The Science Behind the Standard

The MammaCare ®
Method

Since the late 1970s, MammaCare has built the only instructional systems that measure and validate breast exam proficiency against defined performance standards: sensitivity, specificity, and thoroughness.

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MammaCare instructor demonstrating clinical breast examination technique

Where it started

Teaching a physical exam like any other measurable skill.

MammaCare began in the late 1970s at the University of Florida, when Drs. Mark Kane Goldstein and Henry S. Pennypacker, working with Chalmers K. Adams, Diane C. Hall, and Gerald H. Stein, asked a simple question: if instructional technology can teach fingers to read Braille, could it teach fingers to find a lump in breast tissue?

To answer it, the team built the first tactually realistic silicone breast model with embedded simulated lesions, a tool that for the first time made it possible to objectively measure palpation performance rather than simply teach a technique and hope it was retained. That single innovation turned breast examination from a taught habit into a trainable, testable skill.

Read the full bibliography
1976
First published study on simulated lump detection
50 +
Years of continuous, peer-reviewed research
60 +
Published studies referencing the MammaCare Method
NCI/NSF
Early research supported by the National Cancer Institute and National Science Foundation

The technique

The 5 Ps of the MammaCare ® Method

The same five components define a thorough breast exam for healthcare providers performing clinical breast exams and patients performing their own self-breast exams.

P alpation

Using the pads of the fingers in small, overlapping circular motions to feel through, not just across, the tissue.

P ressure

Applying light, medium, and deep pressure at every location to detect abnormalities at every depth of tissue.

P attern

Following a systematic search pattern to ensure no area of tissue is skipped or examined twice.

P erimeter

Covering the full boundary of breast tissue, including the outer edges and axilla, not just the central area.

P ositions

Proper positioning at each phase of the exam allows for easier palpation as the breast tissue will be evenly distributed.

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The performance standards

Three measurable skills. One standard.

Every MammaCare-trained exam is evaluated against the same three criteria, the same ones used across the published research below.

Sensitivity

Detecting all palpable abnormalities present.

Tumor Detected Tumor Missed
Sensitivity illustration: finding all abnormalities present in the breast ✕

Specificity

Distinguishing abnormal findings from normal tissue.

Tumor Detected False Positive
Specificity illustration: distinguishing abnormalities from normal breast tissue to minimize false positives ✕

Thoroughness

Systematically examining all breast tissue.

Tissue Examined Tissue Unexamined
Thoroughness illustration: systematic, complete palpation of all breast tissue ✕

What the research shows

Measured gains, not anecdotes.

24% → 83%
Lump detection proficiency, pre-course to post-course, in published studies of MammaCare-trained providers. Smith et al., 1996
59% → 94%
Primary care providers able to detect 60–100% of lumps in test models, before versus after training. Vetto et al., 2002
1980
Cancer publishes Hall et al., documenting improved lesion detection following MammaCare's experimental training protocol. Hall et al., 1980

The bibliography

Publications referencing MammaCare.

A method built on measurement should be easy to check. Below is the published research documenting the MammaCare Method's development, validation, and the broader clinical case for manual breast examination, grouped as MammaCare maintains them.

MammaCare Training Validation 6
  1. Smith, R. L., Hanchak, N. A., Bloom, H., Leibfreid, D., Xuan, S., & Schlackman, N. (1996). The effectiveness of postgraduate education on the clinical breast examination skills of primary care physicians. American Journal of Managed Care , 2, 989–995.
  2. Vetto, J. T., Petty, J. K., Dunn, N., Prouser, N. C., & Austin, D. F. (2002). Structured clinical breast examination (CBE) training results in objective improvement in CBE skills. Journal of Cancer Education: The Official Journal of the American Association for Cancer Education , 17(3), 124–127.
  3. Corbelli, J., Bonnema, R., Rubio, D., Comer, D., & McNeil, M. (2014). An Effective Multimodal Curriculum to Teach Internal Medicine Residents Evidence-Based Breast Health. Journal of Graduate Medical Education , 6(4), 721–725.
  4. Aliabadi-Wahle, S., Ebersole, M., Choe, E. U., & Beech, D. J. (2000). Training in clinical breast examination as part of a general surgery core curriculum. Journal of Cancer Education: The Official Journal of the American Association for Cancer Education , 15(1), 10–13.
  5. Goldstein, M. K., Mehn, M. A., Pennypacker, H. S., Brost, B. C., Petersen, W. O., & Nicometo, A. M. (2012, July 7). Improved Clinical Breast Examination Competencies Via Intelligent Simulator Training. Meeting of the German Society for Senologie, Stuttgart.
  6. Baier Manwell, L., McNeil, M., Gerber, M. R., Iqbal, S., Schrager, S., Staropoli, C., Brown, R., Veet, L., Haskell, S., Hayes, P., & Carnes, M. (2022). Mini-Residencies to Improve Care for Women Veterans: A Decade of Re-Educating Veterans Health Administration Primary Care Providers. Journal of Women's Health , 31(7), 991–1002.
The Clinical Case for Manual Exam 13
  1. Koo, M. M., von Wagner, C., Abel, G. A., McPhail, S., Rubin, G. P., & Lyratzopoulos, G. (2017). Typical and atypical presenting symptoms of breast cancer and their associations with diagnostic intervals: Evidence from a national audit of cancer diagnosis. Cancer Epidemiology , 48, 140–146.
  2. Haakinson, D. J., Stucky, C. C., Dueck, A. C., Gray, R. J., Wasif, N., Apsey, H. A., & Pockaj, B. (2010). A significant number of women present with palpable breast cancer even with a normal mammogram within 1 year. American Journal of Surgery , 200(6), 712–718.
  3. Larsen, M., Lilleborge, M., Vigeland, E., & Hofvind, S. (2020). Self-reported symptoms among participants in a population-based screening program. Breast (Edinburgh, Scotland) , 54, 56–61.
  4. Huang, N., Chen, L., He, J., et al. (2022, February 21). The Efficacy of Clinical Breast Exams and Breast Self-Exams in Detecting Malignancy or Positive Ultrasound Findings. Cureus , 14(2), e22464.
  5. Mathis, K. L., Hoskin, T. L., Boughey, J. C., Crownhart, B. S., Brandt, K. R., Vachon, C. M., Grant, C. S., & Degnim, A. C. (2010). Palpable presentation of breast cancer persists in the era of screening mammography. Journal of the American College of Surgeons , 210(3), 314–318.
  6. Brown, A. L., Phillips, J., Slanetz, P. J., Fein-Zachary, V., Venkataraman, S., Dialani, V., & Mehta, T. S. (2017). Clinical Value of Mammography in the Evaluation of Palpable Breast Lumps in Women 30 Years Old and Older. AJR. American Journal of Roentgenology , 209(4), 935–942.
  7. Miller, A. B., Wall, C., Baines, C. J., Sun, P., To, T., & Narod, S. A. (2014). Twenty five year follow-up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomised screening trial. BMJ (Clinical Research Ed.) , 348, g366.
  8. Wishart, G. C., Warwick, J., Pitsinis, V., Duffy, S., & Britton, P. D. (2010). Measuring performance in clinical breast examination. The British Journal of Surgery , 97(8), 1246–1252.
  9. Roth, M. Y., Elmore, J. G., Yi-Frazier, J. P., Reisch, L. M., Oster, N. V., & Miglioretti, D. L. (2011). Self-detection remains a key method of breast cancer detection for U.S. women. Journal of Women's Health , 20(8), 1135–1139.
  10. Lehman, C. D., Lee, A. Y., & Lee, C. I. (2014). Imaging management of palpable breast abnormalities. AJR. American Journal of Roentgenology , 203(5), 1142–1153.
  11. Moo, T. A., Jochelson, M. S., Zabor, E. C., Stempel, M., Raiss, M., Mamtani, A., Tadros, A. B., El-Tamer, M., & Morrow, M. (2019). Is Clinical Exam of the Axilla Sufficient to Select Node-Positive Patients Who Downstage After NAC for SLNB? A Comparison of the Accuracy of Clinical Exam Versus MRI. Annals of Surgical Oncology , 26(13), 4238–4243.
  12. Ruddy, K. J., Gelber, S., Tamimi, R. M., Schapira, L., Come, S. E., Meyer, M. E., Winer, E. P., & Partridge, A. H. (2014). Breast cancer presentation and diagnostic delays in young women. Cancer , 120(1), 20–25.
  13. Carney, P. A., Steiner, E., Goodrich, M. E., Dietrich, A. J., Kasales, C. J., Weiss, J. E., & Mackenzie, T. (2006). Discovery of breast cancers within 1 year of a normal screening mammogram: how are they found? Annals of Family Medicine , 4(6), 512–518.
Foundational Research 50
  1. Adams, C. K., Hall, D. C., Pennypacker, H. S., Goldstein, M. K., Hench, L. L., Madden, M. C., Stein, G. H., & Catania, A. C. (1976). Lump detection in simulated human breasts. Perception and Psychophysics , 20, 163–176.
  2. Artmann, A., Heyne, M., Kiechle, M., & Harbeck, N. (2005, June 20 Suppl.). Breast self-examination training and counseling as motivation strategies for breast awareness and participation in breast cancer screening programs (ASCO Annual Meeting Proceedings, Part 1). Journal of Clinical Oncology , 24(18S), 1027.
  3. Atkins, E., Solomon, L. J., Worden, J. K., & Foster, R. (1991). Relative effectiveness of methods of breast self-examination. Preventive Medicine , 14(4), 357–367.
  4. Barton, M. B., Harris, R., & Fletcher, S. W. (1999). Does this patient have breast cancer? The screening clinical breast examination: Should it be done? How? Journal of the American Medical Association , 282(13), 1270–1280.
  5. Benincasa, T. A., King, E. S., Rimer, B. K., Bloom, H. S., Balshem, A., James, J., & Engstrom, P. F. (1996). Results of an office-based training program in clinical breast examination for primary care physicians. Journal of Cancer Education , 11(1), 25–31.
  6. Bloom, H. S., Criswell, E. L., Pennypacker, H. S., Catania, A. C., & Adams, C. K. (1982). Major stimulus dimensions determining detection of simulated breast lesions. Perception and Psychophysics , 32(3), 251–260.
  7. Campbell, H. S., Fletcher, S. W., Lin, S., Pilgrim, C. A., & Morgan, T. M. (1991). Improving physicians' and nurses' clinical breast examination: A randomized controlled trial. American Journal of Preventive Medicine , 7, 1–18.
  8. Campbell, H. S., McBean, M., Mandin, H., & Bryant, H. (1994). Teaching medical students how to perform a clinical breast examination. Academic Medicine , 69(12), 993–995.
  9. Chalabian, J., Formenti, S., Russell, C., Pearce, J., & Dunnington, G. (1998). Comprehensive needs assessment of clinical breast evaluation skills of primary care residents. Annals of Surgical Oncology , 5(2), 166–172.
  10. Coleman, E. A. (1991). Practice and effectiveness of breast self-examination: A selective review of the literature. Journal of Cancer Education , 6(2), 83–92.
  11. Coleman, E. A., & Pennypacker, H. S. (1991). Measuring breast self-examination proficiency. Cancer Nursing , 14(4), 211–217.
  12. Coleman, E. A., & Pennypacker, H. S. (1991). Nursing research to define outcomes of care: Evaluating breast self-examination performance. Journal of Nursing Quality Assurance , 5(3), 65–69.
  13. Coleman, E. A., Riley, M. B., Fields, F., & Prior, B. (1991). Efficacy of breast self-examination teaching methods among older women. Oncology Nursing Forum , 18(3), 561–566.
  14. Coleman, E. A., Lord, J. E., Bowie, M., & Worley, M. J. (1993). A statewide breast cancer screening project. Cancer Nursing , 16(5), 347–353.
  15. Duer, J. D. (1984). Group dissemination of group breast self-examination training technology. Patient Education and Counseling , 7(6), 98–116.
  16. Fletcher, S. W., O'Malley, M. S., & Bunce, L. A. (1985). Physicians' abilities to detect lumps in silicone breast models. Journal of the American Medical Association , 253, 2224–2228.
  17. Fletcher, S. W., O'Malley, M. S., Earp, J. L., Morgan, T. M., Lin, S., & Degnan, D. (1990). How best to teach women breast self-examination. Annals of Internal Medicine , 112(10), 772–779.
  18. Fletcher, S. W., O'Malley, M. S., Pilgrim, C. A., & Gonzalez, J. J. (1989). How do women compare with internal medicine residents in breast lump detection? Journal of General Internal Medicine , 4, 277–283.
  19. Goldstein, M. K., Stein, G. H., & Pennypacker, H. S. (1982). Efficient technology of training breast self-examination. Technical Bulletin, World Health Organization , England.
  20. Goldstein, M. K., Stein, G. H., & Pennypacker, H. S. (1982). On subordination of BSE. American Journal of Public Health , 5(72), 498–499.
  21. Hall, D. C., Adams, C. K., Stein, G. H., Goldstein, M. K., Stephenson, H. S., & Pennypacker, H. S. (1980). Improved detection of human breast lesions following experimental training. Cancer , 46, 408–414.
  22. Hall, D. C., Goldstein, M. K., & Stein, G. H. (1977). Progress in manual breast examination. Cancer , 40, 364–370.
  23. Hilt, G. (1990). Selbstuntersuchung der brust: So nehmen sie den frauen die angst. Ärztliche Praxis , 75(18), 20–21.
  24. Hilt, G. (2005). Bessere infos, mehr früherkennung. Ärztliche Praxis Gynäkologie , 6, 22.
  25. Hilt, G. (2006). Frauen zur Selbstkontrolle motivieren. Ärztliche Praxis Gynäkologie , 5, 24.
  26. Jacob, T. C., Penn, N. E., Giebink, J., & Bastien, R. (1994). A comparison of breast self-examination and clinical examination. Journal of the National Medical Association , 86(1), 40–45.
  27. Kotke, T. E., & Trapp, M. A. (1998). Implementing nurse-based systems to provide American Indian women with breast and cervical cancer screening. Mayo Clinic Proceedings , 73(9), 815–823.
  28. Leight, S. B., Deiriggi, P., Hursh, D., Miller, D., & Leight, V. (2000). The effect of structured training on breast self-examination search behaviors as measured using biomedical instrumentation. Nursing Research , 49(5), 283–289.
  29. Madden, M. C., Hench, L. L., Hall, D. C., Pennypacker, H. S., Adams, C. K., Goldstein, M. K., & Stein, G. H. (1978). Development of a model human breast with tumors for use in teaching breast examination. Journal of Bioengineering , 2, 427–435.
  30. McDermott, M. M., Dolan, N. C., Huang, J., Reitler, D., & Rademaker, A. W. (1996). Lump detection is enhanced in silicone breast models simulating postmenopausal breast tissue. Journal of General Internal Medicine , 11, 112–114.
  31. McDermott, M. M., Dolan, N. C., & Rademaker, A. W. (1996). Effect of breast-tissue characteristics on the outcome of clinical breast examination training. Academic Medicine , 71, 505–507.
  32. McDonald, S., Saslow, D., & Alciati, M. H. (2004). Performance and Reporting of Clinical Breast Examination: A review of the literature. CA: A Cancer Journal for Clinicians , 54(6), 345–361.
  33. Mehn, M. A., Goldstein, M. K., Pennypacker, H. S., Kanuck, K. T., & Thomas, S. J. (2002). Women age 50 and older who are blind or visually impaired learn proficient skill-based breast self-examination. Proceedings of the Fourth Meeting of National Leaders in Women's Health Research [Successful Aging: Women's Health and Well-being in the Second 50 Years], University of Florida, Health Science Center, March 9–11, 2001, Gainesville, Florida.
  34. O'Malley, M. S. (1993). Cost-effectiveness of two nurse-led programs to teach breast self-examination. American Journal of Preventive Medicine , 9(3), 139–145.
  35. Pennypacker, H. S. (1991). Perspective on manual breast examination. Administrative Radiology Journal , 10(7), 33–36.
  36. Pennypacker, H. S., Bloom, H. S., Criswell, E. L., Neelakantan, P., Goldstein, M. K., & Stein, G. H. (1982). Toward an effective technology of instruction in breast self-examination. International Journal of Mental Health , 11(3), 98–116.
  37. Pennypacker, H. S., & Iwata, M. (1990). MammaCare: A case history in behavioural medicine. In D. Blackman & H. Lejeune (Eds.), Behavior analysis in theory and practice: Contributions and controversies (pp. 259–288). Hillsdale, NJ: Lawrence Erlbaum & Associates.
  38. Pennypacker, H. S., Naylor, L., Sander, A. A., & Goldstein, M. K. (1999). Why can't we do better breast examinations? Nurse Practitioner Forum , 10(3), 122–128.
  39. Pennypacker, H. S., & Pilgrim, C. A. (1993). Achieving competence in clinical breast examination. Nurse Practitioner Forum , 4(2), 85–90.
  40. Pilgrim, C. A., Lannon, C., Harris, R. P., Cogburn, W., & Fletcher, S. W. (1993). Improving clinical breast examination training in a medical school: A randomized controlled trial. Journal of General Internal Medicine , 8, 685–688.
  41. Pinto, B. M. (1993). Training and maintenance of breast self-examination skills. American Journal of Preventive Medicine , 9(6), 353–358.
  42. Pinto, B., & Fuqua, W. (1991). Training breast self-examination: A research review and critique. Health Education Quarterly , 18(4), 495–516.
  43. Saslow, D., Hannan, J., Osuch, J., Alciati, M. H., Baines, C., Barton, M., Bobo, J. K., Coleman, C., Dolan, M., Gaumer, G., Kopans, D., Kutner, S., Lane, D., Lawson, H., Meissner, H., Moorman, C., Pennypacker, H., Pierce, P., Sciandra, E., Smith, R., & Coates, R. (2004). Clinical breast examination: Practical recommendations for optimizing performance and reporting. CA: A Cancer Journal for Clinicians , 54(6), 327–344.
  44. Saunders, K. J., Pilgrim, C. A., & Pennypacker, H. S. (1986). Increased proficiency of search in breast self-examination. Cancer , 58, 2531–2537.
  45. Stephenson, H. S., Adams, C. K., Hall, D. C., & Pennypacker, H. S. (1979). Effects of certain training parameters on detection of simulated breast cancer. Journal of Behavioral Medicine , 2(3), 239–250.
  46. Stratton, B. F., Nicholson, M. E., Olsen, L. K., Mahoney, B. S., & Warland, R. H. (1994). Breast self-examination proficiency: Attitudinal, demographic and behavioral characteristics. Journal of Women's Health , 3(3), 185–195.
  47. Thomas, R. G., et al. (1981). Computer aided instruction of breast self-examination. Annals of the World Association for Medical Informatics , 1, 19–22.
  48. Trapp, M. A., Kottke, T. E., Viekrant, R. A., Kaur, J. S., & Sellers, T. A. (1999). The ability of trained nurses to detect lumps in a test set of silicone breast models. Cancer , 86, 1750–1756.
  49. Worden, J. K., Solomon, L. J., Flynn, B. S., Costanza, M. C., Foster, R. S., Jr., Dorwaldt, A. L., & Weaver, S. O. (1990). A community-wide program in breast self-examination training and maintenance. Preventive Medicine , 19(3), 254–269.
  50. Yang, Jui-Chen. (2007). The effects of a breast self-examination education program in Taiwanese women: A triangulation study. Unpublished doctoral dissertation. National Taiwan University.

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