mammography

Mammography

 

Definition

Mammography is the study of the breast using x ray. The actual test is called a mammogram. There are two types of mammograms. A screening mammogram is ordered for women who have no problems with their breasts. It consists of two x-ray views of each breast. A diagnostic mammogram is for evaluation of new abnormalities or of patients with a past abnormality requiring follow-up (i.e., a woman with breast cancer treated with lumpectomy). Additional x rays from other angles or special views of certain areas are taken.

Purpose

The purpose of screening mammography is breast cancer detection. A screening test, by definition, is used for patients without any signs or symptoms in order to detect disease as early as possible. Many studies have shown that having regular mammograms increases a woman's chances of finding breast cancer in an early stage, when it is more likely to be curable. It has been estimated that a mammogram may find a cancer as much as two years before it can be felt. The American Cancer Society, American College of Radiology, American College of Surgeons and American Medical Association recommend annual mammograms for every woman beginning at age 40.

Screening mammograms usually are not recommended for women under age 40 who have no special risk factors and a normal physical breast examination. Below age 40, breasts tend to be "radiographically dense," which means it is difficult to see many details. In 2003, a new technique that introduces radiographic contrast into digital mammograms was proving useful at improving visibility of breast cancer in younger women. Screening mammograms can detect cancers in their earliest stages and greatly reduce mortality, particularly among women age 40 to 69. In fact, a study in 2003 found that women age 40 and older who had annual screening mammograms had better breast cancer prognoses because their cancers were diagnosed at earlier stages than women who had mammograms less often.

Some women are at increased risk for developing breast cancer, such as those with two or more relatives who have the disease. The 2003 American Cancer Society guidelines stated that women at increased risk might benefit from earlier screening mammograms and more frequent intervals for screening. However, the society suggested that evidence was not strong enough at that time to support making specific recommendations concerning screening examinations.

Diagnostic mammography is used to evaluate an existing problem, such as a lump, discharge from the nipple, or unusual tenderness in one area. The cause of the problem may be definitively diagnosed from this study, but further investigation using other methods often is necessary. This exam also is used to evaluate findings from screening mammography.

Description

A mammogram may be offered in a variety of settings. Hospitals, outpatient clinics, physicians' offices, or other facilities may have mammography equipment. In the United States, since October 1, 1994, only places certified by the U.S. Food and Drug Administration (FDA) are legally permitted to perform, interpret, or develop mammograms under the Mammography Quality Standards Act (MQSA).

In addition to the usual paperwork, a woman will be asked to fill out a form seeking information relevant to her risk of breast cancer and special mammography needs. The woman is asked about personal and family history of cancer, details about menstruation, child bearing, birth control, breast implants, other breast surgery, age, and hormone replacement therapy. Information about Breast Self Examination (BSE) and other breast health issues usually are available at no charge.

At some centers, a technologist may perform a physical examination of the breasts before the mammogram. Whether or not this is done, it is essential for the patient to tell the technologist about any lumps, nipple discharge, breast pain, or other concerns.

Clothing from the waist up is removed and a hospital gown or similar covering is put on. The woman stands facing the mammography machine. The technologist exposes one breast and places it on a plastic or metal film holder about the size of a placemat. The breast is compressed as flat as possible between the film holder and a rectangle of plastic (called a paddle), which presses down onto the breast from above. The compression should only last a few seconds, just enough to take the x ray. Good compression can be uncomfortable, but it is necessary to ensure the clearest view of all breast tissues.

Next, the woman is positioned with her side toward the mammography unit. The film holder is tilted so the outside of the breast rests against it, and a corner touches the armpit. The paddle again holds the breast firmly as the x ray is taken. This procedure is repeated for the other breast. A total of four x rays, two of each breast, are taken for a screening mammogram. Additional x rays, using special paddles, different breast positions, or other techniques are usually taken for a diagnostic mammogram.

The mammogram may be seen and interpreted by a radiologist right away, or it may not be reviewed until later. If there are any questionable areas or an abnormality, extra x rays may be recommended. These may be taken during the same appointment. More commonly, especially for screening mammograms, the woman is called back on another day for these additional films.

A screening mammogram usually takes approximately 15 to 30 minutes. A woman having a diagnostic mammogram can expect to spend up to an hour at the mammography facility.

The cost of mammography varies widely. Many mammography facilities accept "self referral." This means women can schedule themselves without a physician's referral. However, some insurance policies require a doctor's prescription to ensure payment. Medicare will pay for annual screening mammograms for all women with Medicare who are age 40 or older and a baseline mammogram for those age 35 to 39.

A digital mammogram is performed in the same way as a traditional exam, but the image is viewed on a computer monitor, stored as a digital file, and can be printed on film. Medicare now pays a small additional fee for digital mammography.

Preparation

The compression or squeezing of the breast for a mammogram is a concern for some women, but necessary to render a quality image. Even with concerns about pain, a 2003 study said that three-fourths of women reported the pain associated with a mammogram as four on a 10-point scale. Mammograms should be scheduled when a woman's breasts are least likely to be tender. One week after the menstrual period is usually best. The MQSA regulates equipment compression for consistency and performance.

Women should not put deodorant, powder, or lotion on their upper body on the day the mammogram is performed. Particles from these products can get on the breast or film holder and may look like abnormalities on the mammogram film.

Aftercare

No special aftercare is required.

Risks

The risk of radiation exposure from a mammogram is considered virtually nonexistent. Experts are unanimous that any negligible risk is far outweighed by the potential benefits of mammography.

Some breast cancers do not show up on mammograms, or "hide" in dense breast tissue. A normal (or negative) study is not a guarantee that a woman is cancer-free. Mammograms find about 85% to 90% of breast cancers.

"False positive" readings also are possible, and 5% to 10% of mammogram results indicate the need for additional testing, most of which confirm that no cancer is present.

Normal results

A mammography report describes details about the x ray appearance of the breasts. It also rates the mammogram according to standardized categories, as part of the Breast Imaging Reporting and Data System (BIRADS) created by the American College of Radiology (ACR). A normal mammogram may be rated as BIRADS 1 or negative, which means no abnormalities were seen. A normal mammogram may also be rated as BIRADS 2 or benign findings. This means that one or more abnormalities were found but are clearly benign (not cancerous), or variations of normal. Some kinds of calcification, lymph nodes, or implants in the breast might generate a BIRADS 2 rating. A BIRADS 0 rating indicates that the mammogram is incomplete and requires further assessment.

Abnormal results

Many mammograms are considered borderline or indeterminate in their findings. BIRADS 3 means an abnormality is present and probably (but not definitely) benign. A follow-up mammogram within a short interval of six months is suggested. This helps to ensure that the abnormality is not changing, or is "stable." This stability in the abnormality indicates that a cancer is probably not present. If the abnormality is cancerous, it will likely grow and change in the time between mammograms. Some women are uncomfortable or anxious about waiting and may want to consult with their doctor about having a biopsy. BIRADS 4 means suspicious for cancer. A biopsy is usually recommended in this case. BIRADS 5 means an abnormality is highly suggestive of cancer. The suspicious area should be biopsied.

Often, screening mammograms are followed up with additional imaging. The reasons are numerous; they may mot mean the radiologist suspects a cancerous lesion, only that he or she cannot make a clear diagnosis from the screening mammogram views. The most common imaging methods are additional views on the mammogram, sometimes called magnification views, and ultrasound. In recent years, some patients have received magnetic resonance imaging (MRI) of the breast. A new technique called dual-energy contrast enhanced digital subtraction mammography is reported to find cancers that may be missed by conventional mammography. It may be ordered in the future as a follow-up study.

Key terms

Breast biopsy — A procedure in which suspicious tissue is removed and examined by a pathologist for cancer or other disease. The breast tissue may be obtained by open surgery or through a needle.

Radiographically dense — Difficult to see details of breast tissue on x ray.

Resources

Books

Henderson, Craig. Mammography & Beyond. Developing Technologies for the Early Detection of Breast Cancer: A Non-technical Summary. Washington, DC: National Academy Press, 2001.

Love, Susan M., with Karen Lindsey. Dr. Susan Love's Breast Book. 3rd ed. Boulder, CO: Perseus Book Group, 2000.

Periodicals

"Contrast Mammography Reveals Hard-to-find Cancers." Cancer Weekly October 14, 2003: 34.

"Mammography in Women Over Forty Catches Disease Earlier." Women's Health Weekly August 14, 2003: 14.

"New Digital Technique Improves Mammography Results." Women's Health Weekly September 18, 2003: 28.

Smith, Robert A., et al. "American Cancer Society Guidelines for Breast Cancer Screening: Update 2003." Cancer May-June 2003: 141-170.

"Stress—Not Pain—Is Major Barrier to Mammography." Contemporary OB/GYN July 2003: 17.

Organizations

American Cancer Society. 1599 Clifton Rd., Atlanta, GA 30329. (800) ACS-2345. http://www.cancer.org.

National Cancer Institute. Office of Cancer Communications, Bldg. 31, Room 10A31, Bethesda, MD 20892. NCI/Cancer Information Service: (800) 4-CANCER. http://cancernet.nci.nih.gov.

U.S. Food and Drug Administration. 5600 Fishers Lane, Rockville, MD 20857. (800) 532-4440. http://www.fda.gov.

mammography

 [mah-mog´rah-fe]

radiography of the breast. The procedure involves exposure to less than one rad of radiation and is considered to have benefits that outweigh the relatively small risk to the patient. During mammography the patient's breasts are placed alternately on a metal plate and radiographs are taken from the side and above.

The American Cancer Society recommends that a baseline mammogram be done between the ages of 35 and 40 for later comparisons if needed. A yearly mammogram is recommended for women over the age of 50 to screen for breast cancer that may not be discovered during other types of breast examination.

Mammograhy. From Damjanov, 2000.

mam·mog·ra·phy

(ma-mog'ră-fē),

Radiologic examination of the female breast with equipment and techniques designed to screen for cancer.

[mammo- + G. graphō, to write]

Mammography can detect carcinoma of the breast sometimes as early as 2 years before a lesion becomes palpable and in many cases before lymph node metastasis has occurred. Mammographic findings that strongly suggest carcinoma are ill-defined densities within breast tissue and microcalcifications. These findings are not specific, however, and the cumulative probability of a woman's having a false-positive mammogram during 10 years of annual examinations approaches 50%. Numerous clinical studies seem to support the value of mammography in reducing the mortality of breast cancer, particularly in women aged 50-69 years. Although some observers have questioned the validity of these studies, the balance of opinion favors a substantial life-sparing role for mammographic screening in both middle-aged and elderly women. Magnetic resonance imaging (MRI) may detect tumors at an earlier stage than mammography, and has been recommended by some authorities for annual surveillance of women at high risk. Scintimammography after intravenous injection of technetium 99m sestamibi may be used to follow up an equivocal mammogram. Positron emission tomography has shown promise in discriminating between benign and malignant breast masses as well as in detecting axillary lymph node metastases in patients with newly diagnosed breast cancer and distant metastases in patients with advanced or recurrent breast carcinoma. Because of the high cost of this procedure, its use is limited to high-risk subjects and those with dense breasts. The higher density of breast tissue in younger women limits the ability of radiography to identify tumors in women between ages 40 and 50, for whom ultrasonography is preferred in evaluation of palpable breast lesions. Research has suggested that for a small fraction of women, exposure to radiation during mammography may actually trigger breast cancer. The American Cancer Society, the National Cancer Institute, and the American College of Radiology recommend a baseline mammogram for every woman by age 40 and annual mammograms after age 50. Mammograms should begin at age 25 for women who are at special risk because of family history. Because some 10% of breast cancers that can be palpated on examination are missed by mammography, annual examination of the breasts by a physician is also recommended. Digital scanning further enhances the detection of microcalcifications and spiculated masses on mammography. However, mammography remains a screening procedure, and diagnosis of breast lesions depends on physical examination and biopsy findings. Federal law requires all facilities in the U.S. that perform mammography provide the examinee with a report of the results in clear, simple language within 30 days after the examination, besides providing a detailed report to the physician who ordered the examination. see also carcinoma of breast.

mammography

(mă-mŏg′rə-fē)

n. pl. mammogra·phies

1. Radiological examination of the breast, used to screen for or evaluate tumors and other abnormalities.

2. The procedure performed to produce a mammogram.

mammography

The radiologic examination of the breast using a dedicated device designed specifically for imaging the breast. Mammography is the single best noninvasive screening procedure for detecting breast cancer: it yields a false negative rate of 5–15% and a false positive of 10%. 24% of biopsies of non-palpable breast masses with calcification (> 15 calcifications or calcifications in a linear or branching fashion) have ductal or lobular carcinoma.

Guidelines for mammography
National Cancer Advisory Board (US)
• High risk women—annual mammogram (MG) breast self-examination (BSE), < age 40.
• Average risk women—annual MG & BSE, age 40–49.
• Low risk women—annual MG & BSE, > age 50.

American Cancer Society and the National Cancer Institute (US)
BSE after age 20, a baseline MG between ages 35–45, and annual or biennial MG thereafter.

Frequency of mammography is a function of the person’s risk factors for BC:
• First-degree relative with BC;
• Caucasian;
• Later pregnancy.

Mammography categories (American College of Radiologists)
0—Incomplete, additional imaging evaluation needed.
1—Negative.
2—Benign finding.
3—Probably benign, short follow-up interval suggested.
4—Suspicious abnormality, biopsy should be considered.
5—Highly suggestive of malignancy, appropriate action warranted.

mammography

Imaging The radiologic examination of the breast using a dedicated device designed specifically for imaging the breast; mammography is the single best noninvasive screening procedure for detecting breast CA; mammography–MG yields a false negative rate of 5-15% and a false positive of 10% Radiology Finely-stippled microcalcifications–white pinpoint-sized dots; suspicious–eg, poorly-circumscribed–geographic densities; other findings–as classified by Wolf are thought to be less reliable; radiation dose during a MG is 25-35 kV/0.025-.035 rem–2.5-3.5 x 10^–4 Sievert; the Am Cancer Society and the NCI–US recommend breast self examination–BSE after age 20, a baseline MG between ages 35-45, and annual or biennial MG thereafter–frequency of mammography is a function of the person's relative risk factors for breast CA–first-degree relative with breast CA, caucasian, later pregnancy; 24% of biopsies of non-palpable breast masses with calcification–> 15 calcifications or calcifications in a linear or branching fashion have ductal or lobular CA Guidelines National Cancer Advisory Board High risk ♀–annual MG & BSE < age 40; average risk ♀–annual MG & BSE 40–49; low risk ♀–annual MG & BSE > age 50. See Breast cancer, Cancer screening, Scintimammography. Cf Lumpectomy.

mam·mog·ra·phy

(mă-mog'ră-fē)

Imaging examination of the breast by means of x-rays; used for screening and diagnosis of breast disease.

[mammo- + G. graphō, to write]

mammography

(ma-mog'ra-fe ) [ mamma + -graphy]

MAMMOGRAPHY SHOWING BREAST CANCER

Radiographic imaging of the breast to screen for and detect breast cancer. Mammography detects about 85% to 90% of existing breast cancers and, along with breast self-examination and regular professional check-ups, increases the rate of early breast cancer detection. Mammography detects more cancers when more than one radiologist interprets each image, a technique called double reading. The American Cancer Society and expert panels convened by the federal government publish guidelines for the frequency of mammographic evaluation in the U.S. Although these guidelines change occasionally, evidence shows that mammographic screening can reduce the risk of dying from breast cancer in women between 40 and 69. See: illustration See: breast cancer for table.

Palpable abnormalities of the breast that appear mammographically benign should nonetheless be further evaluated, e.g., with ultrasonography, fine-needle or core biopsy, or close follow-up examinations.

MAMMOGRAPHY SHOWING BREAST CANCER

digital mammography

Mammography in which the image is collected electronically instead of on film. Compared to standard mammography, it improves the ability to visualize abnormalities in the breasts of women under 50.

illustration

full-field digital mammography

Abbreviation: FFDM
Digital mammography.

mammography

A method of X-ray examination of the breasts using low-radiation (soft) X-rays and specially designed apparatus to reveal density changes that might imply cancer. Mammography is used in cases of suspected breast cancer and as a screening procedure on groups of women. It cannot be relied on to exclude cancer and does not distinguish between benign and malignant tumours, but tumours that cannot be felt may be detected. Mammography has been found to be more reliable if its timing is properly phased with the menstrual cycle. Breast tissue is more dense during the luteal phase (days 15–28).

Patient discussion about mammography

Q. I am going for my first mammography, Is this test harmful? I am going for my first mammography on coming Tuesday…….just was worried as the doctor is suspecting a tumor….Is this test harmful?

A. Generally there is no harm. It may be harmful when you have them during or a week before the menstrual periods as due the tenderness of the breasts may cause discomfort.

Q. I am having mammograms annually since 10 years (now 43). I am having mammograms annually since 10 years (now 43), I'm not sure how much of the "armpit" area is included. I have recently noticed a lump on my right about half way between my breast and my armpit. It can be tricky to locate at times and I really don't think it's anything serious as it feels smooth and round. I do have very dense breasts. I had a core biopsy done on the same breast, upper & outer quadrant, some years ago that was benign. I am going to have my mammo for this year and I was wondering if this area between the breast and the armpit will be covered?

A. It’s difficult to get that area of the armpit in mammogram and I don't think they can get that close. If there is a lump, it will need to be addressed. Just let doctor know. Maybe they will send you for ultrasound. Good luck for your treatment.

Q. I know about breast cancer and I don’t have any lump and I had mammography but nothing was revealed…… I have been diagnosed with breast cancer now, till last week I was suspected with an allergy and I was on antibiotics and suddenly it came with cancer after my biopsy ………I know about breast cancer and I don’t have any lump and I had mammography but nothing was revealed…….anyone with some information on this problem…….now my doctor is planning to give me a chemo…..and all this is going very fast …..

A. again agree with dominic, but that's not harmful if you find a second opinion.
but if the second professional opinion says the same, then i will encourage you to follow your doctor's advise.

the earlier it is taken care, the better the result will be