Q: At what age should healthy women begin having regular mammograms, and how often should they have them?
The American College of Radiology recommends annual screening beginning at age 40 and this is what we recommend at the Breast Center. Women who are considered higher risk may need to begin mammography earlier; such as in these instances:
Women with strong family history:
- first-degree relatives diagnosed with breast cancer especially at pre-menopausal ages (i.e., parent, sibling or child), usually would begin screening with mammography at 5-10 years earlier than the age of diagnosis of the family member
- patient or family member with one of the breast cancer genes (BRCA 1 or BRCA 2)
- Women with a past history of receiving radiation to the chest between ages 10 and 30
Q: Is digital mammography better at detecting cancers?
Recent studies indicate a higher cancer detection rate of digital mammography in certain patients, including those with dense breasts, those under 50 years old, and those who are pre- or perimenopausal.
Q: How long does it take to have a mammogram and how/when do you find out the results?
For screening mammogram patients, our goal is that their exams will be performed and completed in 15 minutes. These exams will be interpreted by the radiologist within 1-2 working days, and letters will be mailed to the patient's home address upon interpretation.
Diagnostic mammography often is a longer exam, because additional images and possibly ultrasound are performed. These patients are given their results at the time of their exam, both verbally and in writing.
Q: When is an ultrasound recommended, and how does it differ from a mammogram?
Ultrasound is used:
- to evaluate any palpable breast lesion
- to evaluate masses, distortions, or asymmetries found on mammography
- to evaluate findings identified on breast MRI
Ultrasound forms images of the breast utilizing sound waves, not X-rays. No compression is required; a warm gel is placed on the skin and an ultrasound probe is rubbed over the skin to obtain the image.
Ultrasound can often show abnormalities which might go undetected on mammography due to extremely dense breast tissue. Ultrasound is used most commonly in conjunction with mammography, not as a replacement for mammography.
Elastography is a very new ultrasound technique which helps to measure the 'hardness' of breast lesions by placing gentle compression on the lesion with the ultrasound probe and comparing ultrasound information before and after the compression. Preliminary studies have indicated that this technology may be useful in differentiating benign and malignant lesions in the breast.
Q: What is the difference between a screening mammogram and a diagnostic mammogram?
Screening mammography is performed in asymptomatic patients -- patients who have no clinical signs or symptoms of breast cancer. Two views of each breast are obtained and are checked for technical adequacy by the technologist. These are interpreted later by the radiologist with results sent to the patient by mail.
Diagnostic mammography is performed in symptomatic patients -- patients who have signs or symptoms of breast cancer such as a palpable lump, nipple discharge, skin changes, etc. We also perform diagnostic mammography in patients with a past history of breast cancer, for follow-up of an abnormal screening mammogram, or for short-term follow-up of probably benign findings. These studies begin with the typical mammography views, with additional views and ultrasound obtained as deemed necessary by the radiologist. The studies are interpreted on line, with results given to the patient immediately.
Q: How does digital mammography differ from traditional film mammography?
A digital mammogram takes less time to perform and typically involves a lower radiation dose to the patient. It also give us the ability to optimize the image, very similar to the way you optimize a digital photograph. Images are stored electronically so the is less chance of images being lost. In addition, images can be interpreted remotely, so second opinion interpretations may become easier.
Q: How do you know if you are at high risk for breast cancer?
High risk factors for breast cancer include:
- Family history of breast cancer - two or more first degree relatives with breast cancer; especially if they were diagnosed when premenopausal
- Personal history or family history of the breast cancer gene BRCA 1 or BRCA 2
- Personal history of radiation therapy to the chest between the ages of 10 and 30 years
- Lifetime risk of breast cancer scored at 20%-25% or greater, based on one of several accepted risk assessment tools that look at family history and other factors. This category often requires consultation with a genetic counselor who can assess breast cancer risk using various computer models.
Q: What will happen to my old breast films if I have a digital mammogram?
We will keep the prior film mammograms in the patient's X-ray jacket. Some of these prior studies will be converted to digital images in order to make it easier for the radiologist to compare them to the new study.
Q: Does it make a difference what type of radiologist reads your mammograms?
At the UMMC Breast Center, all breast imaging studies (mammograms, breast ultrasounds and breast MRI) are interpreted by board-certified radiologists who are subspecialized in breast imaging. Our specialists have more than 20 years of combined experience in interpreting these studies, and this is all that they do. Some studies have suggested that the use of subspecialized radiologists, and the greater experience of radiologists who interpret higher numbers of these exams, improves diagnostic accuracy.
Q: If something suspicious is found on a mammogram, what is the chance that it might be breast cancer?
Approximately 10% of screening mammograms are called back for additional imaging evaluation, which involves diagnostic mammography views and/or ultrasound. Of those that are called back, only about 10% of those require biopsy (90% are either explained as benign findings or simply require short-term follow-up). Of those that are biopsied, only about 30% actually are cancer. Another way to put this is that out of 1,000 screening mammograms performed, approximately 5 patients will be found to have cancer.
Q: What happens if something suspicious is found on my mammogram?
If there is a suspicious finding on your mammogram, you will typically need to have additional views and/or ultrasound performed. The radiologist will consult with you in person and will recommend additional evaluation to make a diagnosis. This might be ultrasound-guided core biopsy, stereotactic breast biopsy, cyst aspiration, needle localization and surgical consultation, or MRI-guided biopsy. We will make every attempt to schedule and perform these procedures as soon as possible, so that our patients do not have to endure a long wait to find out whether or not they have breast cancer.
Q: When is breast MRI recommended for breast cancer screening?
These are the recommendations for screening breast MRI, according to the new American Cancer Society guidelines:
- BRCA1 or BRCA2 gene mutation
- first-degree relative (parent, sibling, child) with a BRCA1 or BRCA2 mutation, even if the patient has yet to be tested herself
- lifetime risk of breast cancer scored at 20%-25% or greater, based on one of several accepted risk assessment tools that look at family history and other factors
- radiation to the chest between the ages of 10 and 30
- Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome, or one of these syndromes based on a history in a first-degree relative
Q: If MRI is better, why not have an MRI right away instead of a mammogram?
MRI is the most highly sensitive imaging study for the detection of invasive breast cancer and recent studies indicate it may also be highly sensitive for the detection of intraductal breast cancer. Although it is highly sensitive, it is not highly specific. This means that it also finds lesions which are not cancerous and leads to false positive results and subsequent biopsies. Because of its high false positive rate, high cost and the fact that it benefits from specialized expertise for interpretation, general screening of the population with breast MRI is not ready for prime time. It should be used only for specific indications, as an adjunct to mammography and breast ultrasound.
At this point, MRI should be used in screening only for high risk patients.
Other indications for the use of breast MRI are:
- evaluation of the extent of disease in patients newly diagnosed with breast cancer, including screening of the contralateral breast
- evaluation of breast implant integrity
- evaluation of patients with metastatic axillary adenopathy with no known primary cancer
- patients with breast cancer who had surgery with close or positive surgical margins (MRI is done before repeat surgery.)
- evaluation of the response of breast cancer to chemotherapy
- distinguishing post-operative scar from recurrent cancer
- problem-solving in certain cases (patients with difficult to interpret mammograms or breast ultrasounds to help clarify equivocal findings)
Q: Are there new techniques being studied to improve the accuracy of breast screening?
There are many exciting technologies being investigated in the field of breast imaging. All of this work is in the hopes of detecting breast cancer at the earliest stage possible to allow patients the best chance for a cure.
One new technology being developed is Tomosynthesis, an adjunct to digital mammography. In conventional mammography, a 3-D structure (the breast) is evaluated with a 2-D image. A major drawback of mammography is that structures can be superimposed on a single image. This can result in cancers being hidden on the image or can cause the false appearance of cancer, leading to unnecessary biopsies, etc. Tomosynthesis is a 3-D digital technique that removes the effect of superimposed structures by taking multiple low dose exposures of the breast and processing the information into 1 mm thick slices. This shows promise in improving detection of breast cancers by mammography and decreasing the rate of false positive studies.
Breast-specific gamma imaging (BSGI) and Positron emission mammography (PEM) are developing nuclear medicine techniques which also show promise in detecting breast cancer at early stages. Rather than depending on the shape or appearance of cancer, these techniques depend on the metabolism or biology of the lesion for detection.