Who should have a mammogram? Is a digital mammogram better than a film-screen (analog) mammogram?
Annual screening mammography is recommended for all women aged 40 and older who have no significant risk factors. Women with a strong family history of breast cancer in a mother, sister or daughter, especially if that cancer occurred when the relative was premenopausal, or if the cancer was bilateral, should consider starting annual screening mammography at age 30, or even younger, if the relative was 30 years of age or younger when diagnosed, or if the patient has tested positive for mutations in the BRCA 1or 2 genes. Digital mammography has been shown to detect more cancers in the following subgroups of women eligible for screening:

1. Women of any age with dense, hard to interpret, breast tissue patterns;
2. Premenopausal or perimenopausal women with dense breast tissue;
3. Women younger than age 50 who have dense breast tissue.

Postmenopausal women with easier to interpret fatty or less dense tissue do not gain an added benefit from having a digital mammogram; virtually the same numbers of cancers are detected in these women no matter whether they have film or digital mammograms. And it is important that women do not delay having an annual mammogram at recommended intervals if they do not have access to a digital mammogram- a good film mammogram is also very accurate in detecting most breast cancers.

Where should I go for my mammogram? Does it make a difference who reads my mammogram?
Women should seek facilities that specialize in comprehensive breast disease diagnosis, and should request that their mammograms be interpreted by a radiologist who reads at least 5000 mammograms each year. Radiologists who interpret 5000 or more mammograms annually have been shown to have better breast cancer detection rates than physicians who interpret only the minimum number of required mammograms (480 per year).

What is computer-aided detection (CAD)? Should I request this as part of my breast evaluation?
Many mammograms are currently interpreted in conjunction with CAD (computer aided detection), a software program that helps analyze possible mammographic abnormalities, bringing them to the radiologist’s attention. Because most of the findings identified by CAD are non-cancerous, it is said to have a very high false positive rate. However, many studies have shown CAD to be a valuable tool in detecting both calcifications (frequently the earliest sign of a breast cancer) as well as small cancerous masses, increasing the numbers of cancers found by both general and expert breast imaging radiologists. The potential down side to this increased detection is that more patients may initially be recalled for additional imaging and/or biopsy than actually have cancer. In most studies, this has not been shown to be a long term problem in patient management.

What type of breast imaging should young women with a breast symptom have?
Breast ultrasound is used instead of an initial mammogram in patients younger than 30, or who may be pregnant. However, if clinical signs or symptoms of a concerning nature exist, even these patients may undergo mammography with appropriate thyroid and abdominal shielding with no significant risk to themselves or to their fetus. Young women with breast lumps or symptoms who are younger than age 30 are extremely unlikely to have breast cancer unless they also have significant familial or genetic risk factors.

When should a woman have a breast ultrasound exam? What are the pros and cons of breast ultrasound?
Breast ultrasound (US) is appropriate for patients with dense breast tissue in whom a previously undiagnosed new lump or thickening exists; it is not particularly helpful when an area of lumpiness is shown to represent fatty tissue on mammography, or when nonspecific and intermittent breast pain occurs in the absence of a clinically worrisome palpable finding. US is also helpful in evaluating new abnormalities seen on mammography, specifically in differentiating a solid from a benign cystic lump, and in guiding minimally invasive breast biopsies. While US may demonstrate abnormalities not seen by mammography, it has a much higher false positive rate than mammography, limiting its cost effectiveness as a screening tool, even in women at risk. In addition, as currently practiced, it is highly user-dependent, with tests performed by more experienced radiologists and techs demonstrating more accurate results. Unlike mammography, the equipment and the personnel performing the breast ultrasound are not at this time regulated, nor are protocols standardized, factors which may limit exam accuracy. Women requiring breast ultrasound should seek facilities in which either a specialized breast imager or specifically trained ultrasound technologist perform the exam, and in facilities that have received voluntary accreditation in the performance of breast ultrasound and ultrasound-guided breast biopsies by the American College of Radiology.

What is breast MRI? How is it used to diagnose breast disease?
Breast MRI (magnetic resonance imaging) is a highly sensitive test best reserved for problem solving and screening in very high risk women. Because it is a very expensive test with variable coverage from third party payers, and because standardization of equipment, scanning protocols, and physician training does not yet exist, MRI should not be recommended at this time as a routine screening tool in women of average risk. Recent published data have suggested that MRI better evaluates the true extent of disease in patients recently diagnosed as having breast cancer in both the abnormal as well as the “normal” breast; this information can be very valuable when planning the optimal surgical and oncologic care for a patient. Women diagnosed as having infiltrating lobular carcinoma, a relatively uncommon cancer that can be difficult to detect on mammography and ultrasound, should also have bilateral MRI scans before a treatment plan is finalized.

Which women at high risk benefit from breast MRI?
Supplemental breast MRI screening has been recommended in addition to mammography for women who have tested positive for the high risk BRCA 1 and 2 mutations, women who have not been tested or have tested negative but who have a strong family history of breast or ovarian cancer which suggests a possible genetic mutation or unusually high degree of personal risk, and patients whose overall lifetime risk of developing breast cancer exceeds 20%. Women who received therapeutic doses of radiation therapy (such as for Hodgkin’s disease) to the chest wall were also recommended by the American Cancer Society to consider MRI breast screening. Because even women who have themselves had breast cancer may not fall into these categories, genetics counseling and testing as well as formal risk assessment may be helpful when determining which patient may benefit from MRI screening.

What are the potential disadvantages to breast MRI? How should it be used in a treatment plan to achieve the best results?
As with breast US, MRI may identify many more questionable benign findings than cancers, leading to unnecessary additional testing and possible biopsies. As no long term outcomes data currently exist that actually show a demonstrated mortality and morbidity reduction attributable to MRI annual screening for high risk patients, these women should consult with their physicians regarding which type of testing is best for them. Women with compromised renal function, or with certain types of metallic objects within their bodies may not be able to undergo MRI scans. Screening MRI is not appropriate as a substitute for a well performed mammogram. It should never be used as the initial examination in a patient with an obvious clinical or mammographic abnormality, and should not be used in place of biopsy for a clinically palpable or suspicious abnormality that is visible on mammography or ultrasound. MRI guided biopsy should be reserved for those suspicious abnormalities that can be identified only on MRI; US or stereotactic biopsy for lesions readily identified ultrasound or mammography is less expensive, usually more rapid, and more appropriate.
Women who require breast MRI should seek facilities with the capability to perform MRI guided biopsies as well; confusion can occur when the MRI and the MRI biopsy are performed at different facilities with different equipment and protocols.