VA Mini Residencies Advance Clinical Breast Exam Skills

The Journal of Women's Health published a landmark report on the 10 year mini-residency training program provided to thousands of VA Primary Care Providers (PCPs). MammaCare provided the hands-on Clinical Breast Exam CBE Simulator-Trainer  for the VA mini-residency program. The PCPs retained and used the performance skills acquired at the mini-residences reporting significantly greater comfort/confidence levels in performing clinical breast exams.

Improving Public Health

The MammaCare CBE Simulator-Trainer was developed and validated with the support of the National Science Foundation and was adopted for clinical training in the Woman Veterans Health Program as well as in CDC's sponsored National Breast and Cervical Early Detection and Prevention Programs (NBCCEDP).  The skill-based technology has begun training advanced clinicial students in U.S. colleges of nursing and medicine to advance clinical breast exam skills. 

Mini-Residencies Improve Care for Women Veterans: A Decade of Re-Educating Veterans HealthAdministration Primary Care Providers

Linda Baier Manwell, MS, Melissa McNeil, MD, MPH, Megan R. Gerber, MD, MPH, Samina Iqbal, MD, Sarina Schrager, MD, MS, Catherine Staropoli, MD, Roger Brown, PhD, Laure Veet, MD, Sally Haskell, MD, MS, Patricia Hayes, PhD, and Molly Carnes, MD, MS

Background: Many primary care providers (PCPs) in the Veterans Health Administration need updated clinical training in women’s health. The objective was to design, implement, and evaluate a training program to increase participants’ comfort with and provision of care to women Veterans, and foster practice changes in women’s health care at their local institutions. 

Methods: The Women’s Health Mini-Residency was developed as a multi-day training program, based on principles of adult learning, wherein knowledge gleaned through didactic presentations was solidified during small-group case study discussions and further enhanced by hands-on training and creation of a facility-specific action plan to improve women Veterans’ care. Pre, post, and 6-month surveys assessed attendees’ comfort with and provision of care to women. The 6-month survey also queried changes in practice, promulgation of program content, and action plan progress 

Results: From 2008 to 2019, 2912 PCPs attended 26 programs. A total of 2423 (83.2%) completed pretraining and 2324 (79.3%) completed post-training surveys. The 6-month survey was sent to the 645 attendees from the first 14 programs; 297 (46.1%) responded. Comparison of pre-post responses indicated significant gains in comfort managing all 19 content areas. Six-month data showed some degradation, but comfort remained significantly improved from baseline. At 6 months, participants also reported increases in providing care to women, including performing more breast and pelvic examinations, dissemination of program content to colleagues, and progress on action plans

Keywords: Veterans health; clinical competence; continuing; curriculum; education; primary health care; women's health.

Global Breast Cancer: The Way Forward

Global Epidemic - Late-Stage Breast Cancer Morbidity and Mortality: Breast cancer is the most frequent, and fatal malignancy in women, worldwide.1 In 2020 alone, 2.3 million women were newly diagnosed, and 685,000 died from breast cancer. Moreover, 7.8 million women live with breast cancer, making it the most prevalent of all cancers according to the world health organization's Global Cancer Observatory (GCO).2 Breast cancer also exceeds all cancers in lost disability-adjusted life years (DALYs) with nearly 20 million years of health lost.3 While the unmet need appears daunting, evidence confirms that early detection programs can markedly downstage the disease for a majority of women, significantly extending their lives and health.20, 21 

Global Breast Exam Competencies: The earliest and most frequent symptom of breast cancer is a lump detected by hand, often at a later stage than necessary due to unskilled performance of the exam.4, 5, 6 Laboratory studies of breast exam accuracy and competencies were conducted beginning in 1980 with the support of the National Cancer Institute (NCI).7, 8, 9, 10, 11, 12, 13 Subsequent research advanced the methods and standards for training and practice with accurately simulated breast models containing subcentimeter lesions engineered to mimic the tactile properties and variations of breasts. Guided palpation on the breast models enabled women and their providers to acquire uniform tactile skills for reliable detection and reporting of small, pea sized suspicious lesions (0.3cm-0.5cm) while reducing false positives and false negatives.14, 15, 16, 17, 18

Global Technology Transforms Touch: Training technology developed with the support of the US National Science Foundation (NSF) led to a computer-guided, self-administered system that directly measures and calibrates the hands of users (trainees) who learn and practice essential tactile skills. The trainer generates a real-time, online digital profile that quantifies performance and validates progress. The system is now training hands throught US and international academic and clinicial instutions to perform competent and thorough breast exams. Trainees’ performance and achievement levels are quantified and automatically reported to instructors and clinical supervisors.

Table 1. presents data analytics from > 5000 students and clinicians.

Global Approach - Literally in Our Hands: A Nobel Prize was awarded this year for recognizing the extraordinary sensitivity and accuracy of human touch receptors.19   The collective evidence now indicates that human biology and technology are now ready to assist in the early detection of breast cancer. The approach for downstaging breast cancer globally is literally in our hands: We know that a small palpable breast lump is the earliest sign of breast cancer, and that early detection and treatment can provide a normal lifespan for millions of women, and finally, we have a proven technology to uniformly train and verify essential skills in hands, everywhere across the connected globe. This powerful yet simple universal training and monitoring technology can provide the essential tactile breast exam skills for millions of women and their caregivers at little cost to bring down the massive global burden of advanced breast cancer.22

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    1. Harbeck, N., Penault-Llorca, F., Cortes, J. et al. Breast cancer. Nat Rev Dis Primers 5, 66 (2019).
    2. Sung, Hyuna, et al. "Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries." CA: a cancer journal for clinicians 71.3 (2021): 209-249.
    3. Ji, Peng, et al. "The burden and trends of breast cancer from 1990 to 2017 at the global, regional, and national levels: results from the global burden of disease study 2017." Frontiers in oncology 10 (2020): 650.
    4. Koo, Minjoung Monica, et al. "Presenting symptoms of cancer and stage at diagnosis: evidence from a cross-sectional, population-based study." The Lancet Oncology 21.1 (2020): 73-79.
    5. Larsen, Marthe, et al. "Self-reported symptoms among participants in a population-based screening program." The Breast 54 (2020): 56-61.
    6. McDonald, Sharon, Debbie Saslow, and Marianne H. Alciati. "Performance and reporting of clinical breast examination: a review of the literature." CA: a cancer journal for clinicians 54.6 (2004): 345-361.
    7. Hall, Deborah C., et al. "Improved detection of human breast lesions following experimental training." Cancer 46.2 (1980): 408-414. 
    8. Stefanek, Michael E., Patti Wilcox, and Anne Marie Huelskamp. "Breast self-examination proficiency and training effects: women at increased risk of breast cancer." Cancer Epidemiology and Prevention Biomarkers 1.7 (1992): 591-596.
    9. Sauter, Edward R., and Mary B. Daly, eds. Breast cancer risk reduction and early detection. Springer Science & Business Media, 2010.
    10. BLOOM, HS, EL CRISWELL, and HS PENNYPACKER. "Major stimulus dimensions determining detection of simulated breast lesions."
    11. Pinto, Bernardine M. "Training and maintenance of breast self-examination skills." American journal of preventive medicine 9.6 (1993): 353-358.
    12. Adams, C. K., Hall, D. C., Pennypacker, H. S., Goldstein, M. K., Hench, L. L., Madden, M. C., ... & Catania, A. C. (1976). Lump detection in simulated human breasts. Perception & Psychophysics, 20(3), 163-167.
    13. Fletcher, Suzanne W., et al. "How best to teach women breast self-examination: A randomized controlled trial." Annals of Internal Medicine 112.10 (1990): 772-779.
    14. Barton, Mary B., Russell Harris, and Suzanne W. Fletcher. "Does this patient have breast cancer?: The screening clinical breast examination: should it be done? How?." Jama 282.13 (1999): 1270-1280.
    15. Vetto, John T., et al. "Structured clinical breast examination (CBE) training results in objective improvement in CBE skills." Journal of Cancer Education 17.3 (2002): 124-127.
    16. Saslow, Debbie, et al. "Clinical breast examination: practical recommendations for optimizing performance and reporting." CA: a cancer journal for clinicians 54.6 (2004): 327-344.
    17. Jacob, Teresa C., et al. "A comparison of breast self-examination and clinical examination." Journal of the National Medical Association   86.1 (1994): 40.
    18. 18. Benincasa, Theresa A., et al. "Results of an office‐based training program in clinical breast examination for primary care physicians." Journal of Cancer Education1 (1996): 25-31.
    20. Duggan, Catherine, et al. "National health system characteristics, breast cancer stage at diagnosis, and breast cancer mortality: a population-based analysis." The Lancet Oncology 22.11 (2021): 1632-1642.
    21. Bain, Carolyn, et al. "Model for early detection of breast cancer in low-resource areas: the experience in Peru." Journal of global oncology   (2018): 1-7.
    22.  pe=2&statistic=5&prevalence=1&population_group=0&ages_group%5B%5D=0&ages_group%5B%5D=17&group_cancer=1&include_ 

Breast Self-Exams Work – Find Breast Cancer Missed on Mammograms Women Report

Women self-detect breast cancer with their hands, cancer that was missed by mammograms according to women and research. At first this may seem to contradict  or even disrupt traditional practices, but biological and clinical evidence supports the women. Hundreds of touch receptors in our fingers comprise an exquisitely sensitive network that improves with practice by establishing new neural pathways (tactile maps) that recognize complex textures as well as the presence of unusual changes within them.  By applying this knowledge to the detection of small breast tumors, MammaCare scientists, with the support  of the National Cancer Institute and National Science Foundation, began the  process of training  every hand that examines a woman, including her own.

I actually found the lump a year earlier while doing a self-breast exam but was told two separate times it was only a cyst. So imagine my surprise when I met with a plastic surgeon at Johns Hopkins in Baltimore for a consult to remove the “cyst” only to be told later it was cancer. -WUSA9 ...Like many young breast cancer patients, Sliwerski was blindsided by her diagnosis. She was just 33, the first-time mother of a 3-month-old, Penelope, when she noticed a lump in her left breast. A month later, she learned she had invasive breast cancer. - Chicago Tribune Harris said early detection of breast cancer is key. She is a fitness enthusiast and was familiar with her body when she noticed a lump that turned out to be cancerous. - MRT Knight had recently been screened but noticed a painful lump during a self-breast exam in early February. She put off seeing the doctors for a couple of weeks, expecting it to be benign like the others she had found….Knight urges everyone, especially those with family history, to seek regular screenings, conduct breast exams and act quickly when something doesn't feel right. - Lancaster Reagle Gazette As Amber Pritchett was doing a breast self-examination in early spring, she found a lump…The 33-year-old human resources employee at Mercer University didn’t think much of it since no one in her family had breast cancer...“It’s probably nothing to worry about. Probably just dense breast tissue,” the doctor told her….Her malignant tumor was four to five centimeters, or nearly two inches in diameter, when she was diagnosed Aug. 28. - Miami Herald Findings published in the Journal of Women’s Health: “Despite increased use of screening mammography, a large percentage of breast cancers are detected by the patients themselves. Patient-noted breast abnormalities should be carefully evaluated. - NCBI I had a mammogram seven months before I found the lump, and it was all clear,” the Seneca Falls resident remembered. “I was getting ready for a trip to Honduras. I brushed (the lump) off. It wasn’t painful, so I went on the vacation. - Fit Times Although Stewart was only 35 and had no family history of breast cancer, the conversation with her daughter encouraged her to do a self-exam. The lump she found in her left breast was cancerous." - The Pilot Turns out she was thirty-seven when she first felt the lump in her breast. She made an appointment with her local doctor, who passed it off as nothing, and continued to say it was nothing for two years—even though it kept getting bigger. - New Yorker The speaker at Monday’s Breast Cancer Awareness Ceremony urged others to regularly do self-breast exams. In Vicki Mathess’ case, her self exam – done in between her yearly mammograms – led to her diagnosis of stage two breast cancer. “I had a mammogram two months before and the mammogram was negative,” she said. “In two months, through a self exam, I discovered a lump. - The Record Delta I actually found the lump a year earlier while doing a self-breast exam but was told two separate times it was only a cyst. So imagine my surprise when I met with a plastic surgeon at Johns Hopkins in Baltimore for a consult to remove the “cyst” only to be told later it was cancer. - WUSA9 I had found a mass in my right breast due to my favorite bra didn't fit. I hand wash all of my bras so I know it wasn't cause my bra had shrunken. By doing a self-exam I found a golf size lump in my breast, said Edwards - KGUN9 Three weeks ago, I was diagnosed with breast cancer. I could only feel the lump whilst lying down and it completely disappeared [when I was] standing up. - Self