The Breast Health Initiative: Standardizing Breast Cancer Screening at Planned Parenthood Affiliates Courtney Benedict, CNM, MSN Manager, Medical Standards Implementation, PPFA

The Breast Health Initiative Provide direct funding for diagnostic breast services for uninsured and provide public health education Develop breast cancer risk assessment tool for use in young women Standardize breast cancer screening practices nationwide among Planned Parenthood affiliates a) National training program b) Evaluate clinician knowledge and practices c) Evaluate curriculum components As you well know, family planning providers have the opportunity to address breast cancer screening with our clients.  In fact, we may serve as a woman’s PCP or only provider that she sees.  Therefore, it is vital for family planning providers to be very familiar and comfortable with discussing breast cancer screening with clients.  Unfortunately, there is a lot of confusion both from providers and clients about what components of breast cancer screening they should undergo, if and when to start it, and how often they should be screened.  In 2012, PPFA set out to provide a comprehensive breast health initiative that was multi-faceted. The bulk of project’s money went towards providing direct funding for diagnostic services. While the other two parts of the initiative focused on how we could standardize breast cancer screening practices and how best to screen our young, relatively healthy patient population for increased breast cancer risk.  Screening our clients for risk had been an issue since a lot of the tools available did not apply to young women. So with the help of Dr. Mark Pearlman, we designed a risk assessment tool (a quick triage questionnaire) that allows us to screen women and refer those to genetic counselors who are identified at potentially increased risk. Finally, the most robust portion of the initiative was the standardized training for health center clinicians across the country that we designed and implemented. Our goals of the training program were to reach as many of our roughly 1700 clinicians as possible and strengthen the knowledge and skills related to breast cancer screening practices. So I would like to talk to you about both of these components today – the risk screening questionnaire that we designed, as well as the training program and the results of the training program and the lessons learned from the project. So first – I would like to show you the risk screening tool we developed…

The Breast Risk Screening Questionnaire (BRSQ) The Breast Risk Screening Questionnaire or BRSQ as we affectionately call it was designed for either clients or clinicians to complete. Some health centers complete the BRSQ on paper and scan into the EHR record, while others have built this tool directly into the EHR and answer it within the EHR. This is done at an initial well woman visit or breast problem visit and then repeated as necessary anytime her or her family’s history changes. The questions found in this tool are adapted from the NCCN’s genetic/familial high-risk assessment for breast and ovarian cancer guidelines. But we re-packaged the information down to three simple questionnaires. The first one is listed here – a simple two question assessment (do you have a history of breast or ovarian cancer and does anyone in your family have a history of breast or ovarian cancer). If the answer to both of these is “no” you are done and we recommend average risk screening for these clients. If she answers yes to either of these questions – you move onto one or both of the other two questionnaires…

The Breast Risk Screening Questionnaire (BRSQ) If she answers yes to the first question (do you have personal history of breast or ovarian cancer), then you complete the follow-up questionnaire that we call BRSQ 2a. If the answer to any of these questions is yes – then she is referred to genetic counseling.

The Breast Risk Screening Questionnaire (BRSQ) If she answers yes on the BRSQ-1 to question 2 (any family members with breast or ovarian cancer), then you complete BRSQ-2b. If any of the answers are yes on this questionnaire, you refer for genetic counseling.

The Breast Risk Screening Questionnaire (BRSQ) This is a required screening per our Medical Standards and Guidelines Uninsured client referrals to genetic counselors has been challenging Evaluation ongoing into usability and validity The BRSQ was introduced in 2012 and has been fully implemented into our health centers per our Medical Standards and Guidelines. The rollout has been smooth for the most part with the largest barrier being financial for those clients who are uninsured and cannot afford genetic counseling. There is currently a research project underway looking into the usability of the tool. This evaluation will likely expand in the coming year into looking at the validity of the tool and how well this it identifies those at high risk and what its potential for detecting cancers at an earlier stage might be. Are there any questions at this point about the BRSQ tool before I move onto to highlighting the training program?

Curriculum Components I would now like to introduce you to the BHI training program we conducted. Our goal with the training program was to train core group of clinician trainers throughout the country in fundamental concepts of breast cancer screening. We chose a train-the-trainer approach to maximize the reach of our training, as well as provide a multitude of curriculum components so that trainers could customize the training for their setting and needs.  We managed to train 100 trainers from 71 different PP affiliates through three regional trainings that took place over a 7-month time frame. Let’s take a look at the curriculum a little closer...The curriculum components included completion of five breast cancer screening eLearning modules, that had to be completed prior to the in-person training that was to be held. The five courses included: An Overview of Breast Cancer; Health History Components and Breast Cancer Risk Screening; Clinical Breast Exam Technique and Documentation; Breast Cancer Screening Recommendations; and finally Managing Mammogram Results. These took approximately 2.5 hours to complete. The second curriculum component included a didactic lecture at an in-person training with a breast specialist who expounded upon the principles in the eLearning modules and provided a detailed video demonstration of a CBE. CBE trainers then rotated through three training exercises – including case study discussions with the breast specialist, silicone breast model mass detection and documentation exercise, and CBE practice with standardized patients. Finally, the sixth curriculum component gave trainers ideas about how to disseminate the training at the local level and each trainer was given a trainer’s toolkit that included their own silicone breast models and resources to replicate the training components.

Train-the-Trainer Evaluation Objectives Evaluate the quality of curriculum components Discover which components were replicated by trainers Evaluate whether the curriculum was effective in: - increasing knowledge - standardizing clinical practices Our objectives in evaluating this training program was threefold – to evaluate the quality of the curriculum components and get feedback about individual training components; to record what components of the training were replicated by CBE trainers; and finally to evaluate the curriculum in its ability to increase knowledge and standardize breast cancer screening practices.

Methods Pre-training survey - baseline knowledge of breast cancer screening - baseline clinical practices - confidence providing the services Post-training survey (3-months) - retention of information from TTT - which components were replicated and feedback Post-training survey (6-months) - post-training clinical practices The methods for evaluation included multiple surveys of the CBE trainers. We collected a pre-training survey that measured their baseline knowledge of breast cancer screening recommendations and compare to baseline, their individual clinical breast exam practices and their confidence in providing these services. After the CBE TTT training, the trainers completed another survey that asked them to evaluate the quality of the curriculum and the usefulness of these components. Three months post-training we evaluated the trainers’ retention of the knowledge from the training and got an update from them on which of the training components they had replicated and how many clinicians were reached through the training. Finally, the trainers completed a six-month post-training survey that allowed us to get an update on the trainings they had performed and well as the trainers’ post-training clinical practices to compare to baseline.

Results – Most Helpful Curriculum Components The evaluation of the various curriculum components was very positive. The trainers felt that the eLearning modules and CBE practice on standardized patients were the most helpful. The majority also felt that the didactic lecture with the breast specialist was very helpful. Almost 60% felt the silicone breast model practice was very helpful and we received some direct feedback about the models that they were not lifelike. Greater than 50% felt the trainer resources and time given at the training to plan their local trainings was helpful.

Results – Practice Change PRE-SCORE POST-SCORE Spent 3 minutes or more on CBE 56% 95% Used circular breast search pattern during CBE 60% 3% Used vertical strip breast search pattern during CBE 46% 89% When we evaluated the changes in practice following the standardized curriculum, we found some statistically significant changes in CBE practice. While we did not prescribe an ideal time to spend performing the CBE, 95% of the participants were spending 3 minutes or more on CBE following the training – compared to 56% prior to the training. 60% reported using a circular breast search pattern during CBE prior to the training, while only 3% were using this pattern post-training. 89% of participants were using the vertical strip search pattern following the training versus 46% prior to the training. We advocated strongly for the use of vertical strip patterned search during the training.

Results – Mean Knowledge Scores Mean knowledge scores of breast cancer screening guidelines increased post-training (15.9 to 18.5) Highest increases in knowledge about: - screening recommendations for women ages 20-39 - when to initiate CBE screening - recommendations for women with increased genetic risk for breast cancer Following completion of the training, the mean knowledge scores of breast cancer screening guidelines increased from 15.9 pre-training to 18.5 post-training. The highest increases in knowledge occurred specifically in the screening recommendations for women ages 20-39, when to initiate CBE screening, and what recommendations to make for women who are found to be at increased risk for breast cancer due to genetic factors.

Results – Curriculum Replicated >1000 clinicians were trained in some curriculum component in first six months Most frequently replicated training component was eLearning module completion Almost half of the trainers were unable to replicate the use of CBE practice on standardized patients Finally, we surveyed the trainers about the volume of staff that they trained as well as what curriculum components they replicated for their local trainings. The 100 trainers across the country were able to train over 1000 clinicians in some component of the curriculum within the first six months post-training. Most frequently, the trainers required that their clinicians complete the eLearning modules. These were found to be easy to rollout across a large geographical area and did not require a large amount of resources to conduct. The trainers used case study exercises, replay of the breast specialist’s didactic lecture video, and practice on silicone breast models equally. We received feedback that these three components were fairly easy to rollout and did not require financial resources but sometimes was difficult to organize if the affiliate had large groups of clinicians spread out geographically. Finally, almost half of the trainers were unable to replicate the CBE practice on standardized patients, mostly citing financial barriers to hiring SPs. Some affiliates were able to perform observed CBE practice on staff or client volunteers and overcame the financial issues in this way.

Conclusion Train-the-trainer curriculum components rated “very helpful” Training improved participants knowledge, comfort, and standardization of practices Effective training model of how to disseminate evidence-based breast cancer screening recommendations Ongoing evaluation of the BRSQ tool In conclusion, the train-the-trainer curriculum that we developed was successful in training a large volume of providers in a short period of time. 50% or more of the participants found all of the curriculum components very helpful. The training served to improve participants’ knowledge of breast cancer screening guidelines, as well as comfort and standardization in clinical breast exam practices. This curriculum and the TTT model serves as an effective training model when needing to disseminate evidence-based breast cancer screening recommendations. This model could likely be applied to other guideline dissemination strategies with success. Finally, we will continue to evaluate the BRSQ risk screening tool and examine the long-term impact of use of such a tool.