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Clinical breast exams are an incredibly valuable screening and early detection tool

Dr. Lily Gutnik is a U.S. breast surgeon specializing in breast cancer. In this interview she talks about her passion for her job, the challenges in breast cancer screening at the global level and why she is fascinated by discovering hands.

DH: Why did you choose to become a doctor and why did you specialize in breast oncology?

Dr. Gutnik: I cannot remember a time when I did not want to be a doctor. In ninth grade honors biology class we did fetal pig dissections and I absolutely loved it. That is when I decided to be a surgeon. During my experience in Malawi, a country in East Africa where I worked on breast cancer research, clinical care and advocacy, I witnessed firsthand huge global disparities regarding breast cancer and decided that this would be my niche. I am fascinated by this subject because it allows me to combine my passion for surgery, research, global public health, and advocacy.

DH: What do you like most about your job and what are the biggest challenges?

Dr. Gutnik: I am very fortunate because I have a job I truly love and work with a fantastic team of nurses, partners, and research and administrative staff. I definitely love the clinical and research aspects of my job equally. I am also the Associate Vice Chair of Global Surgery for the Department of Surgery as well as the Assistant Program Director for the General Surgery Residency–Global Surgery. Therefore, one of the biggest challenges of my job is to balance all these different roles and responsibilities. I just try to take things one day and one week at a time. One of my mentors shared a wonderful analogy with me regarding everyday life. We juggle various balls and some of those balls are made of glass, so the goal every day is to make sure that the glass balls do not drop. I definitely strive to live by that motto.

DH: How did you learn about discovering hands and how did you become involved?

Dr. Gutnik: I learned about discovering hands through one of the cofounders, Phyllis Heydt. I was living in New York at the time and had just returned to the U.S. from Malawi, where my research was centered on training laywomen to conduct clinical breast exams and give breast education talks in clinics within the tertiary referral public hospital and the capital city of Lilongwe. At the time, discovering hands had received an award from the Bayer Foundation to build a franchise in India and thus they were looking for partners. Unfortunately, due to the fact that I was still completing my general surgery training in the U.S. I was not able to take another leave of absence to support the endeavor in India. However, we noted a lot of parallels between the vision and mission of discovering hands and my work. I immediately thought that the concept and model of discovering hands was innovative and fascinating. I have very much wanted to contribute in any meaningful way. At that time, we decided that I would join the advisory board of the India project. I have been involved in similar roles with discovering hands ever since. Currently, I am on the committee for pretac+, which is a discovering hands pilot project partner in Geneva, Switzerland. In this role, particularly, I have been advising on the clinical perspective.

DH: Why do you consider the tactile examination of the breast essential, in addition to screening methods such as mammography and ultrasound?

Dr. Gutnik: Clinical breast exams are an incredibly valuable screening and early detection tool. There have been six global randomized control trials that showed us effectiveness particularly in terms of breast cancer downstaging and even mortality. It is endorsed by several leading international organizations, including the Lancet Commission on Women's Cancers and Equity, WHO, Breast Global Health Initiative and NCCN guidelines, particularly for use in settings where population-based organized screening mammography is not available or possible. There have even been impressive publications, like a 25-year follow-up study done in Canada on mammography and clinical breast exam versus clinical breast exams alone, which showed no difference in breast cancer mortality. Similarly, a recent over-20-year follow-up study of a randomized control trial of a clinical breast exam screening program performed by community health workers in India showed significant downstaging of breast cancer as well as a reduction in mortality for women over 50. This of course does not even mention the numerous single-center and single-country trials while supporting these results. It is a cost-effective, valuable tool that should be added to the arsenal of breast cancer screening and early detection. Additionally, even in settings where mammography is widely available, not all women are comfortable doing it or have other barriers to access it. For example, even in the United States, where screening mammography is available and offered for free for those who may be uninsured or underinsured, there is still only about a 75% mammogram screening rate. As a consequence, a quarter of the population is not screened. There are similar data for various countries in Europe, and some countries have even lower mammography screening rates. Where there has been research to understand why this phenomenon occurs, numerous barriers have been cited, but one thing that has come up is the discomfort and fear associated with mammography. Therefore, at least for these women, a very thorough clinical breast exam could be a very important adjunct to breast cancer screening.

DH: From your point of view, what are the main benefits of the discovering hands method?

Dr. Gutnik: The main benefit of the discovering hands method is that it is truly a win-win scenario.  It takes a traditionally marginalized and ostracized population that is labeled as disabled and turns their disability into a profound capability. They are able to find more tumors and smaller tumors than physicians can. They are able to spend more time with patients than physicians can. They provide a more nurturing and comfortable environment for the patient. Additionally, they are now employed and contribute in a very meaningful way. All the MTEs that I have met have stated how much they love their job and how valued they feel. I remember meeting an MTE who had lost her vision later in life and been rapidly progressing to the point she could only see around 5% of what she saw before her diagnosis. She told me that while she would love science and medicine to advance to find a cure for her disease, but she would actually not want to be fully cured because she loves her job as an MTE so much. That was a very striking and profound moment for me. 

DH: At the moment you are a board member of pretac+, an organization that is currently working on the implementation of discovering hands in Switzerland. How do you support the team and why do recommend that Swiss women take advantage of a tactile breast examination by an MTE?

Dr. Gutnik: I mainly support the team by providing the clinical perspective. I speak with Swiss physicians who might be interested in placing MTEs as interns or eventually hiring them. During the training, I have helped in observing the MTEs do a breast exam and participated in the teaching about breast cancer. My understanding from working with pretac+ is that the Swiss healthcare system varies depending on whether it is offered privately or publicly and which canton a patient resides in, which also affects women’s access to mammography screening. Additionally, as seen in many other countries around the world, even if it is available, women may not want to do a mammography for various reasons, including the pain and discomfort associated with it. discovering hands is another tool in the arsenal of modalities for breast cancer screening and early detection. I do not think that breast cancer screening is or should be a one-size-fits-all model, but that women should have a choice and make the choice that is best for them based on the evidence available. Thus, I think it is important to add MTEs to this tool kit.

DH: At the moment you are based in the U.S., but you have also worked in Africa and support discovering hands in Switzerland. Thus, you have a good overview of the global situation in regard to breast cancer screening. What are the differences and similarities?

Dr. Gutnik: That is a big topic! My specific area of research is focused on screening and early detection strategies, particularly in low-resource settings or for vulnerable populations. In general, the gold standard is still screening mammography. However, it is really truly only endorsed and most effective when you can have it as an organized population screening manner and not as an opportunistic screening. So, a lot of settings are not truly able to do that. This, of course, is all for average-risk women. High-risk screening is a totally separate and complex topic. Nevertheless, there is still a large mammography debate happening among the practitioners globally where there is certainly a group of people that are less supportive of screening mammography because of the harms of overdiagnosis and false positives. It is certainly very important to have a discussion on the risks and benefits mammography when screening patients. Furthermore, even in the U.S. there are various recommendations depending on the professional group or society as to when to start and stop screening and at what interval to do screening. This is also consistent in other European countries. In low-resource settings, mammography is largely inaccessible, so a clinical breast exam is advocated. However, there are still very few true screening programs available for breast cancer in low-resource settings. Furthermore, as already mentioned, even in settings that do have theoretically available screening mammography there are disparities in access and utilization within the countries.

DH: What is your vision for discovering hands in the future?

Dr. Gutnik: Scale! I think it is an incredible model that is innovative and effective. I also think that because it is a social enterprise rather than a charitable organization it has the capacity for greater sustainability and scale. I would love to see discovering hands in every country in the world! I would also like to see more long-term research with outcomes being monitored and reported.

 

Lily Gutnik M.D. is Assistant Professor at the Division of Breast and Endocrine Surgery at the University of Alabama at Birmingham, United States. She also supports the General Surgery Residency Program as an assistant program director for global surgery. Additionally, Dr. Gutnik serves the O’Neal Comprehensive Cancer Center at UAB as an associate scientist in the Cancer Control and Population Science Program. In 2022, she was appointed to the Sparkman Center for Global Health Scholars Program. In May 2022, she was named Associate Vice Chair of Global Surgery for the UAB Department of Surgery.

Dr. Gutnik completed a research fellowship at the Center for Surgery and Public Health at Harvard University/Brigham and Women’s Hospital, where she gained valuable experience in health services research. She served on the Finance and Economics Committee on the Lancet Commission for Global Surgery. Her longstanding research passion has revolved around the impact of breast cancer screening and early detection in low-research settings.

Dr. Gutnik’s full profile can be found at https://www.uab.edu/medicine/surgery/breast-endocrine/faculty/gutnik-lily-a-m-d