Assessing Radiographer's Role in Breast Cancer Screening

This assignment analyzes the role of radiographers in breast cancer screening. It investigates their competence in interpreting mammograms, comparing their diagnostic accuracy to radiologists, and explores their capacity to deliver awareness campaigns about early breast cancer detection among older women. The assessment also delves into the potential of employing radiographers alongside radiologists to address the shortage of radiologists.

Running head: RESEARCH PROPOSAL
PhD research proposal
Name of the Student
Name of the University
Author Note

1RESEARCH PROPOSAL
Executive summary
Breast cancer is one of the most common type of invasive cancer that affects women. It is
considered as the major cause of cancer-related death among women, second to lung cancer.
However, several scientific advances that have been achieved in screening, diagnosis and
treatment often breast cancer have resulted in significant improvements in the rates of survival,
in recent years. Therefore, there is a need to increase awareness of the risk factors and the
associated symptoms. Screening also plays an essential part in reducing the risks of cancer.
Mammography procedures utilize low doses of x-rays to detect early cancer among women.
Thus, radiographers and radiologists are imperative to its screening and diagnosis. This research
proposal therefore intends to evaluate the knowledge and skills of radiographers working in the
mammography departments of 4 hospitals across 2 countries, for detection and categorization of
breast cancer mammographic images as benign and malignant.

2RESEARCH PROPOSAL
Table of Contents
Title..................................................................................................................................................3
Chapter 1: Introduction....................................................................................................................3
Background of the study..............................................................................................................3
Problem statement.......................................................................................................................3
Research aim................................................................................................................................4
Research objective.......................................................................................................................4
Research hypotheses....................................................................................................................4
Chapter 2:Literature Review............................................................................................................5
Chapter 3: Methodology................................................................................................................10
Method outline...........................................................................................................................10
Research design.........................................................................................................................10
Data collection...........................................................................................................................12
Data analysis..............................................................................................................................12
Ethical considerations................................................................................................................13
Limitations.................................................................................................................................13
References......................................................................................................................................14

3RESEARCH PROPOSAL
Title
Comparing ability of radiographers to diagnose benign and malignant breast cancer through
mammography across hospitals in SA and the UK.
Chapter 1: Introduction
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.
Problem statement
Mammograms are routinely administered among women, without apparent symptoms, to
detect benign and malignant breast cancer.
Research aim
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

4RESEARCH PROPOSAL
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.
Research objective
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?
Research hypotheses
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.

5RESEARCH PROPOSAL
Chapter 2:Literature Review
Research question
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.
P Population Individuals breast cancer
I Intervention Mammography
C Comparison NA
O Outcome 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.

6RESEARCH PROPOSAL
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-
Mejía 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

7RESEARCH PROPOSAL
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,

8RESEARCH PROPOSAL
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.

9RESEARCH PROPOSAL
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.

10RESEARCH PROPOSAL
Chapter 3: Methodology
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.
Method outline
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.
Research design
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

11RESEARCH PROPOSAL
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

12RESEARCH PROPOSAL
cancerous. On distribution of the images to the radiographers, a time limit of 2 weeks shall be
provided for completion of the questionnaire.
Data collection
 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.
Data analysis
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

13RESEARCH PROPOSAL
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).
Ethical considerations
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.
Limitations
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.

14RESEARCH PROPOSAL
References
Bleyer, A. and Welch, H.G., 2012. Effect of three decades of screening mammography on
breast-cancer incidence. New England Journal of Medicine, 367(21), pp.1998-2005.
Cooke, A., Smith, D. and Booth, A., 2012. Beyond PICO: the SPIDER tool for qualitative
evidence synthesis. Qualitative Health Research, 22(10), pp.1435-1443.
De Winter, J.C., 2013. Using the Student's t-test with extremely small sample sizes. Practical
Assessment, Research & Evaluation, 18(10), pp.1-12.
Debono, J.C., Poulos, A.E., Houssami, N., Turner, R.M. and Boyages, J., 2015. Evaluation of
radiographers’ mammography screen‐reading accuracy in Australia. Journal of medical
radiation sciences, 62(1), pp.15-22.
Ergu, D. and Kou, G., 2012. Questionnaire design improvement and missing item scores
estimation for rapid and efficient decision making. Annals of Operations Research, pp.1-19.
Holt, J.J. and Pollard, K., 2010. Radiographers' ability to perceive and classify abnormalities on
mammographic images-results of a pilot project. Radiographer: The Official Journal of the
Australian Institute of Radiography, The, 57(2), p.8.
Krosnick, J.A., 2018. Questionnaire design. In The Palgrave Handbook of Survey Research.
Palgrave Macmillan, Cham, pp. 439-455.
Kumar, R., 2014. Research methodology: A step-by-step guide for beginners. Sage, pp.119-131.

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Liu, Y. and Chen, W., 2012. A SAS macro for testing differences among three or more
independent groups using Kruskal-Wallis and Nemenyi tests. Journal of Huazhong University of
Science and Technology--Medical Sciences--, 32(1), pp.130-134.
Marshall, B., Cardon, P., Poddar, A. and Fontenot, R., 2013. Does sample size matter in
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epidemiology, 75, pp.40-46.
Moran, S. and Warren-Forward, H., 2016. The diagnostic accuracy of radiographers assessing
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Omar, L., Burgess, C.C., Tucker, L.D., Whelehan, P. and Ramirez, A.J., 2010. Can
radiographers be trained to deliver an intervention to raise breast cancer awareness, and thereby
promote early presentation of breast cancer, in older women?. Radiography, 16(2), pp.101-107.
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Schumacker, R. and Tomek, S., 2013. Chi-square test. In Understanding Statistics Using R.
Springer New York, pp.169-175.

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Sim, J. and Lewis, M., 2012. The size of a pilot study for a clinical trial should be calculated in
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Tendeiro, J.N. and Meijer, R.R., 2014. Detection of invalid test scores: The usefulness of simple
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Llerenas, A. and Bautista-Arredondo, S., 2015. Radiographers supporting radiologists in the
interpretation of screening mammography: a viable strategy to meet the shortage in the number
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