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Mammography or Mammogram

Written by sshowalter.

A Mammography is an exam that uses low-dose x-rays to make a picture of breast tissue. This picture is called a mammogram. Mammograms can suggest changes in the breast that may be cancerous up to two years before a lump can be felt. Ductal carcinoma in situ (DCIS), an early stage of a type of breast cancer, can also be found with mammography. An early start to treatment may also stop the cancer before it spreads to the rest of the breast tissue or to other organs.

The United States Preventive Services Task Force recommends that women aged 50 and older get a mammography every 2 years. Women who are at high risk for breast cancer (eg, have a family history) may need to have mammograms starting at an earlier age and more often. Most organizations in the US and Canada recommend regular screening. There are differences of opinion among these groups, such as when to start and the time between screenings. Talk to your doctor about what is best for you.

Reasons for Test Include:

  • Detect breast cancer
  • Identify changes in the breast tissue before a lump can be felt
  • Find a lump's location before a biopsy or surgery

Research on Mammograms

Early diagnosis is important to cancer outcomes; but do mammograms really lead to better outcomes? To help find this answer, researchers have looked at whether regular mammograms were able to decrease the rates of death from breast cancer, but the results were mixed.

Some studies suggest that mammograms can decrease the rate of cancer death, while other studies have questioned these findings. What is agreed on is that the effectiveness of the mammogram may change based on the individual and the type of cancer, for example:

  • Aggressive (fast growing) tumors—Younger women tend to have more aggressive cancerous breast tumors. By the time a mammogram finds an aggressive tumor, some cancer cells may have spread to another organ. Therefore, detection may be too late.
  • Indolent (slow growing) tumors—These are more common in older women and make up half of all breast tumors. According to the National Cancer Institute (NCI) panel, these tumors could be detected by breast exams, without regular mammograms. With this type of tumor, women who perform breast self-exams and undergo breast exams by doctors would have as high a survival rate as the women who do have mammograms.
  • Inflammatory breast cancer —This can be very hard to detect by manual exam. A mammogram may be able to detect this type of cancer before visual symptoms appear.
  • High risk groups—Women with a family history of breast cancer may undergo more aggressive screening, although changes in genetic testing may change recommendations in the future.
  • Dense breast tissue makes it harder for mammograms to locate tumors. Young women and menopausal women on hormone therapy tend to have denser breast tissue. This can make a mammogram less effective for women in their 40’s and younger.
  • According to some of the more recent research, women who were told to have mammography screening over a ten year period had a 15% decrease in breast cancer mortality—This means that for every 2,000 women who are told to be screened through a ten year period, one woman will not die from breast cancer because of the screening.

Risks and Limitations

As a screening test, a mammogram can not actually diagnose breast cancer. To diagnose breast cancer, other tests or procedures will need to be done to closely examine the suspicious tissue. A mammogram simply suggests that cancer may or may not be present. Limits of the test can lead to false results. The test can suggest that cancer is present when there is none (false positive), or it may suggest that cancer is not present when there is cancer (false negative). False Positive

Sometimes, a mammogram may suggest that there is a cancerous change in breast tissue when there really is not. Benign (noncancerous) tissue can look suspicious on a mammogram. Follow-up tests to confirm what the tissue is may include additional mammograms, ultrasound exams, breast biopsies, and other medical tests. If the original mammogram was a false positive, the additional medical tests and associated stress are unnecessary.

A review of research found that for every 2,000 women that were told to have mammograms, 200 experienced unnecessary distress because of false positive test results. False Sense of Security

A normal mammogram does not guarantee that you are cancer free. One possibility is that the test result may be a false negative, meaning the mammogram was not able to show a cancer that was there. A clear test may also encourage a false sense of security, which may lead you to ignore symptoms that should be discussed with a doctor. You may be inclined to rely solely on mammograms instead of manual exams at doctor’s appointments or general self-health awareness. Radiation Risk

Radiation can cause cancer and is used during a mammogram. However, the mammogram uses small doses of radiation that are considered safe. Some have voiced concerns about long term exposure with repeated mammograms. Research has not found a link between mammogram testing and cancer development. There appears to be very little risk of harm from this radiation.

What to Expect

Prior to Test

There are no special steps necessary to prepare for this exam.

However, in order to prevent some discomfort, you can try:

  • Scheduling the exam when breast tissue is least tender - This is most often a week after your period.
  • Avoiding caffeinated drinks.
  • Applying skin numbing products—There is an http://www.fda.gov... that some women have died from using too

Tell the technician if you:

  • Are pregnant
  • Are breastfeeding
  • Have breast implants —Ask if the facility uses special techniques to accommodate implants. Implants make it hard to see breast tissue.

On the day of your exam:

  • Do not apply deodorant, talcum powder, lotion, or perfume near your breasts or under your arms.
  • Ask your doctor if you should take a pain medicine like ibuprofen to relieve discomfort.
  • Wear comfortable clothing so you can easily remove your shirt.
  • Remove jewelry.
  • Bring copies of previous mammograms and reports with you. If you have them done in the same facility each time, they will have results of prior years. The doctor can compare the old images to the new ones.
  • Describe any breast problems to the technician before the exam.

Description of Test

You will stand in front of a special x-ray machine. It has a platform to place your breast on. The technician will adjust the height of the platform. One breast will be lifted and placed between special plates that hold film. The plate is brought close to the platform and compresses the breast. This allows for a clearer image. The exam will cause some discomfort. Tell the technician if you feel any pain.

Two pictures of each breast are taken. During one, you face toward the platform and the image is taken looking down at the breast. For the second, you stand beside the machine. This allows for a side view. The x-rays are done on the other breast. Extra images may be needed if you have implants or if the doctor is looking at a specific spot more closely.

The procedure will take between 30-45 minutes and you may feel some discomfort and pain.

After Test

You will wait in the facility until the x-rays are developed. More images may be needed. You can go home after the exam.

The radiologist will look at the images and may speak with you at the end of the exam. You will usually receive your results within 30 days. If you do not, call and ask for the results.

Your doctor will have a report and either send you a letter or talk to you about your condition. The next mammography is usually done in 1-2 years if everything is normal.

Mammograms can sometimes detect things that look like cancer but are not. If something is noticed on the mammogram, you may need to have other tests done, like an ultrasound or a breast biopsy. This will help determine if there is an actual problem or if everything is fine.

Also, like all breast cancer screening tests, the mammogram will not detect every single abnormality.

Call your doctor if any of the following occurs:

  • Changes in a breast, including a lump or thickening
  • Skin discoloration or discharge from the nipple

Who Should Have a Mammogram

In November 2009, the United States Preventive Services Task Force (USPSTF) released updated guidelines for breast cancer screening. The updates called for changes in well-known current practices for mammograms and breast exams. These changes caught a great deal of media attention and raised public confusion and concern.

Breast cancer screening tests are designed to find cancer in people who do not have symptoms. The hope is that finding cancer earlier will prevent cancer deaths. Research has tried to measure how well screening tests are doing this. Current breast cancer screening options include mammograms, breast exam by a healthcare provider, and self breast exam.

The USPSTF is a panel of experts in medicine that reviews research and develops guidelines for disease prevention and screening. The American Cancer Society (ACS) and American Congress of Obstetricians and Gynecologists (ACOG) also provide guidelines for screening. These organizations create their guidelines based on their interpretation of current research.

Below are guidelines from USPSTF, ACS, and ACOG and summaries of current research. These guidelines and evidence summaries are for women with no symptoms or family history of breast cancer.

Age-Based Guidelines for Mammograms in Women Clinical Breast Exam Self Breast Exam
40-49 years 50-74 years 75 years and older
USPSTF Individualized screening/No routine screening* Every two years No specific recommendatio No recommendations were made Not recommended
ACS Every year Every year No recommendation for age to stop Every 3 years for women aged 20-39. Every year starting at age 40 Optional from age 20 on. Women should be informed of potential benefits and harm
ACOG Every 1-2 years Every year No recommendation for age to stop Every year Can be recommended despite lack of supporting evidence

*The USPSTF recommends against telling all women aged 40-49 years they should have mammograms. The decision to start screening every 2 years before the age of 50 years should be an individual one. It should be based on each person’s values regarding specific risks and benefits.

Contention over who should have them:

There have been many studies on mammograms, but they were not done perfectly. As a result, experts analyzing the research may reach different conclusions.

For women 40-69 years, regular mammograms appear to reduce the risk of dying from breast cancer. There is little evidence about the benefit of mammogram in women aged 70 years or older.

Studies suggest that screening starting at age 40 provides a small reduction in the risk of dying from breast cancer when compared to starting screening at age 50. No change in the overall risk of dying has been shown. There is also a chance of having abnormal test results that are not cancer. This can lead to unnecessary tests, procedures, and stress.

Here is an example of the effect of mammography for women 40-49 years. If 1,000 women in this age group get a screening mammogram:

  • 1 woman will have a cancer that is not seen on the mammogram
  • 100 will have an abnormal mammogram. Out of these women:
    • 90 will be watched more closely with imaging, but not have a biopsy
    • 10 of these women with an abnormal mammogram will have a biopsy (to determine if cancer is present)
      • 8 of these women will not have cancer
      • 2 of these women will have cancer discovered

Here is an example of the effect of mammography for women aged 50-69 years. If 1,000 women in this age group get a screening mammogram:

  • 1 woman will have a cancer that is not seen by the mammogram
  • 83 will have an abnormal mammograms. Out of these women:
    • 72 will be watched more closely with imaging, but not have a biopsy
    • 11 will have a biopsy (to determine if cancer is present)
      • 7 of these women will not have cancer
      • 4 of these women will have cancer discovered

References

American Cancer Society http://www.cancer.org/docroot/home/index.asp

The American Congress of Obstetricians and Gynecologists http://www.acog.org/publications/patient_education/bp076.cfm

National Cancer Institute http://www.cancer.gov

Breast Cancer Society of Canada http://www.bcsc.ca/

Radiology for Patients http://www.radiologyinfo.ca

About radiology. American College of Radiology website. Available at: http://www.acr.org . Accessed July 22, 2008.

Breast cancer screening: research and guidelines. EBSCO Health Library website. Available at: http://www.ebscohost.com/thisTopic.php?marketID=15topicID=81 . Updated November 2009. Accessed January 19, 2010.

Breast Cancer Prevention and Screening. EBSCO DynaMed website. Available at: http://www.ebscohost.com/dynamed/what.php . Updated June 2008. Accessed July 29, 2008.

Cancer trends progress report-2007 update. National Cancer Institute website. Available at: http://www.cancer.... . Accessed 11/12/2009.

Clinical Guidelines: Screening for breast cancer: US Preventive Services Task Force Recommendation Statement. Ann Intern Med . 2009 Nov 17;151(10):716-726.

Ferrini R, Mannino E, Ramsdell E, Hill L. Screening mammography for breast cancer: American College of Preventive Medicine practice policy statement. AmJ Prev Med . 1996 Sep-Oct;12(5):340-341. Available at: http://www.acpm.org/breast.htm . Accessed 11/9/2009.

Frequently asked questions. Oklahoma Breast Care Center website. Available at: http://www.okbreastcare.com/faq.html . Accessed July 22, 2008.

Get a Mammogram: Do It for Yourself, Do It for Your Family. National Cancer Institute website. Available at: http://www.cancer.gov/cancertopics/breasthealth/ . Accessed October 28, 2009.

Gøtzsche PC, Nielsen M. Screening for breast cancer with mammography. Cochrane Database of Systematic Reviews . 2009 Oct 7;(4):CD001877.

Mammograms and other breast imaging procedures. American Cancer Society website. Available at: http://www.cancer.... . Accessed October 28, 2009.

Mammography. Radiological Society of North America website. Available at: http://www.radiologyinfo.org . Updated August 2006. Accessed July 22, 2008.

US Preventive Services Task Force. Guide to Clinical Preventive Services: Recommendations of the US Preventive Services Task Force. 3rd ed. Washington, DC: Agency for Healthcare Research and Quality; 2006.

Women's health. Agency for Healthcare Policy and Research website. Available at: http://www.ahrq.gov/ . Published 2006. Accessed July 22, 2008.

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