Slide 1
Mammographic Screening
• Primary Learning Objective
– Discuss the identification and management of
individuals at risk for breast cancer
• Secondary Learning Objective
– Discuss the use and significance of
mammography as a tool for breast cancer
screening
– Discuss issues related to breast cancer screening
This Articulate Module addresses the following learning objectives as they
pertain to mammographic screening for breast cancer
Discuss the use and significance of mammography as a tool for breast cancer
screening
Discuss issues related to breast cancer screening
Answer these two questions.
Why is the diagnostic accuracy of this test improved with advancing age?
What is the significance of densities and calcifications in mammography?
Slide 2
Mammography remains the Gold-Standard,
First-Line Breast Imaging Screening Modality
• Screening Mammography
• Asymptomatic patient
• Negative clinical breast exam
• Starting at age 40; annually thereafter
• Diagnostic Mammography
• Symptomatic patient
• Suspicious findings on clinical breast exam
Title: Gold Standard
Slide 3
Mammographic Screening for
Breast Cancer
• This is a figure from an article in the Huntsville (Alabama) Times.
• It clearly demonstrates that the mortality rate from breast cancer has
significantly decreased since 1990.
• This decrease is due to both the use mammographic screening of women
leading to early detection of cancer and improved treatment regimens for women
with breast cancer.
Slide 4
Warner, E. Breast Cancer Screening
New Eng J Med 365, 1025-1032, 2011.
• This table demonstrates that the current guidelines for screening
mammographies varies with the organizations making the guidelines.
• Each guideline agrees that women between the ages of 50 and 69 should be
screened; however, whether or not it is every year or every other year varies.
• In the 50 to 69 age group, mammography has been reported to reduce
breast cancer-related deaths by up to 30%.
• For women 70 years or older, the decision about screening should be
individualized. Consideration must be given to co-morbidities.
• For of women between 40 and 49 years of age , the decision about screening
should be individualized based on the patient’s risk factors.
•In this age group, mammography has been reported to reduce breast
cancer-related deaths by up to 17%.
TITLE: Breast Screening Guidelines
Slide 5
This illustration, with its associated mammogram, shows the soft tissue
structures typical of a normal pre-menopausal breast. 
The mammogram demonstrates a thin skin margin with no retraction of either the
skin or the nipple. 
The glandular tissue is interspersed with fat and there are regular bands of
suspensory ligaments known as Cooper's ligaments.
There is no dominant or irregular mass and no evidence of microcalcifications
that would indicative of a lesion.
TITLE: Breast Structures on Mammograms
Slide 6
Breast Density vs.
Mammography Findings
The sensitivity and specificity of mammograms varies with age, being as high as
95% in post-menopausal women.
This variability is directly related to the breast density.
Increased breast density of a pre-menopausal breast decreases the ability of the
technique to resolve masses and microcalcifications from normal glandular
tissue. Both are seen as white areas.
This problem is demonstrated by the mammogram on the left taken from a
younger woman. It clearly demonstrates the dense white areas typically seen in
this patient population, especially in those young women who never have been
pregnant.
In contrast, the mammogram on the right is from a post-menopausal woman. The
fibroadipose tissue that replaces glandular tissue has little density. on
mammograms.
In younger patients, additional tests such as ultrasonography, nuclear medicine
study, and MRI have been useful in resolving breast lesions
Slide 7
Mammography Terminology
• Analog Mammography (Plain Film
Mammography)
- x-ray beam directly captured on a film cassette.
- outdated and obsolete.
• 2D Digital Mammography (Digital
Mammography)
- x-ray beam captured on digital detector → converts x-ray
beam into electronic signal → transferred to a computer →
viewed on high- resolution monitor → allows for > image
manipulation.
- can allow for 30% to 40% decrease in radiation dose.
- should be used as Gold-Standard method for screening
and diagnostics.
Title: Terminology
Slide 8
Digital vs. Conventional
Mammography
These are two mammograms of the same breast. The one on the left is a digital
mammogram and the one on the right is a conventional film mammogram. The
ability to resolve abnormal lesions from normal breast tissue is best seen with
digital mammography.
Although more expensive, digital mammography offers a distinct advantage for
detecting lesion in women with dense breasts, with a reported sensitivity of 78%
vs. 51% for film.
Slide 9
Analog versus 2D Digital Mammogram
Less Dense Breasts
Analog Mammogram
2D Digital
Mammogram
More Dense Breasts
Analog
Mammogram
2D Digital Mammography Images
2D Digital
Mammogram
Slide 10
Mammography Terminology
• 3D Digital Mammography (Breast Tomosynthesis)
- camera moves over breast, taking multiple-angle
images, creating a 3D image, and thus minimizing the
impact of overlapping breast tissue.
- allows for even > image manipulation.
- earlier detection of smaller breast cancers.
- be care in ordering! → it may NOT get paid for!
Title: 3D Mammography
Slide 11
Screening for Breast Cancer
Warner, E. Breast Cancer Screening, New J Med 365, 1025-1032, 2011.
This figure, from a recent New England Journal of Medicine article on Breast Cancer
Screening, demonstrates that in the last 20 years there has been a steady decrease in the
incidence of invasive breast cancer. The article states that this is equally due to
improved adjuvant therapies and to increasing use of screening mammography.
The decision to screen either a particular population or a specific patient for a disease
involves weighing benefits against costs. In a cost-benefit assessment screening for
breast cancer leads to reduced risk of death resulting in a gain in the number of lifeyears.
The article points out that the costs include: financial, risk of radiation, patient
inconvenience, and anxiety, the cost of a diagnostic workup in false positive cases and
in over diagnosed the case. The ratio of benefit to cost varies with age of the patient.
Screening mammography for women 50 to 69 years of age has been universally
recommended; in large part due to increased sensitivity of the mammography due to
reduced density and possibly due to slower tumor growth. However, there is little costbenefit to screening women beyond 74 years of age, due to life expectancy of 5-10 years.
Slide 12
Mammography
• Three mammographic
abnormalities that are
suspicious for cancer
include:
• Mass
• Microcalcifications
• Asymmetric Density
Mammographic abnormalities suspicious for cancer include: mass,
microcalcifications and/or an asymmetric density
Screening mammograms are two x-rays are taken of each breast. One is side-toside (medial-lateral) and the other is from top to bottom (cranial - caudal).
The breast is pressed between two pieces of plastic just enough so breast tissue
can best be seen on the mammogram. This process lasts for a few seconds and
is not harmful and minimizes the necessary x-ray dose. The amount of radiation
exposure during mammography is about the same as receiving a dental x-ray.
It has been estimated that if 10,000 women have yearly mammograms for ten
years, the radiation from mammograms will cause one
additional breast cancer death.
Slide 13
Mammography
Average-size lump found by
woman practicing occasional
breast self-exam (BSE)
Average-size lump found by
woman practicing regular
breast self-exam (BSE)
Average-size lump found by
first mammogram
Average-size lump found by
getting regular mammograms
Mammography is better at detecting breast lesions that self-exam.
Smaller breast lesions are commonly found on routine self-exam as
compared to occasional self-exam.
Similarly, smaller lesions are detected with routine mammograms as
compared to the first mammogram.
Overall, mammograms can detect a lesion well before they are clinically
evident.
This is demonstrated in this mammogram that depicts a small, irregular,
mass that was not palpable.
Slide 14
Microcalcifications
Microcalcifications are seen on mammograms as small white dots.
Their presence is often indicative of ductal carcinoma in situ.
The diagnosis of ductal carcinoma in situ (DCIS) was rare before the introduction
of screening mammography.
DCIS accounts for approximately 25% of all cases of breast cancer, with more
than 90% of them being detected only by imaging.
The risk of cancer is 75% when the microcalcification have a ductal distribution,
are fine, and/or have a linear and branching appearance.
There a 30% risk of cancer when the calcification are clustered, fine, irregular,
and/or granular.
(Ref: Adapted from DeMay RM: The Art & Science of Cytopathology, ASCP Press,
Chicago, 1996)
Slide 15
Mammography
Clinical Finding
Infiltrating
Carcinoma
(%)
Infiltrating
Carcinoma
Mean (cm)
Nodal
Metastases
(%)
DCIS
(%)
Microcalcifications
on Mammogram
26
0.6
6
71
Density on
Mammogram
94
1.1
14
4
Palpable Mass
94
2.4
58
2
After Table 23.1 in Robbins
This table correlates the clinical findings with the subsequent pathology.
DCIS rarely presents as a palpable mass or as a density on a mammogram.
However, it is commonly identified by the presence of microclcifications on a
mammogram.
In contrast, a mammographic diagnosis of infiltrating carcinoma is primarily
made by the presence of a dense lesion rather than by the presence of
microcalcifications.
Slide 16
BIRADS:
Breast Imaging, Reporting, and Data System
• Originally designed to utilize standardized
descriptors to characterize mammographic
findings, including:
– Densities/Nodules/Masses/“Asymmetries”
– Calcifications
– Associated Changes (skin thickening, skin
retraction, nipple retraction, architectural
distortion, axillary adenopathy)
– Categorized findings as BIRADS Category 0-5
– Later adapted for image reporting of Ultrasound
and MRI
Title: BIRADS
Slide 17
BI-RADSTM Mammogram
Categories
Category
Assessment
Recommendation
0
Incomplete assessment
Additional Imaging Needed
1
Negative
Routine screening
2
Benign / stable findings
Routine screening
3
Probably benign
Short interval follow-up
4
Suspicious abnormality
Biopsy recommended /
urged
5
Highly suggestive of
malignancy
Appropriate action to be
taken
This table is for your own information. What is your interpretation and which
category would you put it in?
Slide 18
Breast Ultrasound
• Best performed in a targeted-fashion to a particular
area of interest in the breast and not in a screening
fashion to the entire breast.
• Breast modality to distinguish cystic versus solid
lesions.
• Best modality to characterize solid lesions.
• Useful in detecting and defining intraductal lesions
in the evaluation of suspicious nipple discharge.
Title: Breast Ultrasound
Slide 19
Breast MRI
• Should be utilized
selectively in appropriate
selected patients.
• Two categories for
utilization:
– Potential Diagnostic
Utilities
– Potential Screening
Utilities
T
Slide 20
Breast MRI - Diagnostic Tool
•
Evaluating a patient with a “difficult” clinical breast exam and
dense breasts on mammography.
•
Characterizing breast anatomy in the absence of a
mammographic or ultrasound lesion (BI-RADS 2 breast imaging)
in a patient with a clinically suspicious finding on clinical breast
exam.
•
Evaluating clinical concerns in a breast with an augmentation /
implant.
•
Evaluating clinical concerns a mastectomy patient with implant
reconstruction.
•
Evaluating clinical concerns a mastectomy patient with
autologous tissue flap reconstruction.
•
Ruling out multicentric ipsilateral disease or concurrent
contralateral disease in a patient with a newly diagnosed breast
cancer.
•
Monitoring tumor response to preoperative neoadjuvant systemic
chemotherapy in a patient with newly diagnosed breast cancer.
Slide 21
Breast MRI - Screening Tool
•
Annual screening of any patient with a documented hereditary
breast cancer gene mutation. YES! YES! YES!
•
???Annual screening of a patient with a strong family history of
breast cancer but who has had documented negative genetic
testing??? CONTROVERSIAL?
•
???Annual screening of a patient with a strong family history of
breast cancer but who has declined genetic testing???
CONTROVERSIAL?
•
???Annual screening of a patient with a personal history of
breast cancer??? CONTROVERSIAL?
•
???Annual screening of a patient with a personal history of
radiation therapy to the chest for another type of cancer, such as
Hodgkin’s disease, when treated between the ages of 10 and 30
years old??? CONTROVERSIAL?
Slide 22
Recap of Key Points
• Mammography is best in post-menopausal women
because of reduced density.
– It identifies abnormal microcalcifications in most ductal
carcinomas in-situ that can’t be identified on physical exam
– It is capable of identifying smaller lesions that would go
undetected by palpation.
• Use ultrasound in a targeted manner not as a
screening method
• MRI uses include:
– Hereditary breast cancer gene mutation
– Patients with implants
– R/O multicentric disease
– Monitoring chemo effects before surgery
Mammography is best in done on post-menopausal women because of reduce
density.
Abnormal microcalcifications identify most ductal carcinomas in-situ that can’t
be identified on physical exam
Mammography is capable of identifying smaller lesions that go undetected by
palpation.