Two normal and precancerous cervical models are printed using NinjaFlex material and are designed with a penetrable endocervical canal. These models are used to train providers to perform Pap and HPV sample collection and endocervical curettage (ECC; Fig. 5). During use, the models are moistened and corn flour is used to cover the outside surface and line the endocervical canal. The flour can then be removed using different cervical brushes and swabs to demonstrate adequate sample collection. Collected flour is visible on the tip of the brush or curette when extracted.
The gel cervical models are one-time use models used to teach cervical biopsy, cryotherapy, and LEEP. The biopsy gel models are made with four black beads (600 micrometers) lining the edge of the “squamocolumnar junction.” The beads serve as targets to be removed using biopsy forceps, simulating cervical biopsy extraction (Fig. 6). For cryotherapy training, a cryogun can be used to treat the outer surface of the gel cervical model. The model becomes white when frozen and returns to its pink color over time, similar to a human cervix during and after cryotherapy (Fig. 7). For LEEP training, a standard LEEP machine can be used to remove a large sample from the gel cervical model. A “white lesion,” painted on the center of the model using liquid paper, acts as a target that trainees must remove while performing a LEEP (Fig. 8).
The cost of LUCIA is $47 and includes the pelvic frame, vaginal canal, both cervical model holders, the three-dimensional printed cervical models, and six cervical gel molds (Appendix 3, available online at http://links.lww.com/AOG/B274).
For skills training, an assembled LUCIA model is placed on the edge of a table and the trainee sits facing the labial opening. The appropriate cervical model is placed in a holder and is visible when looking through the vaginal canal with a speculum.
Practice of each skill begins with the trainee separating the labia and inserting a speculum. An external light is used to better visualize the cervix, such as a head lamp or book lamp adhered to the pelvic frame. Once the speculum is in place, the trainee can then practice performing Pap and HPV sample collection, visual inspection with acetic acid, colposcopy, cervical biopsy, ECC, cryotherapy, or LEEP on the cervical model. Once complete, the cervical model in the holder can be switched out to practice another skill. Video 1, available online at http://links.lww.com/AOG/B275, shows these skills being performed using LUCIA.
LUCIA was evaluated as a teaching aid in cervical cancer training courses organized by the Project ECHO team from the University of Texas MD Anderson Cancer Center. Project ECHO is a telementoring program linking expert physicians with primary care clinicians in medically underserved areas through regular video conferences.8 MD Anderson complements Project ECHO with locally held courses to increase the capacity of local medical providers for cervical cancer screening, diagnosis, and treatment.
In 2017 and 2018, six training courses were held using LUCIA in El Salvador (n=1); South Texas along the Mexico border (n=2), Sherman, Texas (n=1); and Mozambique (n=2). Institutional Review Board approval to evaluate the models was obtained from MD Anderson and Rice University (Protocol PA17-0562). Anonymous standardized provider evaluations were administered at three courses (Appendix 4, available online at http://links.lww.com/AOG/B274) and completed by 70 participants (36 in El Salvador; 18 in Sherman, Texas; and 16 in Beira, Mozambique). Results are summarized in Table 2 and qualitative feedback is summarized in Appendix 5, available online at http://links.lww.com/AOG/B274. LUCIA received a median score of 4 out of 5 for usefulness, skill improvement, and skill evaluation, and a median score of 5 out of 5 for likelihood to recommend the model and learning value.
The evaluation also asked participants to compare LUCIA with Jhpiego flashcards and an animal tissue model (beef tongue, Appendix 6 available online at http://links.lww.com/AOG/B274) for cervical cancer skills training. Over the three courses, 52 of 70 (74%) respondents preferred LUCIA over Jhpiego flashcards for visual inspection with acetic acid training. Cryotherapy was evaluated only during the course held in El Salvador, where 25 of 36 (69%) respondents preferred LUCIA over the animal tissue model for cryotherapy training. However, only 47% and 41% of respondents preferred LUCIA over the animal tissue model for biopsy and LEEP training, respectively. The main criticism was that the gel models felt too soft and did not cut like real cervical tissue. To overcome this, we increased the gel concentration for biopsy models from 30% to 35% gel wt/vol concentration and the LEEP models from 10% to 15% gel wt/vol concentration for our last course in Beira, Mozambique. We also kept the models refrigerated until immediately before use. A majority of participants in Beira preferred LUCIA for all skills evaluated (14/16 for visual inspection with acetic acid training, 9/16 for biopsy training, 9/16 for LEEP training).
In 2018, the Director-General of the World Health Organization made a global call to action to eliminate cervical cancer, which included improving access to early-stage diagnosis and treatment.9 Improved access includes increasing the number of medical providers trained in the skills of early cervical cancer screening and prevention. LUCIA is a portable, low-cost simulation model that can be used to provide hands-on, comprehensive training for cervical cancer screening, diagnosis, and early treatment techniques in low-resource areas in the United States and globally, where cervical cancer remains a common cancer in women.
In comparison with other models used for hands-on cervical cancer training, LUCIA can train providers on more skills at lower cost. The adaptability to simulate a variety of different skills makes LUCIA an excellent tool to increase local capacity to screen, diagnose, and treat precancerous cervical lesions based on local standards. For example, in rural areas of Latin America and Africa, clinicians and patients have limited access to medical facilities and equipment and therefore often rely on a “screen-and-treat” approach for cervical cancer prevention using visual inspection with acetic acid followed by cryotherapy of visible lesions.10 To better implement “screen-and-treat” methods in rural areas, educators could use LUCIA to teach rural clinicians how to perform visual inspection with acetic acid and cryotherapy. However, in a hospital setting with reliable access to electricity and equipment, local educators may use LUCIA to train clinicians in colposcopy and LEEP.
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