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Official reprint from UpToDate

www.uptodate.com
2013 UpToDate

Authors
Shambhavi Venkataraman, MD
Priscilla J Slanetz, MD, MPH, FACR
Section Editor
Suzanne W Fletcher, MD
Deputy Editor
H Nancy Sokol, MD
Breast imaging: Mammography and ultrasonography
Disclosures
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Dec 2012. | This topic last updated: Dec 4, 2012.
INTRODUCTION Screening mammography is the primary imaging modality for early detection of breast cancer
because it is the only method of breast imaging that consistently has been found to decrease breast cancer-related
mortality [1-3]. Mammography may detect cancer one and a half to four years before a cancer becomes clinically
evident [4,5].
Ongoing technologic advancements, to both enhance mammography and develop other breast imaging modalities,
seek to provide earlier diagnosis of breast disease; more accurate assessment of disease extent and treatment
response; and improve the detection of recurrence.
This topic will review mammography technique, performance capabilities of mammography in particular patient
groups, interpretation of a mammogram report, and the use of breast ultrasound as an adjunct to mammography.
Issues regarding screening for breast cancer, the role of mammography in women with suspected disease, and
surveillance for patients with known breast cancer are discussed separately. (See "Screening for breast
cancer" and "Clinical features, diagnosis, and staging of newly diagnosed breast cancer" and "Approach to the
long-term survivor of breast cancer".) Other imaging techniques for breast disease are discussed separately. (See
"MRI of the breast and emerging imaging technologies".)
MAMMOGRAPHY The first x-ray of the breast, obtained in 1913 from a mastectomy specimen, showed the
presence of primary tumor in the breast specimen as well as spread to the axillary lymph nodes [6]. Calcifications
were reported in radiographs of breast cancer in 1949 [6]. Soon after this, patient positioning for radiographs of the
breast similar to present day standard views were described.
The prototype of the mammography unit was developed in 1965 [6]. Many technical advances have been made
since then to improve the image quality, as well as to reduce the radiation dose to the patient.
A mammogram involves exposing the breast to x-rays. These x-rays are both transmitted through the breast tissue
as well as scattered to the surrounding tissue. The x-rays are attenuated based upon the characteristics of the
breast tissue, and are then absorbed as latent images on the recording device (figure 1). The latent image is
processed and displayed for diagnostic purposes [7].
THE MAMMOGRAPHIC EXAMINATION Routine evaluation includes obtaining two views (craniocaudal and
mediolateral oblique) of each breast. In the craniocaudal (CC) view (image 1), the breast is lifted and positioned on
the plate and compression is applied from above. In the mediolateral oblique (MLO) view (picture 1), the breast is
compressed and imaged from the side. Breast positioning is critical. Improper positioning may lead to exclusion of
parts of the breast from the field of view, risking non-visualization of a cancer (image 2).
These two standard views ensure adequate imaging of the relatively mobile inferior and lateral parts and the
relatively fixed upper and medial parts of the breast. Obtaining two views for each breast aids in distinguishing
overlapping structures from true abnormalities.
The added benefit of detecting more cancers and lower recall rates with two views outweighs the extra cost and
radiation from the second view [8-10]. Studies have shown that 11 to 25 percent of cancers could be missed if only
one view were obtained [8,9]. When circumstances dictate that only one view is to be obtained, the MLO view,
which images a greater amount of breast tissue compared to the CC view, is preferred.
Breast compression Adequate breast compression is necessary to obtain good quality mammograms.
Compression increases the image contrast and decreases the radiation dose. Since compression causes
homogeneous breast thickness, x-ray penetration is uniform through the tissues. Compression also reduces motion
and minimizes superimposition of tissues, improving the diagnostic quality of the study (picture 2).
Compression ideally should be applied until the breast is held firm and immobile. However, the degree of pain and
discomfort experienced during the examination affects the utilization of regular mammography [11,12]. One way of
making the examination more tolerable is to give patients control over the degree of compression [13,14]. The utility
of patient-controlled compression was evaluated in a study of 109 patients undergoing screening mammography. All
women were imaged in the same mammography unit. By random assignment, one breast was compressed by the
technologist and the other by the patient. Patient-controlled compression was significantly less painful, and
preserved image quality [14].
Other attempts to relieve anxiety and discomfort associated with mammography have included use of a soft breast
cushion, premedication with oral analgesics, and application of topical lidocaine to the breast [15-20].
Premedication with topical 4 percent lidocaine gel significantly reduced discomfort during screening
mammograms in one study [18]. The topical medication is best applied in the doctor's office by trained
medical professionals. The topical anesthetic should be applied sparingly, and not to irritated skin, as case
reports of death have been reported when topical anesthetics were applied to large body surface areas for
laser hair removal. The US Food and Drug Administration issued an alert in this regard in 2009 [21].
The use of radiolucent cushions on the compression paddle surface decreased pain in more than 65 percent
of 838 women in one series [20]. Pain decreased by an average of 53 percent compared to the
noncushioned breast in those women who experienced pain relief. There was no compromise in image
quality.
Radiation dose The purpose of screening mammography is to decrease mortality by identifying early stage
breast cancer. There is no evidence that routine screening mammography in women, initiated at age 40, is
associated with increased risk from radiation [22].
There is concern, however, that women with BRCA1 or BRCA2 mutations are at increased risk for radiation-induced
oncogenesis, because of impaired DNA repair mechanisms. For these women, in whom initiation of screening at an
early age is usually recommended, the risk of radiation-induced cancer needs to be balanced against the risk of
gene-related early onset cancer; the appropriate age to initiate mammogram screening is uncertain [23]. (See
"Management of hereditary breast and ovarian cancer syndrome and patients with BRCA mutations".)
For all women, it is important to keep the radiation dose as low as possible without compromising image quality.
The development of more efficient emulsions and screens in film screen mammography has decreased the dose per
exposure [24-26]. Despite technologic improvements, a film screen system does not use all the x-ray photons that
pass through the breast. Digital mammography is associated with a lower radiation dose than film screen
mammography for the same image quality [27-29].
The radiation dose absorbed by the breast depends upon the breast tissue thickness, with the dose absorbed
increasing with the thickness of the breast [29]. Most mammography equipment delivers a mean glandular dose of
0.1 to 0.2 rads (1 to 2 mGy) per exposure. The American College of Radiology recommends that the mean
glandular dose exposure for a breast that is 4.2 cm thick should not exceed 0.3 rads (3 mGy) per image.
The effective radiation dose is often expressed in sievert or millisievert (mSv) units. Sievert units account for relative
sensitivities of different tissues and organs exposed to radiation. The effective dose received from a routine
screening mammogram is 0.7 mSv, equivalent to the dose received from natural background radiation over three
months. (See "Radiation-related risks of imaging studies".)
Film screen mammography Mammogram x-rays pass through the breast tissue and are converted to light by
fluorescent screens. This light causes a chemical reaction in the film emulsion that is processed and displayed as
a grayscale image. In a film screen (analog) mammogram, the image is captured, displayed, and archived for
storage in a film [7,30].
Film has multiple attributes that make it an appropriate medium for mammography:
High spatial resolution (up to 20 line pairs per millimeter) allows demonstration of microcalcifications, lesion
margins, and spiculations [31].
High contrast resolution permits differentiation of subtle differences in soft tissue densities.
The film is easily displayed.
Normal areas of the breast image can be masked to improve visualization of abnormalities.
Multiple examinations can be viewed on serial view panels.
However, film screen mammography has a number of disadvantages, compared to full field digital mammography
(see 'Full field digital mammography' below) [31,32]:
A limited dynamic range makes it difficult to image all components of the breast (fat and dense tissue)
optimally, and to differentiate between small cancers and surrounding breast tissue of similar density.
The inability to manipulate the image following exposure may lead to retakes and increased radiation dose to
the patient.
Film is subject to artifacts from processing and storage.
Films may be misfiled, lost, or otherwise not readily retrievable when comparisons are needed.
Two standard cassettes 18 x 24 cm and 24 x 30 cm are available to accommodate breasts of different sizes.
Women with larger breasts may require more than two views of each breast to ensure imaging of all breast tissues.
Narrow compression paddles (half the width of regular paddle) are also available for women with small breasts and
for men.
Full field digital mammography The first digital mammograms were digitized copies of film screen
mammograms. Digital mammograms are now obtained directly, with digital detectors used in place of film screen
systems. The detectors convert the x-ray photons to an electronic signal. This is changed to a digital value with the
help of an analog to digital converter.
The digital image is further processed and displayed as a gray scale image [30,32-34]. The digital image can be
processed by the computer and displayed in multiple formats. The digital signal can be sent electronically to the
viewing station and displayed on high resolution monitors as a soft copy, or printed on dry laser printers and read
on high luminance viewboxes as a hard copy, similar to film screen mammogram.
Digital mammography has many advantages over film screen mammography [35,36]:
Greater contrast resolution, especially in dense breasts. Wider dynamic range and higher contrast resolution
enables better visualization of skin and peripheral breast tissue [32].
The ability to post process the image by changing contrast and brightness, and by enlarging the image,
increase the ability to detect subtle abnormalities.
The ability to send images electronically, making remote reading possible (teleradiology). In addition, images
can be made available for simultaneous reading at multiple viewing stations, facilitating double reading and
expert consultation as needed.
The ability to store images in optical drives for future reference.
Lower average radiation dose [34].
Digital mammography also has certain disadvantages compared to film screen mammography:
Digital images have less spatial resolution compared to film, which in part is compensated by post
processing.
Higher-resolution display monitors, which are more expensive than standard monitors, are needed to view
the high detail and quality of a digital mammographic image.
Digital systems are expensive, with costs being 1.5 to 4.0 times as much as a film-based system.
Digital versus film screen mammogram Multiple studies have compared the performance of digital and film
screen mammography, and most have found little difference in cancer detection rates [37-46]. The best data come
from the randomized Oslo II Study and the DMIST study.
The largest study, the Digital Mammographic Imaging Screening Trial (DMIST), involved 49,528
asymptomatic women who underwent both film and digital mammography [41]. The overall diagnostic
accuracy was similar with the two modalities, but digital mammography was more accurate for
premenopausal and perimenopausal women, and women with dense breasts [41,42]. No differences in
performance were found between three different digital systems [47].
An analysis using the DMIST data found that screening all women age 40 and older by digital, rather than
film, mammography was not cost-effective, with each quality-adjusted life year (QALY) gained costing
$331,000 [48]. Targeting screening with digital mammography to women 50 years of age was cost-effective
($26,500 per QALY gained).
The Oslo II Study randomly assigned 25,263 women aged 45 to 69 years to either digital or film screen
mammography [39,40]. At two years, the rate of breast cancer detection was significantly higher for those
assigned to full field digital mammography compared to film mammography (0.59 and 0.38 percent
respectively) [40]. The positive predictive value was the same for both technologies. Detection rates of
invasive cancer were higher with digital mammography but essentially the same for ductal carcinoma in situ
[40].
In general, film mammography remains an acceptable screening modality for all women. Digital mammography,
when available, may offer a small screening advantage in women younger than 50 years old.
Online versus offline reading At most centers, once the four standard views (two per breast) are obtained,
and the image quality is approved by the technologist, the woman leaves the center without knowing the results of
the study. The study is later interpreted in batches along with other screening mammograms performed that day.
One radiologist usually reads 40 to 60 mammograms as a batch. Written results are conveyed to the referring
clinician as well as mailed to the patient. At most centers, the patient is contacted by the radiology department to
return for a diagnostic study if additional imaging is required.
Batch reading offers many advantages. The interpreting radiologist is not interrupted during interpretation by
discussions with the technologist or patients between examinations. Batch reading permits double reading, in
which each mammogram is reviewed independently by two radiologists. The prior mammograms of the patient are
generally made available for comparison during batch interpretation. The availability of prior studies facilitates the
evaluation of subtle changes and may decrease the number of false positive results [49-51].
In contrast to batch reading, some centers perform "online reading," where the mammogram is immediately
interpreted by a radiologist. Additional imaging can be performed at the same visit, if needed. Results are conveyed
to the patient after the study is completed. Patients report greater satisfaction with this procedure, citing immediate
knowledge of their results, having the opportunity to talk to a radiologist on the day of their examination, and
reduced anxiety and stress associated with having to return for additional evaluation [52,53]. In a randomized trial,
immediate reading of screening mammograms was associated with less anxiety among women with false positive
mammograms three weeks after mammography [54].
Online reading also has disadvantages. Immediate interpretation necessitates the presence of a radiologist for the
entire session that mammograms are scheduled. The need to immediately perform additional views or an
ultrasound, when indicated, disrupts the schedule and results in longer waiting time for the scheduled patients. The
added radiologist and technologist time, as well as need for additional equipment and space, increases the cost per
examination [55].
A retrospective analysis of 8698 screening mammograms analyzed the rate of recall and cancer detection between
immediate and batch interpretation rates [56]. Rates of additional imaging were higher in the group that had
immediate reading, but there was no difference in the number of cancers detected between the two groups. The
study also found that comparison studies were available less frequently when studies were interpreted immediately
following imaging.
Double reading Double reading refers to a center whereby two radiologists review every screening
mammogram. The aim of double reading is to increase the rate of cancer detection.
Double reading is standard practice in many European countries [57,58], but not in the United States. The
examination can be interpreted by the two radiologists either independently or interpreted together in consensus.
If readers differ in their interpretation of a mammogram study, institutional protocols differ on how this is
adjudicated: patients may be called back for follow-up studies if either reader identifies an abnormality (highest
reader recall), a third reader may review the films to determine need for follow-up (arbitration), or a group of
radiologists, which may or may not include the original readers, discuss the discordant cases (consensus) [59].
One study found that consensus reading resulted in recall for 45 percent of cases reviewed, with malignancy
diagnosed in 11.7 percent of the recalled cases [60]. Review of data collected from over 1 million screening
examinations in women aged 50 to 69 years participating in the Norwegian Breast Cancer Screening Program,
where double reading is standard, found that 23.6 percent of the cancers detected (1326 of 5611) were diagnosed in
women who were recalled for discordant interpretations [61]. About 50 percent of the radiologists in this program
were dedicated mammography readers.
Several studies have demonstrated benefit for double reading but randomized controlled trials have not been
performed to evaluate its impact on long term outcomes. Although not all individual studies have demonstrated an
effect on cancer detection rates, a meta-analysis of seventeen studies found that cancer detection rates were
improved by 10 percent comparing double and single reading (OR 1.10, 95% CI 1.06-1.14) [62]. In this analysis,
2222 women would need to be screened by double reading with arbitration for each additional cancer detected. The
recall rate for double reading with arbitration, compared to single reading, was decreased (0.94, 0.92-0.96), although
the recall rate was increased for double reading without arbitration [62]. In the United States, most often the second
reader is solely looking to identify any abnormality that may have been overlooked by the first radiologist, which
does lead to increased recall rates and false-positive examinations but greater cancer detection rates.
Double reading increases radiologist time and therefore the cost per examination. There may also be a delay before
the final interpretation can be made. Two studies found that both patients and clinicians preferred delayed batch
reading with double reading to immediate reading, once the benefits of double reading were explained [63,64].
Computer aided detection (CAD) Computer-aided detection (CAD) refers to computer-based technology
designed to recognize mammographic patterns and help radiologists identify suspicious areas [65]. CAD reading of
digitalized or digital mammograms places marks in areas of concern, most often calcifications, masses, or
asymmetries, for special attention in review by the radiologist; on average, four marks are placed per mammogram.
The US Food and Drug Administration approved CAD in 1998 after several studies showed the usefulness of CAD in
increasing cancer detection [66-68]. Among Medicare patients receiving screening mammograms between 2004
and 2008, CAD was used in the interpretation of nearly 75 percent of studies [69].
Debate continues over the effectiveness of CAD in breast cancer screening [70,71]. No randomized trials have been
performed to determine its effect on breast cancer mortality.
A meta-analysis of ten studies reported the effect on cancer detection and recall rates [62]. When CAD was
compared with singly-read mammograms, a small statistically insignificant increase in cancer detection (OR
1.04; 95% CI 0.96-1.13) was found, associated with more false positive readings and higher recall rates (OR
1.10; 1.08-1.12).
The effectiveness of CAD for film-screen mammography was evaluated in a study of mammography results
between 1998 and 2006 from centers in seven states participating in the Breast Cancer Surveillance
Consortium and involving more than 1.6 million mammograms; CAD was implemented in 25 of the 90
facilities participating in the consortium [72]. Use of CAD was associated with decreased specificity (OR
0.87, 95% CI 0.85-0.89), lower positive predictive value (OR 0.89, 0.80-0.99), a nonstatistically significant
increase in overall sensitivity (OR 1.06, 0.84-1.33) accounted for by an increase in the diagnosis of ductal
carcinoma in situ (DCIS) but not invasive breast cancer, and no improvement in stage or lymph node status
of detected breast cancer.
CAD increases the detection of ductal carcinoma in situ (DCIS) as CAD software has increased sensitivity to detect
calcifications [73-75]. Since the natural history of DCIS is indolent and uncertain, the benefit of early detection and
treatment for this condition is unclear and the potential for over-treatment of preclinical disease is raised. (See
"Breast ductal carcinoma in situ: Epidemiology, clinical manifestations, and diagnosis" and "Ductal carcinoma in
situ: Treatment and prognosis" and "Microinvasive breast carcinoma".)
Cancer detection rates for single reading with CAD have been compared to double reading [73,76-80]. These
studies find similar rates of cancer detection for the two models of mammographic interpretation. Recall rates have
been reported as both higher [81] and lower [76] for CAD, compared with double reading, and may depend on how
discordant readings were managed with double reading.
The sensitivity of CAD to identify lesions in retrospective readings of breasts with known cancer has been reported
to range from 76 to 94 percent [78,82,83]. The absence of a CAD finding should not negatively influence the
radiologist decision to recall a patient for additional studies.
In summary, CAD may improve the sensitivity of mammographic screening to a limited extent. This may be offset
by a higher recall rate, and the potential for overdiagnosis. CAD has not been proven to improve mortality rates from
breast cancer screening, and the costs associated with the equipment and increased recall rate with CAD may
outweigh possible marginal benefits.
ABNORMALITIES ON MAMMOGRAPHY Mammogram abnormalities include masses, calcifications,
asymmetry, and architectural distortion. The significance of these findings depends on their radiologic appearance
as well as the patient's age, race, and ethnicity. Specific mammographic findings of breast cancer are discussed in
detail separately. (See "Diagnostic evaluation of women with suspected breast cancer".)
The most specific mammographic feature of malignancy is a spiculated focal mass. The positive predictive
value of a mass with a spiculated margin is 81 percent and with irregular shape is 73 percent (picture 3 and
picture 4) [84-86].
The density of a non-calcified mass is a significant factor in predicting malignancy. Seventy percent of
masses with high density were malignant, and 22 percent of masses with low density were malignant in one
study [86].
Clustered microcalcifications (calcium particles of various size and shape measuring between 0.1 to 1 mm in
diameter and numbering more than four to five per cubic centimeter) are seen in approximately 60 percent of
cancers detected mammographically (picture 5). Histologically, these represent intraductal calcifications in
areas of necrotic tumor or calcifications within mucin-secreting tumors.
Linear branching microcalcifications (picture 6) have a higher predictive value for malignancy than do granular
(ie, nonlinear irregular calcifications of varying size and shape) microcalcifications, particularly for high grade
DCIS. However, breast cancers, including DCIS, more often present with the granular type of calcifications.
Calcifications that are not suspicious for malignancy and considered benign include vascular and skin
calcifications, rim-like calcifications, large coarse calcifications (picture 7), and smooth round or oval calcifications
(image 3).
One prospective study linked findings from 10,641 mammograms performed in 20 facilities over four years with the
regional cancer database (Surveillance Epidemiology and End Results program or SEER) [87]. Focal mass was the
most frequent abnormality (56 percent) identified in women found to have breast cancer, followed by calcifications
(29 percent). Asymmetry was a frequent reason for additional evaluation (42 percent), but was a finding in only 12
percent of women with breast cancer.
MAMMOGRAPHY QUALITY CONTROL Variation in mammographic quality and standard of practice throughout
the United States led to the development of the mammographic accreditation program by the American College of
Radiology in 1987 [88,89]. The Mammography Quality Standards Act (MQSA) was passed in 1992 by Congress
[90-92]. The MQSA establishes guidelines for quality control for individual imaging centers and mandates that all
US facilities should be accredited by the American College of Radiology.
The Breast Imaging Reporting and Data System (BI-RADS) [93], was developed by the American College of
Radiology to standardize the mammography report. BI-RADS was initially developed for mammography, but has
now been extended to breast ultrasound and MRI interpretation as well.
The BI-RADS manual consists of standardized language to describe the radiological findings and conclusions. One
of seven final assessments categories should be used at the conclusion of each report (table 1). The final
diagnostic assessment categories indicate the relative likelihood of a normal, benign, or malignant diagnosis based
solely on the imaging findings. The FDA mandates that all mammography reports include a final BI-RADS
assessment category.
The use of BI-RADS results in standardized reporting helps guide decision making and also serves as a useful tool
in collecting data and in auditing individual practices.
The mammography report The organization of the report and the language used to describe abnormalities are
based on the BI-RADS manual [93]. The report contains the following elements:
Indication The main indication for the study and type of examination (screening versus diagnostic) is
stated. Any previous examinations used for comparison are mentioned in the beginning of the report.
Breast density All reports have a statement regarding the breast density. Most radiologists use the four
categories described in the BI-RADS atlas, based on the proportion of glandular (radiodense) tissue with
respect to fatty (radiolucent) tissue. The four main categories are (image 4):
Predominantly fatty (0 to 25 percent dense)
Scattered fibroglandular densities (25 to 50 percent dense)
Heterogeneously dense (51 to 75 percent dense), and
Dense (greater than 75 percent)
Description of abnormalities The main body of the report includes the location and description of any
abnormality using standard BI-RADS descriptors. The location of any lesion is described with reference to a
quadrant or clock position, and the depth within the breast. The breast is arbitrarily divided into anterior,
middle and posterior depth (figure 2). Each breast is divided into four quadrants: upper-outer, upper-inner,
lower-outer and lower-inner (figure 3). The location can also be indicated using the breast as a clock with
nipple in the center (figure 4).
Summary The report concludes with a pertinent summary stating the most important findings and the final
BIRADS assessment category.
The BI-RADS categories The BI-RADS final assessment categories standardize both the reporting of
mammographic findings and the recommendations for further management (ie, routine screening, short interval
follow-up, or biopsy). Assessments are either incomplete (category 0) or final assessment categories (categories 1
through 6) (table 1) [93]. It is important to note that the BI-RADS category only refers to the imaging findings and
does not take clinical findings or presentation into account. Therefore, if the patient has negative imaging evaluation
but has a clinically-suspicious lump, a biopsy may still be indicated even though the BI-RADS category is 1 or 2.
These categories are designated as follows:
BI-RADS 0: Incomplete assessment Need additional imaging evaluation and/or prior mammograms for
comparison This category is used when there is not enough information from the views available to derive
a conclusion. This is more commonly used in screening studies, which are interpreted as abnormal when
the radiologist is not providing immediate reads.
Causes for an incomplete evaluation include technical factors such as suboptimal images due to either
improper positioning or motion (picture 8); a questionable lesion not fully evaluated on the standard
screening views; or unavailability of prior mammograms to confirm stability of a possible focal or diffuse
abnormality. The patient is asked to return for additional mammographic views and/or an ultrasound, or prior
mammograms are required.
BI-RADS 1: Negative This is a completely negative examination (image 1 and picture 1). The woman
should continue with screening mammography and clinical breast examination based on current screening
guidelines.
BI-RADS 2: Benign findings Benign nodules such as fibroadenomas (picture 9) or cysts (picture 10), or
benign vascular or parenchymal calcifications (picture 7) may be reported. There is no concern for
malignancy and no further action needs to be taken. The rationale in reporting these findings is to document
benignity and to prevent unnecessary evaluation. Routine follow-up is recommended.
BI-RADS 3: Probably benign finding This category is used when there is a finding that does not have
characteristic benign features, but the likelihood of malignancy is less than 2 percent. Examples of lesions
in this category would include a parenchymal asymmetry (image 5), calcifications, or a nodule that does not
have classic benign imaging features.
These types of findings are followed at shorter intervals than one year to assess for stability. Generally, the
lesion is followed with diagnostic mammography and/or ultrasound at six month intervals for one year and
annually for an additional two years or every six months for a total of two years [94-96]. Follow-up at shorter
intervals may be requested for close surveillance of a lesion that is not clearly benign. At any of these
interval follow-ups, the lesion could be downgraded (BI-RADS 2) if it declares itself as clearly benign, or
upgraded (BI-RADS 4 or 5) if there is a change with sufficient concern for malignancy.
BI-RADS 4: Suspicious abnormality; Biopsy should be considered This category implies that there is a
lesion with suspicious features for malignancy (picture 5). The chance that the imaging finding is a cancer
ranges between 2 and 94 percent. The degree of suspicion or worry for malignancy varies both with the
lesion and with the interpreter.
The BI-RADS 4 category is very broad, and the findings are compatible with both DCIS and invasive breast
cancer. Subdivisions of this category were introduced to convey the level of concern, so the patient and her
clinician can make an informed decision regarding management. These subcategories are BIRADS 4A
(chance of malignancy 2 to 9 percent); 4B (chance of malignancy 10 to 49 percent); and 4C (chance of
malignancy 50 to 94 percent).
BI-RADS 5: Highly suggestive of malignancy; Appropriate action should be taken Lesions which have
classic worrisome imaging features such as spiculations (picture 3 and picture 4), pleomorphic calcifications
(picture 6), and skin retraction are placed in this category. The suspicion for malignancy is 95 to 100
percent.
BI-RADS 6: Biopsy-proven malignancy; Appropriate action should be taken This includes patients with
established biopsy-proven cancers that have yet to be surgically excised who present for further imaging to
either evaluate the contralateral breast or assess response to neoadjuvant chemotherapy, or who present for
second opinion with interpretation of outside imaging studies.
Clinical decision making
A positive mammography report All reports with BIRADS 0, 4 or 5 need further intervention. In most
institutions, the clinician is contacted to convey the need for biopsy, and both the clinician and patient are
contacted to convey the need for further imaging.
A BI-RADS designation of 4c or 5 should alert the pathologist that a malignant diagnosis is strongly suspected and
that further evaluation of the specimen (and possible rebiopsy) is needed if the biopsy is initially interpreted as
benign.
A negative mammography report A negative mammogram should not deter further intervention if there is
clinical suspicion for malignancy (figure 5). The false-negative rate of screening mammography has been reported
between 10 to 30 percent, with the false-negative rate being highest in women with markedly dense breast tissue
[57-59].
Up to 15 percent of cancers detected on clinical breast examination are not visible even on diagnostic
mammography [58,60,62]. The addition of ultrasound decreases the false negative rate, but still does not exclude
the presence of breast cancer [62].
The final disposition of a palpable abnormality rests with the clinician in the presence of a negative imaging
evaluation as the chance of malignancy ranges between 0 and 3 percent [97,98].
SPECIAL PATIENT POPULATIONS
The dense breast There is much variation in the physical composition of the breast. Differing proportions of fat,
connective tissue, ductal and lobular elements contribute to differences in mammographic breast density.
Mammographic density is not related to the size or firmness of the breast [99,100]. Breast density is greater in
younger women, and is also related to genetic factors, parity, use of estrogen, and body habitus [101,102].
Reduced sensitivity of mammography in younger women is in part related to increased mammographic density,
determined by a higher proportion of breast epithelial and stromal elements in younger breasts [103]. Menstruating
women have variable breast density during different phases of the menstrual cycle [104,105]. Breast density is
increased in the luteal compared with follicular phase, suggesting that mammographic sensitivity can be improved
by obtaining mammograms during the first and second week after menstruation begins, particularly for women who
have used oral contraceptives at some time [105]. Use of hormone therapy slows the age-related change from
dense to fatty breast tissue; in a longitudinal study, this was more pronounced for women taking combination
estrogen and progestin than for those taking estrogen alone [106]. Short-term (one to two months) cessation of
hormone therapy prior to mammography, although advised by some clinicians, had no effect on mammography
recall rates in a randomized trial [107].
Women with dense breast parenchyma (50 to 74 percent density) have a three- to fivefold increased risk for breast
cancer compared to women with breast density <5 percent, even after adjusting for other associated risk factors
[108]. This increased risk is particularly important in women who continue to have dense and nodular breast
parenchyma beyond menopause [109,110].
Increased breast density is established as an independent risk factor for breast cancer [111]. Increased breast
density both increases the risk of breast cancer [112,113] and decreases the sensitivity of mammography to detect
small lesions [112,114,115]. In a study that used a case control method and data from three large screening trials,
the odds ratio for breast cancer detected at mammogram screening was 3.5 (95% CI 2.0-6.7), comparing women
with density in 75 percent of the mammogram and those with breast density in less than 10 percent of the
mammogram [112]. The odds ratio for breast cancer detected within twelve months of a negative mammogram was
significantly higher (17.8, 95% CI 4.8-65.9), again comparing women with high and low density breasts as defined
above.
Digital mammography is more sensitive than film mammography for dense breasts [41,42] and may be preferred,
when available, for women with increased breast density. The role of ultrasound as an adjunct to mammography is
discussed below. (See 'Role of ultrasound' below.)
The BI-RADS guidelines for mammogram interpretation recommend that breast density be reported in a sentence in
every mammogram report [116]. The inter-observer reproducibility of BI-RADS breast density reports is only
moderate, however [117]. Automated measures of breast density are under development, and may be helpful in
identifying women at increased risk for breast cancer who could benefit from measures to reduce risk [118].
Accurate determination of breast density on two-dimensional images might not be possible, however, as measured
density may vary with breast positioning, amount of compression, and distribution of fibrous elements within the
breast [119]. (See "Factors that modify breast cancer risk in women", section on 'Estrogen exposure' and "Factors
that modify breast cancer risk in women".)
Supplemental screening in women with dense breasts The recognition of the increased risk of breast
cancer in women with dense breasts, and the availability of screening ultrasound as an adjunct to mammography,
has led to new guidelines and legal requirements for reporting breast density in the United States. The
Mammography Reporting Act (H.R. 1302) requires that every mammogram report contain information regarding the
patients breast density and language communicating that individuals with more dense breasts may benefit from
supplemental screening tests [120]. Though not strictly enforced, some states (Connecticut, Texas, Virginia,
California, and New York) have adopted this requirement as of 2012. However, with the exception of Connecticut,
insurers are not required to cover the cost of the supplemental sonographic screening.
Preliminary data demonstrate that US screening of women with dense breasts detects on average 0.8 to 10.0
additional cancers per 1000 women screened but has substantial false positives with the biopsy positivity rate being
under 10 percent [121,122].
Magnetic resonance (MR) is not recommended for supplemental screening solely for breast density, because of a
high false-positive rate leading to unnecessary biopsies [123]. Widespread use of MR is also limited by the higher
cost, lack of wide availability, potential adverse reactions to contrast medium, and lower tolerance by patients when
compared to ultrasound. Thus, ultrasound is the adjunctive procedure of choice for women with dense breasts in
whom additional imaging may be indicated. (See 'As adjunct to mammography for screening' below.)
Women with breast implants It is estimated that there are more than two million breast implants in US
women, for purposes of either cosmetic augmentation or reconstruction.
There are many types of breast implants, with the majority consisting of an envelope filled with either silicone gel or
saline [124]. Dual chamber silicone and saline implants are also available. The safety of silicone implants, available
since 1962, has been extensively studied and the US Food and Drug Administration approved the use of silicone
implants in women over the age of 22 years in November 2006 [125].
Women who have breast tissue augmented with implants require routine screening mammography to evaluate the
native breast tissue. Women with reconstructed breasts and no remaining breast tissue do not typically undergo
routine mammography, although there is at least one study that suggests earlier detection of recurrence with
routine imaging [126].
The presence of implants makes mammography more difficult. The implant contents are radiopaque and can
obscure small lesions. In addition the presence of the implant makes it harder to evaluate all parts of the breast and
makes compression challenging [127].
Standard imaging technique in women with breast implants involves four views, rather than the usual two views per
breast. Positioning is important to include as much breast tissue as possible by pushing the implant out of view.
Standard CC and MLO projections of each breast are obtained with the implant included (image 6). These views
permit evaluation of the implant as well as the deep breast tissues adjacent to the implant. The two views are
repeated after the implant is displaced back against the chest wall and the breast tissue is pulled forward [128].
The type of implant, as well as its location (prepectoral or retroglandular versus retropectoral or subpectoral) plays a
role in the ease of imaging. Breasts with implants placed behind the pectoralis muscle (retropectoral or
subpectoral) are easier to position. If the implant cannot be displaced, then tangential views can be obtained.
Mammograms can also help to identify implant-related complications, including whether the implant remains intact
[129,130]. Common problems associated with implants are rupture of the implant capsule with or without leakage of
contents and capsular contraction. However, implant-related complications are best evaluated with dedicated
magnetic resonance imaging [131-133]. (See "MRI of the breast and emerging imaging technologies" and "MRI of
the breast and emerging imaging technologies", section on 'Assessment of breast implants'.)
Women with prior breast biopsy Breast biopsies are performed in approximately 1 to 2 percent of
mammographic screenings in the United States [134], with lower rates in other countries. The effect of a history of
a prior breast biopsy on subsequent mammographic interpretation performance was investigated in a review of data
from the Breast Cancer Surveillance Consortium involving over 2 million mammograms in nearly 800,000 women
[135]. A history of a prior breast biopsy for benign disease was associated with reduced specificity (OR 0.75, 95%
CI 0.79-0.92) and a lower positive predictive value for a referral for breast biopsy (OR 0.85, 0.79-0.92) in subsequent
screening mammograms, compared to women with no prior biopsy history. This may reflect characteristics of the
breast tissue (eg, more fibrocystic) that led to the initial biopsy, tissue effects of the biopsy itself, or differing
thresholds for mammographic interpretation when a prior biopsy history is provided.
Women with breast reconstruction (post mastectomy) Mammography is not routinely performed following
mastectomy [136,137]. When no breast tissue is left behind, mammography provides no substantial added benefit
to clinical examination in detecting recurrence.
Several methods of reconstruction are available following mastectomy. When silicone implants are used, MRI
evaluation for implant-related issues is more sensitive than mammography.
Reconstruction can also be performed by transfer of tissue from other parts of the body, typically muscle to skin. A
TRAM (transverse rectus abdominis myocutaneous) flap consists of muscle and fatty tissue from the abdominal
wall that is moved up to the chest along with an intact blood supply to create the breast mound. Similar
reconstruction can also be performed using the latissimus dorsi muscle. More commonly, DIEP (deep inferior
epigastric perforator) flaps, which consist of abdominal fat with its native blood supply, are performed preferentially
for breast reconstruction. Identifying breast cancer recurrences in the reconstructed flap is important as it has
implications on treatment options.
At present, physical examination is the method of choice in monitoring myocutaneous breast reconstructions.
However, it is difficult to identify lesions that are deep, and can be difficult to distinguish a palpable area of fat
necrosis from recurrent cancer [138].
Both mammography and ultrasound of a reconstructed breast are technically feasible. The mammographic
appearance of recurrence is similar to that seen in a native breast [139,140]. Specific features on mammography
can help distinguish recurrence (image 7) from benign post operative fat necrosis as a cause of a palpable lump
(picture 11). Locating the lesion on ultrasound facilitates intervention. Ultrasound with ultrasound-guided fine needle
aspiration or core biopsy has been shown to be valuable in identifying and in obtaining histopathological
confirmation of recurrence in both clinically palpable as well as occult lesions [139].
There is contradictory evidence regarding routine imaging of asymptomatic women with TRAM flap. In one study,
mammogram screening in 113 asymptomatic women with TRAM flap reconstruction over a period of 25 months
reported a cancer detection rate of 1.9 percent and concluded that routine screening mammography of TRAM flap
reconstructed breast depicts non palpable recurrence [126]. Another study of 554 mammograms in asymptomatic
women with TRAM flap reconstruction found no cancers; 1.4 percent of mammograms were felt to be suspicious,
leading to biopsy [141].
Pregnancy and lactation Screening mammography is not routinely performed in pregnant women. The role of
mammography in pregnancy is for diagnostic purposes: to evaluate suspected cancer, check the contralateral
breast, and assess clinical findings not clarified with ultrasound.
The breast undergoes considerable change during pregnancy and lactation. Most breast disorders encountered in
this period are benign and secondary to hormonal changes. However, breast cancer in pregnancy represents up to
3 percent of all breast cancers [142]. Poor prognosis in pregnancy-associated breast cancer has been attributed,
among other factors, to delay in diagnosis related to difficulties obtaining or interpreting mammograms and
challenges with clinical examination [142].
The hormonal changes in pregnant and lactating women may cause proliferation of ducts and lobules that result in
increased density and nodularity of the breast parenchyma on mammography. These changes make it difficult to
identify small nodules, asymmetries and architectural distortion, and thereby decrease the sensitivity of the
examination [143-145]. Not all women undergo these changes in breast density [146].
The effect of radiation from mammography on the fetus is of some concern. The developing fetus is most
susceptible to effects from radiation in the first few weeks of gestation. In general, radiation doses of more than 5
rads or 50 mGy are considered harmful [147]. A four view standard mammogram with abdominal shielding exposes
the fetus to 0.4 rads or 4 mGy [142,148]. Imaging of a pregnant woman with a palpable finding begins with
ultrasound and mammography is only performed if the sonographic findings are suspicious for malignancy.
Males Male breast cancer, though uncommon, is increasing [149]. The American Cancer Society estimated that
2190 men developed breast cancer with 410 breast cancer deaths in 2012, accounting for less than 1 percent of
total breast cancer diagnoses [150].
Routine screening mammography is not performed in men. Men are referred for imaging when clinical findings such
as a mass, thickening or pain are present.
The initial mammogram evaluation in a male includes standard bilateral CC and MLO views (image 8 and image 9).
Use of narrower paddles may facilitate compression depending on breast size. Similar to females, additional
mammographic views and ultrasound may be indicated to characterize abnormalities and facilitate biopsy if
indicated.
SCREENING VERSUS DIAGNOSTIC MAMMOGRAPHY Mammographic views and subsequent procedures may
differ, depending on whether the examination is ordered for screening (asymptomatic women) or for diagnostic
purposes (work-up of a breast complaint or abnormal finding).
Screening mammogram A screening mammogram is performed in a woman with no clinical symptoms or
complaints. The purpose of the study is to decrease morbidity and mortality by detection of early stage and
therefore treatable breast cancer. Although earlier detection does not necessarily ensure cure, screening
mammography is the best modality currently available to detect clinically occult breast cancer [1,2,151-153].
Two standard views are obtained for each breast. Additional views, such as anterior compression, cleavage view
(image 10) or an exaggerated craniocaudal (XCCL) view (image 11) may be obtained to maximize imaging of all
breast tissue [154].
Diagnostic mammogram Diagnostic mammography is performed in women or men who present with breast
complaints or have an abnormal clinical examination, and in women who have abnormal screening mammography.
Patients with specific breast symptoms, such as a palpable lump, nipple discharge, or focal pain should undergo
diagnostic mammography.
Abnormalities on screening mammography include masses, calcifications, architectural distortion, or asymmetry.
The abnormality could be related to technical factors such as motion, improper positioning or artifacts (picture 8).
Alternatively, the finding might represent benign or malignant breast disease. Even when the abnormality seen on a
screening mammogram is very suspicious for malignancy, additional evaluation is usually indicated to determine
the extent of the lesion and to assess for the presence of any additional findings [155]. Availability of the abnormal
screening mammogram at the time of diagnostic examination is crucial in ensuring the appropriate diagnostic work-
up. This is particularly important when the screening mammogram is performed at a different institution or practice.
The diagnostic examination is always supervised by a radiologist. The views obtained are tailored to evaluate a
specific abnormality, with the adjunctive use of ultrasound if needed in order to make an accurate diagnosis. The
radiologist interprets the images and conveys the findings and recommendations directly to the patient at the time
of the examination.
A focal spot compression view, one type of additional view, is performed by applying focal compression to the area
of interest in the breast using a small compression paddle. This view is helpful to further evaluate an area of
asymmetry or a mass seen on screening mammography (image 12). Spot compression and tangential views of a
palpable area have been shown to detect additional cancers [156].
A magnification spot compression view is performed to further characterize the morphology of calcifications and
shape of a mass. The size, distribution, and morphology of calcifications are seen best on magnification views
(image 13). In addition, magnification views can provide details regarding margins of masses.
A 90 degree lateral view is a true lateral view of the breast. The x-ray beam can travel from either the medial
(mediolateral) or from the lateral (lateromedial) side of the breast. This view is a direct orthogonal view to the CC
(craniocaudal) projection and is useful in triangulating lesions. A delayed lateral view is often performed in evaluating
calcifications. The breast is held in compression for up to two minutes and the image is obtained after the two
minute "delay." This view may help in confirming the presence of a benign pattern of calcifications, called milk of
calcium deposition, associated with benign breast microcysts.
Other views that may be obtained in a diagnostic work-up are tangential views, to further evaluate a palpable area or
to confirm calcifications are dermal in etiology, and rolled CC views. Rolled views are helpful in confirming that a
finding seen only on one of the conventional views represents a true or three-dimensional lesion. For the rolled view,
the patient is positioned similar to the view that depicted the original lesion. The technologist places her hands on
either side of the breast and "rolls" the breast tissue (medial and lateral for the CC view; superior and inferior for the
MLO view). Compression is applied to keep the breast tissues rolled and the image is obtained. The direction of the
roll (medial, lateral, superior, or inferior) is documented on the image. If the lesion is real, the radiologist can use
these images to determine the location of the lesion thereby facilitating performance of a targeted ultrasound.
Surveillance mammogram Mammograms are performed for surveillance in women who have a history of
breast cancer. In many centers, at least for the five years following the diagnosis of breast cancer, such
mammograms are performed similar to diagnostic mammograms, with a radiologist on-site who can interpret the
study at the time of the evaluation and determine if further views or tests are indicated. If the patient does not
develop recurrence within the first five years, the patient returns to routine screening for subsequent years. (See
"Approach to the long-term survivor of breast cancer", section on 'Breast imaging'.)
ROLE OF ULTRASOUND One of the primary roles of ultrasound is in the diagnostic follow-up of an abnormal
screening mammogram. Ultrasound is used to further evaluate masses or asymmetries and can differentiate a solid
mass from a cyst (picture 9 and picture 10). If available, color Doppler ultrasound can aid in the assessment of
breast masses [157]. However, the absence of flow on Doppler does not exclude the possibility of malignancy.
Ultrasonography is also used to provide guidance for biopsies and other interventions. Ultrasound is the first line of
imaging in a woman who is pregnant or less than 30 years old with focal breast symptoms or findings. A
retrospective review of ultrasounds performed in one center for evaluation of focal breast signs or symptoms in
women less than 30 years found that both the sensitivity of ultrasound and negative predictive value for malignancy
were 100 percent [158].
Ultrasound is useful in evaluating the local extent of breast cancer (image 14). Ultrasound can identify additional
tumor in the same breast and alter surgical management in up to 18 percent of women with mammographically
detected breast cancer [159-161]. Evaluation of the axilla in the setting of a newly-diagnosed cancer or a
suspicious finding on mammography provides a noninvasive method to identify axillary nodes suspicious for
metastasis. If seen, the suspicious nodes can readily undergo image-guided biopsy (FNA or core) to confirm or
exclude malignancy, as a positive lymph node would lead to full axillary node dissection rather than sentinel lymph
node biopsy at the time of definitive surgical management.
MRI is superior to ultrasound in evaluating silicone implants for rupture, but ultrasound is often more readily
obtained. Ultrasound is appropriate in evaluating implants in a woman with contradictions to MRI or where MRI is
not available. Ultrasound can be used to check the integrity of a silicone implant capsule. Leak of silicone to the
surrounding breast tissue causes a typical "snowstorm" appearance [162,163]. Similarly, intracapsular rupture can
be diagnosed on ultrasound by a characteristic "stepladder" appearance [164].
As adjunct to mammography for screening The use of ultrasound as an adjunct to mammography in primary
screening for breast cancer has been evaluated in many studies [121,165-167]. The addition of ultrasonography to
mammography increases sensitivity for small cancers but decreases specificity. A large prospective, multicenter
trial conducted through the American College of Radiology Imaging Network (ACRIN Protocol 6666) evaluated the
diagnostic yield of screening ultrasound in addition to mammography in high-risk women with at least
heterogeneously dense breasts on mammography [166]. The study concluded that adding screening ultrasound to
mammography will identify an additional 4.3 cancers per 1000 women screened, but also increase the number of
false-positive results (positive predictive value for mammogram alone 22.6 percent versus 11.2 percent for
mammogram plus ultrasound). Other multicenter trials have reported similar findings [166,168-170]. The majority of
cancers found by ultrasound were node negative [171]. For women with dense breasts as their only risk factor for
breast cancer, the American College of Radiology states that the addition of ultrasound to screening
mammography may be useful for incremental cancer detection [172]. They also note that a decision not to offer
ultrasound screening, due to issues of test reproducibility, high false-positive rates, operator dependency, and a low
positive predictive value for biopsy recommendations, is acceptable within the standard of care.
The US Food and Drug Administration approved an automated ultrasound device in September 2012 to be used as
an adjunct to mammography for asymptomatic women with dense breasts and a negative mammogram [173].
Approval was based upon data from an unpublished study indicating increased breast cancer detection when
automated ultrasound images were viewed in conjunction with mammograms, compared to mammograms alone, for
200 women with dense breasts and negative mammograms. Concerns remain regarding the potential for high false-
positive rates, potentially compounded by the ability of non-radiologists to use this device and interpret images,
although approval requires that training and quality control measures be implemented. In the absence of published
data from a screening trial using this device, we consider currently available evidence inadequate to support the use
of this device.
NEWER MAMMOGRAPHY TECHNIQUES Positron emission mammography (PEM) and breast specific gamma
imaging (BSGI) are functional breast imaging techniques and are discussed separately. (See "MRI of the breast
and emerging imaging technologies".)
Tomosynthesis Breast tomosynthesis (also known as 3-D mammography) has been approved by the US Food
and Drug Administration for routine clinical use [174]. Tomosynthesis is a modification of digital mammography and
uses a moving x-ray source and digital detector. A three dimensional volume of data is acquired and reconstructed
using computer algorithms to generate thin sections of images.
As a modification of digital mammography, tomosynthesis has all the advantages of a standard digital
mammogram. In addition, thin slice reconstruction improves the delineation of a lesion in the slice by eliminating
overlap from surrounding structures. In the screening setting, this helps to decrease recall rates by delineating true
lesions from spurious lesions caused by overlapping structures seen on routine mammography. In the diagnostic
setting, tomosynthesis improves lesion characterization, thereby decreasing the need for biopsy, leading to fewer
false positive biopsies and higher rates of cancer detection [175-180]. In one study two-view tomosynthesis
performed better than digital mammography only for less-experienced radiologists, but the two techniques had
equivalent performance when interpreted by more-experienced radiologists [181]. Reading time required for
tomosynthesis interpretation was nearly twice that needed for digital mammography.
The examination has a slightly longer exposure time of 10 seconds per acquisition compared to standard digital
mammography, which could increase the radiation dose per acquisition and increase the risk of motion artifacts
[182,183]. At present, tomosynthesis is approved only to be performed in conjunction with a conventional
mammogram. Hence, when performed in the screening setting, the patient is exposed to approximately twice the
usual radiation dose, which sometimes is greater if the patient had dense or thick breasts. This technique shows
promise in screening women with dense breast tissue and with high risk for breast cancer, although there are no
prospective large studies to justify its routine use at the present time.
INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, The Basics and
Beyond the Basics. The Basics patient education pieces are written in plain language, at the 5
th
to 6
th
grade
reading level, and they answer the four or five key questions a patient might have about a given condition. These
articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the
Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the
10
th
to 12
th
grade reading level and are best for patients who want in-depth information and are comfortable with
some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these
topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on
patient info and the keyword(s) of interest.)
Basics topics (see "Patient information: Breast cancer screening (The Basics)")
Beyond the Basics topics (see "Patient information: Common breast problems (Beyond the Basics)" and
"Patient information: Breast cancer screening (Beyond the Basics)")
SUMMARY
Screening mammography is the only breast imaging modality that consistently has been found to decrease
breast cancer-related death. Routine evaluation includes obtaining two views (craniocaudal and mediolateral
oblique) of each breast. (See 'The mammographic examination' above.)
Breast compression improves image quality. Patient-controlled compression, oral or topical analgesics, and
cushioned paddles may minimize discomfort. (See 'Breast compression' above.)
The effective radiation dose received from a routine screening mammogram is equivalent to the dose received
from natural background radiation over three months. Women with BRCA1 or BRCA2 mutations may be at
somewhat greater risk for radiation-induced cancer. (See 'Radiation dose' above.)
Full field digital mammography, compared to film mammography, can improve image quality and facilitate
study interpretation, but is more costly and may not significantly impact overall cancer detection rates. Film
mammography remains an acceptable screening modality for all women. Digital mammography, when
available, may offer a small screening advantage in women younger than 50 years old. (See 'Digital versus
film screen mammogram' above.)
Double-reading and computer-aided detection (CAD) may improve the sensitivity of mammogram screening
to a limited extent, but have not been demonstrated to improve mortality rates from breast cancer screening.
CAD may increase patient recall rates. (See 'Double reading' above and 'Computer aided detection
(CAD)' above.)
Diagnostic mammograms are performed to evaluate breast abnormalities (symptoms, clinical findings or
follow-up of abnormal screening mammograms) and are distinguished from screening mammograms.
Additional views are obtained with diagnostic mammograms and these are performed when a radiologist is
immediately available for review of the study. (See 'Screening versus diagnostic mammography' above.)
Increased breast density both increases the risk of breast cancer and decreases the sensitivity of
mammography to detect small lesions. (See 'The dense breast' above.)
Women who have breast tissue augmented with implants require routine screening mammography to
evaluate the native breast tissue. Women with reconstructed breasts and no underlying breast tissue do not
require regular mammography. Standard imaging technique in women with breast implants involves four
views, rather than the usual two per breast. (See 'Women with breast implants' above.)
The Breast Imaging Reporting and Data System (BI-RADS) standardizes reporting for mammography and
ultrasonography and helps guide decision making. It also serves as a useful tool in data collection and audit.
The summary of a BI-RADS report specifies findings as incomplete or as one of six final assessment
categories (table 1). A negative mammogram should not deter further intervention if there is clinical suspicion
for malignancy. (See 'Mammography quality control' above.)
Ultrasound primarily has a diagnostic role in the further evaluation of abnormal mammograms, to distinguish
solid and cystic lesions. It is first-line imaging in women who are pregnant or less than 30 years old with
focal breast symptoms. (See 'Role of ultrasound' above.)
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