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Definition

Mammography is the study of the breast using xrays. The actual test is called a mammogram. It is an xray of the breast which shows the fatty, fibrous and glandular tissues. There are two types of mammograms. A screening mammogram is ordered for women who have no problems with their breasts. It consists of two x-ray views of each breast: a craniocaudal (from above) and a mediolateral oblique (from the sides). A diagnostic mammogram is for evaluation of abnormalities in either men or women. Additional x rays from other angles, or special coned views of certain areas are taken.

Purpose

The purpose of screening mammography is breast cancer detection. A screening test, by definition, is used for patients without any signs or symptoms, in order to detect disease as early as possible. Many studies have shown that having regular mammograms increases a woman's chances of finding breast cancer in an early stage, when it is more likely to be curable. It has been estimated that a mammogram may find a cancer as much as two or three years before it can be felt. The American Cancer Society (ACS) guidelines recommend an annual screening mammogram for every woman of average risk beginning at age 40. Radiologists look specifically for the presence of microcalcifications and other abnormalities that can be associated with malignancy. New digital mammography and computer aided reporting can automatically enhance and magnify the mammograms for easier finding of these tiny calcifications.

The highest risk factor for developing cancer is age. Some women are at an increased risk for developing breast cancer, such as those with a positive family history of the disease. Beginning screening mammography at a younger age may be recommended for these women.

Diagnostic mammography is used to evaluate an existing problem, such as a lump, discharge from the nipple, or unusual tenderness in one area. It is also done to evaluate further abnormalities that have been seen on screening mammograms. The radiologist normally views the films immediately and may ask for additional views such as a magnification view of one specific area. Additional studies such as an ultrasound of the breast may be performed as well to determine if the lesion is cystic or solid. Breast-specific positron emission tomography (PET) scans as well as in MRI (magnetic resonance imaging) may be ordered to further evaluate a tumor, but mammography is still the first choice in detecting small tumors on a screening basis.

Precautions

Screening mammograms are not usually recommended for women under age 40 who have no special risk factors and a normal physical breast examination. A mammogram may be useful if a lump or other problem is discovered in a woman aged 30-40. Below age 30, breasts tend to be "radiographically dense," which means the breasts contain a large amount of glandular tissue which is difficult to image in fine detail. Mammograms for this age group are controversial. An ultrasound of the breasts is usually done instead since it gives no radiation to the patient.

Description

A mammogram may be offered in a variety of settings. Hospitals, outpatient clinics, physician's offices, or other facilities may have mammography equipment. In the United States only places certified by the Food and Drug Administration (FDA) are legally permitted to perform, interpret, or develop mammograms. Mammograms are taken with dedicated machines using high frequency generators, low kvp, molybdenum targets and specialized x-ray beam filtration. Sensitive high contrast film and screen combinations along with prolonged developing enable the visualization of minute breast detail.

In addition to the usual paperwork, a woman will be asked to fill out a questionaire asking for information on her current medical history. Beyond her personal and family history of cancer, details about menstruation, previous breast surgeries, child bearing, birth control, and hormone replacement therapy are recorded. Information about breast self-examination (BSE) and other breast health issues are usually available at no charge.

At some centers, a technologist may perform a physical examination of the breasts before the mammogram. Whether or not this is done, it is essential for the technologist to record any lumps, nipple discharge, breast pain or other concerns of the patient. All visible scars, tattoos and nipple alterations must be carefully noted as well.

Clothing from the waist up is removed, along with necklaces and dangling earrings. A hospital gown or similar covering is put on. A small self-adhesive metal marker may be placed on each nipple by the x-ray technologist. This allows the nipple to be viewed as a reference point on the film for concise tumor location and easier centering for additional views.

Patients are positioned for mammograms differently, depending on the type of mammogram being performed:

• Craniocaudal position (CC): The woman stands or sits facing the mammogram machine. One breast is exposed and raised to a level position while the height of the cassette-holder is adjusted to the same level. The breast is placed mid-film with the nipple in profile and the head turned away from the side being x-rayed. The shoulder is relaxed and pulled slightly backward while the breast is pulled as far forward as possible. The technologist holds the breast in place and slowly lowers the compression with a foot pedal. The breast is compressed between the film holder and a rectangle of plastic (called a paddle). The breast is compressed until the skin is taut and the breast tissue firm when touched on the lateral side. The exposure is taken immediately and the compression released. Good compression can be uncomfortable, but it is very necessary. Compression reduces the thickness of the breast, creates a uniform density and separates over-lying tissues. This allows for a detailed image with a lower exposure time and decreased radiation dose to the patient. The same view is repeated on the opposite breast.
• Mediolateral oblique position (MLO): The woman is positioned with her side towards the mammography unit. The film holder is angled parallel to the pectoral muscle, anywhere from 30-60 degrees depending on the size and height of the patient. The taller and thinner the patient the higher the angle. The height of the machine is level with the axilla (armpit). The arm is placed at the top of the cassette-holder with a corner touching the armpit. The breast is lifted forward and upward and compression is applied until the breast is held firmly in place by the paddle. The nipple should be in profile and the opposite breast held away if necessary by the patient. This procedure is repeated for the other breast. A total of four x-rays, two of each breast, are taken for a screening mammogram. Additional xrays, using special paddles, different breast positions, or other techniques may be taken for a diagnostic mammogram.

The mammogram may be seen and interpreted by a radiologist right away, or it may not be reviewed until later. If there is any questionable area or abnormality, extra x-rays may be recommended. These may be taken during the same appointment. More commonly, especially for screening mammograms, the woman is called back on another day for these additional films.

A screening mammogram usually takes approximately 15-30 minutes. A woman having a diagnostic mammogram can expect to spend up to an hour for the procedure.

The cost of mammography varies widely. Many mammography facilities accept "self referral." This means women can schedule themselves without a physician's referral. However, some insurance policies do require a doctor's prescription to ensure payment. Medicare will pay for annual screening mammograms for all women over age 39.

Preparation

The compression or squeezing of the breast necessary for a mammogram is a concern of many women. Mammograms should be scheduled when a woman's breasts are least likely to be tender. One to two weeks after the first day of the menstrual period is usually best. Some women with sensitive breasts also find that stop ping or decreasing caffeine intake from coffee, tea, colas, and chocolate for a week or two before the examination decreases any discomfort. Women receiving hor mone therapy may also have sensitive breasts. Over-the counter pain relievers are recommended an hour before the mammogram appointment when pain is a significant problem.

Women should not put deodorant, powder, or lotion on their upper body on the day the mammogram is performed. Particles from these products can get on the breast or film holder and may show up as abnormalities on the mammogram. Most facilities will have special wipes available for those patients who need to wash before the mammogram.

Aftercare

No special aftercare is required.

Complications

The risk of radiation exposure from a mammogram is considered minimal and not significant. Experts are unanimous that any negligible risk is by far outweighed by the potential benefits of mammography. Patients who have breast implants must be x-rayed with caution and compression is minimally applied so that the sac is not ruptured. Special techniques and positioning skills must be learned before a technologist can x-ray a patient with breast implants.

Some breast cancers do not show up on mammograms, or "hide" in dense breast tissue. A normal (or negative) study is not a guarantee that a woman is cancer-free. The false-negative rate is estimated to be 15-20%, higher in younger women and women with dense breasts.

False positive readings are also possible. Breast biopsies may be recommended on the basis of a mammogram, and find no cancer. It is estimated that 75-80% of all breast biopsies resulted in benign (no cancer present) findings. This is considered an acceptable rate, because recommending fewer biopsies would result in too many missed cancers.

Results

A mammography report describes details about the x ray appearance of the breasts. It also rates the mammogram according to standardized categories, as part of the Breast Imaging Reporting and Data System (BIRADS) created by the American College of Radiology (ACR). A normal mammogram may be rated as BIRADS 1 or negative, which means no abnormalities were seen. A normal mammogram may also be rated as BIRADS 2 or benign findings. This means there are one or more abnormalities but they are clearly benign (not cancerous), or variations of normal. Some kinds of calcifications, enlarged lymph nodes or obvious cysts might generate a BIRADS 2 rating.

Many mammograms are considered borderline or indeterminate in their findings. BIRADS 3 means either additional images are needed, or an abnormality is seen and is probably (but not definitely) benign. A follow-up mammogram within a short interval of six to twelve months is suggested. This helps to ensure that the abnormality is not changing, or is "stable." Only the affected side will be x-rayed at this time. Some women are uncomfortable or anxious about waiting, and may want to consult with their doctor about having a biopsy. BIRADS 4 means suspicious for cancer. A biopsy is usually recommended in this case. BIRADS 5 means an abnormality is highly suggestive of cancer. A biopsy or other appropriate action should be taken.

Health care team roles

The mammographic x-ray technologist works closely with the radiologist. Films of high quality must be taken so the radiologist can make an accurate diagnosis. The technologist also assists the radiologist when performing biopsies or fine needle aspirations. Analysis of the specimen will be carried out in the laboratory by the medical laboratory technician. It is important for the technologist to fill out the proper laboratory forms. Biopsies performed in the operating room will sometimes require a magnified x-ray of the specimen itself. The technologist must work in conjunction with the surgeon and operating room nurses to make sure the specimen is x-rayed immediately and than returned for further analysis.

All radiology technologists must be certified according to a recognized standard such as that of the American Society of Registered Radiology Technologists. The MQSA, or Mammography Quality Standards Act, enforced by the FDA, ensures that all mammographic xray technologists receive adequate training and continued education to perform special techniques such as mammography of patients with breast implants. It is also part of the technologist's or nurse's job to perform quality assurance and to keep statistics to ensure FDA compliance.

Patient education

The mammography technologist must be empathetic to the patient's modesty and anxiety. He or she must explain that compression is necessary to improve the quality of the image but does not harm the breasts. Patients will be very anxious when additional films are requested. Explaining that an extra view will give the radiologist more information will help to eases the patient's tension. One in eight women in North America will develop breast cancer. Educating the public on monthly breast self-examinations and yearly mammograms will help in achieving an early diagnosis and therefore a better cure.

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KEY TERMS

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Breast biopsy—A procedure where suspicious tissue is removed and examined by a pathologist for cancer or other disease. The breast tissue may be obtained by open surgery, or through a needle.

Craniocaudal—Head to tail, x-ray beam directly overhead the part being examined.

Radiographically dense—An abundance of glandular tissue, which results in diminished film detail.

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Lorraine K. Ehresman