Mammogram Screening: Evidence-Based Practice Change

The Spirit of Inquiry Ignited

Cancer is a grave disease that is highly lethal and often delivers a slow and painful death at later stages. Statistically, in 2008 the mortality rate from cancer was at the level of 62% (Siegel et al., 2014). Breast cancer is one of the most dangerous kinds of cancer forming in ducts and lobules of the breast (in both men and women). In the United States, this type is the second leading cause of death from cancer (after lung cancer) and is found in one woman in eight (DeSantis et al., 2014). In 2017, 252,710 women have been diagnosed with breast cancer, for more than 40,000 of whom the disease is to be lethal (Donepudi, Kondapalli, Amos, & Venkanteshan, 2014). However, advances in mammogram screening and disease treatment have significantly increased survival rates during the last decades (there are now more than three million survivors living in the country).

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Awareness of the symptoms is one of the most important factors in preventing deplorable consequences of breast cancer. Screening mammography is recommended to be performed annually for every woman aged between 40 and 55, especially if they are at increased risk owing to their family history of the disease. Some are advised to begin screenings earlier (approximately at 30) and continue undergoing them lifelong. Although in some cases breast cancer is detected due to the appearance of certain symptoms, it is not infrequent for it to be asymptomatic, which makes screening initiated by healthcare providers particularly important.

The PICOT Question Formulated

In a primary care setting, for women aged 40-55 (P), how effective is provider-initiated conversation regarding recommended screening guidelines and their benefits in detecting breast cancer (I) versus not initiating conversation (C) in increasing patient participation in mammogram screenings for breast cancer (O) over a 6-month period (T)?

Search Strategy Conducted

The search was conducted using numerous databases including Google Scholar, ProQuest, PubMed, and CINHAL. The MESH terms used for the project include: breast cancer, cancer, mammography, screening, cancer detection, and mammogram. After the all relevant studies had been selected, the evaluation for inclusion and exclusion criteria was conducted for them to exclude those that did not provide sufficient information, were not deeply grounded in evidence or outdated. In the advanced search, the timeframe indicated was 2015-2017. The search was narrowed by peer-reviewed and evidence-based studies, which were meant to increase accuracy and productivity of the project.

The acronyms utilized for searching include: BMC, NHS, ACOG, ACS, AHRQ, BCSC, BI-RADS, BSE, PTS, MMG, CBE, DCIS, EPC, LCIS, MRI, NCI, NNS, RR, WHI, WHO.

Critical Appraisal of the Evidence Performed

Several studies were chosen for the purpose of the project at hand. The choice was made based on the quality of evidence, its up-to-date character, and relevance to the intended research. All the selected materials were consistent with the hypothesis and proved the need for further investigation of the issue.

The study conducted by Rzepecki et al. (2017) was aimed to find out if patients pay attention to brochures in the changing room and follow the screening recommendations provided. The researchers also intended to investigate whether these patients made an appointment for an additional consultation after undergoing the screening. It was discovered that the majority of patients notices the information bulletins and more than 20% of them decided to check themselves for melanoma signs. Those who were informed about its symptoms booked a preemptive MMG exam in addition to visiting a dermatologist. This made the researchers conclude that knowledge of basic SSE techniques positively affects patients’ willingness to undergo cancer prevention and early detection procedures and may have an influence on MMG attendance.

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Bayik, Daghan, Kaymakci, Ozturk, and Abaraci (2017) hypothesized that despite BSE and PST scores in Turkish women and teachers being traditionally low, training and awareness seemed to improve the results in three measured variables. The found out that providing breast cancer-related knowledge managed to improve awareness and MMG attendance in a region with traditionally low scores in BSE, MMG, and PST. This implies that that providing instruction and information in any way naturally improves a willingness to undergo the procedure.

Moshki, Taymoory, Khodamoradi, and Roshani (2016) aimed to test the strength of the connection between perceived risk of breast cancer in Iranian women and physician recommendation to perform the screening. The researchers discovered that a physician’s recommendation greatly enhanced chances of follow-up mammography attendance among patients. The mechanisms of influence revolved around inspiring fear through indirect means and making the patients want to conduct additional mammography tests in order to remain on the safe side.

Fisher, Wilkinson, and Valencia (2017) examined the willingness of women to receive additional knowledge on breast cancer. They found out that 93.7% reacted positively to the proposition. The study underlines the general receptiveness of the population towards acquiring new knowledge about breast cancer, which is directly related to MMG attendance rates.

Reder and Colip (2015) hypothesized that a decision aid rendered by a healthcare provider might improve an informed choice in breast cancer screening. They discovered that such an aid indeed increased patient knowledge about the procedure, reduced decisional conflicts, and improved MMG attendance rates. This proved the importance of physician recommendations and consultations in regards to MMG attendance rates.

Evidence Integrated with Clinical Expertise and Patient Preferences to Inform a Decision and Practice Change Implemented

The Purpose of the Project

All the studies reviewed showed that information provision is highly significant in detecting breast cancer. Thus, the project at hand is needed to expand the existing knowledge. That is why it will investigate whether provider-initiated conversation can improve the effect of screening guidelines. As an APRN, I am aware of my crucial role in the primary and secondary prevention of such diseases. The project will show whether my practical skills and theoretical knowledge of the problem are advanced enough to perform a successful intervention and convince even reluctant patients to perform the screening. This will allow me to initiate other screening programs in the future and influence patient preferences in making an informed decision. If the project is successful, it will contribute to the promotion of high-quality care and lead to a considerable practice change, making healthcare providers more involved in the problem (substituting the detached approach that consists in issuing guidelines without additional communication techniques).

Methods and Implementation Plan

The design of this PICOT research will feature a test group and a control group. The test group treatment will involve provider-initiated conversation regarded recommended screening guidelines. The control group will be treated without changes. It should provide a good comparison in order to determine the effectiveness of the approach. It will also show whether increased communication will patients may contribute to their decision-making capabilities and make them more aware of their health choices.

The intervention will last six months. The issue of time is appropriate for this PICOT question, as the effect of provider-initiated conversation does not happen over a short period of time. In order to see if non-intrusive conversations regarding breast cancer detection influence participation in mammogram screenings, a minimum of six months of observation are necessary. It will allow the researchers to detect any short-term and long-term influence patterns if there are any.

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Outcomes Evaluated

In the event of a successful outcome of the project, the data analysis should reveal that the number of women deciding to undergo breast screenings increased among those who participated in a provider-initiated conversation in comparison to those who did not. Furthermore, to have validity and reliability, this study must be replicated to prove that its results can be generalized. Provided that all these conditions are met, the results of the project can be disseminated in the nursing community.

Appendices

Table 1. Evidence Synthesis.

PubMed Database Study #1 Study #2 Study #3 Study #4 Study #5 Synthesis
(P) Population Female patients aged 40 or older. Turkish female patients between 18 and 60 years of age. Iranian women aged 50 years or older. Middle-aged and older English female patients. German patients aged 50 or older. In the majority of cases, patients analyzed for breast cancer and eligible for mammography were between 40 and 60 years old.
(I) Intervention Promotion of skin self-assessment procedures by placing instructional information posters in the changing rooms. Providing education about the importance of self-assessment and mammography among female teachers and students. Examining the relationship between perceived risk of disease after receiving a physician’s recommendation for mammography procedures. Assessing interest and willingness of patients in learning more about breast cancer prevention and screenings via postal surveys. Utilization of a decision-aid program in order to enhance the knowledge and understanding of breast cancer in patients and potentially improve mammography attendance rates. All researches revolved around providing additional information about breast cancer, the importance of mammography, and potential self-diagnosis techniques.
(C) Comparison No comparison. No comparison. The control group did not receive the recommendation from the physician. No comparison. The control group did not receive decision-aid information. Due to the nature of the research, some studies did not require the use of the control group, as effectiveness of the intervention could be assessed by comparing new rates of attendance with old ones as well as the country’s average.
(O) Outcome 68% of patients noticed the information posters.
78% thought it applied to their condition.
20% of the patients performed a self-examination in the changing room.
13% noticed nothing of concern.
60% of those patients made an appointment to a dermatologist.
Mammography rates among patients aged 40 or older were low, but after receiving education and information material about breast cancer the results of MMG testing improved by about 30-38%. The incidence for repeated mammography increased by 49%. Two major factors that contributed to the increase in patients’ desire to undergo MMG included knowledge and family history of breast cancer. The majority of participants viewed the initiative as positive and thought it would improve MMG attendance. Most patients showed a rudimentary knowledge of breast cancer but were unaware of particular factors associated with it. These factors include obesity, weight gain, alcohol consumption, and lack of physical activity. DA proved to be an effective tool for increasing awareness and informed choices. As a result, the number of mammography attendances among the target group increased. All methods of increasing patient awareness about breast cancer and available methods of screening and prevention have had a positive effect on MMG attendance. The results were further enhanced if the patients had any family history of disease, which encouraged them to learn disease prevention methods.
(T) Timeline Exit interviews about the effectiveness of the material were conducted for 8 consecutive days. Intervention was performed for a duration of 2 weeks. Follow-up examinations were performed after a 6-month period to examine short-term and long-term effects of the intervention. The study utilized patient data regarding mammography visits for 12 months since the beginning of the intervention implementation, as mammography tests are supposed to be done on a yearly basis. Not applicable. Potentially used in a larger 10-year study in order to predict the percentage of probability of breast cancer development. The intervention evaluation was completed in 3 months The majority of the studies were conducted within a 6-month timeframe in order to gauge the immediate and long-term effects of the interventions. The majority of the studies have discovered that providing cancer knowledge improves MMG attendance both in the short-term and long-term perspective.

Table 2. Evaluation Table.

Citation Design Sample Size Major Variables (Dependent and Independent) Study Findings: Strengths and Weaknesses Level of Evidence Evidence Synthesis
Rzepecki, A. K., Jain, N., Ali, Y., Chavez, L., Choi, J., Schlosser, B., … Robinson, J. K. (2017). Promoting early detection of melanoma during the mammography experience. International Journal of Women’s Dermatology, 3(4), 195-200. Quantitative design. 560 patients agreed to the interview after mammography. Dependent variables:
  • Whether the patient read the brochures in the changing room.
  • Did they examine themselves after receiving information?
  • Did they make an appointment for an additional consultation after?

Independent variables:

  • The presence of actual signs of melanoma.
  • Age, race.
  • Prior levels of knowledge and cancer education.
The study found that the majority of the patients noticed the information bulletins and over 20% of them checked themselves for any signs of melanoma. Those who found any symptoms of concern booked a preemptive MMG exam in addition to visiting a dermatologist (Rzepecki et al., 2017).

Strengths: Shows a correlation between raising awareness and taking actions to prevent cancer in the early stages.
Weaknesses: No direct evidence between counteracting melanoma and increasing MMG attendance. A limit on time in the changing rooms might have caused a decrease in SSE scores.

Medium-High. Awareness of symptoms of diseases and knowledge of basic SSE techniques positively improves patients’ willingness to undergo cancer prevention and early detection procedures and may have an influence on MMG attendance.
Bayik, T. A., Daghan, S., Kaymakci, S., Ozturk, D. R., & Abaraci, Z. (2017). Effect of structured training programme on the knowledge and behaviors of breast and cervical cancer screening among the female teachers in Turkey. BMC Women’s Health, 17(1), 123. Quantitative design. 101 participants:
  • 37 teachers.
  • 64 students.
Dependent variables:
  • BSE knowledge.
  • PST knowledge.
  • MMG attendance.

Independent variables:

  • The effects of awareness training and practical education on dependent variables.
Despite BSE and PST scores in Turkish women and teachers being traditionally low, training and awareness seemed to improve the results in three measured variables (Bayik et al., 2017).

Strengths: Large search sample (3 times larger than necessary for this research design).
Weaknesses: Lack of literature findings in regards to the validity of chosen study instruments.

Medium. Providing breast cancer-related knowledge managed to improve awareness and MMG attendance in a region with traditionally low scores in BSE, MMG, and PST. Shows that providing instruction and information in any way naturally improves a willingness to undergo the procedure.
Moshki, M., Taymoory, P., Khodamoradi, S., & Roshani, D. (2016). Relationship between perceived risk and physician recommendation and repeat mammography in the female population in Tehran, Iran. Asian Pacific Journal of Cancer Prevention, 17(3), 161-166. Quantitative design. 601 women aged 50 years or older. Dependent variables:
  • Variance in repeat mammography.

Independent variables:

  • Perceived risk of breast cancer.
  • Knowledge of breast cancer.
  • Family history of breast cancer.
The study found that a physician’s recommendation greatly enhances chances of follow-up mammography attendance among patients (Moshki, Taymoory, Khodamoradi, & Roshani, 2016).
Strengths of research: Large sample size, direct correlation with this PICOT research.
Weaknesses of research: self-reported questionnaires, difficulty to measure perceived risk.
High. A physician’s recommendation directly influenced the incidence of repeat mammography in the target population. The mechanisms of influence revolve around inspiring fear through indirect means and making the patients want to conduct additional mammography tests in order to remain on the safe side.
Fisher, B. A., Wilkinson, L., & Valencia, A. (2017). Women’s interest in a personal breast cancer risk assessment and lifestyle advice at NHS mammography screening. Journal of Public Health, 39(1), 113-121. Quantitative. 1803 completed questionnaires from individual female patients aged 50 or older. Dependent variables:
  • Interest in personal risk assessment.
  • Independent variables:
  • Personal knowledge about breast cancer.
  • Attitudes towards cancer prevention.
This study examined the willingness of women to receive additional knowledge on breast cancer. 93.7% reacted positively to the proposition (Fisher, Vilkinson, & Valencia, 2017).

Research strengths: Large sample.

Research weaknesses: 2/3 of questionnaires were not returned.

Medium. This study is valuable to our PICOT research as it underlines the general receptiveness of the population towards acquiring new knowledge about breast cancer, which is directly related to MMG attendance rates.
Reder, M., & Colip, P. (2015). Does a decision aid improve informed choice in mammography screening? Study protocol for a randomized controlled trial. BMC Women’s Health, 15(53), 1-8. Quantitative. 7400 women aged 50 or older from the district of Westfalen-Lippe, Germany. Dependent variables:
  • Choice in mammography.

Independent variables:

  • Personal knowledge about breast cancer.
  • Decision-aids.
  • Decisional conflicts.
Decision-aids increased patient knowledge about the procedure, reduced decisional conflicts, and improved MMG attendance rates (Reder & Colip, 2015).

Strengths: Direct correlation between MMG attendance and the intervention, very large sample.

Weaknesses: Unclear if results were caused by increase in knowledge or fear of consequences.

High. This study showcases the importance of physician recommendations and consultations in regards to MMG attendance rates. Results consistent with other findings.

References

Bayik, T. A., Daghan, S., Kaymakci, S., Ozturk, D. R., & Abaraci, Z. (2017). Effect of structured training programme on the knowledge and behaviors of breast and cervical cancer screening among the female teachers in Turkey. BMC Women’s Health, 17(1), 123.

DeSantis, C., Ma, J., Bryan, L., & Jemal, A. (2014). Breast cancer statistics, 2013. CA: A cancer journal for clinicians, 64(1), 52-62.

Donepudi, M. S., Kondapalli, K., Amos, S. J., & Venkanteshan, P. (2014). Breast cancer statistics and markers. Journal of Cancer Research and Therapeutics, 10(3), 506-511.

Fisher, B. A., Wilkinson, L., & Valencia, A. (2017). Women’s interest in a personal breast cancer risk assessment and lifestyle advice at NHS mammography screening. Journal of Public Health, 39(1), 113-121.

Moshki, M., Taymoory, P., Khodamoradi, S., & Roshani, D. (2016). Relationship between perceived risk and physician recommendation and repeat mammography in the female population in Tehran, Iran. Asian Pacific Journal of Cancer Prevention, 17(3), 161-166.

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Reder, M., & Colip, P. (2015) Does a decision aid improve informed choice in mammography screening? Study protocol for a randomized controlled trial. BMC Women’s Health, 15(53), 1-8.

Rzepecki, A. K., Jain, N., Ali, Y., Chavez, L., Choi, J., Schlosser, B., … Robinson, J. K. (2017). Promoting early detection of melanoma during the mammography experience. International Journal of Women’s Dermatology, 3(4), 195-200.

Siegel, R., Ma, J., Zou, Z., & Jemal, A. (2014). Cancer statistics, 2014. CA: A Cancer Journal for Clinicians, 64(1), 9-29.

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StudyCorgi. (2021, July 8). Mammogram Screening: Evidence-Based Practice Change. Retrieved from https://studycorgi.com/mammogram-screening-evidence-based-practice-change/

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