Understanding the needs of women undergoing breast ultrasound: Are male radiologists still needed?

Elisabeth Sartoretti; Selina Largiadèr; Thomas Sartoretti; Simin Laures; Martin Alexander Walter; Eva Monti; Ina Füchsel; Mira Dettling; Stephan Pfister; Peter Dubsky; Alexander Ort; Sabine Sartoretti-Schefer; Matthias Meissnitzer; Klaus Hergan; Rosemarie Forstner; Simon Matoori; Rasmus Bech- Hohenberger; John M Froehlich; Tino Plümecke; Dorothee Harder; Dow Mu Koh; Andreas Gutzeit

doi:10.1371/journal.pone.0291007

. 2023 Nov 8;18(11):e0291007. doi: 10.1371/journal.pone.0291007

Understanding the needs of women undergoing breast ultrasound: Are male radiologists still needed?

Elisabeth Sartoretti ^1,^2,^#, Selina Largiadèr ^1,^#, Thomas Sartoretti ^1,², Simin Laures ³, Martin Alexander Walter ^1,⁴, Eva Monti ¹, Ina Füchsel ⁵, Mira Dettling ⁵, Stephan Pfister ⁴, Peter Dubsky ⁶, Alexander Ort ¹, Sabine Sartoretti-Schefer ⁵, Matthias Meissnitzer ⁷, Klaus Hergan ⁷, Rosemarie Forstner ⁷, Simon Matoori ⁸, Rasmus Bech- Hohenberger ⁹, John M Froehlich ⁴, Tino Plümecke ¹, Dorothee Harder ¹⁰, Dow Mu Koh ¹¹, Andreas Gutzeit ^1,^4,^6,^12,^*

Editor: Aloysius Gonzaga Mubuuke¹³

¹Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland

²Faculty of Medicine, University of Zurich, Zurich, Switzerland

³Institute of Radiology, Cantonal Hospital Aarau, Aarau, Switzerland

⁴Institute of Radiology and Nuclear Medicine, Hirslanden Klinik St. Anna, Lucerne, Switzerland

⁵Department of Radiology, Cantonal Hospital Winterthur, Winterthur, Switzerland

⁶St. Anna Breast Center, Hirslanden Klinik St. Anna, Lucerne, Switzerland

⁷Department of Radiology, Paracelsus Medical University Salzburg, Salzburg, Austria

⁸Faculté de Pharmacie, Université de Montréal, Montréal, Canada

⁹Faculty of Medicine, University of Copenhagen, Copenhagen, Denmark

¹⁰Department of Radiology, University Hospital of Basel, University of Basel, Basel, Switzerland

¹¹Department of Radiology, Royal Marsden Hospital, Surrey, United Kingdom

¹²Department of Chemistry and Applied Biosciences, Institute of Pharmaceutical Sciences, ETH Zurich, Zurich, Switzerland

¹³Makere University College of Health Sciences, UGANDA

Competing Interests: The authors have declared that no competing interests exist.

^✉

* E-mail: andreas.gutzeit@unilu.ch

Contributed equally.

Roles

Elisabeth Sartoretti: Conceptualization, Writing – original draft

Selina Largiadèr: Conceptualization, Data curation, Writing – original draft

Thomas Sartoretti: Conceptualization, Data curation, Writing – original draft, Writing – review & editing

Simin Laures: Conceptualization, Writing – original draft

Martin Alexander Walter: Writing – original draft

Eva Monti: Writing – original draft

Ina Füchsel: Writing – original draft

Mira Dettling: Writing – original draft

Stephan Pfister: Writing – original draft

Peter Dubsky: Writing – original draft

Alexander Ort: Formal analysis, Writing – original draft

Sabine Sartoretti-Schefer: Writing – original draft

Matthias Meissnitzer: Writing – original draft

Klaus Hergan: Conceptualization, Data curation, Formal analysis

Rosemarie Forstner: Writing – original draft

Simon Matoori: Writing – original draft

Rasmus Bech- Hohenberger: Supervision, Validation, Visualization, Writing – original draft

John M Froehlich: Conceptualization, Investigation, Methodology, Supervision

Tino Plümecke: Data curation, Writing – original draft, Writing – review & editing

Dorothee Harder: Conceptualization, Writing – original draft, Writing – review & editing

Dow Mu Koh: Data curation, Formal analysis, Writing – original draft

Andreas Gutzeit: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing

Aloysius Gonzaga Mubuuke: Editor

PMCID: PMC10631629 PMID: 37939048

Abstract

Introduction

A trend towards less male radiologists specializing in breast ultrasound was observed. A common notion in the field of breast radiology is, that female patients feel more comfortable being treated by female radiologists. The aim of the study was to understand and report the needs of women undergoing breast ultrasound with regards to the sex of the radiologist performing the investigation.

Methods

Informed consent was obtained from all patients prior to inclusion in a prospective bi-center quality study. At center 1 (72 patients), the women were examined exclusively by female radiologists, at center 2 (100 patients) only by male radiologists. After the examination the patients were asked about their experiences and their wishes for the future.

Results

Overall, women made no distinction between female and male radiologists; 25% of them wanted a female radiologist and 1.2% wanted a male radiologist. The majority (74%) stated that it made no difference whether a female or male radiologist performed the examination. The majority of women in group 2, who were investigated exclusively by male radiologists, stated that they had no preferences with regard to the sex of the radiologist (93%); 5% of the women wished to be investigated solely by a female radiologist and 2% exclusively by a male radiologist.

Discussion

The majority of women undergoing breast ultrasound are unconcerned about the radiologist’s sex. It would appear that women examined by male radiologists are less selective about the sex of the examining radiologist.

Trial registration

Written informed consent was obtained from all patients. All patient data were anonymized. The physicians had no access to any further personal data. National regulations did not require dedicated ethics approval with anonymized lists or retrospective questionnaires.

Introduction

Mammography is the gold standard for breast cancer screening and diagnosis in women [1]. However, an additional ultrasound screening may be recommended in specific situations, such as women with a higher breast density, high-risk populations, or ambiguous findings on mammography [2]. In recent years, it has become increasingly clear that more attention should be given to the welfare of female patients in medicine because they have different needs, physiological conditions, and respond differently to treatment than male patients [3–5]. These differences are addressed in the field of gender medicine [6].

Despite scarce evidence, female patients are consistently reported to dislike consulting male physicians and would be more likely to prefer a female physician [7–9]. This is also evident in surveys of gynecologists: while 7% of gynecologists in 1970 were female, currently women comprise about 60% of gynecologists [10].

Male radiologists also appear to be less interested in female imaging and breast care than their female counterparts, although we lack official data in this regard. However, an inquiry at the European Society of Radiology (ESR) regarding the sex ratio of their memberships and specialization revealed that the female/male ratio of the ESR, which currently counts about 123,500 members, is 39/61%. In contrast, the European Diploma in Breast Imaging (EDBI) had a majority of accreditations being given to women in recent years, with a female/male ratio of 70/30% [11].

The reasons for this are not clear. Apart from personal interest, the perceived demands and needs for specific radiological personnel have a significant influence on a resident’s intentions to be trained in a sub-specialty. When asked about this, male doctors showed uncertainty as to whether they were still desired by patients in a field with a majority of female patients.

The aim of the present study was to understand and report the needs of women undergoing breast ultrasound with regard to the sex of the radiologist performing the investigation.

Methods

Study subjects

This prospective two-center study was conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from all participants. All participant data were anonymized as part of a routine quality assurance measure at the institutions. According to national regulations, no explicit ethics approval is required under these conditions. The study was conducted at the hospital (Cantonal Hospital Winterthur): Center 1, and the breast center at hospital (Breast center Lucerne): Center 2. Centers 1 and 2 are certified breast imaging centers performing approximately 5000 and 9000 breast examinations, respectively, each year.

A total of 172 participants were included between August 2021 and May 2022. Inclusion criteria were the following: a) consecutive participants referred to the radiology department for mammography and ultrasound; b) participants consented to a complete structured telephone interview with a trained team of female quality managers 1 to 7 days after the examination; c) only participants with BI-RADS 1 or 2 were included. The reason was that participants from BI-RADS 3 onwards are subject to significant stress and the latter could influence the results of the study. Furthermore, their worry might limit their willingness to be interviewed. Exclusion criteria were the following: a) participants younger than 18 years of age; b) participants unwilling to speak to the quality mangers in a telephone interview; c) participants with BI-RADS 3 lesions or worse on ultrasound; d) participants not available for an interview during the mentioned period.

Study design

Prior to the examination, participants were asked if they were willing to participate in a telephone interview following their examination.

The initial mammography was performed in centers 1 and 2 on a Philips Mammomat Inspiration or a SenoClaire® digital breast tomosynthesis system of Siemens Healthcare. The mammography was evaluated immediately by the radiologist A.G, S.P.,I.F., M.D., and was followed by a standard ultrasound examination performed on a Voluson E8 machine, General Electric Healthcare, or a GE Logiq E9. The participants were not personally acquainted with the radiologists.

After application of the exclusion criteria (Fig 1), 172 participants were included in the study (72 at center 1 and 100 at center 2).

Center 1: Participants investigated exclusively by female radiologists

At this center the female participants were cared for exclusively by female radiologists and technicians. Each of the two female board-certified radiologists at this center I.F., M.D had 14 years of experience in specialized ultrasound investigations. The doctor-participant conversation was conducted by each radiologist without prior standardization or agreement. Mammography was performed by a female technician. The numbers of ultrasound examinations were divided equally between the two female radiologists. Participants were not free to choose a radiologist. Unknown to the participant, the time taken for the ultrasound investigation was measured with a stopwatch. The experimental setup is illustrated in Fig 2.

Fig 2 — In Center 1 the participants were cared for exclusively by female radiologists. The doctor- participant communication was done without prior standardization between radiologists. Patients had no choice with regards to which radiologist undertook their examination as part of the normal routine.

Center 2: Participants investigated exclusively by male radiologists

The ultrasound investigations were performed exclusively by male radiologists. The two male certified male radiologists A.G.,S.P. had 25 and 20 years of experience, respectively, in specialized breast ultrasound. Before starting the examination, the female participants were asked whether they were willing to be examined by male radiologists. No participant refused or asked for a female radiologist. The doctor-participant communication during the procedure was not standardized. The mammography was performed by a female technician. The numbers of ultrasound examinations were divided equally between the two male radiologists. Unknown to the participant, the time taken for the ultrasound investigation was measured with a stopwatch. The experimental setup is shown in Fig 3.

Fig 3 — In Center 2, female participants were managed exclusively by male radiologists. Before starting with ultrasound examination, participants were asked, if it was okay for them as female patients to be examined by a male radiologist. No woman refused to be examined by a male radiologist in our study, although there would have always been an alternate female radiologist available.

Telephone interview

At 1–7 days after the imaging examination, each participant received a telephone call. The interviews were conducted by three trained female interviewers from the quality management staff at the institution. A total of 5 questions were addressed to each patient and the responses recorded. The duration of the interview, and the duration of the interview relative to the imaging studies were documented. The questions and responses are summarized in Table 1.

Table 1. Summary of the telephone interviews.

	All patients (n = 172)	Center 1 Female Radiologists (n = 72)	Center 2 Male Radiologists (n = 100)	Fischers exact test for Center 1 versus Center 2
What is the sex of your gynecologist/ general physician? (male/female/other)	female: 112 (65.1%) male: 60 (34.9%) other: 0 (0%)	female: 53 (73.6%) male: 19 (26.4%) other; 0 (0%)	female: 59 (59%) male: 41 (41%) other: 0 (0%)	P = 0.053
Did you select a gynecologist or general physician because of his/her sex (man/woman) or could you also imagine being cared for by the opposite sex?	only female: 64 (37.2%) only male: 10 (5.8%) I do not care: 98 (57%)	only female: 32 (44.4%) only male: 8 (11.2%) I do not care: 32 (44.4%)	only female: 32 (32%) only male: 2 (2%) I do not care: 66 (66%)	P = 0.003
The mammography was performed by a female technician. What would you prefer in the future? (only female technician, only male technician, I don’t care)?	only female: 108 (62.8%) only male: 0 (0%) I do not care: 64 (37.2%)	only female: 50 (69.4%) only male: 0 (0%) I do not care: 22 (30.6%)	only female: 58 (58%) only male: 0 (0%) I do not care: 42 (42%)	p = 0.15
Who would you like to have as your attending radiologist in the future? (only female radiologist, only male radiologist, I don’t care)	only female: 43 (25%) only male: 2 (1.2%) I do not care: 127 (73.8%)	only female: 38 (52.8%) only male: 0 (0%) I do not care: 34 (47.2%)	only female: 5 (5%) only male: 2 (2%) I do not care: 93 (93%)	p<0.001
How important was the discussion with the radiologist? (1 = unimportant, 5 = very important)	5; (5.5)– 4.84 ± 0.48	5; (5.5)– 4.83 ± 0.5	5; (5.5)– 4.84 ± 0.47	P = 0.94

Open in a new tab

This table summarizes the interview questions and answers given. The results are divided into the following categories: all patients, Center 1 and Center 2.

The questions (Table 1) were developed by a board-certified senologist with a master’s degree in psychology and three years of experience in psychology and data management A.G.

Statistical analysis

Data distribution was checked visually by means of boxplots, histograms and barplots. To check for differences in categorical, polytomous data between the two centers, two-tailed Fisher’s exact tests were computed. To check for differences in continuous, ordinal data between the two centers, two-tailed Mann-Whitney-U-Tests were computed. P-values <0.05 were considered significant. All analyses were performed with the statistical software R (version 3.3.3) (R Core Team, 2017).

Results

Inclusion and exclusion criteria are shown in Fig 1.

After exclusion a total of 172 participants remained. 72 participants in center 1 (mean age: 61.3 ±11.9 years), 100 participants in center 2 (mean age 60.8 ± 10.4 years) remained.

The mean duration of the ultrasound examination and the discussion of its findings was 528.2 (9 minutes) ± 107.6 sec. (range: 240–960 sec.) The duration of discussion did not differ between center 1 and 2 (p > 0.05). The telephone interviews were conducted on average 377.5 ± 254.7 sec. (6 minutes.) (Range: 155–2100 sec.). The questions and responses are summarized in Table 1.

Women who undergo breast ultrasound do not care whether a female or a male radiologist performs the examination (female radiologist only 25%, male radiologist only 1.2%, does not matter 74%). However, the follow-up inquiry of women who were exclusively attended to by female radiologists at center 1 suggests that women would still prefer to be cared for by women (52% only female radiologist, 0% only male radiologist, 47% does not matter). On the other hand, at the follow-up inquiry of women who underwent breast ultrasound examinations performed exclusively by a team of male radiologists (center 2), the majority of the women had no specific preferences about the sex of radiologist at future visits and did not wish to be served exclusively by a female or a male radiologist in the future (female radiologist only 5%, male radiologist only 2%, does not matter 93%).

Our results showed that a minority of women would like to undergo breast examinations exclusively by a female or a male radiologist. Therefore, male radiologists routinely ask the patient whether she finds the setting acceptable. Considering the data reported from center 2 in our study (2% wished to see a male radiologist), it would be appropriate for a female radiologist to ask the patient the same question. The scenario is depicted in Fig 4 as a suggestion.

Fig 4 — In Center 2 a small proportion of patients indicated that they would like to be examined exclusively by a male radiologist. To respect the needs of all patients, female radiologists should also ask about patient’s preference concerning the sex of their radiologist.

Many participants said that they did not care about the doctor’s sex as long as he/she was friendly and competent. In both groups, the final discussion with the radiologist was extremely important to the women, regardless of whether the radiologist was male or female (p = 0.9).

The distribution of female and male gynecologists among the surveyed participants was relatively balanced. However, slightly more participants at center 1 preferred a female gynecologist, while the views were more balanced at center 2. At center 2, the participants were indifferent to the sex of the gynecologist. The impact of these data on radiological care cannot be evaluated at the present time.

At both centers, a clear majority preferred to undergo mammography by a female technician. It should be noted that, in Switzerland, this investigation has been the domain of female technicians for many years. Male technicians, despite their potential interests or skills, in most cases are not permitted to perform this investigation.

Discussion

Women undergoing an ultrasound investigation of the breast do not have a specific preference for a male or female radiologist. Overall, 73% percent of women did not care whether the radiologist is female or male. Additionally at center 2, which was manned exclusively by male radiologists, the majority of the participants at this center did not care about the sex of the radiologist in future investigations (93%, p< 0.05).

Patients who undergo an investigation of the breast are almost exclusively women, but occasionally also men. To our knowledge, no previous study has addressed the sex-specific needs of women undergoing radiological or ultrasound investigations of the breast. A few studies in gynecology have addressed this topic. Although we lack robust data, it is widely assumed that female patients reject male physicians. It has been reported that up to 93% of women wish to be treated by a female physician and reject the notion of a male physician [8, 9, 12–14]. However, this notion was not confirmed in the present study. At our center 2 about 66% of the women were indifferent to the sex of the gynecologist. In other words, the above-mentioned studies may not reflect the preferences of our study cohort. Notably, many of the cited study groups examined women from not Western countries and the authors were largely women. While the authors have no intention of expressing a cultural or sex-specific bias, it should be noted that a society focused on the exclusive care of women by women may influence the future expectations of patients. This was also observed at our center 1, where only women were available to perform the examination. By contrast, the women at center 2, which was examined by male radiologists, had more diverse opinions. By contrast, the women at center 2, which was serviced by male radiologists, had more diverse opinions concerning the sex of their attending radiologist.

An important reason to have male radiologists in ultrasound teams is that male patients are also investigated in radiology departments; this is due to the increasing incidence of male breast cancer throughout the world [15–18]. Furthermore, increasing numbers of transsexual women with hormonal stimulation are likely to develop breast cancer [19–21]. The prevalence of gynecomastia among men is also high, and these men have to undergo ultrasound investigations [22]. For this reason, a breast cancer screening program for men and transgender women is already being discussed. Given the fact that mixed patients cohorts are examined by specialized ultrasound teams, it would be appropriate to have male doctors in radiology teams. This is consistent with the need for health care systems worldwide to address sex-related inequalities and restrictive sexual norms in the medical profession. The phenomenon affects female and male doctors to the same degree [23].

Based on the presented data, we assume that the discussion about the radiologist’s sex is not of that great importance to female patients. According to the feedback from our patients at both centers, the competence expressed by the radiologist is much more important than his/her sex. Few male radiologists are interested in breast ultrasound. This might be due to the notion that female patients do not give preference to male doctors. However, the data obtained in the present investigation show that male specialists are quite welcome.

The present investigation permits no conclusive statement as to whether these data will have an impact on women’s preferences for a female or male gynecologist, or whether they will have no preferences in this regard. In fact, while 37% of patients wish to be cared for by a female gynecologist, only 6% wished for a male gynecologist. But the majority of women appear to be indifferent to the sex of the gynecologist (57%). With regard to radiographers, the majority (63%) of women at both centers would like to be examined by a female technician. Again, the body of robust data in this regard is sparse. However, the few published data are similar to ours. In one study, 46% of women said they would be uncomfortable if a man performed the mammography [24]. However, in a large Australian study, male radiographers were used to perform mammography when there was a shortage of radiographers, and the majority of female patients had no problems with a male radiographer [25]. As with radiologists in center 2, the acceptance level of female patients increases when they come into contact with mixed, competent teams and have good experiences.

The limitations of this study are, that the investigation was limited to two centers. We assume that the results significantly depend on the social structure. Therefore, it would be appropriate to perform further surveys in other countries and determine the respective regional needs of female patients. Additionally, patients at centers 1 and 2 were only cared for by two radiologists each, who were highly experienced. More radiologists with different degrees of training should be included in future investigations.

Conclusion

We believe that the notion of female patients giving preference to female radiologists for their breast ultrasound examination is incorrect and does not take the actual needs of female patients into account. The majority of female patients were indifferent to the sex of the radiologist and were much more willing to accept the doctor’s sex when they were examined by mixed teams. Female patients are much more willing to accept the doctor’s sex when they are examined by mixed teams. We advocate mutual tolerance and efforts to train more male specialists in this fascinating and increasingly important subspecialty of radiology. From the patient’s point of view, a competent radiologist is most welcome regardless of his/her sex.

Supporting information

S1 Checklist. PLOS ONE clinical studies checklist.

(DOCX)

Click here for additional data file.^{(36.3KB, docx)}

Abbreviation

BI- RADS: Breast Imaging Reporting and Data System

Data Availability

All relevant data are within the manuscript and its Supporting Information files.

Funding Statement

The authors received no specific funding for this work.

References

1.Expert Panel on Breast Imaging:, Mainiero MB, Moy L, Baron P, Didwania AD, diFlorio RM, et al. ACR Appropriateness Criteria® Breast Cancer Screening. J Am Coll Radiol. 2017. Nov;14(11S):S383–S390 [DOI] [PubMed] [Google Scholar]
2.Niell BL, Freer PE, Weinfurtner RJ, Arleo EK, Drukteinis JS. Screening for Breast Cancer. Radiol Clin North Am. 2017. Nov;55(6):1145–1162 doi: 10.1016/j.rcl.2017.06.004 [DOI] [PubMed] [Google Scholar]
3.Shashar R, Amiel GE. Is It Time for a "Me-Too" Movement Against Attitudes Towards Women Suffering from Nongynecological Malignancies? J Cancer Educ. 2021. Oct;36(5):897–898 doi: 10.1007/s13187-021-02092-1 [DOI] [PubMed] [Google Scholar]
4.Aguillard K, Gemeinhardt G, McCurdy S, Schick V, Hughes R. "Helping Somebody Else Has Helped Me Too": Resilience in Rural Women With Disabilities With Experiences of Interpersonal Violence. J Interpers Violence. 2021. doi: 10.1177/08862605211016356 [DOI] [PubMed] [Google Scholar]
5.Nguyen BT, Streeter LH, Reddy RA, Douglas CR. Gender bias in the medical education of obstetrician-gynaecologists in the United States: A systematic review. Aust N Z J Obstet Gynaecol. 2022 [DOI] [PubMed] [Google Scholar]
6.Baggio Giovannella, Corsini Alberto, Floreani Annarosa, Giannini Sandro and Zagonel Vittorina. "Gender medicine: a task for the third millennium" Clinical Chemistry and Laboratory Medicine (CCLM), vol. 51, no. 4, 2013, pp. 713–727. [DOI] [PubMed] [Google Scholar]
7.Zuckerman M, Navizedeh N, Feldman J, McCalla S, Minkoff H. Determinants of women’s choice of obstetrician/gynecologist. J Womens Health Gend Based Med. 2002. Mar;11(2):175–80 doi: 10.1089/152460902753645317 [DOI] [PubMed] [Google Scholar]
8.Rizk DE, El-Zubeir MA, Al-Dhaheri AM, Al-Mansouri FR, Al-Jenaibi HS. Determinants of women’s choice of their obstetrician and gynecologist provider in the UAE. Acta Obstet Gynecol Scand. 2005. Jan;84(1):48–53. doi: 10.1111/j.0001-6349.2005.00705.x [DOI] [PubMed] [Google Scholar]
9.Piper I, Shvarts S, Lurie S. Women’s preferences for their gynecologist or obstetrician. Patient Educ Couns. 2008. Jul;72(1):109–14. doi: 10.1016/j.pec.2008.02.004 [DOI] [PubMed] [Google Scholar]
10.Male Doctors are disappearing from gynecology. Not everybody is thrilled about it. Los Angelos Times. https://www.latimes.com/health/la-me-male-gynos-20180307-htmlstory.html, 24.05.2022
11.Official request to the European Society of Radiology (ESR) as of April 2022. [Google Scholar]
12.Alsafar FA, Tehsin F, Alsaffar KM, Albukhaytan WA. Physicians’ Gender Influence on the Patients’ Choice of Their Treating Obstetrician-Gynecologist in the Eastern Province of Saudi Arabia. Cureus. 2022. Mar 24;14(3):e23457. doi: 10.7759/cureus.23457 [DOI] [PMC free article] [PubMed] [Google Scholar]
13.Subki AH, Agabawi AK, Hindi MM, Butt NS, Alsallum MS, Alghamdi RA, et al. How Relevant is Obstetrician and Gynecologist Gender to Women in Saudi Arabia? Int J Womens Health. 2021. Oct 11;13:919–927. doi: 10.2147/IJWH.S284321 [DOI] [PMC free article] [PubMed] [Google Scholar]
14.Amir H, Abokaf H, Levy YA, Azem F, Sheiner E. Bedouin Women’s Gender Preferences When Choosing Obstetricians and Gynecologists. J Immigr Minor Health. 2018. Feb;20(1):51–58. doi: 10.1007/s10903-016-0522-z [DOI] [PubMed] [Google Scholar]
15.Ruddy KJ, Winer EP. Male breast cancer: risk factors, biology, diagnosis, treatment, and survivorship. Ann Oncol. 2013. Jun;24(6):1434–43 doi: 10.1093/annonc/mdt025 [DOI] [PubMed] [Google Scholar]
16.Abdelwahab Yousef AJ. Male Breast Cancer: Epidemiology and Risk Factors. Semin Oncol. 2017. Aug;44(4):267–272. doi: 10.1053/j.seminoncol.2017.11.002 [DOI] [PubMed] [Google Scholar]
17.Nofal MN, Yousef AJ. The diagnosis of male breast cancer. Neth J Med. 2019. Dec;77(10):356–359. [PubMed] [Google Scholar]
18.Benassai G, Miletti A, Calemma F, Furino E, De Palma GD, Quarto G. Male breast cancer: an update. Ann Ital Chir. 2020;91:359–365 [PubMed] [Google Scholar]
19.Chesebro AL, Rives AF, Shaffer K. Male Breast Disease: What the Radiologist Needs to Know. Curr Probl Diagn Radiol. 2019. Sep-Oct;48(5):482–493 doi: 10.1067/j.cpradiol.2018.07.003 [DOI] [PubMed] [Google Scholar]
20.Parikh U, Mausner E, Chhor CM, Gao Y, Karrington I, Heller SL. Breast Imaging in Transgender Patients: What the Radiologist Should Know. Radiographics. 2020. Jan-Feb;40(1):13–27. doi: 10.1148/rg.2020190044 [DOI] [PubMed] [Google Scholar]
21.Matoori S, Donners R, Garcia Nuñez D, Nguyen-Duong S, Riopel C, Baumgartner M, et al. Transgender health and medicine—Are radiological devices prepared? Eur J Radiol. 2022. Jun;151:110320. doi: 10.1016/j.ejrad.2022.110320 [DOI] [PubMed] [Google Scholar]
22.Fagerlund A, Lewin R, Rufolo G, Elander A, Santanelli di Pompeo F, Selvaggi G. Gynecomastia: A systematic review. J Plast Surg Hand Surg. 2015;49(6):311–8. doi: 10.3109/2000656X.2015.1053398 [DOI] [PubMed] [Google Scholar]
23.Hay K, McDougal L, Percival V, Henry S, Klugman J, Wurie H, et al. Disrupting gender norms in health systems: making the case for change. Lancet. 2019. Jun 22;393(10190):2535–2549. doi: 10.1016/S0140-6736(19)30648-8 [DOI] [PMC free article] [PubMed] [Google Scholar]
24.Fitzpatrick P, Winston A, Mooney T. Radiographer gender and breast-screening uptake. Br J Cancer. 2008. Jun 3;98(11):1759–61 doi: 10.1038/sj.bjc.6604385 [DOI] [PMC free article] [PubMed] [Google Scholar]
25.Warren-Forward HM, Mackie B, Alchin M, Mooney T, Fitzpatrick P. Perceptions of Australian clients towards male radiographers working in breast imaging: Quantitative results from a pilot study. Radiography (Lond). 2017. Feb;23(1):3–8. doi: 10.1016/j.radi.2016.05.006 [DOI] [PubMed] [Google Scholar]

PLoS One. doi: 10.1371/journal.pone.0291007.r001

Decision Letter 0

Aloysius Gonzaga Mubuuke

29 Jun 2023

PONE-D-23-14827Understanding the needs of women undergoing breast ultrasound: Are male radiologists still needed?PLOS ONE

Dear Dr. Gutzeit,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Aug 13 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Aloysius Gonzaga Mubuuke

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. Thank you for stating the following financial disclosure:

"We have no fundings to declare. "

At this time, please address the following queries:

a) Please clarify the sources of funding (financial or material support) for your study. List the grants or organizations that supported your study, including funding received from your institution.

b) State what role the funders took in the study. If the funders had no role in your study, please state: “The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.”

c) If any authors received a salary from any of your funders, please state which authors and which funders.

d) If you did not receive any funding for this study, please state: “The authors received no specific funding for this work.”

Please include your amended statements within your cover letter; we will change the online submission form on your behalf.

3. Thank you for stating the following in your Competing Interests section:

"No authors have competing interests. "

Please complete your Competing Interests on the online submission form to state any Competing Interests. If you have no competing interests, please state "The authors have declared that no competing interests exist.", as detailed online in our guide for authors at http://journals.plos.org/plosone/s/submit-now

This information should be included in your cover letter; we will change the online submission form on your behalf.

4. We note that you have stated that you will provide repository information for your data at acceptance. Should your manuscript be accepted for publication, we will hold it until you provide the relevant accession numbers or DOIs necessary to access your data. If you wish to make changes to your Data Availability statement, please describe these changes in your cover letter and we will update your Data Availability statement to reflect the information you provide.

5. Please amend the manuscript submission data (via Edit Submission) to include author Dr. Froehlich John M.

6. We note that Figures 2,3 and 4 in your submission contain copyrighted images. All PLOS content is published under the Creative Commons Attribution License (CC BY 4.0), which means that the manuscript, images, and Supporting Information files will be freely available online, and any third party is permitted to access, download, copy, distribute, and use these materials in any way, even commercially, with proper attribution. For more information, see our copyright guidelines: http://journals.plos.org/plosone/s/licenses-and-copyright.

We require you to either (1) present written permission from the copyright holder to publish these figures specifically under the CC BY 4.0 license, or (2) remove the figures from your submission:

a. You may seek permission from the original copyright holder of Figures 2,3 and 4 to publish the content specifically under the CC BY 4.0 license.

We recommend that you contact the original copyright holder with the Content Permission Form (http://journals.plos.org/plosone/s/file?id=7c09/content-permission-form.pdf) and the following text:

“I request permission for the open-access journal PLOS ONE to publish XXX under the Creative Commons Attribution License (CCAL) CC BY 4.0 (http://creativecommons.org/licenses/by/4.0/). Please be aware that this license allows unrestricted use and distribution, even commercially, by third parties. Please reply and provide explicit written permission to publish XXX under a CC BY license and complete the attached form.”

Please upload the completed Content Permission Form or other proof of granted permissions as an "Other" file with your submission.

In the figure caption of the copyrighted figure, please include the following text: “Reprinted from [ref] under a CC BY license, with permission from [name of publisher], original copyright [original copyright year].”

b. If you are unable to obtain permission from the original copyright holder to publish these figures under the CC BY 4.0 license or if the copyright holder’s requirements are incompatible with the CC BY 4.0 license, please either i) remove the figure or ii) supply a replacement figure that complies with the CC BY 4.0 license. Please check copyright information on all replacement figures and update the figure caption with source information. If applicable, please specify in the figure caption text when a figure is similar but not identical to the original image and is therefore for illustrative purposes only.

7. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments:

The reviewers have provided useful comments to improve the paper. In addition to these, please explain clearly the statistical methods that were used to the reader.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: I Don't Know

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thanks for this interesting study on understanding the needs of women undergoing breast ultrasound. The study included consecutive participants referred to the radiology department for mammography and ultrasound at two certified breast imaging centers performing approximately 5000 and 9000 breast examinations each year between August 2021 and May 2022. Were there any male participants or transsexual women seen?

The authors blinded the country where this study was done but it would be good to provide data on how many males/ transsexual women are referred for breast imaging to provide context for this study and the recommendations made. Especially since the authors advocate for efforts to train more male specialists in this field (lines 343 and 344).

The authors state that after application of the exclusion criteria (Figure 1), 172 participants were included, however, the quoted figure 1 shows 174 participants were included.

The statistical analysis section of the write up is not very informative. More detail on exactly how data was handled would be helpful.

It seems as though the women prefer a female physician where the option is available. For example; majority of the women in both centers 1 (69.4%) and 2 (58%) preferred a female technician to do their mammogram arguably because a female technician was available. Although a small percentage 30.6% in center 1 and 42% in center did not care about the sex of the practitioner, no woman opted for a male technician.

Majority of the women (52.8%) in center 1 where female radiologists were available still preferred only female compared to only 2% who preferred male in center 2 where the male radiologists were available.

Perhaps the women 'don't care' simply because they know their preferred option may not be available.

Please provide reference for this statement "Based on the published literature, we assume that the discussion about the radiologist’s sex is entirely irrelevant to female patients" in lines 311 and 312. As well as this "Few male radiologists are interested in breast ultrasound" (line 314).

Repetition in lines 296- 298.

Reviewer #2: I am pleased to recommend accepting the submitted article for publication. The study presents the results of original research, providing valuable insights into the topic. The findings reported in this study have not been published elsewhere, which adds to the existing body of knowledge. My only concern is the large number of authors, I would like to know what their contributions were.

The experiments, statistics, and other analyses conducted in this research are of good technical standard. The authors have described these methods with sufficient detail, allowing for reproducibility and understanding of the study design. The data presented in the article support the conclusions drawn by the authors in an appropriate and logical manner.

One notable strength of this article is its clear and intelligible presentation. The authors have effectively communicated their research in standard English, making it accessible to a wide range of readers. The article also adheres to the ethical standards of experimentation and research integrity, demonstrating the authors' commitment to conducting their study in an ethically responsible manner.

In summary, this article fulfills the essential criteria for acceptance. It presents original research with good findings, good technical standards, appropriate conclusions supported by data, clear and accessible language, adherence to ethical standards, and compliance with reporting guidelines. Therefore, I recommend accepting this article for publication.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: Yes: Elsie Kiguli-Malwadde

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Attachment

Submitted filename: Review notes.docx

Click here for additional data file.^{(11.9KB, docx)}

PLoS One. 2023 Nov 8;18(11):e0291007. doi: 10.1371/journal.pone.0291007.r002

Author response to Decision Letter 0

27 Jul 2023

Dear ladies and gentlemen

We gave detailed comments in the section: "answer to the editor".

Thank you very much.