary to evaluate which sources are most relevant to your research question.

For each publication, ask yourself:

What question or problem is the author addressing?
What are the key concepts and how are they defined?
What are the key theories, models, and methods?
Does the research use established frameworks or take an innovative approach?
What are the results and conclusions of the study?
How does the publication relate to other literature in the field? Does it confirm, add to, or challenge established knowledge?
What are the strengths and weaknesses of the research?

Make sure the sources you use are credible , and make sure you read any landmark studies and major theories in your field of research.

You can use our template to summarize and evaluate sources you’re thinking about using. Click on either button below to download.

Take notes and cite your sources

As you read, you should also begin the writing process. Take notes that you can later incorporate into the text of your literature review.

It is important to keep track of your sources with citations to avoid plagiarism . It can be helpful to make an annotated bibliography , where you compile full citation information and write a paragraph of summary and analysis for each source. This helps you remember what you read and saves time later in the process.

Prevent plagiarism. Run a free check.

To begin organizing your literature review’s argument and structure, be sure you understand the connections and relationships between the sources you’ve read. Based on your reading and notes, you can look for:

Trends and patterns (in theory, method or results): do certain approaches become more or less popular over time?
Themes: what questions or concepts recur across the literature?
Debates, conflicts and contradictions: where do sources disagree?
Pivotal publications: are there any influential theories or studies that changed the direction of the field?
Gaps: what is missing from the literature? Are there weaknesses that need to be addressed?

This step will help you work out the structure of your literature review and (if applicable) show how your own research will contribute to existing knowledge.

Most research has focused on young women.
There is an increasing interest in the visual aspects of social media.
But there is still a lack of robust research on highly visual platforms like Instagram and Snapchat—this is a gap that you could address in your own research.

There are various approaches to organizing the body of a literature review. Depending on the length of your literature review, you can combine several of these strategies (for example, your overall structure might be thematic, but each theme is discussed chronologically).

Chronological

The simplest approach is to trace the development of the topic over time. However, if you choose this strategy, be careful to avoid simply listing and summarizing sources in order.

Try to analyze patterns, turning points and key debates that have shaped the direction of the field. Give your interpretation of how and why certain developments occurred.

If you have found some recurring central themes, you can organize your literature review into subsections that address different aspects of the topic.

For example, if you are reviewing literature about inequalities in migrant health outcomes, key themes might include healthcare policy, language barriers, cultural attitudes, legal status, and economic access.

Methodological

If you draw your sources from different disciplines or fields that use a variety of research methods , you might want to compare the results and conclusions that emerge from different approaches. For example:

Look at what results have emerged in qualitative versus quantitative research
Discuss how the topic has been approached by empirical versus theoretical scholarship
Divide the literature into sociological, historical, and cultural sources

Theoretical

A literature review is often the foundation for a theoretical framework . You can use it to discuss various theories, models, and definitions of key concepts.

You might argue for the relevance of a specific theoretical approach, or combine various theoretical concepts to create a framework for your research.

Like any other academic text , your literature review should have an introduction , a main body, and a conclusion . What you include in each depends on the objective of your literature review.

The introduction should clearly establish the focus and purpose of the literature review.

Depending on the length of your literature review, you might want to divide the body into subsections. You can use a subheading for each theme, time period, or methodological approach.

As you write, you can follow these tips:

Summarize and synthesize: give an overview of the main points of each source and combine them into a coherent whole
Analyze and interpret: don’t just paraphrase other researchers — add your own interpretations where possible, discussing the significance of findings in relation to the literature as a whole
Critically evaluate: mention the strengths and weaknesses of your sources
Write in well-structured paragraphs: use transition words and topic sentences to draw connections, comparisons and contrasts

In the conclusion, you should summarize the key findings you have taken from the literature and emphasize their significance.

When you’ve finished writing and revising your literature review, don’t forget to proofread thoroughly before submitting. Not a language expert? Check out Scribbr’s professional proofreading services !

This article has been adapted into lecture slides that you can use to teach your students about writing a literature review.

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If you want to know more about the research process , methodology , research bias , or statistics , make sure to check out some of our other articles with explanations and examples.

Sampling methods
Simple random sampling
Stratified sampling
Cluster sampling
Likert scales
Reproducibility

Statistics

Null hypothesis
Statistical power
Probability distribution
Effect size
Poisson distribution

Research bias

Optimism bias
Cognitive bias
Implicit bias
Hawthorne effect
Anchoring bias
Explicit bias

A literature review is a survey of scholarly sources (such as books, journal articles, and theses) related to a specific topic or research question .

It is often written as part of a thesis, dissertation , or research paper , in order to situate your work in relation to existing knowledge.

There are several reasons to conduct a literature review at the beginning of a research project:

To familiarize yourself with the current state of knowledge on your topic
To ensure that you’re not just repeating what others have already done
To identify gaps in knowledge and unresolved problems that your research can address
To develop your theoretical framework and methodology
To provide an overview of the key findings and debates on the topic

Writing the literature review shows your reader how your work relates to existing research and what new insights it will contribute.

The literature review usually comes near the beginning of your thesis or dissertation . After the introduction , it grounds your research in a scholarly field and leads directly to your theoretical framework or methodology .

A literature review is a survey of credible sources on a topic, often used in dissertations , theses, and research papers . Literature reviews give an overview of knowledge on a subject, helping you identify relevant theories and methods, as well as gaps in existing research. Literature reviews are set up similarly to other academic texts , with an introduction , a main body, and a conclusion .

An annotated bibliography is a list of source references that has a short description (called an annotation ) for each of the sources. It is often assigned as part of the research process for a paper .

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Grey literature: An important resource in systematic reviews

Affiliation.

1 Nuffield Department of Primary Care Health Sciences, Centre for Evidence-Based Medicine, Department for Continuing Education, The University of Oxford, Oxford, UK.
PMID: 29266844
DOI: 10.1111/jebm.12265

Systematic reviews aid the analysis and dissemination of evidence, using rigorous and transparent methods to generate empirically attained answers to focused research questions. Identifying all evidence relevant to the research questions is an essential component, and challenge, of systematic reviews. Grey literature, or evidence not published in commercial publications, can make important contributions to a systematic review. Grey literature can include academic papers, including theses and dissertations, research and committee reports, government reports, conference papers, and ongoing research, among others. It may provide data not found within commercially published literature, providing an important forum for disseminating studies with null or negative results that might not otherwise be disseminated. Grey literature may thusly reduce publication bias, increase reviews' comprehensiveness and timeliness and foster a balanced picture of available evidence. Grey literature's diverse formats and audiences can present a significant challenge in a systematic search for evidence. However, the benefits of including grey literature may far outweigh the cost in time and resource needed to search for it, and it is important for it to be included in a systematic review or review of evidence. A carefully thought out grey literature search strategy may be an invaluable component of a systematic review. This narrative review provides guidance about the benefits of including grey literature in a systematic review, and sources for searching through grey literature. An illustrative example of a search for evidence within grey literature sources is presented to highlight the potential contributions of such a search to a systematic review. Benefits and challenges of grey literature search methods are discussed, and recommendations made.

Keywords: evidence; grey literature; publication bias; search; systematic review.

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Research article
Open access
Published: 16 May 2019

An analysis of current practices in undertaking literature reviews in nursing: findings from a focused mapping review and synthesis

Helen Aveyard ORCID: orcid.org/0000-0001-5133-3356 1 &
Caroline Bradbury-Jones 2

BMC Medical Research Methodology volume 19 , Article number: 105 ( 2019 ) Cite this article

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In this paper we discuss the emergence of many different methods for doing a literature review. Referring back to the early days, when there were essentially two types of review; a Cochrane systematic review and a narrative review, we identify how the term systematic review is now widely used to describe a variety of review types and how the number of available methods for doing a literature review has increased dramatically. This led us to undertake a review of current practice of those doing a literature review and the terms used to describe them.

We undertook a focused mapping review and synthesis. Literature reviews; defined as papers with the terms review or synthesis in the title, published in five nursing journals between January 2017–June 2018 were identified. We recorded the type of review and how these were undertaken.

We identified more than 35 terms used to describe a literature review. Some terms reflected established methods for doing a review whilst others could not be traced to established methods and/or the description of method in the paper was limited. We also found inconsistency in how the terms were used.

We have identified a proliferation of terms used to describe doing a literature review; although it is not clear how many distinct methods are being used. Our review indicates a move from an era when the term narrative review was used to describe all ‘non Cochrane’ reviews; to a time of expansion when alternative systematic approaches were developed to enhance rigour of such narrative reviews; to the current situation in which these approaches have proliferated to the extent so that the academic discipline of doing a literature review has become muddled and confusing. We argue that an ‘era of consolidation’ is needed in which those undertaking reviews are explicit about the method used and ensure that their processes can be traced back to a well described, original primary source.

Peer Review reports

Over the past twenty years in nursing, literature reviews have become an increasingly popular form of synthesising evidence and information relevant to the profession. Along with this there has been a proliferation of publications regarding the processes and practicalities of reviewing [ 1 , 2 , 3 , 4 ], This increase in activity and enthusiasm for undertaking literature reviews is paralleled by the foundation of the Cochrane Collaboration in 1993. Developed in response to the need for up-to-date reviews of evidence of the effectiveness of health care interventions, the Cochrane Collaboration introduced a rigorous method of searching, appraisal and analysis in the form of a ‘handbook’ for doing a systematic review [ 5 ] .Subsequently, similar procedural guidance has been produced, for example by the Centre for Reviews and Dissemination (CRD) [ 6 ] and The Joanna Briggs Institute [ 7 ]. Further guidance has been published to assist researchers with clarity in the reporting of published reviews [ 8 ].

In the early days of the literature review era, the methodological toolkit for those undertaking a literature was polarised, in a way that mirrored the paradigm wars of the time within mixed-methods research [ 9 ]. We refer to this as the ‘dichotomy era’ (i.e. the 1990s), The prominent methods of literature reviewing fell into one of two camps: The highly rigorous and systematic, mostly quantitative ‘Cochrane style’ review on one hand and a ‘narrative style’ review on the other hand, whereby a body of literature was summarised qualitatively, but the methods were often not articulated. Narrative reviews were particularly popular in dissertations and other student work (and they continue to be so in many cases) but have been criticised for a lack of systematic approach and consequently significant potential for bias in the findings [ 10 , 11 ].

The latter 1990s and early 2000, saw the emergence of other forms of review, developed as a response to the Cochrane/Narrative dichotomy. These alternative approaches to the Cochrane review provided researchers with reference points for performing reviews that drew on different study types, not just randomised controlled trials. They promoted a systematic and robust approach for all reviews, not just those concerned with effectiveness of interventions and treatments. One of the first published description of methods was Noblet and Hare’s (1998) ‘Meta-ethnography’ [ 12 ]. This method, although its name suggests otherwise, could incorporate and synthesise all types of qualitative research, not just ethnographies. The potential confusion regarding the inclusion of studies that were not ethnographies within a meta-ethnography, promoted the description of other similar methods, for example, the meta-synthesis of Walsh and Downe (2005) [ 13 ] and the thematic synthesis of Thomas and Harden (2008) [ 14 ]. Also, to overcome the dichotomy of the quantitative/qualitative reviews, the integrative review was described according to Whitemore and Knafl (2005) [ 15 ]. These reviews can be considered to be literature reviews that have been done in a systematic way but not necessarily adhering to guidelines established by the Cochrane Collaboration. We conceptualise this as the ‘expansion era’. Some of the methods are summarised in Table 1 .

Over the past two decades there has been a proliferation of review types, with corresponding explosion of terms used to describe them. A review of evidence synthesis methodologies by Grant and Booth in 2009 [ 20 ] identified 14 different approaches to reviewing the literature and similarly, Booth and colleagues [ 21 ] detailed 19 different review types, highlighting the range of review types currently available. We might consider this the ‘proliferation era’. This is however, somewhat a double-edged sword, because although researchers now have far more review methods at their disposal, there is risk of confusion in the field. As Sabatino and colleagues (2014) [ 22 ] have argued, review methods are not always consistently applied by researchers.

Aware of such potential inconsistency and also our own confusion at times regarding the range of review methods available, we questioned what was happening within our own discipline of nursing. We undertook a snap-shot, contemporary analysis to explore the range of terms used to describe reviews, the methods currently described in nursing and the underlying trends and patterns in searching, appraisal and analysis adopted by those doing a literature review. The aim was to gain some clarity on what is happening within the field, in order to understand, explain and critique what is happening within the proliferation era.

In order to explore current practices in doing a literature review, we undertook a ‘Focused Mapping Review and Synthesis’ (FMRS) – an approach that has been described only recently. This form of review [ 19 ] is a method of investigating trends in academic publications and has been used in a range of issues relevant to nursing and healthcare, for example, theory in qualitative research [ 23 ] and vicarious trauma in child protection research [ 24 ].

A FMRS seeks to identify what is happening within a particular subject or field of inquiry; hence the search is restricted to a particular time period and to pre-identified journals. The review has four distinct features: It: 1) focuses on identifying trends in an area rather than a body of evidence; 2) creates a descriptive map or topography of key features of research within the field rather than a synthesis of findings; 3) comments on the overall approach to knowledge production rather than the state of the evidence; 4) examines this within a broader epistemological context. These are translated into three specific focused activities: 1) targeted journals; 2) a specific subject; 3) a defined time period. The FMRS therefore, is distinct from other forms of review because it responds to questions concerned with ‘what is happening in this field?’ It was thus an ideal method to investigate current practices in literature reviews in nursing.

Using the international Scopus (2016) SCImago Journal and Country Rank, we identified the five highest ranked journals in nursing at that time of undertaking the review. There was no defined method for determining the number of journals to include in a review; the aim was to identify a sample and we identified five journals in order to search from a range of high ranking journals. We discuss the limitations of this later. Journals had to have ‘nursing’ or ‘nurse’ in the title and we did not include journals with a specialist focus, such as nutrition, cancer etcetera. The included journals are shown in Table 2 and are in order according to their ranking. We recognise that our journal choice meant that only articles published in English made it into the review.

A key decision in a FMRS is the time-period within which to retrieve relevant articles. Like many other forms of review, we undertook an initial scoping to determine the feasibility and parameters of the project [ 19 ]. In our previous reviews, the timeframe has varied from three months [ 23 ] to 6 years [ 24 ]. The main criterion is the likelihood for the timespan to contain sufficient articles to answer the review questions. We set the time parameter from January 2017–June 2018. We each took responsibility for two and three journals each from which to retrieve articles. We reviewed the content page of each issue of each journal. For our purposes, in order to reflect the diverse range of terms for describing a literature review, as described earlier in this paper, any paper that contained the term ‘review’ or ‘synthesis’ in the title was included in the review. This was done by each author individually but to enhance rigour, we worked in pairs to check each other’s retrieval processes to confirm inter-rater consistency. This process allowed any areas of uncertainty to be discussed and agreed and we found this form of calibration crucial to the process. The inclusion and exclusion criteria are shown in Table 3 .

Articles meeting the inclusion criteria, papers were read in full and data was extracted and recorded as per the proforma developed for the study (Table 4 ). The proforma was piloted on two papers to check for usability prior to data extraction. Data extraction was done independently but we discussed a selection of papers to enhance rigour of the process. No computer software was used in the analysis of the data. We did not critically appraise the included studies for quality because our purpose was to profile what is happening in the field rather than to draw conclusions from the included studies’ findings.

Once the details from all the papers had been extracted onto the tables, we undertook an analysis to identify common themes in the included articles. Because our aim was to produce a snap-shot profile, our analysis was thematic and conceptual. Although we undertook some tabulation and numerical analysis, our primary focus was on capturing patterns and trends characterised by the proliferation era. In line with the FMRS method, in the findings section we have used illustrative examples from the included articles that reflect and demonstrate the point or claim being made. These serve as useful sources of information and reference for readers seeking concrete examples.

Between January 2017 and June 2018 in the five journals we surveyed, a total of 222 papers with either ‘review’ or ‘synthesis’ in the title were retrieved and included in our analysis. We identified three primary themes: 1) Proliferation in names for doing a review; 2) Allegiance to an established review method; 3) Clarity about review processes. The results section is organised around these themes.

Proliferation in names for doing a review

We identified more than 35 terms used by authors to describe a literature review. Because we amalgamated terms such as ‘qualitative literature review’ and ‘qualitative review’ the exact number is actually slightly higher. It was clear from reading the reviews that many different terms were used to describe the same processes. For example qualitative systematic review, qualitative review and meta-synthesis, qualitative meta-synthesis, meta-ethnography all refer to a systematic review of qualitative studies. We have therefore grouped together the review types that refer to a particular type of review as described by the authors of the publications used in this study (Table 5 ).

In many reviews, the specific type of review was indicated in the title as seen for example in Table 5 . A striking feature was that all but two of the systematic reviews that contained a meta-analysis were labelled as such in the title; providing clarity and ease of retrieval. Where a literature review did not contain a meta-analysis, the title of the paper was typically referred to a ‘systematic review’; the implication being that a systematic review is not necessarily synonymous with a meta-analysis. However as discussed in the following section, this introduced some muddying of water, with different interpretations of what systematic review means and how broadly this term is applied. Some authors used the methodological type of included papers to describe their review. For example, a Cochrane-style systematic review was undertaken [ 25 ] but the reviewers did not undertake a meta-analysis and thus referred to their review as a ‘quantitative systematic review’.

Allegiance to an established literature review method

Many literature reviews demonstrated allegiance to a defined method and this was clearly and consistently described by the authors. For example, one team of reviewers [ 26 ] articulately described the process of a ‘meta-ethnography’ and gave a detailed description of their study and reference to the origins of the method by Noblet and Hare (1988) [ 12 ]. Another popular method was the ‘integrative review’ where most authors referred to the work of one or two seminal papers where the method was originally described (for example, Whitemore & Knafl 2005 [ 15 ]).

For many authors the term systematic review was used to mean a review of quantitative research, but some authors [ 27 , 28 , 29 ],used the term systematic review to describe reviews containing both qualitative and quantitative data.

However in many reviews, commitment to a method for doing a literature review appeared superficial, undeveloped and at times muddled. For example, three reviews [ 30 , 31 , 32 ] , indicate an integrative review in the title of their review, but this is the only reference to the method; there is no further reference to how the components of an integrative review are addressed within the paper. Other authors do not state allegiance to any particular method except to state a ‘literature review’ [ 33 ] but without an outline of a particular method for doing so. Anther review [ 34 ] reports a ‘narrative review’ but does not give further information about how this was done, possibly indicative of the lack of methods associated with the traditional narrative review. Three other reviewers documented how they searched, appraised and analysed their literature but do not reference an over-riding approach for their review [ 35 , 36 , 37 ]. In these examples, the review can be assumed to be a literature review, but the exact approach is not clear.

In other reviews, the methods for doing a literature review appear to be used interchangeably. For example in one review [ 38 ] the term narrative review was used in the title but in the main text an integrative review was described. In another review [ 39 ] two different and distinct methods were combined in a ‘meta-ethnographic meta-synthesis’.

Some authors [ 40 , 41 ] referred to a method used to undertake their review, for example a systematic review, but did not reference the primary source from where the method originated. Instead a secondary source, such as a textbook is used to reference the approach taken [ 20 , 42 ].

Clarity about review processes

Under this theme we discerned two principal issues: searching and appraisal. The majority of literature reviews contain three components- searching, appraisal and analysis, details of which are usually reported in the methods section of the papers. However, this is not always the case and for example, one review [ 43 ] provides only a search strategy with no information about the overall method or how critical appraisal or analysis were undertaken. Despite the importance of the process of analysis, we found little discussion of this in the papers reviewed.

The overwhelming trend for those doing a literature review was to describe a comprehensive search; although for many in our sample, a comprehensive search appeared to be limited to a database search; authors did not describe additional search strategies that would enable them to find studies that might be missed through electronic searching. Furthermore, authors did not define what a comprehensive search entailed, for example whether this included grey literature. We identified a very small number of studies where authors had undertaken a purposive sample [ 26 , 44 ]; in these reviews authors clearly stated that their search was for ‘seminal papers’ rather than all papers.

We reviewed the approaches to critical appraisal described in the papers and there were varying interpretations of what this means and which aspect of the included articles were to be subject to appraisal. Some authors [ 36 , 45 , 46 ] used the term ‘critical appraisal’ to refer to relevance of the paper to the review, rather than quality criteria. In that sense critical appraisal was used more as an inclusion criterion regarding relevance, rather than quality in the methods used. Mostly though, the term was used to describe the process of critical analysis of the methodological quality of included papers included in a review. When the term was used in this way to refer to quality criteria, appraisal tools were often used; for example, one review [ 47 ] provides a helpful example when they explain how a particular critical appraisal tool was used to asses the quality of papers in their review. Formal critical appraisal was undertaken by the vast majority reviewers, however the role of critical appraisal in the paper was often not explained [ 33 , 48 ]. It was common for a lot of detail to be provided about the approach to appraisal, including how papers were assessed and how disagreements between reviewers about the quality of individual papers were resolved, with no further mention of the subsequent role of the appraisal in the review. The reason for doing the critical appraisal in the review was often unclear and furthermore, in many cases, researchers included all papers within their review regardless of quality. For example, one team of reviewers [ 49 ] explained how the process, in their view, is not to exclude studies but to highlight the quality of evidence available. Another team of reviewers described how they did not exclude studies on the basis of quality because of the limited amount of research available on the topic [ 50 ].

Our review has identified a multiplicity of similar terms and approaches used by authors when doing a literature review, that we suggests marks the ‘proliferation era’. The expansion of terms used to describe a literature review has been observed previously [ 19 , 21 ]. We have identified an even wider range of terms, indicating that this trend may be increasing. This is likely to give the impression of an incoherent and potentially confusing approach to the scholarly undertaking of doing a literature review and is likely to be particularly problematic for novice researchers and students when attempting to grapple with the array of approaches available to them. The range of terms used in the title of papers to describe a literature review may cause both those new to research to wonder what the difference is between a qualitative evidence synthesis and a qualitative systematic review and which method is most suitable for their enquiry.

The clearest articles in our review were those that reported a systematic review with or without a meta-analysis. For example, one team of reviewers [ 25 ] undertook a Cochrane-style systematic review but did not undertake a meta-analysis and thus referred to their review as a ‘quantitative systematic review’. We found this form of labelling clear and helpful and is indeed in line with current recommendations [ 8 ]. While guidelines exist for the publication of systematic reviews [ 8 , 51 ], given the range of terms that are used by authors, some may be unclear when these guidelines should apply and this adds some confusion to the field. Of course, authors are at liberty to call their review processes whatever they deem appropriate, but our analysis has unearthed some inconsistencies that are confusing to the field of literature reviewing.

There is current debate about the status of literature reviews that are not ‘Cochrane’ style reviews [ 52 ]. Classification can be complex and whilst it might be tempting to refer to all non Cochrane-style reviews as ‘narrative reviews’ [ 52 ], literature reviews that conform to a recognised method would generally not be considered as such [ 53 ] and indeed the Cochrane Collaboration handbook refers to the principles of systematic review as applicable to different types of evidence, not just randomised controlled trials [ 5 ] .This raises the question as to whether the term systematic review should be an umbrella term referring to any review with an explicit method; which is implicit in the definition of a systematic review, but which raises the question as to how rigorous a method has to be to meet these standards, a thorny issue which we have identified in this study.

This review has identified a lack of detail in the reporting of the methods used by those doing a review. In 2017, Thorne raised the rhetorical question: ‘What kind of monster have we created?‘ [ 54 ]. Critiquing the growing investment in qualitative metasyntheses, she observed that many reviews were being undertaken that position themselves as qualitative metasyntheses, yet are theoretically and methodologically superficial. Thorne called for greater clarity and sense of purpose as the ‘trend in synthesis research marches forward’ [ 54 ]. Our review covered many review types, not just the qualitative meta-synthesis and its derivatives. However, we concur with Thorne’s conclusion that research methods are not extensively covered or debated in many of the published papers which might explain the confusion of terms and mixing of methods.

Despite the proliferation in terms for doing a literature review, and corresponding associated different methods and a lack of consistency in their application, our review has identified how the methods used (or indeed the reporting of the methods) appear to be remarkably similar in most publications. This may be due to limitations in the word count available to authors. However for example, the vast majority of papers describe a comprehensive search, critical appraisal and analysis. The approach to searching is of particular note; whilst comprehensive searching is the cornerstone of the Cochrane approach, other aproaches advocate that a sample of literature is sufficient [ 15 , 20 ]. Yet in our review we found only two examples where reviewers had used this approach, despite many other reviews claiming to be undertaking a meta-ethnography or meta-synthesis. This indicates that many of those doing a literature review have defaulted to the ‘comprehensive search’ irrespective of the approach to searching suggested in any particular method which is again indicative of confusion in the field.

Differences are reported in the approach to searching and critical appraisal and these appear not to be linked to different methods, but seem to be undertaken on the judgement and discretion of the reviewers without rationale or justification within the published paper. It is not for us to question researchers’ decisions as regards managing the flow of articles through their reviews, but when it comes to the issue of both searching and lack of clarity about the role of critical appraisal there is evidence of inconsistency by those doing a literature review. This reflects current observations in the literature where the lack of clarity about the role of critical appraisal within a literature review is debated . [ 55 , 56 ].

Our review indicates that many researchers follow a very similar process, regardless of their chosen method and the real differences that do exist between published methods are not apparent in many of the published reviews. This concurs with previously mentioned concerns [ 54 ] about the superficial manner in which methods are explored within literature reviews. The overriding tendency is to undertake a comprehensive review, critical appraisal and analysis, following the formula prescribed by Cochrane, even if this is not required by the literature review method stated in the paper. Other researchers [ 52 ] have questioned whether the dominance of the Cochrane review should be questioned. We argue that emergence of different methods for doing a literature review in a systematic way has indeed challenged the perceived dominance of the Cochrane approach that characterised the dichotomy era, where the only alternative was a less rigourous and often poorly described process of dealing with literature. It is positive that there is widespread acknowledgement of the validity of other approaches. But we argue that the expansion era, whereby robust processes were put forward as alternatives that filled the gap left by polarisation, has gone too far. The magnitude in the number of different approaches identified in this review has led to a confused field. Thorne [ 54 ] refers to a ‘meta-madness’; with the proliferation of methods leading to the oversimplification of complex literature and ideas. We would extend this to describe a ‘meta-muddle’ in which, not only are the methods and results oversimplified, but the existence of so many terms used to describe a literature review, many of them used interchangeably, has added a confusion to the field and prevented the in-depth exploration and development of specific methods. Table 6 shows the issues associated with the proliferation era and importantly, it also highlights the recommendations that might lead to a more coherent reviewing community in nursing.

The terms used for doing a literature review are often used both interchangeably and inconsistently, with minimal description of the methods undertaken. It is not surprising therefore that some journal editors do not index these consistently within the journal. For example, in one edition of one journal included in the review, there are two published integrative reviews. One is indexed in the section entitled as a ‘systematic review’, while the other is indexed in a separate section entitled ‘literature review’. In another edition of a journal, two systematic reviews with meta-analysis are published. One is listed as a research article and the other as a review and discussion paper. It seems to us then, that editors and publishers might sometimes also be confused and bewildered themselves.

Whilst guidance does exist for the publication of some types of systematic reviews in academic journals; for example the PRISMA statement [ 8 ] and Entreq guidelines [ 51 ], which are specific to particular qualitative synthesis, guidelines do not exist for each approach. As a result, for those doing an alternative approach to their literature review, for example an integrative review [ 15 ], there is only general publication guidance to assist. In the current reviewing environment, there are so many terms, that more specific guidance would be impractical anyway. However, greater clarity about the methods used and halting the introduction of different terms to mean the same thing will be helpful.

Limitations

This study provides a snapshot of the way in which literature reviews have been described within a short publication timeframe. We were limited for practical reasons to a small section of high impact journals. Including a wider range of journals would have enhanced the transferability of the findings. Our discussion is, of course, limited to the review types that were published in the timeframe, in the identified journals and which had the term ‘review’ or ‘synthesis’ in the title. This would have excluded papers that were entitled ‘meta-analysis’. However as we were interested in the range of reviews that fall outside the scope of a meta-analysis, we did not consider that this limited the scope of the paper. Our review is further limited by the lack of detail of the methods undertaken provided in many of the papers reviewed which, although providing evidence for our arguments, also meant that we had to assume meaning that was unclear from the text provided.

The development of rigorous methods for doing a literature review is to be welcomed; not all review questions can be answered by Cochrane style reviews and robust methods are needed to answer review questions of all types. Therefore whilst we welcome the expansion in methods for doing a literature review, the proliferation in the number of named approaches should be, in our view, a cause for reflection. The increase in methods could be indicative of an emerging variation in possible approaches; alternatively, the increase could be due to a lack of conceptual clarity where, on closer inspection, the methods do not differ greatly and could indeed be merged. Further scrutiny of the methods described within many papers support the latter situation but we would welcome further discussion about this. Meanwhile, we urge researchers to make careful consideration of the method they adopt for doing a literature review, to justify this approach carefully and to adhere closely to its method. Having witnessed an era of dichotomy, expansion and proliferation of methods for doing a literature review, we now seek a new era of consolidation.

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Aveyard, H., Bradbury-Jones, C. An analysis of current practices in undertaking literature reviews in nursing: findings from a focused mapping review and synthesis. BMC Med Res Methodol 19 , 105 (2019). https://doi.org/10.1186/s12874-019-0751-7

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Literature reviews as independent studies: guidelines for academic practice

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Review articles or literature reviews are a critical part of scientific research. While numerous guides on literature reviews exist, these are often limited to the philosophy of review procedures, protocols, and nomenclatures, triggering non-parsimonious reporting and confusion due to overlapping similarities. To address the aforementioned limitations, we adopt a pragmatic approach to demystify and shape the academic practice of conducting literature reviews. We concentrate on the types, focuses, considerations, methods, and contributions of literature reviews as independent, standalone studies. As such, our article serves as an overview that scholars can rely upon to navigate the fundamental elements of literature reviews as standalone and independent studies, without getting entangled in the complexities of review procedures, protocols, and nomenclatures.

Literature Reviews: An Overview of Systematic, Integrated, and Scoping Reviews

On being ‘systematic’ in literature reviews

Overview of the Integrative Review

Avoid common mistakes on your manuscript.

1 Introduction

A literature review – or a review article – is “a study that analyzes and synthesizes an existing body of literature by identifying, challenging, and advancing the building blocks of a theory through an examination of a body (or several bodies) of prior work (Post et al. 2020 , p. 352). Literature reviews as standalone pieces of work may allow researchers to enhance their understanding of prior work in their field, enabling them to more easily identify gaps in the body of literature and potential avenues for future research. More importantly, review articles may challenge established assumptions and norms of a given field or topic, recognize critical problems and factual errors, and stimulate future scientific conversations around that topic. Literature reviews Footnote 1 come in many different formats and purposes:

Some review articles conduct a critical evaluation of the literature, whereas others elect to adopt a more exploratory and descriptive approach.

Some reviews examine data, methodologies, and findings, whereas others look at constructs, themes, and theories.

Some reviews provide summaries by holistically synthesizing the existing research on a topic, whereas others adopt an integrative approach by assessing related and interdisciplinary work.

The number of review articles published as independent or standalone studies has been increasing over time. According to Scopus (i.e., search database ), reviews (i.e., document type ) were first published in journals (i.e., source type ) as independent studies in 1945, and they subsequently appeared in three digits yearly from the late 1980s to the late 1990s, four digits yearly from the early 2000s to the late 2010s, and five digits in the year 2021 (Fig. 1 ). This increase is indicative that reviewers and editors in business and management research alike see value and purpose in review articles to such a level that they are now commonly accepted as independent, standalone studies. This development is also reflected in the fact that some academic journals exclusively publish review articles (e.g., the Academy of Management Annals , or the International Journal of Management Reviews ), and journals publishing in various fields often have special issues dedicated to literature reviews on certain topic areas (e.g., the Journal of Management and the Journal of International Business Studies ).

Full-year publication trend of review articles on Scopus (1945–2021)

One of the most important prerequisites of a high-quality review article is that the work follows an established methodology, systematically selects and analyzes articles, and periodically covers the field to identify latest developments (Snyder 2019 ). Additionally, it needs to be reproducible, well-evidenced, and transparent, resulting in a sample inclusive of all relevant and appropriate studies (Gusenbauer and Haddaway 2020; Hansen et al. 2021 ). This observation is in line with Palmatier et al. ( 2018 ), who state that review articles provide an important synthesis of findings and perspectives in a given body of knowledge. Snyder ( 2019 ) also reaffirmed this rationale, pointing out that review articles have the power to answer research questions beyond that which can be achieved in a single study. Ultimately, readers of review articles stand to gain a one-stop, state-of-the-art synthesis (Lim et al. 2022a ; Popli et al. 2022) that encapsulates critical insights through the process of re-interpreting, re-organizing, and re-connecting a body knowledge (Fan et al. 2022 ).

There are many reasons to conduct review articles. Kraus et al. ( 2020 ) explicitly mention the benefits of conducting systematic reviews by declaring that they often represent the first step in the context of larger research projects, such as doctoral dissertations. When carrying out work of this kind, it is important that a holistic overview of the current state of literature is achieved and embedded into a proper synthesis. This allows researchers to pinpoint relevant research gaps and adequately fit future conceptual or empirical studies into the state of the academic discussion (Kraus et al., 2021 ). A review article as an independent or standalone study is a viable option for any academic – especially young scholars, such as doctoral candidates – who wishes to delve into a specific topic for which a (recent) review article is not available.

The process of conducting a review article can be challenging, especially for novice scholars (Boell and Cecez-Kecmanovic 2015 ). Therefore, it is not surprising that numerous guides have been written in an attempt to improve the quality of review studies and support emerging scholars in their endeavors to have their work published. These guides for conducting review articles span a variety of academic fields, such as engineering education (Borrego et al. 2014 ), health sciences (Cajal et al. 2020 ), psychology (Laher and Hassem 2020 ), supply chain management (Durach et al. 2017 ), or business and entrepreneurship (Kraus et al. 2020 ; Tranfield et al. 2003 ) – the latter were among the first scholars to recognize the need to educate business/management scholars on the roles of review studies in assembling, ascertaining, and assessing the intellectual territory of a specific knowledge domain. Furthermore, they shed light on the stages (i.e., planning the review, conducting the review, reporting, and dissemination) and phases (i.e., identifying the need for a review, preparation of a proposal for a review, development of a review protocol, identification of research, selection of studies, study quality assessment, data extraction and monitoring progress, data synthesis, the report and recommendations, and getting evidence into practice) of conducting a systematic review. Other scholars have either adapted and/or developed new procedures (Kraus et al. 2020 ; Snyder 2019 ) or established review protocols such as the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram (Moher et al. 2015 ). The latter provides a checklist that improves transparency and reproducibility, thus reducing questionable research practices. The declarative and procedural knowledge of a checklist allows users to derive value from (and, in some cases, produce) methodological literature reviews.

Two distinct and critical gaps or issues provide impetus for our article. First, while the endeavors of the named scholars are undoubtedly valuable contributions, they often encourage other scholars to explain the methodology of their review studies in a non-parsimonious way ( 1st issue ). This can become problematic if this information distracts and deprives scholars from providing richer review findings, particularly in instances in which publication outlets impose a strict page and/or word limit. More often than not, the early parts (i.e., stages/phases, such as needs, aims, and scope) of these procedures or protocols are explained in the introduction, but they tend to be reiterated in the methodology section due to the prescription of these procedures or protocols. Other parts of these procedures or protocols could also be reported more parsimoniously, for example, by filtering out documents, given that scientific databases (such as Scopus or Web of Science ) have since been upgraded to allow scholars to select and implement filtering criteria when conducting a search (i.e., criterion-by-criterion filtering may no longer be necessary). More often than not, the procedures or protocols of review studies can be signposted (e.g., bracket labeling) and disclosed in a sharp and succinct manner while maintaining transparency and replicability.

Other guides have been written to introduce review nomenclatures (i.e., names/naming) and their equivalent philosophical underpinnings. Palmatier et al. ( 2018 ) introduced three clearly but broadly defined nomenclatures of literature reviews as independent studies: domain-based reviews, theory-based reviews, and method-based reviews. However, such review nomenclatures can be confusing due to their overlapping similarities ( 2nd issue ). For example, Lim et al. ( 2022a ) highlighted their observation that the review nomenclatures associated with domain-based reviews could also be used for theory-based and method-based reviews.

The two aforementioned issues – i.e., the lack of a parsimonious understanding and the reporting of the review methodology , and the confusion emerging from review nomenclatures – are inarguably the unintended outcomes of diving into an advanced (i.e., higher level) understanding of literature review procedures, protocols, and nomenclatures from a philosophical perspective (i.e., underpinnings) without a foundational (i.e., basic level) understanding of the fundamental (i.e., core) elements of literature reviews from a pragmatic perspective. Our article aims to shed light on these issues and hopes to provide clarity for future scholarly endeavors.

Having a foundational understanding of literature reviews as independent studies is (i) necessary when addressing the aforementioned issues; (ii) important in reconciling and scaffolding our understanding, and (iii) relevant and timely due to the proliferation of literature reviews as independent studies. To contribute a solution toward addressing this gap , we aim to demystify review articles as independent studies from a pragmatic standpoint (i.e., practicality). To do so, we deliberately (i) move away from review procedures, protocols, and nomenclatures, and (ii) invest our attention in developing a parsimonious, scaffolded understanding of the fundamental elements (i.e., types, focuses, considerations, methods, and contributions) of review articles as independent studies.

Three contributions distinguish our article. It is worth noting that pragmatic guides (i.e., foundational knowledge), such as the present one, are not at odds with extant philosophical guides (i.e., advanced knowledge), but rather they complement them. Having a foundational knowledge of the fundamental elements of literature reviews as independent studies is valuable , as it can help scholars to (i) gain a good grasp of the fundamental elements of literature reviews as independent studies ( 1st contribution ), and (ii) mindfully adopt or adapt existing review procedures, protocols, and nomenclatures to better suit the circumstances of their reviews (e.g., choosing and developing a well-defined review nomenclature, and choosing and reporting on review considerations and steps more parsimoniously) ( 2nd contribution ). Therefore, this pragmatic guide serves as (iii) a foundational article (i.e., preparatory understanding) for literature reviews as independent studies ( 3rd contribution ). Following this, extant guides using a philosophical approach (i.e., advanced understanding) could be relied upon to make informed review decisions (e.g., adoption, adaptation) in response to the conventions of extant review procedures, protocols, and nomenclatures (Fig. 2 ).

Foundational and advanced understanding of literature reviews as independent studies

2 Fundamental elements of literature reviews as independent studies

A foundational understanding of literature reviews as independent studies can be acquired through the appreciation of five fundamental elements – i.e., types, focuses, considerations, methods, and contributions – which are illustrated in Fig. 3 and summarized in the following sections.

Fundamental elements of literature reviews as independent studies

There are two types of literature reviews as independent studies: systematic literature reviews ( SLRs ) and non-systematic literature reviews ( non-SLRs ). It is important to recognize that SLRs and non-SLRs are not review nomenclatures (i.e., names/naming) but rather review types (i.e., classifications).

In particular, SLRs are reviews carried out in a systematic way using an adopted or adapted procedure or protocol to guide data curation and analysis, thus enabling transparent disclosure and replicability (Lim et al. 2022a ; Kraus et al. 2020 ). Therefore, any review nomenclature guided by a systematic methodology is essentially an SLR. The origin of this type of literature review can be traced back to the evidence-based medicine movement in the early 1990s, with the objective being to overcome the issue of inconclusive findings in studies for medical treatments (Boell and Cecez-Kecmanovic 2015 ).

In contrast, non-SLRs are reviews conducted without any systematic procedure or protocol; instead, they weave together relevant literature based on the critical evaluations and (subjective) choices of the author(s) through a process of discovery and critique (e.g., pointing out contradictions and questioning assertions or beliefs); they are shaped by the exposure, expertise, and experience (i.e., the “3Es” in judgement calls) of the author(s). Therefore, non-SLRs are essentially critical reviews of the literature (Lim and Weissmann 2021 ).

2.2 Focuses

Unlike Palmatier et al. ( 2018 ) who considered domain-based reviews, theory-based reviews, and method-based reviews as review nomenclatures, we consider domain , theory , and method as three substantive focuses that can take center stage in literature reviews as independent studies. This is in line with our attempt to move away from review nomenclatures when providing a foundational understanding of literature reviews as independent studies.

A review that is domain-focused can examine: (i) a concept (e.g., customer engagement; Lim et al. 2022b ; digital transformation; Kraus et al. 2021 ; home sharing; Lim et al. 2021 ; sharing economy; Lim 2020 ), (ii) a context (e.g., India; Mukherjee et al. 2022a ), (iii) a discipline (e.g., entrepreneurship; Ferreira et al. 2015 ; international business; Ghauri et al. 2021 ), (iv) a field (e.g., family business; Lahiri et al. 2020 ; Rovelli et al. 2021 ; female entrepreneurship; Ojong et al. 2021 ), or (v) an outlet (e.g., Journal of Business Research ; Donthu et al. 2020 ; Management International Review ; Mukherjee et al. 2021 ; Review of Managerial Science ; Mas-Tur et al. 2020 ), which typically offer broad, overarching insights.

Domain-focused hybrids , such as the between-domain hybrid (e.g., concept-discipline hybrid, such as digital transformation in business and management; Kraus et al. 2022 ; religion in business and entrepreneurship; Kumar et al. 2022a ; personality traits in entrepreneurship; Salmony and Kanbach 2022 ; and policy implications in HR and OB research; Aguinis et al., 2022 ) and the within-domain hybrid (e.g., the concept-concept hybrid, such as customer engagement and social media; Lim and Rasul 2022 ; and global business and organizational excellence; Lim 2022 ; and the discipline-discipline hybrid, such as neuromarketing; Lim 2018 ) are also common as they can provide finer-grained insights.

A review that is theory-focused can explore a standalone theory (e.g., theory of planned behavior; Duan and Jiang 2008 ), as well as a theory in conjunction with a domain , such as the concept-theory hybrid (e.g., behavioral control and theory of planned behavior; Lim and Weissmann 2021 ) and the theory-discipline hybrid (e.g., theory of planned behavior in hospitality, leisure, and tourism; Ulker-Demirel and Ciftci 2020 ), or a theory in conjunction with a method (e.g., theory of planned behavior and structural equation modeling).

A review that is method-focused can investigate a standalone method (e.g., structural equation modeling; Deng et al. 2018 ) or a method in conjunction with a domain , such as the method-discipline hybrid (e.g., fsQCA in business and management; Kumar et al. 2022b ).

2.3 Planning the review, critical considerations, and data collection

The considerations required for literature reviews as independent studies depend on their type: SLRs or non-SLRs.

For non-SLRs, scholars often rely on the 3Es (i.e., exposure, expertise, and experience) to provide a critical review of the literature. Scholars who embark on non-SLRs should be well versed with the literature they are dealing with. They should know the state of the literature (e.g., debatable, underexplored, and well-established knowledge areas) and how it needs to be deciphered (e.g., tenets and issues) and approached (e.g., reconciliation proposals and new pathways) to advance theory and practice. In this regard, non-SLRs follow a deductive reasoning approach, whereby scholars initially develop a set of coverage areas for reviewing a domain, theory, or method and subsequently draw on relevant literature to shed light and support scholarly contentions in each area.

For SLRs, scholars often rely on a set of criteria to provide a well-scoped (i.e., breadth and depth), structured (i.e., organized aspects), integrated (i.e., synthesized evidence) and interpreted/narrated (i.e., describing what has happened, how and why) systematic review of the literature. Footnote 2 In this regard, SLRs follow an inductive reasoning approach, whereby a set of criteria is established and implemented to develop a corpus of scholarly documents that scholars can review. They can then deliver a state-of-the-art overview, as well as a future agenda for a domain, theory, or method. Such criteria are often listed in philosophical guides on SLR procedures (e.g., Kraus et al. 2020 ; Snyder 2019 ) and protocols (e.g., PRISMA), and they may be adopted/adapted with justifications Footnote 3 . Based on their commonalities they can be summarized as follows:

Search database (e.g., “Scopus” and/or “Web of Science”) can be defined based on justified evidence (e.g., by the two being the largest scientific databases of scholarly articles that can provide on-demand bibliographic data or records; Pranckutė 2021 ). To avoid biased outcomes due to the scope covered by the selected database, researchers could utilize two or more different databases (Dabić et al. 2021 ).

Search keywords may be developed by reading scholarly documents and subsequently brainstorming with experts. The expanding number of databases, journals, periodicals, automated approaches, and semi-automated procedures that use text mining and machine learning can offer researchers the ability to source new, relevant research and forecast the citations of influential studies. This enables them to determine further relevant articles.

Boolean operators (e.g., AND, OR) should be strategically used in developing the string of search keywords (e.g., “engagement” AND “customer” OR “consumer” OR “business”). Furthermore, the correct and precise application of quotation marks is important but is very frequently sidestepped, resulting in incorrect selection processes and differentiated results.

Search period (e.g., between a specified period [e.g., 2000 to 2020] or up to the latest full year at the time or writing [e.g., up to 2021]) can be defined based on the justified scope of study (e.g., contemporary evolution versus historical trajectory).

Search field (e.g., “article title, abstract, keywords”) can be defined based on justified assumptions (e.g., it is assumed that the focus of relevant documents will be mentioned in the article title, abstract, and/or keywords).

Subject area (e.g., “business, management, and accounting”) can be defined based on justified principles (e.g., the focus of the review is on the marketing discipline, which is located under the “business, management, and accounting” subject area in Scopus).

Publication stage (e.g., “final”) can be defined based on justified grounds (e.g., enabling greater accuracy in replication).

Document type (e.g., “article” and/or “review”), which reflects the type of scientific/practical contributions (e.g., empirical, synthesis, thought), can be defined based on justified rationales (e.g., articles selected because they are peer-reviewed; editorials not selected because they are not peer-reviewed).

Source type (e.g., “journal”) can be defined based on justified reasons (e.g., journals selected because they publish finalized work; conference proceedings not selected because they are work in progress, and in business/management, they are usually not being considered as full-fledged “publications”).

Language (e.g., “English”) can be determined based on justified limitations (e.g., nowadays, there are not many reasons to use another language besides the academic lingua franca English). Different spellings should also be considered, as the literature may contain both American and British spelling variants (e.g., organization and organisation). Truncation and wildcards in searches are recommended to capture both sets of spellings. It is important to note that each database varies in its symbology.

Quality filtering (e.g., “A*” and “A” or “4*”, “4”, and “3”) can be defined based on justified motivations (e.g., the goal is to unpack the most originally and rigorously produced knowledge, which is the hallmark of premier journals, such as those ranked “A*” and “A” by the Australian Business Deans Council [ABDC] Journal Quality List [JQL] and rated “4*”, “4”, and “3” by the Chartered Association of Business Schools [CABS] Academic Journal Guide [AJG]).

Document relevance (i.e., within the focus of the review) can be defined based on justified judgement (e.g., for a review focusing on customer engagement, articles that mention customer engagement as a passing remark without actually investigating it would be excluded).

Others: Screening process should be accomplished by beginning with the deduction of duplicate results from other databases, tracked using abstract screening to exclude unfitting studies, and ending with the full-text screening of the remaining documents.

Others: Exclusion-inclusion criteria interpretation of the abstracts/articles is obligatory when deciding whether or not the articles dealt with the matter. This step could involve removing a huge percentage of initially recognized articles.

Others: Codebook building pertains to the development of a codebook of the main descriptors within a specific field. An inductive approach can be followed and, in this case, descriptors are not established beforehand. Instead, they are established through the analysis of the articles’ content. This procedure is made up of several stages: (i) the extraction of important content from titles, abstracts, and keywords; (ii) the classification of this content to form a reduced list of the core descriptors; and (iii) revising the codebook in iterations and combining similar categories, thus developing a short list of descriptors (López-Duarte et al. 2016 , p. 512; Dabić et al. 2015 ; Vlacic et al. 2021 ).

2.4 Methods

Various methods are used to analyze the pertinent literature. Often, scholars choose a method for corpus analysis before corpus curation. Knowing the analytical technique beforehand is useful, as it allows researchers to acquire and prepare the right data in the right format. This typically occurs when scholars have decided upon and justified pursuing a specific review nomenclature upfront (e.g., bibliometric reviews) based on the problem at hand (e.g., broad domain [outlet] with a large corpus [thousands of articles], such as a premier journal that has been publishing for decades) (Donthu et al. 2021 ). However, this may not be applicable in instances where (i) scholars do not curate a corpus of articles (non-SLRs), and (ii) scholars only know the size of the corpus of articles once that corpus is curated (SLRs). Therefore, scholars may wish to decide on a method of analyzing the literature depending on (i) whether they rely on a corpus of articles (i.e., yes or no), and (ii) the size of the corpus of articles that they rely on to review the literature (i.e., n = 0 to ∞).

When analytical techniques (e.g., bibliometric analysis, critical analysis, meta-analysis) are decoupled from review nomenclatures (e.g., bibliometric reviews, critical reviews, meta-analytical reviews), we uncover a toolbox of the following methods for use when analyzing the literature:

Bibliometric analysis measures the literature and processes data by using algorithm, arithmetic, and statistics to analyze, explore, organize, and investigate large amounts of data. This enables scholars to identify and recognize potential “hidden patterns” that could help them during the literature review process. Bibliometrics allows scholars to objectively analyze a large corpus of articles (e.g., high hundreds or more) using quantitative techniques (Donthu et al. 2021 ). There are two overarching categories for bibliometric analysis: performance analysis and science mapping. Performance analysis enables scholars to assess the productivity (publication) and impact (citation) of the literature relating to a domain, method, or theory using various quantitative metrics (e.g., average citations per publication or year, h -index, g -index, i -index). Science mapping grants scholars the ability to map the literature in that domain, method, or theory based on bibliographic data (e.g., bibliographic coupling generates thematic clusters based on similarities in shared bibliographic data [e.g., references] among citing articles; co-citation analysis generates thematic clusters based on commonly cited articles; co-occurrence analysis generates thematic clusters based on bibliographic data [e.g., keywords] that commonly appear together; PageRank analysis generates thematic clusters based on articles that are commonly cited in highly cited articles; and topic modeling generates thematic clusters based on the natural language processing of bibliographic data [e.g., article title, abstract, and keywords]). Footnote 4 Given the advancement in algorithms and technology, reviews using bibliometric analysis are considered to be smart (Kraus et al. 2021 ) and technologically-empowered (Kumar et al. 2022b ) SLRs, in which a review has harnessed the benefits of (i) the machine learning of the bibliographic data of scholarly research from technologically-empowered scientific databases, and (ii) big data analytics involving various science mapping techniques (Kumar et al. 2022c ).

Content analysis allows scholars to analyze a small to medium corpus of articles (i.e., tens to low hundreds) using quantitative and qualitative techniques. From a quantitative perspective , scholars can objectively carry out a content analysis by quantifying a specific unit of analysis . A useful method of doing so involves adopting, adapting, or developing an organizing framework . For example, Lim et al. ( 2021 ) employed an organizing (ADO-TCM) framework to quantify content in academic literature based on: (i) the categories of knowledge; (ii) the relationships between antecedents, decisions, and outcomes; and (iii) the theories, contexts, and methods used to develop the understanding for (i) and (ii). The rapid evolution of software for content analysis allows scholars to carry out complex elaborations on the corpus of analyzed articles, so much so that the most recent software enables the semi-automatic development of an organizing framework (Ammirato et al. 2022 ). From a qualitative perspective , scholars can conduct a content analysis or, more specifically, a thematic analysis , by subjectively organizing the content into themes. For example, Creevey et al. ( 2022 ) reviewed the literature on social media and luxury, providing insights on five core themes (i.e., luxury brand strategy, luxury brand social media communications, luxury consumer attitudes and perceptions, engagement, and the influence of social media on brand performance-related outcomes) generated through a content (thematic) analysis. Systematic approaches for inductive concept development through qualitative research are similarly applied in literature reviews in an attempt to reduce the subjectivity of derived themes. Following the principles of the approach by Gioia et al. ( 2012 ), Korherr and Kanbach ( 2021 ) develop a taxonomy of human-related capabilities in big data analytics. Building on a sample of 75 studies for the literature review, 33 first-order concepts are identified. These are categorized into 15 second-order themes and are finally merged into five aggregate dimensions. Using the same procedure, Leemann and Kanbach ( 2022 ) identify 240 idiosyncratic dynamic capabilities in a sample of 34 studies for their literature review. They then categorize these into 19 dynamic sub-capabilities. The advancement of technology also makes it possible to conduct content analysis using computer assisted qualitative data analysis (CAQDA) software (e.g., ATLAS.ti, Nvivo, Quirkos) (Lim et al. 2022a ).

Critical analysis allows scholars to subjectively use their 3Es (i.e., exposure, expertise, and experience) to provide a critical evaluation of academic literature. This analysis is typically used in non-SLRs, and can be deployed in tandem with other analyses, such as bibliometric analysis and content analysis in SLRs, which are used to discuss consensual, contradictory, and underexplored areas of the literature. For SLRs, scholars are encouraged to engage in critical evaluations of the literature so that they can truly contribute to advancing theory and practice (Baker et al. 2022 ; Lim et al. 2022a ; Mukherjee et al. 2022b ).

Meta-analysis allows scholars to objectively establish a quantitative estimate of commonly studied relationships in the literature (Grewal et al. 2018 ). This analysis is typically employed in SLRs intending to reconcile a myriad of relationships (Lim et al. 2022a ). The relationships established are often made up of conflicting evidence (e.g., a positive or significant effect in one study, but a negative or non-significant effect in another study). However, through meta-analysis, scholars are able to identify potential factors (e.g., contexts or sociodemographic information) that may have led to the conflict.

Others: Multiple correspondence analysis helps to map the field, assessing the associations between qualitative content within a matrix of variables and cases. Homogeneity Analysis by Means of Alternating Least Squares ( HOMALS ) is also considered useful in allowing researchers to map out the intellectual structure of a variety of research fields (Gonzalez-Loureiro et al. 2015 ; Gonzalez-Louriero 2021; Obradović et al. 2021 ). HOMALS can be performed in R or used along with a matrix through SPSS software. In summary, the overall objective of this analysis is to discover a low dimensional representation of the original high dimensional space (i.e., the matrix of descriptors and articles). To measure the goodness of fit, a loss function is used. This function is used minimally, and the HOMALS algorithm is applied to the least squares loss functions in SPSS. This analysis provides a proximity map, in which articles and descriptors are shown in low-dimensional spaces (typically on two axes). Keywords are paired and each couple that appears together in a large number of articles is shown to be closer on the map and vice-versa.

When conducting a literature review, software solutions allow researchers to cover a broad range of variables, from built-in functions of statistical software packages to software orientated towards meta-analyses, and from commercial to open-source solutions. Personal preference plays a huge role, but the decision as to which software will be the most useful is entirely dependent on how complex the methods and the dataset are. Of all the commercial software providers, we have found the built-in functions of (i) R and VOSviewer most useful in performing bibliometric analysis (Aria and Cuccurullo 2017 ; R Core Team 2021 ; Van Eck and Waltman 2014 ) and (ii) Stata most useful in performing meta-analytical tasks.

Many different analytical tools have been used. These include simple document counting, citation analysis, word frequency analysis, cluster analysis, co-word analysis, and cooperation analysis (Daim et al. 2006 ). Software has also been produced for bibliometric analysis, such as the Thomson Data Analyzer (TDA), which Thomson Reuters created, and CiteSpace developed by Chen ( 2013 ). VOSviewer helps us to construct and visualize bibliometric networks, which can include articles, journals, authors, countries, and institutions, among others (Van Eck and Waltman 2014 ). These can be organized based on citations, co-citations, bibliographic coupling, or co-authorship relations. In addition, VOSviewer provides text mining functions, which can be used to facilitate a better understanding of co-occurrence networks with regards to the key terms taken from a body of scientific literature (Donthu et al. 2021 ; Wong 2018 ). Other frequently used tools include for bibliometric analysis include Bibliometrix/Biblioshiny in R, CitNetExplorer, and Gephi, among others.

2.5 Contributions

Well-conducted literature reviews may make multiple contributions to the literature as standalone, independent studies.

Generally, there are three primary contributions of literature reviews as independent studies: (i) to provide an overview of current knowledge in the domain, method, or theory, (ii) to provide an evaluation of knowledge progression in the domain, method, or theory, including the establishment of key knowledge, conflicting or inconclusive findings, and emerging and underexplored areas, and (iii) to provide a proposal for potential pathways for advancing knowledge in the domain, method, or theory (Lim et al. 2022a , p. 487). Developing theory through literature reviews can take many forms, including organizing and categorizing the literature, problematizing the literature, identifying and exposing contradictions, developing analogies and metaphors, and setting out new narratives and conceptualizations (Breslin and Gatrell 2020 ). Taken collectively, these contributions offer crystalized, evidence-based insights that both ‘mine’ and ‘prospect’ the literature, highlighting extant gaps and how they can be resolved (e.g., flags paradoxes or theoretical tensions, explaining why something has not been done, what the challenges are, and how these challenges can be overcome). These contributions can be derived through successful bibliometric analysis, content analysis, critical analysis, and meta-analysis.

Additionally, the deployment of specific methods can bring in further added value. For example, a performance analysis in a bibliometric analysis can contribute to: (i) objectively assessing and reporting research productivity and impact ; (ii) ascertaining reach for coverage claims ; (iii) identifying social dominance and hidden biases ; (iv) detecting anomalies ; and (v) evaluating ( equitable ) relative performance ; whereas science mapping in bibliometric analysis can contribute to: (i) objectively discovering thematic clusters of knowledge ; (ii) clarifying nomological networks ; (iii) mapping social patterns ; (iv) tracking evolutionary nuances ; and (v) recognizing knowledge gaps (Mukherjee et al. 2022b , p. 105).

3 Conclusion

Independent literature reviews will continue to be written as a result of their necessity, importance, relevance, and urgency when it comes to advancing knowledge (Lim et al. 2022a ; Mukherjee et al. 2022b ), and this can be seen in the increasing number of reviews being published over the last several years. Literature reviews advance academic discussion. Journal publications on various topics and subject areas are becoming more frequent sites for publication. This trend will only heighten the need for literature reviews. This article offers directions and control points that address the needs of three different stakeholder groups: producers (i.e., potential authors), evaluators (i.e., journal editors and reviewers), and users (i.e., new researchers looking to learn more about a particular methodological issue, and those teaching the next generation of scholars). Future producers will derive value from this article’s teachings on the different fundamental elements and methodological nuances of literature reviews. Procedural knowledge (i.e., using control points to assist in decision-making during the manuscript preparation phase) will also be of use. Evaluators will be able to make use of the procedural and declarative knowledge evident in control points as well. As previously outlined, the need to cultivate novelty within research on business and management practices is vital. Scholars must also be supported to choose not only safe mining approaches; they should also be encouraged to attempt more challenging and risky ventures. It is important to note that abstracts often seem to offer a lot of potential, stating that authors intend to make large conceptual contributions, broadening the horizons of the field.

Our article offers important insights also for practitioners. Noteworthily, our framework can support corporate managers in decomposing and better understanding literature reviews as ad-hoc and independent studies about specific topics that matter for their organization. For instance, practitioners can understand more easily what are the emerging trends within their domain of interest and make corporate decisions in line with such trends.

This article arises from an intentional decoupling from philosophy, in favor of adopting a more pragmatic approach. This approach can assist us in clarifying the fundamental elements of literature reviews as independent studies. Five fundamental elements must be considered: types, focuses, considerations, methods, and contributions. These elements offer a useful frame for scholars starting to work on a literature review. Overview articles (guides) such as ours are thus invaluable, as they equip scholars with a solid foundational understanding of the integral elements of a literature review. Scholars can then put these teachings into practice, armed with a better understanding of the philosophy that underpins the procedures, protocols, and nomenclatures of literature reviews as independent studies.

Data availability

Our manuscript has no associate data.

Our focus here is on standalone literature reviews in contrast with literature reviews that form the theoretical foundation for a research article.

Scoping reviews, structured reviews, integrative reviews, and interpretive/narrative reviews are commonly found in review nomenclature. However, the philosophy of these review nomenclatures essentially reflects what constitutes a good SLR. That is to say, a good SLR should be well scoped, structured, integrated, and interpreted/narrated. This observation reaffirms our position and the value of moving away from review nomenclatures to gain a foundational understanding of literature reviews as independent studies.

Given that many of these considerations can be implemented simultaneously in contemporary versions of scientific databases, scholars may choose to consolidate them into a single (or a few) step(s), where appropriate, so that they can be reported more parsimoniously. For a parsimonious but transparent and replicable exemplar, see Lim ( 2022 ).

Where keywords are present (e.g., author keywords or keywords derived from machine learning [e.g., natural language processing]), it is assumed that each keyword represents a specific meaning (e.g., topic [concept, context], method), and that a collection of keywords grouped under the same cluster represents a specific theme.

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Wilson J , Tanuseputro P , Myran DT, et al. Characterization of Problematic Alcohol Use Among Physicians: A Systematic Review. JAMA Netw Open. 2022;5(12):e2244679. doi:10.1001/jamanetworkopen.2022.44679

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Characterization of Problematic Alcohol Use Among Physicians: A Systematic Review

1 Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
2 The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
3 ICES, Ontario, Canada
4 Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
5 Bruyere Research Institute, Ottawa, Ontario, Canada
6 Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
7 Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
8 School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
9 Department of Psychiatry, University of Ottawa, Ontario, Canada
10 Deptartment of Mental Health, The Ottawa Hospital, Ottawa, Ontario, Canada
11 Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin, Germany

Question How common is problematic alcohol use among physicians, and what characteristics are associated with it in physicians?

Findings In this systematic review of 31 studies involving 51 680 participants in 17 countries, problematic alcohol use in physicians was identified by a self-reported survey, with reported use increasing over time. Methods of assessment and outcome definitions were highly variable, and limited information was identified on how problematic alcohol use varies among physicians based on age, sex, specialty, and training stage.

Meaning Key epidemiologic information of the prevalence of problematic alcohol use in physicians and associated risk factors are unknown, hampering the ability to identify high-risk individuals for targeted interventions.

Importance Problematic alcohol use in physicians poses a serious concern to physicians' health and their ability to provide care. Understanding the extent and characteristics of physicians with problematic alcohol use will help inform interventions.

Objective To estimate the extent of problematic alcohol use in physicians and how it differs by physician sex, age, medical specialty, and career stage (eg, residency vs practicing physician).

Evidence Review Preferred Reporting Items for Systematic Reviews and Meta-analyses ( PRISMA ) 2020-compliant systematic review, searching Medline, Embase, and PsychInfo from January 2006 to March 2020. Search terms included Medical Subject Headings terms and keywords related to physicians as the population and problematic alcohol use as the primary outcome. The quality of studies was assessed using the Newcastle-Ottawa Scale. We included articles where problematic alcohol use was measured by a validated tool (ie, Alcohol Use Disorders Identification Test [AUDIT], AUDIT Version C [AUDIT-C], or CAGE [Cut down, Annoyed, Guilty, and Eye-opener] questionnaire) in practicing physicians (ie, residents, fellows, or staff physicians).

Findings Thirty-one studies involving 51 680 participants in 17 countries published between January 2006 and March 2020 were included. All study designs were cross-sectional, self-reported surveys. Problematic alcohol use varied widely regardless of measurement method (0 to 34% with AUDIT; 9% to 35% with AUDIT-C; 4% to 22% with CAGE). Reported problematic alcohol use increased over time from 16.3% in 2006 to 2010 to 26.8% in 2017 to 2020. The extent of problematic use by sex was examined in 19 studies, by age in 12 studies, by specialty in 7 studies, and by career stage in 5 studies. Seven of 19 studies (37%) identified that problematic alcohol use was more common in males than females. Based on the wide heterogeneity of methods for included studies, limited conclusions can be made on how problematic alcohol use varies based on physician age, sex, specialty, and career stage.

Conclusions and Relevance Studies about problematic alcohol use in physicians demonstrate a high degree of heterogeneity in terms of methods of measurement, definitions for problematic alcohol use, and cohorts assessed. Most studies are primarily self-reported, precluding the ability to determine the true prevalence among the profession. Few studies provide relevant comparisons to aid in identifying key risk groups for targeted interventions.

Emerging evidence suggests physicians are at a higher risk of burnout and mental health conditions, including depression and anxiety, than the general population. 1 - 8 Physicians are prone to occupational distress, which may facilitate problematic drinking habits, including drinking alcohol frequently, binge drinking, and alcohol use disorder. 9 Although historical evidence suggests problematic alcohol use may be similar to those of the general population, this may be shifting over the last few decades with changes in the demographic composition of the physician workforce. 10 - 15

Identifying problematic alcohol use in physicians is difficult. Behaviors that may indicate problematic alcohol use in a physician may include changes in behavior from baseline, loss of reliability, frequent medical complaints, mood changes, and legal problems due to impaired driving. 10 , 16 Physicians with problematic alcohol use may be high functioning, making the identification of potential impairment challenging. 17 Furthermore, societal stigma and fear of reprisal from professional colleges for reporting or seeking care for problematic alcohol use may encourage physicians with problematic alcohol use to keep their problems hidden. 18

Given the long-term effects of alcohol on cognitive processes (including judgment, mood, impulse control, and learning), as well as health impacts (including cardiovascular disease, cancer, and liver cirrhosis), decreasing problematic alcohol use in physicians will improve physician health and well-being with the potential to improve patient care. 19 - 22 Regarding patient care, problematic alcohol use has obvious and foreseeable clinical sequelae, such as an increase in physician error and absenteeism. 11 , 23 As such, we conducted a systematic review of the literature to determine how common problematic alcohol use is reported by physicians and whether it differs by sex, age, specialty or career stage.

This review followed an a priori protocol (PROSPERO CRD42022304799) developed and conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses ( PRISMA ) reporting guideline ( Figure ). We included peer-reviewed published studies or prepublication reporting on problematic alcohol use as measured with Alcohol Use Disorders Identification Test (AUDIT), AUDIT Version C (AUDIT-C), and the Cut down, Annoyed, Guilty, and Eye-opener (CAGE) questionnaire, among medical residents, fellows, and staff physicians that were published in English between January 2006 and March 2020. We excluded studies that (1) examined the prevalence of problematic alcohol use in medical students or nonphysician health care professionals (eg, nurses); (2) included both physicians and nonphysicians without reporting on both groups separately; (3) restricted data collection during major societal upheaval or crisis (eg, a war); or (4) were not original articles (eg, comments, letters, and reviews).

The primary outcome of interest in this study was the prevalence of alcohol use disorders or unhealthy alcohol use in this population, identified by standardized questionnaire, including the AUDIT, AUDIT-C, and the CAGE questionnaire. For this review, problematic alcohol use included hazardous, potentially hazardous, risky, at-risk, harmful, problematic, or heavy drinking or alcohol use, as well as alcohol misuse, alcohol dependence, and alcohol use more than low-risk guidelines and alcohol use disorder. Further detailed descriptions of the AUDIT, AUDIT-C, and CAGE questionnaires, including their structure, sensitivity, specificity, and what contexts they have been validated in, are included in eAppendix 1 in the Supplement 1 . Details on the search strategy, data selection, and extraction and quality assessment are provided in eAppendix 2 in Supplement 1 . Because there was a high degree of heterogeneity in the methods of measurement and definitions used, data synthesis (ie, meta-analysis and meta-regression) were not conducted.

This review included 31 cross-sectional studies, 24-48 involving a total of 51 680 medical residents and physicians across 17 countries. The characteristics of all studies can be found in Table 1 .

Our search of Medline, Embase, and PsycInfo yielded 30 857 records. After screening titles and abstracts, 447 were deemed eligible for full-text review. Of these, 32 studies were unable to be retrieved, 242 were published prior to January 2006, 58 lacked a clear outcome definition (eg, a validated questionnaire was not used), 48 were not original articles (eg, comments, letters, and reviews), 21 were not in English, and 15 included mixed populations (eg, health care workers without separate data reported for physicians). In total, 31 studies satisfied the inclusion and exclusion criteria of this study.

The number of participants in each study ranged from 36 to 7288 (median, 790; mean, 1667). Sixteen studies took place in Europe (3 in Denmark, 2 each in Austria, Germany, and Italy, 1 each in Belgium, Finland, France, Lithuania, Switzerland, and Spain, and 1 in Norway and Germany), 8 in North America (all in the US), 2 in Australia, 2 in Africa (both in Nigeria), and 1 each in South America (Brazil), Asia (Lebanon), and Oceania (Fiji). Eight studies 25 , 40 , 42 , 44 , 49 - 51 , 53 included participants from a single specialty, 7 studies 27 , 33 , 34 , 37 , 38 , 43 , 46 did not report the specialties of their participants, and 16 studies 24 , 26 , 28 - 32 , 35 , 36 , 39 , 41 , 45 , 47 , 48 , 52 , 54 included participants from a variety of specialties. Twelve studies 25 , 27 - 29 , 31 , 33 , 38 , 42 , 47 , 50 , 51 , 53 included fully trained physicians only (either reported this directly or this was assumed because the study reported time in practice), 7 studies 26 , 30 , 32 , 35 , 43 , 44 , 49 included residents only, 7 studies 34 , 37 , 39 , 46 , 48 , 52 , 54 did not report the career stage of included participants, and 5 studies 24 , 36 , 40 , 41 , 45 included physicians in varying career stages.

The primary outcome was identified via self-report in all studies. No population-based studies using routinely collected health data were identified. The questionnaire used to identify problematic alcohol use was the CAGE in 7 of 31 studies, 48 - 54 the AUDIT in 16 of 31 studies, 24 - 38 , 48 and the AUDIT-C in 11 of 31 studies. 37 - 47 Three studies used more than 1 questionnaire. 37 , 38 , 48

The cut-off for what constituted problematic alcohol use varied between studies using the AUDIT and AUDIT-C. Additionally, 12 studies 25 , 26 , 35 , 39 - 44 , 46 - 48 used different scoring cut-offs for problematic drinking based on sex, whereas 19 studies 24 , 27 - 34 , 36 - 38 , 45 , 49 - 54 did not.

Studies using the AUDIT commonly used a cut-off of greater or equal to 8, but some used greater or equal to 7 or 6. The AUDIT questionnaire is well validated, with high sensitivity, and lower but still acceptable specificity for problematic alcohol use, although rates vary depending on the cut-off score used to identify a positive screen of a total of 40 possible points. 55 , 56 A previous study 57 demonstrated that among those diagnosed as having hazardous or harmful alcohol use, 92% had an AUDIT score of 8 or more, and 94% of those with nonhazardous consumption had a score of less than 8. Sensitivity varies between 97% for hazardous use, 95% for harmful drinking, and 51% to 59% for at-risk or heavy drinking. Specificity varies between 78% for hazardous use, 85% for harmful use, and 91% to 96% for at-risk heavy drinking. 57 , 58

Most studies 37 - 42 , 44 , 45 , 47 using the AUDIT-C used a cut-off of greater than 5 or 4. A cut-off of 4 or more has a sensitivity of 86% and specificity of 72% in identifying patients with heavy drinking and/or active problematic alcohol use or dependence. 59

Studies 48 - 54 using the CAGE questionnaire all were consistent, with a score of greater than or equal to 2 constituting a positive screen for alcohol abuse. The CAGE has demonstrated a mean (SD) sensitivity of 71% and specificity of 90% in varied samples of patients. 60 The scoring criteria for each study can be found in Table 1 .

The reported extent of problematic alcohol use in physicians varied widely across all studies. The proportion of a positive screen varied between 0% to 34% for studies 24 - 38 , 48 using the AUDIT, 8.6% to 34.9% for studies 37 - 47 using the AUDIT-C, and 3.8% to 22.0% for studies 48 - 54 using the CAGE questionnaire. The response rates varied between 6.1% to 100%, and 4 studies 27 , 35 , 46 , 52 did not report a response rate. ( Tables 1 , 2 , and 3 ).

Nineteen studies 24 , 26 , 28 - 31 , 36 - 38 , 40 - 46 , 48 , 50 , 54 reported problematic alcohol use by sex ( Table 2 ). Of these studies, the proportion of the male sample size varied between 25% and 75.5%. Problematic alcohol use was significantly higher in males than females in 7 studies and females than males in 4 studies. In general, recent studies (ie, published between 2015-2020) were more likely to report a female preponderance in problematic alcohol use. All (3 of 3) of the studies 41 , 42 , 44 of physicians in the US reported higher rates of problematic alcohol use in females than males. One 43 of 2 studies 43 , 46 including Italian physicians showed that females were more likely to be at risk of high-risk drinking, while their male colleagues were more at risk of low-risk drinking, compared to no risk drinking. The other study 46 in Italy showed that females were more likely to screen positive for hazardous alcohol consumption. Studies in the rest of Europe 24 , 28 , 31 , 37 , 40 , 45 , 48 , 50 , 54 and Nigeria 29 , 30 demonstrated that males were at a greater risk of screening positive for problematic alcohol use, while evidence in Australia was inconclusive. 26 , 36 , 38

Twelve studies 24 , 28 , 30 , 31 , 36 , 37 , 41 , 42 , 46 , 48 , 50 , 54 reported problematic alcohol use by age ( Table 2 ). All studies 24 , 28 , 30 , 31 , 36 , 37 , 41 , 42 , 48 , 50 , 54 reported problematic alcohol use by age based on age groupings except for one study, 46 which reported it as a median and range. Problematic alcohol use was higher in younger physicians in 2 studies and higher in older physicians in 2 studies. There were no significant differences in problematic alcohol use by age in 5 studies, and 3 studies did not report the statistical significance of their results.

Seven studies 24 , 30 , 35 , 36 , 41 , 45 , 48 reported problematic alcohol use by medical specialty ( Table 3 ). Five studies 24 , 36 , 41 , 45 , 48 compared physicians across all specialties, while 2 studies 30 , 35 compared problematic alcohol use in (1) surgeons vs general practitioners or medical officers vs all other physicians and (2) psychiatrists vs nonpsychiatrists. The extent of problematic alcohol use by medical specialty was similar in 5 studies. One study 45 found that surgeons (including general surgery, obstetrics and gynecology, and surgical subspecialties) and anesthetists were significantly associated with hazardous drinking (OR, 1.4; 95% CI, 1.1-1.8; P < .001) compared with nonsurgical specialties (including internal medicine and subspecialties, pediatrics and psychiatry). Another study 41 found that the prevalence of alcohol abuse or dependence was statistically significant ( P = .001) between specialties, with the highest prevalence among dermatologists and orthopedic surgeons and the lowest prevalence among general pediatricians and neurologists.

Five studies 24 , 30 , 40 , 41 , 44 reported problematic alcohol use by career stage ( Table 3 ). One study 40 found hazardous drinking was higher in practicing physicians vs residents (29.4% vs 24.0% based on an AUDIT-C score of >5 in males and >4 in females; P = .05). Another study 44 used the AUDIT-C to assess alcohol misuse (≥4 in males and ≥3 in females) and alcohol abuse (≥5 in males and ≥4 in females) based on postgraduate year (PGY) of training. Rates of alcohol misuse increased significantly with the year of training ( P = .011), while alcohol abuse varied. 44 Another study 24 compared the extent of hazardous (AUDIT 8-15) and harmful alcohol use (AUDIT 16-19) in medical specialists and general practitioners vs junior doctors with no significant difference detected ( P = .754). One study 30 reported that among hazardous users (AUDIT≥5), 30% were interns, 50% were residents, and 20% were consultants, but no indicators of statistical significance were reported. Although this study did not formally report outcomes based on the career stage, Oreskovich et al 41 found that the extent of problematic alcohol use or dependence based on the AUDIT-C (≥5 in males and ≥4 in females) decreased significantly with years of practice ( P < .001).

Risk-of-bias assessment based on the Newcastle-Ottawa Risk-of-Bias Score found that 21 studies were graded as good quality, with 10 as poor ( Table 4 ). All studies lost a point based on self-reported data. Most were penalized as not being representative of the target population (ie, a wide range of diverse physicians by specialty, sex, age, and career stage) or an unclear response rate (ie, less than 50%).

We conducted a systematic review to determine the extent of problematic alcohol use in physicians and identify high-risk groups or periods to inform screening and interventions. Overall, we identified 31 self-reported, cross-sectional, survey-based studies that reported the extent of problematic alcohol use in physicians. Most studies had low response rates, with only 4 of 31 studies exceeding 80%. Importantly, no population-based studies were identified, thereby limiting our understanding of the prevalence of problematic alcohol use in physicians.

AUDIT, AUDIT-C, and/or the CAGE questionnaire were most used to identify problematic alcohol; however, the definition of what constituted a positive screen for problematic alcohol use varied widely between studies (0%-34% using AUDIT, 8.6%-34.9% using AUDIT-C, and 3.8%-22.0% those using CAGE). In comparison, the prevalence of alcohol use disorder worldwide in 2019 was 1.45%, with prevalence rates highest in males aged 25 to 34 years. 61 , 62 There is evidence to suggest that doctors are at an increased risk of anxiety and depression compared to the general population. 3 , 63 , 64 Our results suggest that problematic alcohol use is also higher in physicians compared to the general population, although population-based studies with longitudinal designs or using health administrative data are needed to verify this trend.

We did observe an increase in the reported proportion of problematic alcohol use in physicians over the last 15 years from 16.3% to 26.8%. It remains unknown whether this increase is indeed accurate or whether it is due to increased transparency by physicians in self-reporting problematic alcohol use because of a changing culture of medicine.

The extent of problematic alcohol use by sex was examined in most (19 of 31) studies, and the largest proportion of these studies (7 of 19) reported a higher extent of problematic use in males than females. There were no clear differences in the extent of problematic alcohol use by age, physician specialty, and career stage. As such, key information on the extent of problematic alcohol use among physicians remains unknown.

Available data surrounding the extent of problematic alcohol use in physicians have historically come from license and disciplinary actions, known or registered problematic users, mortality rates, hospital admissions, and treatment populations, and surveys of selected groups of physicians. 12 As these are highly select groups, the prevalence of problematic alcohol use in physicians remains unknown. Studies included in the current review are self-reported and are prone to biases limiting generalizability and accuracy. Self-reported alcohol consumption has been shown to amount to approximately 40% to 60% of total alcohol sales in the general population, which highlights the high likelihood that the extent on problematic alcohol use using self-reported data and is likely a vast underestimation of its true prevalence. 65 , 66 Most studies reported low response rates suggesting physicians may be hesitant to participate in studies assessing problematic alcohol use. Physicians who use alcohol-related screening questionnaires as part of their practice may be familiar with the scoring systems and may answer in such a way as to screen negative for problematic alcohol use. Physicians may be likely to underreport use for fear of reprisal by colleagues and licensing boards. Therefore, the low levels of problematic alcohol use identified in this review likely underestimate the scale and consequent harms from alcohol use by physicians.

Periods of risk, specifically by age or career stage, that may increase one’s risk of problematic alcohol use were not identifiable. No differences in the extent of problematic alcohol use based on age was noted, suggesting that all age periods are equal risk or the heterogeneity and underreporting make identification of a true high risk age group difficult. Previous research suggests problematic alcohol use is higher in medical students than in practicing physicians, consistent with higher alcohol use in the general population. 67 - 72 However, this may culturally based as Western countries are more likely to consume more alcohol in general. 73 We were unable to identify differences in problematic alcohol use based on career stage, and it remains unclear whether career stage may influence a physician’s risk of problematic alcohol use.

In regard to sex-based differences, studies seem to report a male preponderance in problematic alcohol use, yet given the wide heterogeneity of the studies in terms of outcome reporting, quality of evidence, and geographical distribution, definitive conclusions are uncertain. Trends in drinking patterns in female physicians are likely driven by changing drinking patterns in women in general, suggesting that sex differences in drinking prevalence are converging. 74 , 75 In the United States, the prevalence of high-risk drinking between 2001 and 2012 increased by 57.9% in women, relative to a 15.5% increase in men. 76 We found geographic differences with female physicians in the US and Italy being more likely to screen positive for problematic alcohol use than men, whereas the converse was true in the rest of Europe and Nigeria. This observed geographic variability in sex differences appears consistent with the general population. 77 Stress-related drinking has been noted to be a unique factor in alcohol use in women, and given the stressful nature of the profession of medicine, female physicians may be at an increased risk. 78 Furthermore, the phenomenon of telescoping is more prevalent in female physicians than male physicians, as they are more likely to initiate alcohol use at a later age, but with shorter times from use to dependence and treatment. 79 , 80 Female medical students may be more prone to developing problematic drinking habits throughout medical school, such that by the end of their training, rates of problematic alcohol use are similar between males and females. 67

The identification of specialty-related differences in problematic alcohol use would also be very helpful to inform targeted screening for problematic alcohol use in physicians, workplace health promotion, and system-level change. Nonetheless, we found only 2 studies reported the extent of problematic alcohol use by specialty. These 2 studies reported surgical specialties are more likely to screen positive for problematic alcohol use relative to those in a nonsurgical specialty. Future research should aim to identify what specialties, including surgery, are associated with an increased risk of alcohol use and what environmental factors may be related.

Cultural changes minimizing stigma and reducing obstacles to seeking help may encourage physicians who suffer in silence to seek help. Future research could also aim to better understand factors that limit physician disclosure of problematic alcohol use and ultimately deconstruct these factors to promote care-seeking behavior in physicians. Furthermore, a clearer understanding of what sex, age, physician specialties, and career stages are most at risk for problematic alcohol use would help inform the development of physician health programs that identify problematic alcohol use and establish timely interventions for those in need.

This review has limitations. The primary outcomes of studies included in this review were very heterogeneous, which rendered comparison between studies quite challenging. We chose to include studies that reported on hazardous, potentially hazardous, risky, at-risk, harmful, problematic, or heavy drinking or alcohol use, as well as alcohol misuse, alcohol dependence, alcohol use more than low-risk guidelines, and alcohol use disorder. This was chosen to provide as comprehensive a picture as possible of the nature of problematic alcohol use in physicians. Nonetheless, some of these outcomes are discrete entities; for example, alcohol use more than low-risk guidelines is different from alcohol use disorder. We also did not select a specific cut-off for what constituted problematic alcohol use based on the AUDIT or AUDIT-C questionnaires and rather reported on the individual outcomes that were reported by each study however unstandardized they were. This made direct comparisons difficult and outlined the need for a large population-based study assessing the prevalence of problematic alcohol use based on an internationally accepted definition and standardized reporting. Furthermore, although this review included studies from across the globe, which increases the applicability and external validity of the review, cultural factors related to drinking patterns make it challenging to compare patterns of problematic alcohol use between countries. Lastly, given the number of articles retrieved in our initial literature search, we excluded articles that reported on binge drinking only. Nonetheless, binge drinking is not without its consequences and is generally considered to be a behavior indicative of problematic alcohol use and could contribute to physician impairment and poor patient outcomes.

In this systematic review, we found that the prevalence of self-reported problematic alcohol use in physicians varied widely. All studies were survey-based and self-reported, with variable outcome definitions of problematic alcohol use and inconsistent reporting on differences across sex, age, physician specialty, and career stage. Future population-based studies with longitudinal designs or using health administrative data could help identify the prevalence of and salient risk factors for problematic alcohol use in physicians.

Accepted for Publication: October 13, 2022.

Published: December 9, 2022. doi:10.1001/jamanetworkopen.2022.44679

Corresponding Author: Manish M. Sood, Ottawa Hospital Research Institute, The Ottawa Hospital, Civic Campus, 2-014 Administrative Services Building, 1053 Carling Ave, Box 693, Ottawa, ON K1Y 4E9, Canada ( [email protected] ).

Author Contributions : Ms Wilson had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Wilson, Dhaliwal, Tang, Sood.

Acquisition, analysis, or interpretation of data: Wilson, Tanuseputro, Myran, Dhaliwal, Hussain, Noor, Roberts, Solmi, Sood.

Drafting of the manuscript: Wilson, Solmi.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Wilson, Hussain, Noor.

Administrative, technical, or material support: Myran, Dhaliwal, Hussain, Tang.

Supervision: Tanuseputro, Dhaliwal, Solmi, Sood.

Conflict of Interest Disclosures: Mr Dhaliwal reported receiving a Government of Ontario Queen Elizabeth II Graduate Scholarship in Science and Technology and a Mitacs Globalink Research Award outside the submitted work. Dr Solmi reported receiving personal fees from Angelini, Lundbeck, and Otsuka outside the submitted work. Dr Sood reported receiving personal fees from AstraZeneca outside the submitted work. No other disclosures were reported.

Funding/Support: This work was supported by the Canadian Medical Association.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The opinions, results, and conclusions herein are those of the authors and do not reflect the official policy or position of the funding sources.

Data Sharing Statement : See Supplement 2 .

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v.8(3); 2016 Jul

The Literature Review: A Foundation for High-Quality Medical Education Research

a These are subscription resources. Researchers should check with their librarian to determine their access rights.

Despite a surge in published scholarship in medical education 1 and rapid growth in journals that publish educational research, manuscript acceptance rates continue to fall. 2 Failure to conduct a thorough, accurate, and up-to-date literature review identifying an important problem and placing the study in context is consistently identified as one of the top reasons for rejection. 3 , 4 The purpose of this editorial is to provide a road map and practical recommendations for planning a literature review. By understanding the goals of a literature review and following a few basic processes, authors can enhance both the quality of their educational research and the likelihood of publication in the Journal of Graduate Medical Education ( JGME ) and in other journals.

The Literature Review Defined

In medical education, no organization has articulated a formal definition of a literature review for a research paper; thus, a literature review can take a number of forms. Depending on the type of article, target journal, and specific topic, these forms will vary in methodology, rigor, and depth. Several organizations have published guidelines for conducting an intensive literature search intended for formal systematic reviews, both broadly (eg, PRISMA) 5 and within medical education, 6 and there are excellent commentaries to guide authors of systematic reviews. 7 , 8

A literature review forms the basis for high-quality medical education research and helps maximize relevance, originality, generalizability, and impact.
A literature review provides context, informs methodology, maximizes innovation, avoids duplicative research, and ensures that professional standards are met.
Literature reviews take time, are iterative, and should continue throughout the research process.
Researchers should maximize the use of human resources (librarians, colleagues), search tools (databases/search engines), and existing literature (related articles).
Keeping organized is critical.

Such work is outside the scope of this article, which focuses on literature reviews to inform reports of original medical education research. We define such a literature review as a synthetic review and summary of what is known and unknown regarding the topic of a scholarly body of work, including the current work's place within the existing knowledge . While this type of literature review may not require the intensive search processes mandated by systematic reviews, it merits a thoughtful and rigorous approach.

Purpose and Importance of the Literature Review

An understanding of the current literature is critical for all phases of a research study. Lingard 9 recently invoked the “journal-as-conversation” metaphor as a way of understanding how one's research fits into the larger medical education conversation. As she described it: “Imagine yourself joining a conversation at a social event. After you hang about eavesdropping to get the drift of what's being said (the conversational equivalent of the literature review), you join the conversation with a contribution that signals your shared interest in the topic, your knowledge of what's already been said, and your intention.” 9

The literature review helps any researcher “join the conversation” by providing context, informing methodology, identifying innovation, minimizing duplicative research, and ensuring that professional standards are met. Understanding the current literature also promotes scholarship, as proposed by Boyer, 10 by contributing to 5 of the 6 standards by which scholarly work should be evaluated. 11 Specifically, the review helps the researcher (1) articulate clear goals, (2) show evidence of adequate preparation, (3) select appropriate methods, (4) communicate relevant results, and (5) engage in reflective critique.

Failure to conduct a high-quality literature review is associated with several problems identified in the medical education literature, including studies that are repetitive, not grounded in theory, methodologically weak, and fail to expand knowledge beyond a single setting. 12 Indeed, medical education scholars complain that many studies repeat work already published and contribute little new knowledge—a likely cause of which is failure to conduct a proper literature review. 3 , 4

Likewise, studies that lack theoretical grounding or a conceptual framework make study design and interpretation difficult. 13 When theory is used in medical education studies, it is often invoked at a superficial level. As Norman 14 noted, when theory is used appropriately, it helps articulate variables that might be linked together and why, and it allows the researcher to make hypotheses and define a study's context and scope. Ultimately, a proper literature review is a first critical step toward identifying relevant conceptual frameworks.

Another problem is that many medical education studies are methodologically weak. 12 Good research requires trained investigators who can articulate relevant research questions, operationally define variables of interest, and choose the best method for specific research questions. Conducting a proper literature review helps both novice and experienced researchers select rigorous research methodologies.

Finally, many studies in medical education are “one-offs,” that is, single studies undertaken because the opportunity presented itself locally. Such studies frequently are not oriented toward progressive knowledge building and generalization to other settings. A firm grasp of the literature can encourage a programmatic approach to research.

Approaching the Literature Review

Considering these issues, journals have a responsibility to demand from authors a thoughtful synthesis of their study's position within the field, and it is the authors' responsibility to provide such a synthesis, based on a literature review. The aforementioned purposes of the literature review mandate that the review occurs throughout all phases of a study, from conception and design, to implementation and analysis, to manuscript preparation and submission.

Planning the literature review requires understanding of journal requirements, which vary greatly by journal ( table 1 ). Authors are advised to take note of common problems with reporting results of the literature review. Table 2 lists the most common problems that we have encountered as authors, reviewers, and editors.

Sample of Journals' Author Instructions for Literature Reviews Conducted as Part of Original Research Article a

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Common Problem Areas for Reporting Literature Reviews in the Context of Scholarly Articles

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Locating and Organizing the Literature

Three resources may facilitate identifying relevant literature: human resources, search tools, and related literature. As the process requires time, it is important to begin searching for literature early in the process (ie, the study design phase). Identifying and understanding relevant studies will increase the likelihood of designing a relevant, adaptable, generalizable, and novel study that is based on educational or learning theory and can maximize impact.

Human Resources

A medical librarian can help translate research interests into an effective search strategy, familiarize researchers with available information resources, provide information on organizing information, and introduce strategies for keeping current with emerging research. Often, librarians are also aware of research across their institutions and may be able to connect researchers with similar interests. Reaching out to colleagues for suggestions may help researchers quickly locate resources that would not otherwise be on their radar.

During this process, researchers will likely identify other researchers writing on aspects of their topic. Researchers should consider searching for the publications of these relevant researchers (see table 3 for search strategies). Additionally, institutional websites may include curriculum vitae of such relevant faculty with access to their entire publication record, including difficult to locate publications, such as book chapters, dissertations, and technical reports.

Strategies for Finding Related Researcher Publications in Databases and Search Engines

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Search Tools and Related Literature

Researchers will locate the majority of needed information using databases and search engines. Excellent resources are available to guide researchers in the mechanics of literature searches. 15 , 16

Because medical education research draws on a variety of disciplines, researchers should include search tools with coverage beyond medicine (eg, psychology, nursing, education, and anthropology) and that cover several publication types, such as reports, standards, conference abstracts, and book chapters (see the box for several information resources). Many search tools include options for viewing citations of selected articles. Examining cited references provides additional articles for review and a sense of the influence of the selected article on its field.

Box Information Resources

Web of Science a
Education Resource Information Center (ERIC)
Cumulative Index of Nursing & Allied Health (CINAHL) a
Google Scholar

Once relevant articles are located, it is useful to mine those articles for additional citations. One strategy is to examine references of key articles, especially review articles, for relevant citations.

Getting Organized

As the aforementioned resources will likely provide a tremendous amount of information, organization is crucial. Researchers should determine which details are most important to their study (eg, participants, setting, methods, and outcomes) and generate a strategy for keeping those details organized and accessible. Increasingly, researchers utilize digital tools, such as Evernote, to capture such information, which enables accessibility across digital workspaces and search capabilities. Use of citation managers can also be helpful as they store citations and, in some cases, can generate bibliographies ( table 4 ).

Citation Managers

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Knowing When to Say When

Researchers often ask how to know when they have located enough citations. Unfortunately, there is no magic or ideal number of citations to collect. One strategy for checking coverage of the literature is to inspect references of relevant articles. As researchers review references they will start noticing a repetition of the same articles with few new articles appearing. This can indicate that the researcher has covered the literature base on a particular topic.

Putting It All Together

In preparing to write a research paper, it is important to consider which citations to include and how they will inform the introduction and discussion sections. The “Instructions to Authors” for the targeted journal will often provide guidance on structuring the literature review (or introduction) and the number of total citations permitted for each article category. Reviewing articles of similar type published in the targeted journal can also provide guidance regarding structure and average lengths of the introduction and discussion sections.

When selecting references for the introduction consider those that illustrate core background theoretical and methodological concepts, as well as recent relevant studies. The introduction should be brief and present references not as a laundry list or narrative of available literature, but rather as a synthesized summary to provide context for the current study and to identify the gap in the literature that the study intends to fill. For the discussion, citations should be thoughtfully selected to compare and contrast the present study's findings with the current literature and to indicate how the present study moves the field forward.

To facilitate writing a literature review, journals are increasingly providing helpful features to guide authors. For example, the resources available through JGME include several articles on writing. 17 The journal Perspectives on Medical Education recently launched “The Writer's Craft,” which is intended to help medical educators improve their writing. Additionally, many institutions have writing centers that provide web-based materials on writing a literature review, and some even have writing coaches.

The literature review is a vital part of medical education research and should occur throughout the research process to help researchers design a strong study and effectively communicate study results and importance. To achieve these goals, researchers are advised to plan and execute the literature review carefully. The guidance in this editorial provides considerations and recommendations that may improve the quality of literature reviews.

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Comparison of urban climate change adaptation plans in selected european cities from a legal and spatial perspective.

1. Introduction

compare solutions between more vulnerable countries and less vulnerable ones [ 16 ];
contrast approaches in Western European and Central and Eastern European countries [ 17 ].
Does the content of municipal climate change adaptation plans align with the diagnosis of climate challenges at a broader geographical level and with the scientific discourse?
How can/do legal and institutional conditions determine the effectiveness of implementing these plans?
How do provisions within these plans translate into urban spatial planning?

2. Literature Review

The critical links between urban planning and climate challenges;
The way city authorities should respond to such challenges institutionally;
What is the relevance of urban climate change adaptation plans against this background?
Protecting green open spaces [ 19 , 20 , 21 ];
Shaping green infrastructure [ 22 , 23 ];
Expanding environmental protection [ 24 , 25 ];
Protection against weather hazards [ 26 , 27 , 28 ];
Water management [ 29 , 30 , 31 ].
Identify the challenges and aims for climate change adaptation in cities;
Ensure a holistic view of these goals and challenges, especially from a cross-sectoral policy perspective;
Provide an opportunity for flexible action, based on in-depth expert analyses.
Sanchez-Plaza et al. [ 51 ] emphasize the importance of thoroughly evaluating the findings of climate change adaptation plans. Jung et al. [ 52 ] explicitly point out the need for spot-checking the assumptions made in such plans [ 53 ].
On the other hand, Lee et al. [ 54 ] stress the need for climate change adaptation plans to be based on in-depth, interdisciplinary studies. According to these authors, such studies will facilitate the evaluation of a plan’s provisions.
spatial plans also include development parameters (building height, building intensity, etc.). Moreover, these parameters can block or enable certain developments [ 74 , 75 ]. In addition, there is a need to include less frequently used parameters in the plans, e.g., forcing the planting of trees or the use of green roofs.
Facilitate investments in renewable energy sources [ 76 , 77 , 78 , 79 ];
Prepare areas for the implementation of green infrastructure and in various other ways extend the range of green areas in cities (parks, green roofs, etc.), enabling the widest possible protection of nature in cities [ 80 , 81 , 82 ];
Set aside space for climate shelters or emergency areas (in the context of sudden weather changes).

3. Materials and Methods

They are states located in different parts of the same continent. This gives a certain coherence to their legal, political, and social features (manifested, among other things, by the fact that all of them are members of the European Union).
Despite this consistency, there are also significant differences between them. Spain is a Western European country, Poland is a Central Eastern European country, and Greece is a Southern European country. The differences lie both in the levels of climate challenges and with the approaches to public policies [ 18 ]. Undoubtedly, it is interesting and necessary to compare public policy responses in these countries, especially when studying urban climate change adaptation plans. The countries studied also have varying gross domestic product, with Spain having the highest and Greece the lowest [ 83 ].
The climate challenges for Athens are extreme heat, urban heat island, energy consumption in municipal buildings and facilities, transportation, densely packed neighborhoods, and pollution—traffic congestion [ 57 ];
The climate challenges for Barcelona are the need for a reduction in traffic and its emissions, the loss of thermal comfort (especially in summer), the increase in heavy rains, and the increase in the intensity of droughts and problems with urban water supply [ 84 , 85 ];
The climate challenges for Warsaw include sudden weather changes and the progressive development of the urban heat island effect [ 26 , 86 ];
It provides insight into how adaptation plans operate in countries with diverse climates and social attitudes towards climate challenges. It also allows for an examination of whether the level of climate risks and societal attitudes impact the use of such plans.
Additionally, it offers the opportunity to investigate how adaptation plans work in different parts of Europe, considering their varying institutional characteristics.
In the first step, the team created a questionnaire with common questions about climate challenges and municipal climate change plans (the question sheet can be found at the end of the article). It was based on insights gained from the literature and the previous studies conducted by the authors. The questions were directed to the co-authors—national experts in the field of urban planning and climate challenges in the countries studied (questionnaires were not directed to other people who were not co-authors of the article). The questions from the questionnaire were adapted to the research questions in the article.
In a second step, representatives of each surveyed country or city answered all questions. It is important to note here that the authors specialize in the national climatic and spatial conditions of these countries.
In the third step, the team compared responses from each country’s representatives and organized them into a table. The answers were carefully reviewed by all authors. This step was essential to ensure that the diverse land use planning legislation, policies, and administrative structures across the three countries did not hinder the comparability of results. It also made the subsequent analysis clearer and more straightforward.
In the final and fourth step, the results were aggregated in tabular form (see Table 1 , Table 2 , Table 3 and Table 4 ). The development of these tables was crucial for organizing the information collected in the questionnaire, and it became the basis for preparing the results and writing the Discussion and Conclusions sections.

Issues Requiring Action by Sectors	Greece	Spain	Poland
Air quality	No	No	No
Water resources	Yes	Yes	Yes
Coast/littoral	Yes	Yes	Yes
Mountain areas	No	No	Yes
Forestry	Yes	No	Yes
Forest fires	No	Yes	No
Biodiversity and ecosystems	Yes	Yes	Yes
Fishery and aquaculture	Yes	Yes	No
Desertification	No	Yes	No
Urban build (connection with climate adaptation)	Yes	No	Yes
Spatial planning	No	No	Yes
Health	Yes	Yes	Yes
Agriculture	Yes	Yes	Yes
Tourism	Yes	Yes	No
Infrastructure and transportation	Yes	Yes	Yes
Mining	Yes	No	No
Energy	Yes	Yes	Yes
Insurance	Yes	No	No
Cultural heritage	Yes	Yes	No
Social attitudes	No	No	Yes
Innovation	No	No	Yes

4.1. Climate Challenges from the Perspective of the Central Documents of the Studied Countries

4.2. legal conditions for the adoption and content of municipal climate change adaptation plans in the countries studied.

City	Athens	Barcelona	Warsaw
Legal conditions	No obligation to adopt a plan at the municipal level. The provisions of the plan are not legally binding. Adopting climate change adaptation plans at the regional level is mandatory.	No obligation to adopt a plan at the municipal level. The plan’s provisions are not legally binding. In some regions, regional climate change laws were passed that require the preparation of local adaptation plans (Basque Country, Catalonia, Valencian Community).	No obligation to adopt a plan at the municipal level. The provisions of the plan are not legally binding.
Key elements of the plan content
Main recommendations included in the plan

Greece	Spain	Poland
Local Urban Plans (LUPs) and Special Urban Plans (SUPs). The Local Urban Plans (L. 4258/2014, art. 2): The Special Urban Plans: situations due to lack or inadequacy of urban planning.	The state Climate Change Law (2021) includes the obligation to incorporate climate change in regional and urban planning and management, with the following principles: For its part, it is necessary to consider the principle of prevention of natural risks and severe accidents in the planning of land uses. Risks derived from climate change will also be included:	There is a lack of spatial planning instruments that can be directly linked to the response to climate challenges. There is a lack of clear ranking of spatial planning objectives in the context of climate challenges. It is only possible to indicate that some parts of the spatial planning instruments can be linked to climate challenges. This is framed chaotically and haphazardly (especially from the perspective of climate challenges). Examples include:

4.3. Linking Climate Change Adaptation Plans with Spatial Planning

City	Athens	Barcelona	Warsaw
Key spatial recommendations in climate change adaptation plans	Installation of photovoltaic systems in municipal buildings. Installation of photovoltaic systems on the roofs of Athens. Mapping of the street lighting network to replace all the lamps. Upgrading and widening sidewalks, light traffic roads, and walkways. Expansion of the bicycle paths network. Restorations and renovations of public areas. Pocket parks. Establishment and acquisition of green spaces. Building shell planting, green roofs, walls, and stops. Green roads, corridors, and routes.	Rehabilitation of homes for vulnerable people. Create new green areas: “Barcelona, city of shadow”. Create “climate shelters”. Regulate pavements and roofs to increase the albedo. Adapt current urban planning regulations to climate change. Use draining pavements. Creation of “superblocks” throughout the city, to reduce vehicle circulation and recover the streets for citizens.	Implementation of sustainable development. Protection of green spaces. Management of rainwater in the rainfall area. Considering the heat island in planning documents, including monitoring and causal factors. Considering potential flooding and flood risk analyses in planning documents.

They refer to particularly important areas (irrespective of administrative boundaries), which require special regulations;
Their regulations are implemented swiftly;
Previously adopted Local Urban Plans need to be adapted to their content.

4.4. Effectiveness of Municipal Climate Change Adaptation Plans

5. discussion, 5.1. key topics addressed in the article.

Considering supra-local guidelines, particularly those outlined in national strategic documents;
The legal features of climate change adaptation plans;
The way and extent to which climate change adaptation plans relate to spatial planning;
Verifying the potential and actual implementation of climate change adaptation plan provisions, as well as evaluating the implementation process.

5.2. Linking the Content of Surveyed Climate Change Adaptation Plans to Climate Challenges and a Characterization of the Legal Considerations for the Plans

The details of provisions: Plans cannot be too general and fragmented, like in Warsaw (see Table 2 ). On the one hand, they should set general objectives (linked to the national level); however, these objectives must be translated into detailed, specific guidelines (something done well in Athens). It is also worth highlighting the example of Barcelona, where the guideline plan is formulated to lend itself to rapid evaluation.
The mechanisms for evaluating provisions: Here, defining them as an obligation for public authorities (public participation included) provides an opportunity for more effective implementation. The literature underscores the importance of ongoing evaluation when implementing climate change adaptation plans. The examples of Barcelona and Athens (see Table 2 ) validate the relevance of this requirement in certain planning contexts. Conversely, the limited evaluation processes in Warsaw highlight that overlooking this aspect can lead to substantial difficulties in implementing climate change adaptation strategies in cities.
The link between climate change adaptation plans and spatial planning: A major prerequisite for successfully implementing climate change adaptation plans is aligning spatial planning instruments with them. This issue is associated with the third research question, which examines how climate change adaptation objectives intersect with urban spatial policies. This analysis is detailed in Table 3 and Table 4 , which relate climate objectives to urban spatial policies. Countries like Greece and Spain offer two possible approaches: integrating climate guidelines into existing statutory instruments or developing dedicated ‘climate-spatial’ instruments for quicker and more adaptable responses. Adaptation plans should also incorporate specific directives for spatial planning, with the Barcelona plan serving as a notable illustration of this integration.

5.3. Links between Climate Change Adaptation Plans and Spatial Planning Instruments

5.4. limitations of the study.

Verifying features of climate change adaptation plans in other countries. This comparison seems justified, and the article highlights critical criteria in this respect;
Considering the possibility of compiling and comparing other acts concerning climate in individual countries. This comparison should also include the regional perspective;
Identifying “climate-spatial” demands (the example of Barcelona seems most inspiring in this respect) and developing a comprehensive European catalog.

6. Conclusions

Climate change adaptation plans in Athens and Barcelona are prepared more ambitiously and in a more systemically thought-out manner than the plan for Warsaw. However, in Poland, the government is currently considering changing the regulations on climate change adaptation plans (and taking into account solutions from other countries);
When translating the content of adaptation plans into the spatial sphere, the solutions are more in-depth in the Spanish and Greek systems (which, of course, does not exclude the possibility of further partial revisions).

Author Contributions

Institutional review board statement, informed consent statement, data availability statement, conflicts of interest.

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Click here to enlarge figure

Greece	Spain	Poland
Improve the Municipality’s ability to address the increasing urban temperatures. Transform the built environment to establish neighborhoods that are more livable, appealing, and sustainable. Increase in RES share in electricity consumption. Sustainable and smart mobility.	Approval of urban plans for the creation of urban superblocks, which already has concrete examples in the L’Eixample área. Since 2019, creation of a network of 300 climate shelters in public buildings in the city. Approval of the expansion of the Prat de Llobregat desalination plant with the new floating desalination plant in the port of Barcelona, which will increase the desalination capacity of the first one by 14 hm /year (60 hm /year). This guarantees 40% of Barcelona’s urban supply in the event that a new drought could endanger the supply from the water transfer from the Ter River. In 2023, the construction of 31 new rainwater tanks has been approved to store rainwater and reduce the risk of flooding in the urban area.	No significant effects. The plans are a postulatory instrument without broader translation into concrete spatial effects.

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Nowak, M.J.; Bera, M.; Lazoglou, M.; Olcina-Cantos, J.; Vagiona, D.G.; Monteiro, R.; Mitrea, A. Comparison of Urban Climate Change Adaptation Plans in Selected European Cities from a Legal and Spatial Perspective. Sustainability 2024 , 16 , 6327. https://doi.org/10.3390/su16156327

Nowak MJ, Bera M, Lazoglou M, Olcina-Cantos J, Vagiona DG, Monteiro R, Mitrea A. Comparison of Urban Climate Change Adaptation Plans in Selected European Cities from a Legal and Spatial Perspective. Sustainability . 2024; 16(15):6327. https://doi.org/10.3390/su16156327

Nowak, Maciej J., Milena Bera, Miltiades Lazoglou, Jorge Olcina-Cantos, Dimitra G. Vagiona, Renato Monteiro, and Andrei Mitrea. 2024. "Comparison of Urban Climate Change Adaptation Plans in Selected European Cities from a Legal and Spatial Perspective" Sustainability 16, no. 15: 6327. https://doi.org/10.3390/su16156327

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Open access
Published: 22 July 2024

Symptom impact and health-related quality of life (HRQoL) assessment by cancer stage: a narrative literature review

Karen C. Chung 1 ,
Anushini Muthutantri 2 ,
Grace G. Goldsmith 2 ,
Megan R. Watts 2 ,
Audrey E. Brown 2 &
Donald L. Patrick 3

BMC Cancer volume 24 , Article number: 884 ( 2024 ) Cite this article

39 Accesses

Metrics details

Cancer stage at diagnosis is an important prognostic indicator for patient outcomes, with detection at later stages associated with increased mortality and morbidity. The impact of cancer stage on patient-reported outcomes is poorly understood. This research aimed to understand symptom burden and health related quality of life (HRQoL) impact by cancer stage for ten cancer types: 1) ovarian, 2) lung, 3) pancreatic, 4) esophageal, 5) stomach, 6) head and neck, 7) colorectal, 8) anal, 9) cervical, and 10) liver and bile duct.

Ten narrative literature reviews were performed to identify and collate published literature on patient burden at different stages of disease progression. Literature searches were conducted using an AI-assisted platform to identify relevant articles published in the last five (2017–2022) or ten years (2012–2022) where articles were limited. Conference abstracts were searched for the last two years (2020–2022). The geographic scope was limited to the United States, Canada, Europe, and global studies, and only journal articles written in English were included.

A total of 26 studies with results stratified by cancer stage at diagnosis (and before treatment) were selected for the cancer types of lung, pancreatic, esophageal, stomach, head and neck, colorectal, anal, and cervical cancers. Two cancer types, ovarian cancer, and liver and bile duct cancer did not return any search results with outcomes stratified by disease stage. A general trend was observed for worse patient-reported outcomes in patients with cancer diagnosed at an advanced stage of disease compared with diagnosis at an earlier stage. Advanced disease stage was associated with greater symptom impact including general physical impairments such as pain, fatigue, and interference with functioning, as well as disease/region-specific symptom burden. Poorer HRQoL was also associated with advanced disease with commonly reported symptoms including anxiety and depression.

Conclusions

Overall, the general trend for greater symptom burden and poorer HRQoL seen in late stage versus early-stage disease across the included cancer types supports the importance for early diagnosis and treatment to improve patient survival and decrease negative impacts on disease burden and HRQoL.

Peer Review reports

Introduction

Cancer stage at diagnosis is an important prognostic indicator for patient outcomes, with detection at later stages associated with increased mortality and morbidity. An estimated 2,001,140 new cancer cases will occur in the United States in 2024 along with 611,720 cancer deaths [ 1 ]. Many cancers are diagnosed during late (distant) stage including 55% of ovarian cancer cases, 53% of lung cancer cases, 51% of pancreatic cancer cases, 38% of esophageal cancer cases, and 36% of stomach cancer cases [ 2 ]. Stage at diagnosis is an important predictor both for treatment efficacy and survival, but diagnosis times vary by cancer type [ 2 ].

The World Health Organization identified two strategies which allow for more effective cancer treatment: 1) diagnosing symptomatic cancer as early as possible, and 2) screening for asymptomatic cancer or pre-cancerous lesions in non-symptomatic target populations [ 3 ]. The US Preventive Services Task Force (USPSTF) recommends single cancer screening based on age and sex for lung (also risk-based), colon, and cervical cancers, among others [ 4 , 5 , 6 , 7 , 8 ]. For cancers with screening paradigms such as cervical cancer, most cases (43%) are diagnosed in early stage where 5-year survival rates are high (91.2%). However, for cancers without screening paradigms, such as pancreatic cancer, most cases (51%) are diagnosed in late stage, where 5-year survival rates are very low (3.2%) [ 2 ].

Currently, the level of invasiveness of cancer screening varies by cancer type and location, ranging from more invasive procedures such as colonoscopy for colorectal cancer and Papanicolaou test (pap smear) for cervical cancer, to less invasive procedures such as blood-based tests or imaging tests such as mammography or low-dose computed tomography. A key focus of current research for cancer screening is less invasive multi-cancer screening technologies, such as blood-based multi-cancer detection screening assays [ 9 ]. This multi-cancer early detection (MCED) approach has the potential to improve treatment outcomes through earlier diagnosis of a wide range of cancer types, in addition to improving health-related quality of life (HRQoL) for patients with a positive diagnosis.

Cancer type and cancer stage may be associated with specific symptomatology, with overall symptoms and symptom impact being greater in advanced disease stages [ 10 ]. Advanced cancer stage and increased symptoms are associated with worse HRQoL, which may be evaluated through patient reported outcome measures (PROMs). PROMs are self-reported questionnaires which provide a qualitative/quantitative measurement of various aspects of a patient’s health, including HRQoL, functional status, and symptoms and symptom burden, directly by the patient without clinician interpretation [ 11 ]. Inclusion of PROMs in clinical practice in oncology can be associated with benefits including improvements in care, prognosis, communication, patient safety, and risk identification such as symptom control and identification [ 12 ].

The purpose of this narrative review was to identify and collate published literature on symptom impact at different stages of disease progression for a range of 10 cancer types: 1) ovarian, 2) lung, 3) pancreatic, 4) esophageal, 5) stomach, 6) head and neck, 7) colorectal, 8) anal, 9) cervical, and 10) liver and bile duct. This will provide valuable information on symptom impact and HRQoL by cancer type and stage at diagnosis. In contrast to a systematic review, this narrative review was not intended to identify and report all the literature available for symptom impact but rather focused on the information most relevant to healthcare providers who are interested in understanding the burden of disease on patients with specific types of cancer.

Search strategy

Ten narrative literature reviews were performed to identify and collate published literature on patient burden at different stages of disease progression for the following cancer types: 1) ovarian, 2) lung, 3) pancreatic, 4) esophageal, 5) stomach, 6) head and neck, 7) colorectal, 8) anal, 9) cervical, and 10) liver and bile duct. Disease terms for each cancer type were run in an artificial intelligence (AI)-assisted platform (EVID PRO) [ 13 ] to identify relevant articles published within the last 5 years (January 2017—December 2022). Where the number of articles identified for a specific cancer type were limited to less than 10 articles, in the case of ovarian, esophageal, stomach, anal, cervical, and liver and bile duct cancers, this was extended to 10 years (January 2012—December 2022). The geographic scope was limited to the United States (U.S.), Canada, Europe and global studies, and only journal articles written in English were included. The EVID PRO tool automatically scans and pulls articles with any specific acronyms, scales, and/or PRO instruments. Electronic searches were supplemented with grey literature searches of relevant conference meeting abstracts restricted to the last 2 years (2020–2022). Congresses included: American Society of Clinical Oncology (ASCO), European Society for Medical Oncology (ESMO), and Professional Society for Health Economics and Outcomes Research (ISPOR) (for all indications), Digestive Disease Week (DDW) (GI cancers only), European Respiratory Society (ERS) (lung cancer), and American Head and Neck Society (AHNS) (head and neck).

Study selection

For each literature review, an initial screening was performed on the title and abstract of the identified articles followed by a full-text review of articles considered relevant. The PICOS (Population, Intervention, Comparison, Outcomes, Study Design) criteria are shown in Table 1 . Studies were considered for inclusion if patient staging information was reported; outcomes included impact of cancer-related symptoms by cancer type (by stage of disease preferred), as assessed by standardized/ validated instruments (e.g., EORTC QLQ-C30, MDASI); and met the geographic and language limits described above. Studies were excluded if the study population was pretreated (treatment may affect HRQoL/PRO and thus not reflect cancer specific symptoms/impact), if studies were conducted outside US/Europe (unless global), if outcomes reported were related to treatment or were only reported post intervention (no baseline scores), and if only instruments not previously validated were implemented.

Data extraction

Following selection of relevant literature from screening and full text review, data from publications meeting the PICOS elements were extracted into standardized extraction tables in an Excel workbook by one reviewer. A second author reviewed all data extractions for completeness and accuracy. Any discrepancies encountered were discussed and resolved by a third independent reviewer.

Across all cancer types, 150 articles reporting PRO data that included information on disease staging were selected. In most of these studies PRO data were not reported with results stratified by disease stage, and instead reported outcomes with patients of varying disease stages grouped together ( n = 54) or included patients within a particular disease stage ( n = 70). After excluding these studies, 26 studies across 8 cancer types reporting PRO results stratified by disease stage were selected for inclusion. Two cancer types, liver and bile duct, and ovarian did not return any search results with outcomes stratified by disease stage.

Descriptions of the PRO instruments used in the 26 included studies are provided in Table 2 [ 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 ]. For each study across the 8 cancer types with results stratified by disease stage, a description including study design, PRO instruments and results, and any statistical analyses performed is presented in Table 3 . The results for these 8 cancer types are organized by the primary stage at which each cancer type is most often diagnosed according to the National Cancer Institute SEER statistics: 1) late stage/distant, 2) regional stage, and 3) early stage/localized [ 34 ]. SEER statistics for the 10 cancer types included in the original scope of this review are presented in Table 4 .

Disease staging varied throughout the 26 included studies and is reported as described in each study. Disease staging may have been described descriptively (ex. early-stage vs advanced stage) or according to a staging system such as the TNM Classification of Malignant Tumors (TNM) developed by the Union for International Cancer Control (UICC). The TNM is used for describing cancer based on: 1) tumor size and tissue location (T0 indicating no evidence of a tumor and T1-T4 describing the progressive size and invasiveness), 2) spread to lymph nodes (N0 indicating no regional nodal spread and N1-N3 indicating progressively distal nodal spread), and 3) presence of metastases (M0 indicating no metastases and M1 indicating presence of metastases) [ 58 ]. The combination of these 3 factors from the TNM system can then be used for simplified cancer staging (Stages I, II, III, and IV) [ 58 ]. While categorization as early or advanced disease based on staging varies between cancer types, generally Stage I indicates localized cancer (T1-T2, N0, M0), stage II indicates early-stage locally advanced cancer (T2-T4, N0, M0), stage III indicates late-stage locally advanced cancer (T1-T4, N1-N3, M0), and stage IV indicates metastatic cancer (T1-T4, N1-N3, M1) [ 58 ].

Cancers predominantly diagnosed at distant stage

Lung cancer.

The primary stage of diagnosis for lung cancer is at a distant stage, accounting for 53% of diagnoses [ 34 ]. For lung cancer, HRQoL and symptom burden by disease stage was reported using PRO instruments including Patient-Reported Outcomes Measurement Information System (PROMIS) [ 35 ], Short-Form Survey-8 (SF-8) [ 36 ], 12-item anorexia/cachexia scale (A/CS-12) [ 37 ], Short-Form Survey-12 (SF-12) [ 38 ], Revised Psychosocial Screen for Cancer (PSSCAN-R) [ 39 ], MD Anderson Symptom Inventory (MDASI) [ 40 ], and quality of life (QoL) single item scales [ 40 ]. Overall, findings suggested that both physical and mental HRQoL were impaired in advanced stages compared with early-stage disease.

Patients with stage III or IV disease reported significantly poorer physical and mental HRQoL versus patients with stage I disease [ 38 ]. Physical HRQoL scores were 41.16 and 37.74 in patients with stage III or IV disease and 43.9 in patients with stage I disease (SF-12, P for trend < 0.001). Mental HRQoL scores were 46.26 and 45.22 in patients with stage III or IV disease and 49.28 in patients with stage I disease (SF-12, p for trend < 0.001). Additionally, between patients with advanced versus early stage disease, poorer HRQoL measured using single-item QoL scales was reported for emotional well-being (6.5 vs 7.1, P < 0.03), physical well-being (5.7 vs 6.6, P < 0.002), and overall QoL (6.3 vs 7.2, P < 0.001) [ 40 ].

A correlation between advanced disease stage and poorer mental health was also reported in studies using other PRO instruments. Advanced disease stage was significantly associated with an increased prevalence of emotional problems (SF-8, P < 0.001) [ 36 ]. Additionally, anxiety was more prevalent in patients with metastases versus those without metastases (PSSCAN-R, Odds Ratio (OR): 1.46, P < 0.001), although this association was not found for depression (Odds Ratio (OR): 1.10, P = 0.196) [ 39 ].

Greater symptom prevalence and impact were also associated with patients with advanced disease. Patients with stage III/IV disease reported worse fatigue versus patients with stage I/II disease (PROMIS, 54.6 vs 58.2) based on a clinically meaningful difference of 3 points (as defined by the study authors for the PROMIS instrument) [ 35 ]. Social function was also worse in patients with stage III/IV disease (47.2 vs 43.7), indicating that the higher symptom burden reported by patients with advanced disease also has a broader impact on patient functioning [ 35 ]. These results are supported by a second study that reported a greater prevalence of both physical and emotional symptoms (measured using the MDASI) in patients with advanced disease compared with patients with early-stage disease [ 40 ]. Symptoms significantly associated with advanced disease included sleep problems (3.5 vs 2.5, P < 0.001), drowsiness (2.6 vs 1.6, P < 0.001), fatigue (3.9 vs 2.2, P < 0.001), sadness (2.9 vs 1.9, P < 0.002), pain (3.5 vs 2.1, P < 0.001), shortness of breath (3.2 vs 2.2, P < 0.001), lack of appetite (2.1 vs 1.3, P < 0.001), and dry mouth (1.9 vs 1.2, P < 0.008). Advanced disease was also associated with increased symptom interference for the domains of work (4.4 vs 2.3, P < 0.001), enjoying life (3.8 vs 2.3, P < 0.001), general activity (3.9 vs 2.0, P < 0.001), mood (3.4 vs 2.3, P < 0.001), walking (3.4 vs 1.8, P < 0.001), and relationships with others (2.2 vs 1.2, P < 0.001). Risk for anorexia/cachexia was not significantly associated with disease stage (A/CS-12, P = 0.09) [ 37 ].

Pancreatic cancer

The primary stage of diagnosis for pancreatic cancer is at distant stage, accounting for 51% of diagnoses [ 34 ]. HRQoL and symptom outcomes in patients with pancreatic cancer were evaluated using the SF-12 [ 41 ] and MDASI [ 42 ]. Worse physical HRQoL was associated with advanced tumor stage (I-IV) (SF-12, P for trend < 0.001), although this association was not significant for mental HRQoL (SF-12, P for trend 0.16) [ 41 ]. Additionally, patients in stage III/IV had higher symptom scores compared with patients in stage II/III (MDASI, 51.8 vs 47.3), indicating worse symptom severity, although no statistical tests or P values were reported [ 42 ].

Esophageal cancer

The primary stage of diagnosis for esophageal cancer is at distant stage, accounting for 38% of diagnoses [ 34 ]. For esophageal cancer, results stratified by disease stage were reported for the instruments Functional Assessment of Cancer Therapy-General (FACT-G) [ 43 ], FACT-Esophageal (FACT-E) [ 43 , 44 ], FACT-Esophageal Cancer Subscale (FACT-ECS) [ 43 , 44 ], and European Quality of Life Five Dimension questionnaire (EQ-5D-3L) [ 43 ].

Better HRQoL was reported in patients with stage II/III disease versus patients in stage IV [ 43 ]. Patients with stage II/ III disease reported a mean (SD) EQ-5D baseline utility score of 0.82 (0.13) compared with a score of 0.72 (0.18) in patients with stage IV or recurrent disease. Given a minimally important difference in EQ-5D Health Utility Score (HUS) of 0.07, this indicates that patients with stage IV or recurrent disease have clinically meaningful impaired HRQoL compared with patients with early-stage disease [ 43 ]. Poorer HRQoL with advanced disease stage was also reported using disease specific instruments. Patients in stage IV showed directionally poorer scores versus patients in stage II/III for symptoms associated with esophageal cancer (FACT-ECS, 40.2 vs 46.0) and HRQoL subscales such as emotional well-being (FACT-E, 13.6 vs 17.0). However, p values were not reported for these comparisons [ 43 ]. A statistically significant trend between higher T-stage and worse HRQoL was reported between patients with T4 disease versus T1 (FACT-ECS, 44.5 vs 58.7, P < 0.002), however this trend was not significant for all instruments (FACT-E, P = 0.65) [ 44 ].

Stomach cancer

The primary stage of diagnosis for stomach cancer is at distant stage, accounting for 36% of diagnoses [ 34 ]. A significantly greater prevalence of reported cancer symptoms was associated with advanced disease stage, with results stratified by both T stage (1–4) and UICC stage (I-IV) [ 45 ]. A higher prevalence of alarm symptoms (dysphagia, weight loss, bleeding, vomiting) was reported by patients with T-stage 3/4 versus T-stage 1/2 (OR: 2.54, P < 0.0001), and for patients with UICC stage III/IV versus UICC stage I/II (OR: 3.02, P < 0.0001).

Cancers predominately diagnosed at regional stage

Head and neck cancer.

The primary stage of diagnosis for head and neck cancer is at regional stage, accounting for 51% of diagnoses [ 34 ]. For head and neck cancer, results stratified by disease stage were reported for the PRO instruments National Comprehensive Cancer Network Distress Thermometer (NCCN DT) [ 47 ], Pittsburgh Sleep Quality Index (PSQI) [ 49 ], Apnea/Hypopnea Index (AHI) [ 48 ], and Eating Assessment Tool-10 (EAT-10) [ 46 ]. There was a significant correlation between advanced disease (higher T stage) and problems with swallowing (i.e., increased severity of swallowing impairment; EAT-10, P < 0.02) [ 46 ]. No statistically significant differences based on disease stage were reported for distress (NCCN DT) [ 47 ], sleep quality [ 49 ], or apnea and hypoxia [ 48 ].

Colorectal cancer

The primary stage of diagnosis for colorectal cancer is at regional stage, accounting for 36% of diagnoses [ 34 ]. In colorectal cancer, HRQoL and symptom burden by disease stage was reported using a range of PRO assessments including SF-12 [ 50 , 51 ], PROMIS [ 35 ], FACT-Colorectal (FACT-C) and NSABP Symptom Checklist (SCL-17) [ 52 ], PERFORM fatigue questionnaire [ 53 ], and Hospital Anxiety and Depression Scale (HADS) [ 54 ]. Across all PRO assessments, advanced stage disease was generally associated with poorer HRQoL and increased symptomology and burden.

Significantly poorer physical and mental HRQoL was reported for patients with late-stage versus early-stage disease [ 50 ]. Comparing between patients in stage IV versus stage I, advanced disease was associated with significantly lower scores (poorer HRQoL) for both physical HRQoL (SF-12 PCS, 40.8 vs 46.9, P < 0.001) and mental HRQoL (SF-12, 46.0 vs 50.1, P < 0.001). Additionally, another study also evaluated ethnicity (white, black, or Hispanic) as a factor in HRQoL outcomes [ 51 ]. While advanced disease stage in all ethnicities was significantly associated with poorer physical HRQoL (SF-12 PCS, P < 0.05, for all), worse mental HRQoL with advanced disease was not observed, regardless of ethnicity. In comparing HRQoL in patients with stage II vs stage III cancer, significantly poorer HRQoL was reported in patients with stage III cancer (FACT-C TOI, 66.1 vs 64.0, P < 0.004) [ 52 ].

An increase in symptoms and the impact of symptoms on functioning were also associated with advanced stage disease. Clinically meaningful differences (defined by the study authors as a difference of 3 points for the PROMIS instrument) were reported in patients with stage IV and stage III cancer versus stage I/II across a range of functions and symptoms. Poorer functioning was reported in patients with stage III and IV disease versus patients with stage I/II for physical (41.8 and 43.4 vs 46.5), social (45.4 and 48.0 vs 51.2), and cognitive function (49.1 and 49.7 vs 52.9) [ 35 ]. Symptoms of pain (56.5 vs 52.1, stage IV vs stage I/II) and fatigue (56.5 vs 50.8, stage IV vs stage I/II) were also clinically worse in patients with advanced disease [ 35 ]. However, other studies reported no significant difference in fatigue between early and advanced-stage disease using other PRO instruments (SF-36 vitality subscale [ 52 ] and PERFORM 12-item scale [ 53 ]). Symptom impact was also significantly associated with advanced disease stage. Patients with stage III reported greater symptom impact (pain, vision and hearing problems, and GI problems) compared with patients with stage II cancer (SCL-17, 8.5 vs 7.2, P < 0.001) [ 52 ]. Additionally, depression was significantly more prevalent in patients with metastatic disease versus those without (HADS, 31% vs 23%, P < 0.015), although this association was not statistically significant when comparing patients based on T stage or N stage [ 54 ].

Cancers predominately diagnosed at localized stage

Anal cancer.

The primary stage of diagnosis for anal cancer is at localized stage, accounting for 43% of diagnoses [ 34 ]. For anal cancer, symptom burden was described stratified by T-stage (T 1–4) [ 55 ]. Overall, the most common symptoms reported by patients with anal cancer were anal bleeding (78%), anal/perianal pain (29% and 24%, respectively), weight loss (31%), tumor on self-examination (26%), and foreign body sensation (22%). Patients with locally advanced cancer (T3/T4) reported significantly greater prevalence of constipation and abdominal pain ( P < 0.02), and perianal pain and weight loss ( P < 0.01). Meanwhile, pruritus was significantly more frequent in patients with early T stages ( P < 0.01). Patients with more advanced disease reported significantly more symptoms than those with less advanced tumors (average total number of symptoms for T1 vs T4, 2.1 vs 4.4, P < 0.01) indicating overall poorer HRQoL.

Cervical cancer

The primary stage of diagnosis for cervical cancer is at localized stage, accounting for 43% of diagnoses [ 34 ]. For cervical cancer, results stratified by disease stage were reported for the PRO instruments European Organization For Research And Treatment Of Cancer Core Quality of Life questionnaire (EORTC QLQ-C30) and EORTC cervical cancer questionnaire (EORTC QLQ-CX24) [ 56 ], PROMIS [ 35 ], and HADS [ 56 , 57 ]. In terms of global HRQoL (measured using EORTC QLQ-C30), there was no statistically significant association between cancer stage, early vs locally advanced, and global score (72.9 vs 76.1, P = 0.264). Symptom burden was assessed through the PRO instruments, PROMIS, and HADS, and the disease-specific EORTC QLQ-CX24 instrument. Patients with locally advanced cancer reported significant impairments versus patients with early stage for sexual activity (EORTC QLQ-CX24, 9.1 vs 17.1, P < 0.004) and sexual enjoyment (EORTC QLQ-CX24, 22.9 vs 52.1, P < 0.006) [ 56 ]. Poorer mental and physical HRQoL was reported between patients with stage I cancer versus stage II/III/IV cancer for the PROMIS domains of pain interference (51.1 vs 56.1), fatigue (51.8 vs 56.6), anxiety (51.5 vs 54.9), depression (50.0 vs 53.6), physical function (48.4 vs 41.2), social function (52.6 vs 46.9), and cognitive function (51.7 vs 47.9) [ 35 ]. Depression and anxiety were evaluated based on FIGO staging in two studies [ 56 , 57 ]. No significant differences were reported for either anxiety or depression, although one study noted a directional trend of more patients with locally advanced disease reporting anxiety compared with patients with early-stage disease (HADS, 63% vs 53%) [ 56 ].

In this narrative literature review of patient reported outcomes assessing symptom impact and health-related quality of life across 10 different cancer types, a general trend was observed for worse PRO results in patients with cancer diagnosed at an advanced stage of disease versus patients diagnosed at an earlier stage. Advanced disease stage was associated with greater prevalence of symptoms and increased symptom impact including general physical impairments such as pain, fatigue, and interference with functioning, as well as disease/region-specific symptom burden. Poorer HRQoL was also associated with advanced disease with commonly reported symptoms including anxiety and depression.

HRQoL, measured using generic PRO instruments, was worse in patients with advanced stage disease compared with patients with early-stage disease across cancer types. A range of generic instruments were used to measure HRQoL including the SF-12, reported in 4 studies [ 36 , 39 , 46 , 48 ]. Clinically meaningful differences in HRQoL and symptoms were also reported for other PRO instruments such as PROMIS, with patients with advanced stage disease reporting worse HRQoL and more symptoms than patients with early stage disease [ 35 ]. Increased prevalence and/or interference of pain was correlated with advanced disease stage for colorectal cancer [ 35 ], lung cancer [ 35 , 40 ], cervical cancer [ 35 ], and anal cancer [ 55 ]. This included both general pain [ 35 , 40 ], and cancer type/site-specific pain such as perianal and abdominal pain in anal cancer [ 55 ]. Other general symptoms correlated with advanced disease included fatigue and sleep disturbances in lung, colorectal, and cervical cancers [ 35 , 40 ], impairments in physical and cognitive function in colorectal and cervical cancer [ 35 ], nausea, lack of appetite, or anorexia and cachexia for lung cancer [ 37 ] and anal cancer [ 55 ].

The results of this review also highlight the increased burden of disease-specific symptoms in patients with advanced stage disease. Results from cancer-type specific PRO instruments were reported for the cancer types of colorectal (FACT-C TOI), cervical (EORTC QLQ-CX24), and esophageal (FACT-ECS) cancers. For both colorectal and esophageal cancer, a statistically significant association was reported between advanced cancer stage and worse HRQoL scores, as measured by the relevant disease-specific PRO instrument [ 44 , 52 ]. For cervical cancer, advanced cancer stage was associated with statistically significant impairments in sexual activity and enjoyment [ 56 ]. In addition, disease-specific symptoms that correlated with advanced stage disease were seen in stomach cancer for alarm symptoms (dysphagia, weight loss, bleeding, vomiting) [ 45 ], and in head and neck cancer with trouble swallowing [ 46 ]. Together, these findings highlight the importance of using disease-specific PRO instruments to assess HRQoL and support the previously published observation that disease specific instruments are likely more sensitive to detect differences both between therapies [ 59 , 60 ], but also, in the case of this review, when comparing between patients in different disease stages [ 59 , 60 ].

Increased symptom burden can also impact a patient’s functional status, such as physical, emotional, or social functioning. Findings from this review show that advanced disease was associated with increased symptom interference in multiple areas including ability to work, walk, and general activity in lung cancer [ 40 ], and greater overall symptom burden in colorectal cancer [ 52 ] and anal cancer [ 55 ]. Increased prevalence or severity of emotional problems with more advanced disease was reported for multiple cancer types. Increased prevalence of emotional problems was correlated with advanced cancer stage for colorectal cancer [ 35 , 50 , 54 ], lung cancer [ 36 , 38 , 39 , 40 ], and cervical cancer [ 35 ]. Statistically significant trends for worse mental HRQoL with advanced disease stage were also reported for colorectal cancer [ 46 ] and lung cancer [ 36 ]. Additionally, there was a statistically significant association between metastatic disease in colorectal cancer and prevalence of depression, although results were non-significant when stratified by T-stage or N-stage [ 52 ]. However, in cervical cancer, a statistically significant association was not found between advanced disease stage and prevalence of anxiety or depression [ 54 , 55 ].

Across the 10 cancer types assessed in this review, 8 cancer types reported PRO results stratified by disease stage, while no studies were identified for the cancer types of liver and bile duct, or ovarian cancer. The number of studies found with results stratified by disease stage varied between cancer types and this is likely impacted by multiple variables including cancer prevalence and incidence, screening availability, distribution of cancer stage at diagnosis, treatment options, and efficacy and survival rates. The greatest number of studies found were for lung and colorectal cancer, returning 6 results each. Perhaps unsurprisingly, these cancers are the most prevalent of the 10 cancers included in the scope of this review: 1,388,422 for colorectal cancer, and 603,989 for lung cancer (Table 4 ) [ 34 ]. In contrast, no studies with results stratified by disease stage were found for the cancer types liver and bile duct, and ovarian, despite relatively high U.S. prevalence rates, 105,765 and 236,511, respectively (Table 4 ) [ 34 ]. The lack of results for these two cancers may be due to the lack of screening paradigms available for these cancers, thus resulting in the majority of cases being detected in later stages. Among the 10 cancers included in the scope of this narrative literature review, the stage at which each cancer type is primarily diagnosed varies. While stage distribution at diagnosis for colorectal cancer is more evenly distributed between early/localized stage (35% of cases), regional stage (36% of cases), and late/distant stage (23% of cases), other cancers are more highly skewed towards diagnosis at the advanced (distant) stage, including lung (53% of cases), pancreatic (51% of cases), esophageal (38% of cases), stomach (36% of cases), and ovarian (55% of cases) (Table 4 ) [ 34 ]. In general, 5-year survival rates are greater for those cancers that are more often diagnosed in earlier stages, although exceptions apply (e.g., liver and bile duct) [ 2 ]. Overall, data support the importance of early diagnosis and treatment to improve survival rates and reduce the negative impact of late diagnosis on patient symptom burden and HRQoL.

A few key limitations are present in this narrative literature review. First, while database searches were conducted in a systematic manner, this work was not intended to be a systematic review. Therefore, the studies selected are considered to be of most relevance to the question being addressed but may not include all relevant references. While the primary objective of this narrative literature review was to identify and collate published literature on patient burden at different stages of disease progression for the ten selected cancers, the secondary objective was to evaluate HRQoL based on cancer type and stage, within and between different cancer types. However, selected literature was heterogenous in terms of patient populations and study design. This review included both prospective and retrospective studies, the latter of which carries additional limitations including the potential for bias due to missing or misreported data. Also, while this review was focused on identifying patients with PRO assessments at the time of diagnosis and prior to treatment, the nature of retrospective claims analyses means that it is sometimes difficult to determine if patients may have previously received treatment. Additionally, studies may not have been powered for PRO endpoints. Statistical comparisons were not reported in all studies and few studies reported minimally important differences. Taken together, these factors limited the ability to draw strong conclusions.

The findings of this narrative literature review support the search for improvements in cancer screening and earlier detection and treatment. Studies with results stratified by disease stage were limited, likely due to some cancers primarily being detected at advanced stages. Although the HRQoL data lacked consistent stratification by cancer stage, advanced stage cancer at diagnosis and prior to treatment was generally associated with worse HRQoL. This observation was expected due to stage or spread of disease likely playing a significant role in symptom impact burden. Overall, this supports the importance of detecting and treating cancer at earlier stages when patients may be asymptomatic or have lower symptom burden to minimize the increased negative impact on HRQoL and functional status observed in cancers diagnosed in advanced stage.

Availability of data and materials

No datasets were generated or analysed during the current study.

Abbreviations

12-Item anorexia/cachexia scale

Apnea/Hypopnea Index

American Head and Neck Society

American Society of Clinical Oncology

Digestive Disease Week

Eating Assessment Tool-10

European Organization For Research And Treatment Of Cancer Core Quality of Life questionnaire

EORTC cervical cancer questionnaire

European Quality of Life Five Dimension questionnaire

European Respiratory Society

European Society for Medical Oncology

Functional Assessment of Cancer Therapy-Colorectal

Functional Assessment of Cancer Therapy-Esophageal

Functional Assessment of Cancer Therapy-Esophageal Cancer Subscale

Functional Assessment of Cancer Therapy-General

International Federation of Gynecology and Obstetrics

Hospital Anxiety and Depression Scale

Health-related quality of life

Health Utility Score

Professional Society for Health Economics and Outcomes Research

Multi-cancer early detection

Mental Component Summary

MD Anderson Symptom Inventory

National Comprehensive Cancer Network Distress Thermometer

Physical Component Summary

Population, Intervention, Comparison, Outcomes, Study Design

Patient-Reported Outcomes Measurement Information System

Patient reported outcome measures

Pittsburgh Sleep Quality Index

Revised Psychosocial Screen for Cancer

National Surgical Adjuvant Breast and Bowel Project (NSABP) Symptom Checklist

Short-Form Survey-12

Short-Form Survey-36

Short-Form Survey-8

Trial Outcome Index

Union for International Cancer Control

US Preventive Services Task Force

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This review was conducted by Genesis Research Group with funding provided by GRAIL, Inc.

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K.C.C., A.M., G.G.G., M.R.W., and A.E.B. contributed to research design, synthesis and interpretation of findings. G.G.G. and M.R.W. contributed to acquisition, analysis, and interpretation of review data. K.C.C., G.G.G., A.E.B. and D.L.P. contributed to synthesis and interpretation of findings and critically reviewed draft manuscripts. All authors have read and approved the final manuscript.

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K.C.C. is an employee of GRAIL, Inc. with stock ownership in Illumina, Bristol Myers Squibb, Gilead, Baxter, and Bayer. A.E.B. and G.G.G. are current employees of Genesis Research Group, A.M. and M.R.W. are former employees of Genesis Research Group. D.L.P. provides consulting to GRAIL, Inc.

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Chung, K.C., Muthutantri, A., Goldsmith, G.G. et al. Symptom impact and health-related quality of life (HRQoL) assessment by cancer stage: a narrative literature review. BMC Cancer 24 , 884 (2024). https://doi.org/10.1186/s12885-024-12612-z

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