Reviewer's report
Title:Pain-preventing strategies in mammography: an observational study of
simultaneously recorded pain and breast mechanics throughout the entire breast
compression cycle
Version:1Date:29 December 2014
Reviewer: Alfonso Frigerio
Reviewer's report:
The Authors made a remarkable work in addressing one delicate issue related to
mammography, a medical test that rates among the most widely used in
asymptomatic persons. This paper appears to me a well planned, original work,
based on sound data collected through ingenious technical and methodological
ideas.
The question posed by the authors (Pain preventing strategies in mammography)
is well defined. The methods are appropriate and well described. Data are sound;
figures appear to be genuine; the manuscript adhere to the relevant standards for
reporting and data deposition; the discussion and conclusions are well balanced
and adequately supported by the data. A few limitations of the work are clearly
stated. Bibliographical references appear complete. The title and abstract
accurately convey what has been found and the writing is clearly acceptable.
In fact, I have been uncertain whether to rate this paper's 'Level of interest' as 'An
article of outstanding merit and interest in its field' or - as I eventually decided to -
as 'An article of importance in its field' mainly due to the extremely specific
aspect concerned. I believe that the Authors are to be congratulated on a very
brilliant and detailed work, that may be expected to serve as a valuable reference
for future developments in the field, both on the clinical side and for industries
that develop and produce mammography units.
Some of the points made in this article look to me as a welcome, well-based
proof of concepts and ideas already considered in my clinical experience (among
these, the prominent importance of 'target pressure' as compared to the most
commonly referred to 'target force'); some other points come as surprising
insights, such as the concept of 'creep motion' and the analysis of its different
components, vascular and soft-tissue.
In the following lines, I shall try to briefly comment a few elements of the article,
both in general terms and with reference to specific points.
I suggest that among these comments, the Authors may find some suggestions
for
'Discretionary revisions' - ie, ideas that they may decide to work on or to ignore.
* I suggest that some words may be devoted to commenting about image quality
vs compression force or pressure vs breast thickness vs pain
* In Table 1 the meaning of 'Intercept' might be not evident
* the comment on the effect of the duration of the clamping period as a negative
predictor of pain (namely, that according to the protocol... the radiographer
worked faster when the patient reported pain) looks to me as not really
convincing.
* I found most interesting the analysis of the 2 phases of compression, and the
importance of the duration of the clamping period. However, I suggest that an
optimal management of the deformation period might play a major role in pain
experience. Which in fact is in accordance with the Authors' idea to plan some
more studies on the strategies of applying pressure
* this also leads me to suggest that a some more thoughts may be devoted to the
discussion of the relationship between the radiographer and the woman:
psychological attitudes of both parties involved, sympathetic behavior, prejudice
(hence the importance of previous experience of pain), etc
* also: how much of the pain is to be related to this operator/women relationship
and to the ensuing women's stiffness, movement during the procedure etc?
* also, could the Authors add some comments on why the pain scores from the
previous mammo experience were such significant predictors of pain? I should
suggest 4 possibilities (not necessarily mutually exclusive): 1 related to the
objective patient characteristics (e.g., very small breast), 2 related to the
subjective patient characteristics (psychology, personal attitude, etc), 3 the
prejudice related to a previous negative experience that would impact on the
woman/radiographer relationship during the exam, 4 would be the remarkable
reproducibility of mammo techniques at the Nijmegen Medical Centre, so that
each time the test experience would tend to be exactly the same
* strategies for reducing clamping phase duration (research recommendation 2):
why not consider some remote control that at the end of compression trigger the
X-ray tube preparation phase while the radiographer moves to the operating
console, such that - when there - he/she can start from the preliminary exposure
(anode already spinning...) etc
* recommendations for further research 1 and 2 look very promising to me. As to
recommendation 1a) could it be considered 'applying the same "maximal"
pressure to all breasts etc [allowing for some inferior pressure on the patient's
request]. On the whole, I am totally in favor of the Authors' suggested line of
research.
Level of interest: An article of importance in its field
Quality of written English: Acceptable
Statistical review: No, the manuscript does not need to be seen by a statistician.
Declaration of competing interests:
I declare that I have no competing interests