Mammograms

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(Mammography, Digital Mammograms, Screening Mammography, Diagnostic Mammography)

Summary

A mammogram, or mammography, is a specialized x-ray procedure used to create detailedBreast cancer begins in the tissues, cells and ducts of the female or male breast. images of the breast. It is used to detect changes in the breast tissue, such as thickened tissue lumps or calcification that may indicate the presence of breast cancer, and finding them early can significantly increase a patient’s odds of survival. Mammography can detect some abnormalities between one and three years before they can be felt.

Mammograms can be ordered by a physician to detect a variety of breast disorders, ranging from cysts (fluid-filled sacs) to cancer. Mammograms may be ordered to:

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Screen for a condition. Used when women have no signs or symptoms of breast cancer or other breast abnormalities.

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Diagnose a condition. Used to check for cancer based on signs, symptoms or other test results.

A mammogram is conducted with the use of a special imaging machine on an outpatient basis. The test is administered by a radiation technologist, usually someone who has been specially trained for mammograms. The mammogram images are stored on films that are reviewed by a physician (physician mammographer) and often additional cancer specialists, for any signs of abnormalities.

Mammograms are currently the most effective way to screen for early breast cancer. The American Cancer Society recommends that women age 40 and older have a mammogram every year, while the National Cancer Institute recommends mammograms every one to two years for this age group.
About mammograms

A mammogram is a special x-ray of the breasts used to diagnose abnormalities, including breast cancer. It is the single most effective way to detect cancer in its early stages, when it is most treatable. Mammography can find abnormalities between one and three years before they can be felt. When breast cancer is detected before it has spread to the lymph nodes, patients have a five-year survival rate of 98 percent, according to the American Cancer Society (ACS). Only one or two mammograms out of every 1,000 leads to a diagnosis of cancer.

Mammograms detect cancer by revealing tissues that are denser than those in the normal tissues of the breast. They can detect lesions as small as 0.5 centimeters (0.2 inches). Most lumps cannot be felt until they are at least 1 centimeter (0.4 inches).

Mammograms can detect calcium deposits in the breast. Appearing as small, white dots on film, these can be the result of cell secretions, cell debris, inflammation, trauma, previous radiation or foreign bodies. Calcium deposits that are tiny and irregularly shaped (microcalcifications) are often associated with cancer. They may appear alone or in clusters. When found, they may prompt a follow-up mammogram or a biopsy. Microcalcifications are the most common sign on a mammogram of ductal carcinoma in situ (early noninvasive cancer confined to the breast ducts).

Larger, coarser deposits (macrocalcification) are sometimes the result of a benign (noncancerous) condition called fibroadenoma. This is a common tumor of the female breast. Aging of the breast arteries, old injuries and inflammation are also common causes of macrocalcification. Macrocalcifications are not cancerous and are found in half of women over age 50 and in one in 10 women under 50, according to the ACS.

Masses or lumps can occur with or without calcifications. While they are sometimes cancerous, they are often cysts (a non-cancerous collection of fluid) or benign tumors, such as fibroadenomas. If a cyst is suspected, it will need to be confirmed with either a fine needle aspiration or a breast ultrasound. Suspected cancerous masses will likely require a biopsy for confirmation. As with calcifications, masses can be caused by benign breast conditions or by breast cancer. The size, shape and edges (margins) of the mass help the physician determine whether or not it is cancer. The physician will also look for:

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Dense areas that appear in only one breast

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Dense areas or microcalcifications that were not seen in the patient’s last mammogram

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Distorted areas (which may suggest tumors that have invaded nearby tissues)

Sometimes, dense areas in mammograms indicate tissue packed with glands that make calcifications and masses harder to detect. On the other hand, dense areas may also indicate cancer itself.

If suspicious areas are found, a physician may order an ultrasound or needle aspiration to help determine whether the mass is solid (such as in a tumor) or is a fluid-filled cyst. If nipple discharge is present, a physician may order an x-ray exam called galactography, a procedure in which a fine plastic tube is placed into the opening of the nipple’s duct and a contrast material is injected into the duct.

Patients may obtain mammograms from many different facilities, including hospitals, clinics, physicians’ offices and x-ray or imaging centers. Mobile units also provide mammograms during screening events at shopping malls, community centers and offices. A federal law called the Mammography Quality Standards Act (MQSA) regulates mammography. Under MQSA, all mammography personnel and facilities, including mobile units, in the United States must be accredited and be certified by the Food and Drug Administration (FDA). In addition, these facilities must pass annual inspections and display their FDA certificate in a location visible to patients.

The ACS recommends that women age 40 and older have a mammogram every year, while the National Cancer Institute (NCI) recommends mammograms every one to two years for this age group.

Although mammograms are the most effective way to screen for breast cancer, studies have shown that many women fail to get them regularly. Common reasons provided by women included fear, embarrassment and most often, cost. Mammogram costs vary according to a patient's insurance coverage. Medicaid and private insurance typically cover the full cost of an annual screening mammogram on women over 40. Medicare, however, only covers 80 percent of the cost, forcing women to pay the remaining 20 percent. Many states offer mammograms at low or no cost to women who qualify based on income.

Women at higher risk of breast cancer should consult their physician about when to begin scheduling mammograms, and how often to have the procedure. Risk factors that may increase the scheduling of mammograms include:

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Personal history of breast cancer

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Breast cancer in mother or sister

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Family history or personal history of gene abnormalities associated with cancer (e.g., BRCA1 or BRCA2 genes)

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No pregnancies or first pregnancy after age 35

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Early onset of menstruation

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Late menopause

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History of atypical findings or prior breast biopsies

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Treatment with radiation therapy to the chest or neck before age 30

Mammograms are most effective when used to examine the breasts of women over age 40. As a woman ages, breast tissue increasingly is replaced with fat. By the time a woman reaches menopause, there are usually just a few strands of breast tissue left. Fat appears gray on mammograms, making it easy to see the white spots that indicate abnormalities. In contrast, the breasts of younger women are usually too dense to provide good mammogram images.

In many cases, an ultrasound or magnetic resonance imaging (MRI) is a good substitute for women in the MRI is an imaging test used in cancer diagnosis, to guide treatment and to monitor for relapse.older age group. MRI in conjunction with a mammogram also may be recommended for women who are at high risk for the disease. The ACS recommends women in their 20s and 30s have a clinical breast exam by a health professional every three years, preferably at the time of their mammogram.
Limitations of mammograms

Mammography tests are not perfect. Only the part of the breast that extends from the body can be imaged. This makes it easier to get an accurate picture of a large breast than a smaller breast. In addition, the periphery of the breast does not appear on the image at all. It also may be difficult to detect abnormalities that exist in the breast tissue adjacent to the chest wall.

Breast cancers are most likely to develop in dense tissue, where they are most difficult to detect. Mammograms can result in false negative readings (particularly in younger women, who have dense breast tissue) or false positive readings. In a false negative reading, dense breast tissue may obscure a tumor and the mammogram may fail to detect its presence. In a false positive, the mammogram appears abnormal when, in fact, no cancer is present.

Other factors that can significantly impact the accuracy of the test include:

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Quality of film used

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Experience and skill of the technician and radiologist. The appearance of breast tissue on a mammogram varies significantly from woman to woman. A skilled technician may be able to obtain more accurate films. The skill and experience of the radiologist can make a difference in how accurately the mammogram is analyzed.

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Breast density. Breast tissue becomes fattier and has fewer glands as women age, which results in mammograms that are easier to interpret. Breast tissue that is denser, as in younger women, makes it more difficult to detect abnormalities.

In addition, mammography does not detect all cancers. In some cases, such as the armpit or chest wall, the area of the body is not easily viewable. However, a lump may be felt in a breast exam. In other cases, the cancer may be too small to be revealed by this test. Up to 20 percent of breast cancers are missed by mammograms, according to the National Cancer Institute. For this reason, mammograms and physical exams are considered to be complementary techniques.

Mammograms of women with breast implants can be very difficult to interpret. The x-rays used in mammography do not easily penetrate silicone or saline implants, making it harder to image overlying and underlying breast tissue.

Women with implants are likely to have four additional images taken. Known as implant displacement (ID) views, they involve pushing the implant against the chest wall while the breast is pulled over it. This provides better imaging of the front part of the breast. This technique is not as effective in women who have experienced the formation of scar tissue around the implants. ID images are most successful in women whose implants are placed underneath the chest muscle.

Women who have had breast-conserving surgery, or lumpectomy, will need to continue to schedule regular mammograms, while women who have had their breast removed will no longer need mammograms of that area. Patients should consult with their physician about how breast cancer surgery might impact their need for future mammograms.
Types and differences of mammograms

Physicians order mammograms to detect or diagnose breast abnormalities ranging from cysts to cancer. Mammograms may be performed for different purposes and include:

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Screening mammogram. Used when women have no signs or symptoms of breast cancer. The goal is to detect cancers in the earliest state. A screening mammogram typically requires two x-rays of each breast.

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Cranial-caudal. Examines the breasts from above.

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Mediolateral-oblique. Examines the breasts from an angle that includes breast tissue extending to the armpit.

The initial mammogram is often called the baseline mammogram. Radiologists use this image as a baseline against which they will compare future mammograms.

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Diagnostic mammogram. Used to check for cancer due to symptoms or other test results, including screening mammograms. Diagnostic mammograms may include more images and may concentrate on specific areas of the breast. Changes in the breast that may indicate the need for a mammogram include:

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Lumps
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Pain
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Nipple thickening, retraction or discharge
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Change in breast size or shape, or change in overlying skin

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After a woman has been diagnosed with breast cancer, she will continue to receive regular diagnostic mammograms.

Diagnostic mammograms are also used to evaluate the breasts of women with implants, which sometimes can obscure the presence of the disease.

Before the mammogram test

In preparing for a mammogram, women can gather information that may be valuable to the physician. Information to report includes:

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Problems with breasts
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Past breast biopsies or surgeries
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Whether the patient has implants
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Whether the patient is pregnant or nursing
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Whether the patient is using hormone replacement therapy or taking hormones or treatment for any breast disorders
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Timing of menstrual cycle
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Whether the patient has started menopause

Patients who schedule an exam at a new facility should be sure to bring prior mammograms and accompanying reports with them. It is important to bring the original mammogram films, rather than copies. Federal law requires that all mammography facilities give patients their original mammograms when needed.

During a mammogram, a woman’s breasts will be compressed. Patients should not schedule these exams when breasts are likely to be tender, such as the week before or week of a menstrual period. The week after a menstrual period is often the time when a woman’s breasts are least tender.

On the day of the test, women should not apply any of the following under their arms or to their breasts:

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Deodorants and antiperspirants
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Powders
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Lotions
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Creams
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Perfumes

Some of these cosmetics can cause densities on mammograms, leading to confusion during the reading of the mammogram.

Women with a history of breast pain (mastalgia) or tenderness should consider taking an over-the-counter pain medication about one hour prior to a mammogram.
During the mammogram test

The patient will be given a gown and asked to remove clothing from the waist up. She will also be asked to remove neck jewelry. Some mammography facilities are now using skin markers to help identify certain normal features of the breast, including the nipple and any surgical scars, raised moles and other natural details. The markers are placed on the patient’s skin and can be easily identified when the physician mammographer later reads the mammogram. In some cases, markers may also be used to identify suspicious lumps and other abnormalities. These markers aid physicians in reading the mammograms.

During the test, the patient stands in front of an x-ray machine designed for mammography. A technician positions a breast on a platform that holds the x-ray film and raises or lowers the platform depending on the patient’s height. The patient’s head, arms and torso will be adjusted to allow an unobstructed view of the breast. It may take the technician several attempts before the correct position is achieved for the image.

A clear, plastic plate then gradually presses the breast against the platform. This helps spread out and separate the breast tissue so x-rays can penetrate it more accurately. The pressure also helps hold the breast still, decreasing any potentially blurring of the image. Although this pressure lasts only for a few seconds and is not harmful, some women may experience discomfort or pain. This should be reported to the technician, although in many cases it cannot be avoided as the positioning or pressure is necessary to obtain an accurate image.

Patients are asked to stand still and hold their breath as images are taken. Usually, images will be taken of both breasts. During a diagnostic mammogram, the technician takes images from various angles and may increase the magnification of images or focus on areas of concern.

After a set of images have been taken, women are often asked to wait to get dressed until the radiologist has viewed the films. If the films are not adequate or an area of concern is noted, additional images may need to be taken at that time.

A mammography procedure usually takes about 30 minutes.