Mammography

What is Mammography?

Mammography is specialized medical imaging that uses a low-dose x-ray system to see inside the breasts. A mammography exam, called a mammogram, aids in the early detection and diagnosis of breast diseases in women.
An x-ray (radiograph) is a noninvasive medical test that helps physicians diagnose and treat medical conditions. Imaging with x-rays involves exposing a part of the body to a small dose of ionizing radiation to produce pictures of the inside of the body. X-rays are the oldest and most frequently used form of medical imaging.

What are some common uses of the procedure?

Mammograms are used as a screening tool to detect early breast cancer in women experiencing no symptoms. They can also be used to detect and diagnose breast disease in women experiencing symptoms such as a lump, pain, skin dimpling or nipple discharge.

Screening Mammography

Mammography plays a central part in early detection of breast cancers because it can show changes in the breast up to two years before a patient or physician can feel them. Current guidelines from the U.S. Department of Health and Human Services (HHS) and the American College of Radiology (ACR) recommend screening mammography every year for women, beginning at age 40. Research has shown that annual mammograms lead to early detection of breast cancers, when they are most curable and breast-conservation therapies are available.
The National Cancer Institute (NCI) adds that women who have had breast cancer, and those who are at increased risk due to a family history of breast or ovarian cancer, should seek expert medical advice about whether they should begin screening before age 40 and the need for other types of screening. If you are at high risk for breast cancer, you may need to obtain a breast MRI in addition to your annual mammogram.
See the Breast Cancer Treatment page for information about breast cancer therapy.

Diagnostic Mammography

Diagnostic mammography is used to evaluate a patient with abnormal clinical findings—such as a breast lump or nipple discharge—that have been found by the woman or her doctor. Diagnostic mammography may also be done after an abnormal screening mammogram in order to evaluate the area of concern on the screening exam.

How should I prepare for the mammogram?

Before scheduling a mammogram, the American Cancer Society (ACS) and other specialty organizations recommend that you discuss any new findings or problems in your breasts with your doctor. In addition, inform your doctor of any prior surgeries, hormone use, and family or personal history of breast cancer.
Do not schedule your mammogram for the week before your menstrual period if your breasts are usually tender during this time. The best time for a mammogram is one week following your period. Always inform your doctor or x-ray technologist if there is any possibility that you are pregnant.
The ACS also recommends you:
Do not wear deodorant, talcum powder or lotion under your arms or on your breasts on the day of the exam. These can appear on the mammogram as calcium spots.
Describe any breast symptoms or problems to the technologist performing the exam.
Obtain your prior mammograms and make them available to the radiologist if they were done at a different location. This is needed for comparison with your current exam and can often be obtained on a CD.
Ask when your results will be available; do not assume the results are normal if you do not hear from your doctor or the mammography facility.

How is the procedure performed?

Mammography is performed on an outpatient basis.
During mammography, a specially qualified radiologic technologist will position your breast in the mammography unit. Your breast will be placed on a special platform and compressed with a clear plastic paddle. The technologist will gradually compress your breast.
Breast compression is necessary in order to:
Even out the breast thickness so that all of the tissue can be visualized.
Spread out the tissue so that small abnormalities are less likely to be hidden by overlying breast tissue.
Allow the use of a lower x-ray dose since a thinner amount of breast tissue is being imaged.
Hold the breast still in order to minimize blurring of the image caused by motion.
Reduce x-ray scatter to increase sharpness of picture.
You will be asked to change positions between images. The routine views are a top-to-bottom view and an angled side view. The process will be repeated for the other breast. Compression is still necessary for tomosynthesis imaging in order to minimize motion, which degrades the images. During screening breast tomosynthesis, two-dimensional images are also obtained or created from the synthesized 3-D images.
You must hold very still and may be asked to keep from breathing for a few seconds while the x-ray picture is taken to reduce the possibility of a blurred image. The technologist will walk behind a wall or into the next room to activate the x-ray machine.
When the examination is complete, you may be asked to wait until the radiologist determines that all the necessary images have been obtained.
The examination process should take about 30 minutes.

What will I experience during and after the procedure?

You will feel pressure on your breast as it is squeezed by the compression paddle. Some women with sensitive breasts may experience discomfort. If this is the case, schedule the procedure when your breasts are least tender. Be sure to inform the technologist if pain occurs as compression is increased. If discomfort is significant, less compression will be used. Always remember compression allows better quality mammograms.

Who interprets the results and how do I get them?

A radiologist, a physician specifically trained to supervise and interpret radiology examinations, will analyze the images and send a signed report to your primary care or referring physician, who will discuss the results with you.
You will also be notified of the results by the mammography facility.
Follow-up examinations may be necessary. Your doctor will explain the exact reason why another exam is requested. Sometimes a follow-up exam is done because a potential abnormality needs further evaluation with additional views or a special imaging technique. A follow-up examination may also be necessary so that any change in a known abnormality can be monitored over time. Follow-up examinations are sometimes the best way to see if treatment is working or if a finding is stable or changed over time.

What are the benefits vs. risks?

Benefits
Imaging of the breast improves a physician’s ability to detect small tumors. When cancers are small, the woman has more treatment options.
The use of screening mammography increases the detection of small abnormal tissue growths confined to the milk ducts in the breast, called ductal carcinoma in situ (DCIS). These early tumors cannot harm patients if they are removed at this stage and mammography is an excellent way to detect these tumors. It is also useful for detecting all types of breast cancer, including invasive ductal and invasive lobular cancer.
No radiation remains in a patient’s body after an x-ray examination.
X-rays usually have no side effects in the typical diagnostic range for this exam.
Risks
There is always a slight chance of cancer from excessive exposure to radiation. However, the benefit of an accurate diagnosis far outweighs the risk.
The effective radiation dose for this procedure varies. See the Safety page for more information about radiation dose.
False Positive Mammograms. Five percent to 15 percent of screening mammograms require more testing such as additional mammograms or ultrasound. Most of these tests turn out to be normal. If there is an abnormal finding, a follow-up or biopsy may have to be performed. Most of the biopsies confirm that no cancer was present. It is estimated that a woman who has yearly mammograms between ages 40 and 49 has about a 30 percent chance of having a false-positive mammogram at some point in that decade and about a 7 percent to 8 percent chance of having a breast biopsy within the 10-year period.
Women should always inform their physician or x-ray technologist if there is any possibility that they are pregnant. See the Safety page for more information about pregnancy and x-rays.

Breast Ultrasound

What is Ultrasound Imaging of the Breast?

Ultrasound is safe and painless, and produces pictures of the inside of the body using sound waves. Ultrasound imaging, also called ultrasound scanning or sonography, involves the use of a small transducer (probe) and ultrasound gel placed directly on the skin. High-frequency sound waves are transmitted from the probe through the gel into the body. The transducer collects the sounds that bounce back and a computer then uses those sound waves to create an image. Ultrasound examinations do not use ionizing radiation (as used in x-rays), thus there is no radiation exposure to the patient. Because ultrasound images are captured in real-time, they can show the structure and movement of the body’s internal organs, as well as blood flowing through blood vessels.
Ultrasound imaging is a noninvasive medical test that helps physicians diagnose and treat medical conditions.
Doppler ultrasound, also called color Doppler ultrasonography, is a special ultrasound technique that allows the physician to see and evaluate blood flow through arteries and veins in the abdomen, arms, legs, neck and/or brain (in infants and children) or within various body organs such as the liver or kidneys.
Ultrasound imaging of the breast produces a picture of the internal structures of the breast.
During a breast ultrasound examination, the sonographer or physician performing the test may use Doppler techniques to evaluate blood flow or lack of flow in any breast mass. In some cases, this may provide additional information as to the cause of the mass.

What are some common uses of the procedure?

Determining the Nature of a Breast Abnormality
The primary use of breast ultrasound is to help diagnose breast abnormalities detected by a physician during a physical exam (such as a lump) and to characterize potential abnormalities seen on mammography or breast magnetic resonance imaging (MRI).

Ultrasound imaging can help to determine if an abnormality is solid (which may be a non-cancerous lump of tissue or a cancerous tumor), fluid-filled (such as a benign cyst) or both cystic and solid.

Doppler ultrasound is used to assess blood supply in breast lesions.
Supplemental Breast Cancer Screening
Mammography is the only screening tool for breast cancer that is known to reduce deaths due to breast cancer through early detection. Even so, mammograms do not detect all breast cancers. Some breast lesions and abnormalities are not visible or are difficult to interpret on mammograms. Breasts that are considered dense have a lot of glandular and connective tissues and not much fatty tissue, and that makes cancer harder to detect.

Many studies have shown that ultrasound and magnetic resonance imaging (MRI) can help supplement mammography by detecting breast cancers that may not be visible with mammography. Your doctor can help you determine if either of these tests is appropriate for you. MRI is more sensitive than ultrasound in depicting breast cancer, but MRI may not be available to all women. If screening MRI is performed, then screening ultrasound is not needed, though ultrasound may be used to characterize and biopsy abnormalities seen on MRI. When ultrasound is used for screening, abnormalities not visible with mammography may be identified, including some that may require biopsy. Many of the abnormalities found with screening breast ultrasound are not cancer (false positives). See the Breast Cancer Screening page for more information.
Ultrasound can be offered as a screening tool for women who:
are at high risk for breast cancer and unable to undergo an MRI examination.
are pregnant or should not be exposed to x-rays (which are necessary for a mammogram).
have increased breast density — when the breasts have a lot of glandular and connective tissue and not much fatty tissue (see the Dense Breasts page for more information).
Ultrasound-guided Breast Biopsy
When an ultrasound examination reveals a suspicious breast abnormality, a physician may choose to perform an ultrasound-guided biopsy. Because ultrasound provides real-time images, it is often used to guide biopsy procedures. An ultrasound exam will usually need to be performed before the biopsy in order to plan the procedure and to determine if this method of biopsy can be used.

What are the benefits vs. risks?

Benefits
Most ultrasound scanning is noninvasive (no needles or injections).
Occasionally, an ultrasound exam may be temporarily uncomfortable, but it should not be painful.
Ultrasound is widely available, easy-to-use and less expensive than other imaging methods.
Ultrasound imaging is extremely safe and does not use any ionizing radiation.
Ultrasound scanning gives a clear picture of soft tissues that do not show up well on x-ray images.
Ultrasound provides real-time imaging, making it a good tool for guiding minimally invasive procedures such as needle biopsies and fluid aspiration.
Ultrasound imaging can help detect lesions in women with dense breasts.
Ultrasound may help detect and classify a breast lesion that cannot be interpreted adequately through mammography alone.
Using ultrasound, physicians are able to determine that many areas of clinical concern are due to normal tissue (such as fat lobules) or benign cysts. For most women 30 years of age and older, a mammogram will be used together with ultrasound. For women under age 30, ultrasound alone is often sufficient to determine whether an area of concern needs a biopsy or not.
Risks
For standard diagnostic ultrasound, there are no known harmful effects on humans.
Interpretation of a breast ultrasound examination may lead to additional procedures such as follow-up ultrasound and/or aspiration or biopsy. Many of the areas thought to be of concern turn out to be non-cancerous (false positives).

What are the limitations of Ultrasound Imaging of the Breast?
Ultrasound is one of the tools used in breast imaging, but it does not replace annual mammography.
Many cancers are not visible on ultrasound. Many calcifications seen on mammography cannot be seen on ultrasound. Some early breast cancers only show up as calcifications on mammography. MRI findings that are due to cancer are not always seen with ultrasound.
Biopsy may be recommended to determine if a suspicious abnormality is cancer or not.
Most suspicious findings on ultrasound that require biopsy are not cancers.
Many facilities do not offer ultrasound screening, even in women with dense breasts, and the procedure may not be covered by some insurance plans.
It is important to choose a facility with expertise in breast ultrasound, preferably one where the radiologists specialize in breast imaging. Ultrasound depends on the abnormality being recognized at the time of the scan as it is a “real-time” examination. This requires experience and good equipment. One measure of a facility’s expertise in breast ultrasound can be found in its ACR accreditation status. Check the facilities in your area by searching the ACR-accredited facilities database.