Mammography Health Article

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.