"This recommendation represents national recognition that our program is on the forefront of medical education and early detection," said Donald Austin, M.D., director of the BHEP, associate director for cancer control and prevention in the OHSU Cancer Institute, and professor of public health and preventive medicine in the OHSU School of Medicine.
A committee of nationally recognized experts convened by the American Cancer Society in collaboration with the U.S. Centers for Disease Control and Prevention offers this and other recommendations in a report published in the November/December 2004 issue of CA: A Cancer Journal for Clinicians. The recommendations could help standardize the practice of clinical breast exam and lead to better evidence to show the effectiveness of clinical breast exam in the early detection of breast cancer.
"It is not possible to find breast cancer at its earliest stages the way most clinicians perform clinical breast exams," said Elizabeth Steiner, M.D., associate director of the BHEP and research assistant professor of family medicine in the OHSU School of Medicine. "Breast cancer remains the most common cancer among American women and is the second leading cause of cancer deaths in women, yet most physicians report they have received little if any instruction on how to conduct a complete breast exam."
Clinical breast examination, or CBE, is an examination of the breasts by a health care professional to find palpable cancers early, when there are more treatment options and there may be a better chance for survival. Various methods of CBE are practiced widely. A 2003 study showed 90 percent of women 40 or older had received a CBE at some time, with about 75 percent having received one in the previous year.
The OHSU program was founded to provide medical students, residents and practicing clinicians throughout Oregon with standardized CBE training that improves their ability to detect palpable cancer at its earliest stages. It is a collaboration involving many units of the School of Medicine, including the OHSU Cancer Institute, the Department of Public Health and Preventive Medicine, and the Department of Family Medicine in the OHSU School of Medicine. The CDC awarded $250,000 to Austin in 2003 to support CBE training for medical students through the program.
The comprehensive training program stems from evidence-based research that reveals breast exams should include proper positioning of the patient, methodical thoroughness, a vertical-strip pattern as opposed to a circular or wedge technique, correct finger movements, three levels of pressure, and a comprehensive area of coverage. The founders of MammaCare, a nationally recognized resource for breast exam training, conducted a significant amount of this research. In October 2003, the OHSU Cancer Institute opened the only MammaCare training center west of the Mississippi River. Health professionals travel to the center from around the country to learn how to train others in this breast exam technique.
The OHSU Cancer Institute provides the only comprehensive program teaching the standardized CBE not only to medical students, residents and practicing clinicians, but also to professionals who will bring this technique to a wider audience within their own communities. Part of the Institute's program includes the integration of live training models, women who are trained to provide feedback about pressure and technique to health care providers as they learn the exam method.
"Feedback from live models is important because some providers worry they will hurt women and won't apply enough pressure to detect abnormalities in deeper tissue," said Steiner, who is helping several academic health centers across the nation replicate the OHSU program. "Teaching medical students and residents before they go into practice offers a more productive way to ensure all new clinicians learn a standard method of breast exam."
In its report, the committee also recommends standardizing the interpretation and reporting of CBE findings to improve accuracy and consistency. A lack of standard reporting, terms and formats for documentation could prove to be impediments to maximizing the benefits of clinical breast exams, according to the authors. "Thus, even if CBE were performed uniformly to its highest potential sensitivity and specificity, differences in interpretation and how findings are reported limit the potential benefits of this exam to guide further evaluation and lead to the earlier treatment of breast cancer," report authors noted.
"Uniform interpretation and reporting also are important components in evaluating the effectiveness of CBE in detecting early-stage breast cancer," said Nancy Prouser, M.S., BHEP manager. "For this reason, our programs also teach standardized documentation of all breast findings, along with evidence-based clinical decision making for management of these findings."
With the support of the OHSU Medical Research Foundation, Austin has created a pilot study to examine outcome data from the BHEP training program. "We know our method results in practitioners finding more lumps on breast models than practitioners trained through standard methods," Prouser said. "Now we are studying whether it helps clinicians diagnose breast cancer earlier."
The committee also makes recommendations on exam follow-up, public education, and research and quality improvement. Visit http://CAonline.
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