Vertical-strips method for breast self-exam uses ?touch intelligence?

A psychologist?s behavioral insight leads to a better way of finding breast lumps.

By Bridget Murray
Monitor staff

In the mid 1970s, Henry Pennypacker, PhD, was disturbed to hear that women weren?t detecting cancerous lumps in their breasts until the growths were so large they were hard to treat. Pennypacker believed there had to be a way to help women find lumps sooner, when they?re the size of a pea.

'I figured if we can teach the fingers to read Braille, then we can surely teach them to find breast lumps smaller than golf balls,' says Pennypacker. 'Why not [detect] lumps as small as three millimeters? It seemed possible.'

Pennypacker believed the job was one for behavioral psychologists because it required an understanding of psychophysics?how the brain registers what the senses encounter. Specifically, this case demanded an investigation of touch?how women can train their fingers to read the feel of their flesh. It was a task that Pennypacker and his colleagues, psychologists Mark Goldstein, PhD, and Calvin Adams, PhD, took on with the help of a grant from the National Cancer Institute.

'In the garment industry, workers can distinguish between different kinds of fabrics just by feeling them,' says Pennypacker. 'We decided to extend this sort of touch intelligence to finding a lump in a breast.' By the late ?70s, he and his colleagues had devised a new method of breast self-exam, MammaCare. The method is just now catching on among health professionals and patients, and is replacing older methods as the mainstay of breast exam. Using the method, women cover a wide swath of the chest where lumps might lurk and distinguish potentially harmful lumps from normal fibrous breast material. They do this by palpating the breasts in vertical strips and using varying amounts of pressure.

According to Harvard University physician Mary Barton, MD, the method has a research-proven track record of catching smaller lumps than do circular or radial patterns of breast self-exam?two other methods long endorsed by the medical community. Pennypacker and his colleagues have since patented and trademarked MammaCare and now market it to doctors, nurses and patients through the company of which he is president, the Mammatech Corporation in Gainesville, Fla. Officially sanctioned by the American Cancer Society, the MammaCare vertical-strips method is used by an estimated 250,000 women. And that number appears to be growing.

'Think about it, you don?t mow your lawn or paint a room in circles?you do it in strips,' says Kathy Coleman, a Boston nurse who was once a MammaCare skeptic but now teaches the method. 'Why would you do your breast self-exam any other way?'

A behavioral bent

Pennypacker may have inherited his entrepreneurial drive from his father. As a young boy he watched his father?s small timber operation on their Missoula, Mont., homestead grow into a successful timber mill. Always one to set high goals for himself, Pennypacker decided to enroll in Duke University?s doctoral program in clinical psychology after earning his bachelor?s degree?a triple major in mathematics, psychology and philosophy?and his master?s degree in psychology from the University of Montana.

On starting the doctoral program, however, Pennypacker soon found himself more interested in behavioral psychology?particularly in how to change and modify animal behavior?than in listening to people?s problems. He changed his doctoral focus to experimental psychology and pursued his research interests in experimental and behavioral psychology, mainly studying galvanic skin response and eyelid reflexes in humans and monkeys.

Around that time, Pennypacker also grew fascinated by studies exploring the use of operant conditioning with psychotic patients. His interests were turning to changing the behavior of people. In 1962, after finishing his doctoral degree in under three years, Pennypacker moved to a post as an assistant professor at the University of Florida. While there, during the latter 1960s and early 1970s, he focused his efforts on developing behavioral technologies from science for the larger benefit of society. He began by using Skinnerian behavioral principles to develop more effective teaching practices in schools.

Then he and his colleague Mark Goldstein started applying their behavioral skills to medicine. In one project, they used their understanding of touch to develop buttons for a device that monitored the drinking habits of alcoholics. If patients failed to respond to a page from the hospital, it meant they were too drunk to punch in a code on the buttons.

A breast-exam breakthrough

It was in 1974 that Pennypacker and Goldstein heard the call to develop better breast-lump detection techniques, a chance for Pennypacker to apply his understanding of behavioral psychology to yet another situation involving touch. It was 'a basic problem of psychophysics,' says Pennypacker. 'How do you educate the fingers to detect changes in breast tissue?'

To find out, he and his colleagues teamed up with physicians, biomedical engineers and technicians and investigated such questions as 'What?s the smallest lump the fingers can feel?' and 'How does lump hardness, mobility and depth affect detectability?'

Their work with breast-cancer patients and sophisticated silicon models led to three major advances in breast self-exam, according to nurse Terri Ades, editor for Health Content at the American Cancer Society. They found that women detect smaller lumps when taught to:

? Tell the difference between a potentially cancerous or malignant lump and natural fibrous tissue in many women?s breasts.

? Examine a wide-ranging area of the upper body?from the armpit to the breast bone, from the collarbone to the bra line?using a vertical-strips search pattern. This covers areas outside the main breast, where 60 percent of lumps are found.

? Use light, medium and deep pressure when palpating for breast lumps.

According to Ades, this method 'may work best for most women' and is increasingly being used by health professionals. It is most effective when learned on the researchers? manufactured breast models, which she says are 'the best available today.' Pennypacker and his colleagues dubbed their method MammaCare and in 1982 founded the Mammatech Corporation to protect, market and distribute it.

The company employs 11 nurses and support staff to train medical professionals how to use the method in examining women and to pass on the method to their patients. By teaching people the original technique and providing MammaCare breast models, Pennypacker hopes to keep the method from getting diluted. 'For MammaCare to really work for women, it must be taught well and the standards maintained,' he says. Women interested in learning the method on their own can order the $74 video, training kit and breast models directly from Mammatech via its web site or its toll-free phone-line, (800)-626-2273.

The MammaCare method

Not only is MammaCare the most vigorously researched breast-exam method, but 'Studies have shown it to be superior to other methods like the round circle method,' says Harvard?s Barton.

Her colleague Suzanne Fletcher, MD, published a study on MammaCare?s efficacy in the journal, Annals of Internal Medicine (Vol. 12, No. 10, p. 772?779) in 1990. In the study, MammaCare-trained women found more lumps than women trained in the circular technique.

Despite such findings, however, many women and medical practitioners continue using the breast-exam techniques. According to Pennypacker, the technique has been slow to catch on because his company hasn?t aggressively marketed it to the general public, although it does sell directly to patients. To boost the method?s distribution, some health consultants, such as Coleman, are teaching condensed versions of it to women.

Learning the complete version of the method from the video, or from a physician, nurse or Mammatech staffer, usually takes about an hour. Here?s the basic procedure:

? Women learn the texture of human breasts by palpating silicone breast models that teach them the difference between normal tissue (fatty, knotty and cystic breast masses) and abnormal lumps.

? Women memorize a vertical-strips (grid) pattern of examining every possible inch of their breast tissue (see diagrams).

? Women use the pads of their fingers, not the tips, to cover more tissue.

? Women train their fingers to use differing degrees of pressure as they press the tissue, so they can detect lumps attached to the rib cage, free floating or attached to the outermost layer of the breast.

The basic premise of MammaCare 'isn?t rocket science,' says Pennypacker.

'If you want to discover uranium, first you figure out what it looks like, then you mine the places it might be,' he says. 'It?s the same with breast lumps. First you teach the fingers what they?re looking for, then you put those fingers in contact with every bit of breast tissue.'