The Lancet 'Under Review': Status Meanings, Timelines, and What to Expect

If your Lancet submission has moved to Under Review, you've cleared one of the most selective desk screens in clinical publishing. The Lancet rejects over 90% of submissions at the desk. Getting to peer review puts you in a small minority.

Here's what each stage actually means, how long to expect, and what the editorial team is looking for.

Lancet's Review Pipeline

The Desk Screen (>90% Rejected Here)

The Lancet's desk rejection rate is among the highest in academic publishing. Senior editors evaluate three things in roughly this order:

1. Global health significance. More than any other top medical journal, Lancet prioritizes research with implications for global health. Studies that address health equity, populations in low- and middle-income countries, or diseases of global burden get editorial attention. A perfectly designed trial of a first-world disease with limited global relevance may not pass the desk.

2. Practice-changing potential. Will this study change clinical guidelines? Will health policymakers reference it? The Lancet wants research that moves the needle on how medicine is practiced at scale.

3. Methodological strength. Large, well-designed clinical trials, prospective cohort studies, and systematic reviews with strong methodology. The Lancet expects statistical rigor and adequate power for the claims being made.

If your paper cleared this screen, the editors believe it has genuine Lancet-level significance. That's a meaningful signal.

What Happens During Peer Review

Once your paper moves to Under Review, the Lancet editor assigns 2-3 reviewers. The reviewer selection process is careful:

• Reviewers have direct expertise in your clinical area
• They don't have conflicts of interest with your research group
• Lancet tries to include at least one reviewer from a different geographic region than the authors

Reviewer turnaround is typically 2-3 weeks per reviewer, but delays happen. If one reviewer is slow, the editor will usually wait rather than decide on incomplete feedback. This can extend the review phase to 6+ weeks.

What reviewers evaluate:

• Clinical significance: does this actually change practice?
• Methodological rigor: study design, statistical analysis, potential biases
• Ethical considerations: patient consent, trial registration, conflict disclosure
• Global relevance: does this matter beyond one healthcare system?
• Presentation quality: is the paper clearly written and well-structured?

Timeline Expectations

Lancet decisions come faster than some journals but slower than NEJM (which targets 21 days). If you haven't heard anything after 8 weeks in review, a polite inquiry to the editorial office is reasonable.

Decision Outcomes

After peer review, the Lancet editor will reach one of these decisions:

Accept (rare on first round). Fewer than 5% of papers are accepted without revision. If you get a clean accept, congratulations. It almost never happens.

Major revision. The most common positive outcome. Reviewers and editors want specific changes, additional analyses, or clarifications. Lancet revision requests are usually detailed and specific. Address every single point.

Reject after review. Even getting to review doesn't guarantee publication. Maybe 40-50% of reviewed papers ultimately get rejected. The editor's letter will usually explain what fell short.

How to Handle Revision Requests

If you get a revision invitation from the Lancet:

1. Respond to every point. Create a point-by-point response document. Don't skip anything, even if you disagree.
2. Be transparent about limitations. If you can't do what a reviewer asks (additional data, new analyses), explain why clearly.
3. Stick to the timeline. Lancet gives a revision deadline. Respect it. If you need an extension, ask early.
4. Don't add new data unnecessarily. Respond to what's asked. Adding unrequested analyses can complicate the re-review.
5. Highlight changes clearly. Track changes or a highlighted version makes re-review faster.

If The Lancet Rejects You

The Lancet's rejection rate after review is significant. Your paper was strong enough for review, which means it's competitive at other top journals:

The Lancet family: If the main journal rejects you, the editor may suggest a Lancet specialty journal. Lancet Oncology, Lancet Infectious Diseases, Lancet Respiratory Medicine, and Lancet Public Health are all high-impact in their own right. Take the suggestion seriously.

When to Follow Up

• 0-3 weeks under review: Don't contact the journal. This is normal.
• 4-6 weeks: Still normal. Peer review takes time.
• 6-8 weeks: A polite inquiry is appropriate: "I'm writing to inquire about the status of manuscript THELANCET-D-XXXX. Any update on expected timeline would be appreciated."
• 8+ weeks: Follow up again if you haven't heard back from the first inquiry.

More Resources

• Lancet journal guide
• NEJM under review - comparing the NEJM process
• JAMA vs NEJM - the top two US clinical journals
• Acceptance rates across 50+ journals
• Review timelines compared