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Low-Cost Instructional Apparatus to Improve Training for Cervical Cancer Screening and Prevention

Parra, Sonia, MSc; Oden, Maria, PhD; Schmeler, Kathleen, MD; Richards-Kortum, Rebecca, PhD for the Rice360 Student Team,

doi: 10.1097/AOG.0000000000003140
Contents: Medical Education: Procedures and Instruments
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BACKGROUND: Cervical cancer remains one of the leading causes of cancer for women in medically underserved areas. This is in part due to a lack of trained clinicians to provide the necessary diagnosis and treatment of precancerous lesions to prevent cervical cancer. Increasing medical provider knowledge and skills is important for the early detection and prevention of cervical precancer and cancer in medically underserved areas of the United States and globally.

METHOD: LUCIA is a low-cost, universal cervical cancer instructional apparatus that can be used to teach and practice a variety of essential skills for cervical cancer screening, diagnosis, and treatment, including: visual inspection with acetic acid, Pap and human papillomavirus DNA specimen collection, colposcopy, endocervical curettage, cervical biopsy, cryotherapy, and loop electrosurgical excision procedure.

EXPERIENCE: LUCIA was used to provide hands-on training in six courses held in Texas (n=3), El Salvador (n=1), and Mozambique, Africa (n=2). Standardized provider evaluations were administered at three of these courses and resulted in mean scores of 4.12/5 for usefulness, 4.46/5 for skill improvement, and 4.43/5 for ease of skill evaluation.

CONCLUSION: LUCIA provides dynamic, real-time feedback that allows trainees to learn and practice important skills related to cervical cancer prevention while simulating a patient exam.

LUCIA is a portable, low-cost pelvic model that allows clinicians to learn and practice procedures performed in the screening, diagnosis, and treatment of cervical precancer.

Rice University, and the University of Texas MD Anderson Cancer Center, Houston, Texas.

Corresponding author: Rebecca Richards-Kortum, PhD, 6500 Main Street, Houston, TX 77005; email: rkortum@rice.edu.

Supported by the NCI of the NIH under award numbers R01 CA186132-01 and R01 CA186132-Supplement, the Rice Engineering Alumni Student Project Grant Program, the Lemelson Foundation—Developing Country Program, the Cancer Prevention and Research Institute of Texas (CPRIT) PP150012, the Prevent Cancer Foundation, the Raul Tijerina Foundation, and the Joe Family Fund.

Financial Disclosure The authors did not report any potential conflicts of interest.

Presented as a poster at the annual meeting of the Society of Gynecologic Oncology, March 24–27, 2018, New Orleans, Louisiana.

* For a list of co-authors making up the Rice360 Student Team, see Appendix 1 online at http://links.lww.com/AOG/B274.

The authors thank the Project ECHO team, especially Ellen Baker, MD, MPH, Melissa Lopez, MS, and Mila Salcedo, MD, PhD, at the University of Texas MD Anderson Cancer Center for including LUCIA as part of their cervical cancer education program, as well as all medical personnel who provided feedback on the model. They would also like to thank Veronica Leautaud, PhD, from the Rice360 Institute for Global Health for assistance in coordinating model development. Sonia Parra would like to acknowledge the support of the Baylor College of Medicine Medical Scientist Training Program.

Each author has confirmed compliance with the journal's requirements for authorship.

Peer reviews and author correspondence are available at http://links.lww.com/AOG/B276.

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND) , where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

Received October 17, 2018

Received in revised form December 14, 2018

Accepted December 20, 2018

Cervical cancer is preventable; however, it remains one of the leading causes of cancer-related death among women in low- and middle-income countries.1 Although cervical cancer incidence has decreased in high-income countries owing to the implementation of screening programs, cervical cancer rates remain elevated in poor and medically underserved communities.2

A number of tools are available for the early detection and treatment of cervical cancer and its precursors in low-resource settings. Screening tests include Pap and human papillomavirus (HPV) testing as well as visual inspection with acetic acid.3 Depending on the setting, patients who screen positive undergo further testing with colposcopy and biopsy or immediate treatment using cryotherapy or a loop electrosurgical excision procedure (LEEP) to remove precancerous lesions and prevent progression to invasive cancer. These clinic-based procedures provide a cost-effective means of preventing cervical cancer.4,5 Unfortunately, medically underserved areas lack sufficient numbers of trained providers, in part due to limited opportunities for hands-on training.6

There are commercially available mannequins to help teach cervical cancer screening skills, but these simulators are costly for use in low-resource settings (Table 1). Low-cost options include flashcards developed by Jhpiego to teach providers to recognize lesions during visual inspection with acetic acid.7 To practice biopsy, cryotherapy, and LEEP, animal tissue is often used (eg, beef tongue), but these models do not integrate the ability to teach screening, detection, and treatment skills.

Table 1

Table 1

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METHOD

We developed and evaluated LUCIA (Low-cost Universal Cervical cancer Instructional Apparatus), a low-cost cervical cancer training model ($47) that can be used to provide hands-on training for all of the necessary skills related to cervical cancer prevention.

LUCIA is a portable simulation model designed to act as a hands-on teaching aid for clinician education. LUCIA allows trainees to practice cervical cancer screening, diagnosis, and early treatment techniques while simulating a gynecologic exam (Fig. 1). LUCIA consists of a wooden pelvic frame, a vaginal canal (made from polyvinyl chloride pipe, waterproof fabric, and foam), cervical model holders, and a variety of cervical models. There are two cervical model holders: a stationary holder and a holder with a rotating arm attached to a small clamp. The cervical model holder with a small clamp is lined with aluminum foil so that a conductive current can pass through when practicing LEEPs. Both allow different cervical models to be interchanged so trainees can practice different skills.

Fig. 1

Fig. 1

LUCIA includes 20 three-dimensional printed cervical models (printed using polylactic acid) painted to depict the visible differences between a normal cervix, benign findings such as Nabothian cysts, cervical precancerous lesions including acetowhite changes, high-grade cervical precancer with abnormal vasculature, and findings consistent with invasive cervical cancer (Fig. 2). These models are used to practice identifying abnormal findings as well as provide hands-on training. LUCIA also comes with six molds used to make cervical models from ballistics gel (see Appendix 2, available online at http://links.lww.com/AOG/B274, for instructions to make gel models). All cervical models are designed to anatomic scale (3-cm diameter, 2–2.5-cm length), and to be interactive to train the user to perform a variety of skills.

Fig. 2

Fig. 2

The three-dimensional printed cervical models are used to train visual inspection with acetic acid and colposcopy (Figs. 3 and 4). Precancerous cervical models are painted with thermochromic paint that changes color from pink to white when exposed to temperatures above 88°F. This allows “white lesions” to appear after the application of hot water to simulate a positive visual inspection with acetic acid or colposcopy result when acetic acid is applied. The high-grade precancer and cancer models have vasculature painted on them using red paint, which absorbs green light, causing the vessels to appear dark when using the green filter feature of a colposcope.

Fig. 3

Fig. 3

Fig. 4

Fig. 4

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.

Fig. 5

Fig. 5

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).

Fig. 6

Fig. 6

Fig. 7

Fig. 7

Fig. 8

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.

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EXPERIENCE

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.

Table 2

Table 2

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).

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DISCUSSION

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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REFERENCES

1. Torre LA, Bray F, Siegel RL, Ferlay J, Lortet-Tieulent J, Jemal A. Global cancer statistics, 2012. CA Cancer J Clin 2015;65:87–108.
2. National Institutes of Health. Cervical cancer: fact sheet. Bethesda (MD): National Cancer Institute; 2010.
3. World Health Organization. WHO guidelines for screening and treatment of precancerous lesions for cervical cancer prevention. Geneva (Switzerland): World Health Organization; 2013.
4. Goldie SJ, Gaffikin L, Goldhaber-Fiebert JD, Gordillo-Tobar A, Levin C, Mahé C, et al. Cost-effectiveness of cervical-cancer screening in five developing countries. N Engl J Med 2005;353:2158–68.
5. Mezei AK, Armstrong HL, Pedersen HN, Campos NG, Mitchell SM, Sekikubo M, et al. Cost-effectiveness of cervical cancer screening methods in low- and middle-income countries: a systematic review. Int J Cancer 2017;141:437–46.
6. Willcox ML, Peersman W, Daou P, Diakité C, Bajunirwe F, Mubangizi V, et al. Human resources for primary health care in sub-Saharan Africa: progress or stagnation? Hum Resour Health 2015;13:76.
7. Blumenthal PD, McIntosh N. Cervical cancer prevention learning resource package: visual inspection of the cervix: flash card set. Available at: http://resources.jhpiego.org/resources/cervical-cancer-prevention-learning-resource-package-visual-inspection-cervix-flash-card. Retrieved August 31, 2018.
8. Lopez MS, Baker ES, Milbourne AM, Gowen RM, Rodriguez AM, Lorenzoni C, et al. Project ECHO: a telementoring program for cervical cancer prevention and treatment in low-resource settings. J Glob Oncol 2016;3:658–65.
9. Ghebreyesus TA. Cervical cancer: an NCD we can overcome. Geneva (Switzerland): World Health Organization; 2018.
10. Paul P, Winkler JL, Bartolini RM, Penny ME, Huong TT, Nga le T, et al. Screen-and-treat approach to cervical cancer prevention using visual inspection with acetic acid and cryotherapy: experiences, perceptions, and beliefs from demonstration projects in Peru, Uganda, and Vietnam. Oncologist 2013;18:1278–84.
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