Background of the study
Statistical studies provide evidence for the diagnosis of more than 1.7 million cases of breast cancer in the year 2012 (Torre et al. 2015). Mammography refers to special kind of breast imaging technique that utilizes low doses of x-rays for detection of cancer, at a stage when it is curable. The role of radiologists has evolved over the years with their increased involvement in patient care (Bleyer and Welch 2012). Most studies focus on the increasing importance of image interpretation that has been undertaken in several countries such as, the UK and Netherlands for the past two decades (Holt and Pollard 2010). Furthermore, there are a wide range of training programs that illustrate the essential role of radiographers in screening mammography and elaborate on the fact that trained radiographers can interpret mammograms similar to radiologists. Thus, mammograms aid in diagnosis and early detection of breast cancer among women.
Mammograms are routinely administered among women, without apparent symptoms, to detect benign and malignant breast cancer.
The objective of the research is determining the ability of mammography radiographers across 4 hospitals in the Saudi Arabia and UK. The study aims to describe and identify features of malignant and benign cancer in the mammographic projections. The project will further establish the capability of the radiographers in describing the imaging pathway for clarification of the disease pathologies.
There are several objectives that the research intends to achieve. These are stated below:
- What is the effectiveness of providing training to mammography radiographers for reading the images?
- Does this training provided to radiographers facilitate the ability to read the images without further training?
- Do further training courses and continued professional education increase performance of radiographers in reading the images?
The three research hypothesis that will help in speculating the outcomes of the intended research are mentioned below:
- Radiographers selected from the 2 selected countries (Saudi Arabia and the UK) will easily distinguish between benign and malignant cancer from the mammographic images.
- The clinical knowledge and experience of the radiographers from the selected country will help them in reporting cancer
- The knowledge gained by the radiographers belonging to the 2 communities will be distinct from each other due to difference in their professional education.
The research question that will be addressed in the literature review is as follows:
Can radiographers diagnose benign and malignant breast cancer through mammography?
The research question has been kept specific and has been broken down into several components based on the PICO framework. This PICO format is generally considered for framing foreground questions that govern a research (Cooke, Smith and Booth 2012). PICO refers to population, intervention, comparison and outcome.
Individuals breast cancer
Early detection and prevention
Several key terms, in combination with boolean operators such as ‘AND’, ‘OR’, and ‘NOT’ were used for searching relevant literature. These boolean operators were made use of, for expanding and narrowing down the search results. The operators helped to connect the search terms together. ‘AND’ helped in narrowing down the hits and included relevant search terms that were present in the database records (McGowan et al. 2016). The Boolean operator ‘OR’ helped in connecting synonyms. Thus, it broadened the search hits. On the other hand, the term ‘NOT’ was used to exclude unnecessary terms from the search.
Electronic databases such as CINAHL and MEDLINE were searched for the relevant articles that were published in English, not prior to 2010, and were peer reviewed. The research articles published prior to 2010 were not included for the literature review (Raebel et al. 2013).
Multiple trials have been carried out in recent years to investigate the roles of radiographers in early diagnosis of benign and malignant cancer. A study conducted by Torres-Mej?a et al. (2015) focused on devising an alternative approach to evaluate to the traditional model of radiologists in interpretation or screening of mammography in several countries. The study recruited 15 radiographers from the state of Mexico based on certain eligibility criteria that included a formal role in mammography facility, completion of adequate training for radiographers, a minimum 6 months of experience in breast imaging and X-ray imaging and consent from the institutions for their participation in the study. The authors conducted a training program at a Digital Diagnostic Center, for a total duration of over 6 months. The training programs primarily encompassed conduction of clinical lectures and in-service training modules by three experienced radiologists. The participants were subjected to interpretation of digital mammographies using the Breast Imaging Reporting and Data System (BI-RADS) system. With a progress in time, the number of mammographies that were assigned to each participant increased, followed by weekly feedbacks. The median number of images interpreted by the radiographers was 777, over a period of 122 training hours. A formal evaluation using a self-administered test confirmed the presence of 15 biopsy confirmed cancers, 14 non-cancers that were judged by the U.S expert radiologists judged, and 81 non-cancers that were judged as no findings. The expert radiologists stated that of the 15 confirmed breast cancer images, 3 were obvious, 5 subtle and 7 intermediate. Statistical analysis revealed that all radiographers had received a median duration of training for 2.5 years, prior to which they did not have any experience. While the median sensitivity was found to be 73.3 % (IQR: 46.7-86.7 %), the average false positive was 49.5 % (IQR: 34.7–57.9 %). Furthermore, it was found that employment of radiologists for interpreting mammographic images was more cost effective when compared to radiographers. Thus, the study supported the role of radiographers as good non-radiologist candidates for interpreting the images, owing to their professional dedication and experience.
Similar findings were supported by another study that aimed to assess the accuracy of radiographers in screening mammography images (Debono et al. 2015). The study enrolled 10 radiographers based on their diagnostic and screening capacity having radiography experience ranging from 7-47 years. No formalized screening training was conducted and the respondents were made to screen 500 mammogram images. Selection bias was removed by not informing the participants of the prevalence of cancer in the population. The mammography images were stratified into 3 categories namely, normal mammograms; benign mammograms and malignant mammograms, on the basis of their histology. The participants were made to perform screening over a series of sessions, without specific time limits. They were blinded to the original reports of radiologists. Approximately 20-155 mammograms were screened by each radiographer. A bivariate model was used to account for the correlation between specificity and sensitivity. The accuracy of radiographers was found to vary with specificity levels ranging from 74.8–96.2% and sensitivity levels from 76.0–92.0%. Thus, the results were able to determine the fact that radiographers had reasonable levels of specificity and sensitivity, upon comparison with the gold standard. The results also provided evidence for the fact that majority of radiographers demonstrated greater abnormality in detection ability when compared to previous studies. Thus, it was postulated that an increase in formal training will improve the accuracy levels among radiographers.
The roles and responsibilities of consultant radiographers were investigated by another qualitative study that sent questionnaires to 24 consultant breast radiographers working in the UK (Rees 2014). An assessment was carried out for the 22 complete responses sent by the participants that suggested an increase in the number of consultant radiographers in recent years. 17 participants spoke of moving away from their work citing professional boredom and lack of job satisfaction. Analysis of the questionnaire responses suggested that the most radiographers strive for additional knowledge and displayed a willingness to progress for adorning their professional role and responsibility. Thus, the study emphasized on the fact that professional training and continuing education is imperative to an improvement in their performance.
The performance of radiographers in assessing or screening mammograms was compared with radiologists in a systematic review conducted by Moran and Warren-Forward (2016). The review included studies that focused on radiographer participants, with or without adequate training and compared them to the gold standard. Quantitative studies that examined the diagnostic outcomes for the radiographers were included in the review. On the other hand, it excluded abstracts, case studies and narrative reviews from the analysis. On carrying out a thorough analysis of current literature it was found that radiographers have the necessary skills for displaying proficiency in reporting or screening of mammograms. The review further emphasized on the fact that there is a need to provide advanced training to radiographers, which in turn will help them to utilize their skills on a regular basis. Further analysis of the results suggested that the radiographers should be provided with adequate time and resources before the interpretation of mammograms is reported.
The feasibility of providing training to radiographers for delivering a one-to-one treatment for raising awareness on breast cancer among older women was investigated by some authors (Omar et al. 2010). The study included two radiographers from breast screening services located at London and trained them over a period of 3 months, following which their competence to deliver appropriate intervention was evaluated on the basis of randomly selected interviews. 3 of the 4 participants demonstrated minimum competency criteria for the practice interventions. However, their competence improved over time. The mean scores for the confidence items showed an increase between the first and third days of training. An improvement was observed in delivering the interventions with progress in time. Further analysis of the results during follow up showed that delivery of intervention helped in enhancing the interaction of the radiographers with the women who attended the breast screening programs. Thus, the study helped to conclude that adoption to the training programs is feasible as well as challenging while implementing these interventions for early prevention of breast cancer.
This section will describe the actions that are intended to be taken for investigating the research questions and will also illustrate the rationale that is to be applied for implementation of some specific procedures meant for identification, selection and analysis of the information. The section will encompass steps that are well researched and carefully formulated (Kumar 2014). It contains information on data collection, the sample for the study, outcomes to be measured, data analysis tools and the expected interpretations of the results.
This study will be conducted over period of 6 months and will involve 40 radiographers, experienced in interpreting mammography images. The participants will be recruited across 4 hospitals, from two countries namely, Saudi Arabia and the UK. Not less than 10 radiographers shall be enrolled from each hospital to ensure that the sample reflects the educational background of the country selected. The primary objective of the study is establishing the capability of specialist mammography radiographers from two countries for identification, naming and description of benign and malignant lesions in mammographic projections. The study will be carried out in two phases.
Phase 1- This will involve study and assessment of the abilities and educational levels of the radiographers across 4 healthcare centres in the UK and Saudi Arabia. A structured questionnaire will be used as the data collection tool, which will be distributed in the selected hospitals. The structured questionnaire will help in gathering and collating information related to demographic data from the population under investigation (Krosnick 2018). Various sources shall be used to formulate the questionnaire, for ensuring that it is adequately framed and well structured. All forms of biases with regards to the questions shall be eliminated. Numerical ranking of the collected data will help to gather both qualitative and quantitative information (Ergu and Kou 2012).
Some of the questions related to demography present in the structured questionnaire will encompass the following aspects:
- Years of experience in mammography detection
- Advanced training courses in the area of mammography
- Attending multidisciplinary departmental meetings
- Extra readings on mammography
- Continuing professional education
Their understanding and knowledge on mammography image detection and identification shall also be investigated using several projections. Thus, the questionnaire will act as a sample of convenience (Marshall et al. 2013). Thus, a minimum of 20 radiographers need to be recruited from each country to avoid bias in the survey results. The data will be complied by moving across cities in Saudi Arabia and the UK.
Phase 2- This phase will involve detecting the capability of the recruited participants to discern and differentiate between benign and malignant breast cancer by observing the mammogram images that will be displayed on a computer screen. The images will be clear enough to distinguish between benign and malignant cancer forms. Not less than 6 images will be selected and they will vary in their patterns namely, normal to abnormal and benign to cancerous. On distribution of the images to the radiographers, a time limit of 2 weeks shall be provided for completion of the questionnaire.
- A pilot study will be conducted. It will acts as a preliminary trial that will be performed before conduction of the aforementioned study. The pilot study will be conducted to specifically check the validity and effectiveness of the questionnaire, by ensuring that the respondents face no difficulty in answering it (Sim and Lewis 2012). It will also eliminate all kinds of issues that might arise during data analysis.
- The structured questionnaires are the primary data collection tool that would help in assessing the capabilities of the radiographers in 2 phases.
Phase 1- The variables for this phase are:
- Educational level of the radiographers
- Experience in mammography
- Advance training and its application
Therefore, nonparametric tests will primarily be applied for analysis of the collected data that is both qualitative (nominal) as well as quantitative (ratio) data. Data in a nonparametric test is not required to be fitted in normal distribution (Tendeiro and Meijer 2014). Thus, no assumptions shall be made about the population parameter. The Kruskall-Wallis test will be used to calculate the percentage of the qualitative data and will be described through tables, charts, paragraphs and bar graphs (Liu and Chen 2012).?On the other hand, statistical and mathematical procedures will be applied on the quantitative data, depending on its distribution. Chi-square tests will be used to compute them, following which they will be arranged in bar charts (Schumacker and Tomek 2013).
Phase 2- The variables for this phase are:
- Ability of the radiographers to accurately assess and classify the mammography images.
Therefore, both parametric and nonparametric statistical tests shall be put to use for analysis of this data. Independent t-test and chi-square test will be performed for the analysis of their capabilities (De Winter 2013).
Prior permission will be taken from the mammography departments of the hospitals for retrieving the projections. The study shall be guided by ethical principles by respecting the rights of the respondents. The reports shall be presented without any manipulation.
The major difficulties are related to the lack of adequate scientific literature sources on this topic in Saudi Arabia. Another concern is associated to difficulty in data collection from radiographers in Saudi Arabia, owing to their cultural beliefs and social taboos.
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