2. How are screening and diagnostic mammograms different?

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1 Mammgrams cmprises public dmain material frm the Natinal Cancer Institute at the Natinal Institutes f Health, an agency f the U.S. Department f Health and Human Services. Mammgrams Key Pints A mammgram is an x-ray picture f the breast. Screening mammgrams are used t check fr breast cancer in wmen wh have n signs r symptms f the disease. Diagnstic mammgrams are used t check fr breast cancer after a lump r ther sign r symptm f the disease has been fund. Screening mammgraphy can help reduce the number f deaths frm breast cancer amng wmen ages 40 t 74. Ptential limitatins f screening mammgraphy include false-psitive results, verdiagnsis and vertreatment, false-negative results, and radiatin expsure. 1. What is a mammgram? A mammgram is an x-ray picture f the breast. Mammgrams can be used t check fr breast cancer in wmen wh have n signs r symptms f the disease. This type f mammgram is called a screening mammgram. Screening mammgrams usually invlve tw x-ray pictures, r images, f each breast. The x-ray images make it pssible t detect tumrs that cannt be felt. Screening mammgrams can als find micrcalcificatins (tiny depsits f calcium) that smetimes indicate the presence f breast cancer. Mammgrams can als be used t check fr breast cancer after a lump r ther sign r symptm f the disease has been fund. This type f mammgram is called a diagnstic mammgram. Besides a lump, signs f breast cancer can include breast pain, thickening f the skin f the breast, nipple discharge, r a change in breast size r shape; hwever, these signs may als be signs f benign cnditins. A diagnstic mammgram can als be used t evaluate changes fund during a screening mammgram r t view breast tissue when it is difficult t btain a screening mammgram because f special circumstances, such as the presence f breast implants (see Questin 11). 2. Hw are screening and diagnstic mammgrams different? Diagnstic mammgraphy takes lnger than screening mammgraphy because mre x-rays are needed t btain views f the breast frm several angles. The technician may magnify a suspicius area t prduce a detailed picture that can help the dctr make an accurate diagnsis. 3. What are the benefits f screening mammgrams? Early detectin f breast cancer with screening mammgraphy means that treatment can be started earlier in the curse f the disease, pssibly befre it has spread. Results frm randmized clinical trials and ther studies shw that screening mammgraphy can help reduce the number f deaths frm 1

2 breast cancer amng wmen ages 40 t 74, especially fr thse ver age 50 (1). Hwever, studies t date have nt shwn a benefit frm regular screening mammgraphy in wmen under age 40 r frm baseline screening mammgrams (mammgrams used fr cmparisn) taken befre age What are sme f the ptential limitatins f screening mammgrams? False-psitive results. False-psitive results ccur when radilgists decide mammgrams are abnrmal but n cancer is actually present. All abnrmal mammgrams shuld be fllwed up with additinal testing (diagnstic mammgrams, ultrasund, and/r bipsy) t determine whether cancer is present. False-psitive results are mre cmmn fr yunger wmen, wmen wh have had previus breast bipsies, wmen with a family histry f breast cancer, and wmen wh are taking estrgen (fr example, menpausal hrmne therapy). False-psitive mammgram results can lead t anxiety and ther frms f psychlgical distress in affected wmen. The additinal testing required t rule ut cancer can als be cstly and time cnsuming and can cause physical discmfrt. Overdiagnsis and vertreatment. Screening mammgrams can find cancers and cases f ductal carcinma in situ (DCIS, a nninvasive tumr in which abnrmal cells that may becme cancerus build up in the lining f breast ducts) that need t be treated. Hwever, they can als find cancers and cases f DCIS that will never cause symptms r threaten a wman s life, leading t "verdiagnsis" f breast cancer. Treatment f these latter cancers and cases f DCIS is nt needed and leads t "vertreatment." Overtreatment expses wmen unnecessarily t the adverse effects assciated with cancer therapy. Because dctrs ften cannt distinguish cancers and cases f DCIS that need t be treated frm thse that d nt, they are all treated. False-negative results. False-negative results ccur when mammgrams appear nrmal even thugh breast cancer is present. Overall, screening mammgrams miss abut 20 percent f breast cancers that are present at the time f screening. The main cause f false-negative results is high breast density. Breasts cntain bth dense tissue (i.e., glandular tissue and cnnective tissue, tgether knwn as fibrglandular tissue) and fatty tissue. Fatty tissue appears dark n a mammgram, whereas fibrglandular tissue appears as white areas. Because fibrglandular tissue and tumrs have similar density, tumrs can be harder t detect in wmen with denser breasts. False-negative results ccur mre ften amng yunger wmen than amng lder wmen because yunger wmen are mre likely t have dense breasts. As a wman ages, her breasts usually becme mre fatty, and false-negative results becme less likely. False-negative results can lead t delays in treatment and a false sense f security fr affected wmen. Sme f the cancers missed by screening mammgrams can be detected by clinical breast exams (physical exams f the breast dne by a health care prvider). 2

3 Finding cancer early des nt always reduce a wman s chance f dying frm breast cancer. Even thugh mammgrams can detect malignant tumrs that cannt be felt, treating a small tumr des nt always mean that the wman will nt die frm the cancer. A fast-grwing r aggressive cancer may have already spread t ther parts f the bdy befre it is detected. Wmen with such tumrs live a lnger perid f time knwing that they likely have a fatal disease. In additin, screening mammgrams may nt help prlng the life f a wman wh is suffering frm ther, mre life-threatening health cnditins. Radiatin expsure. Mammgrams require very small dses f radiatin. The risk f harm frm this radiatin expsure is extremely lw, but repeated x-rays have the ptential t cause cancer. The benefits f mammgraphy, hwever, nearly always utweigh the ptential harm frm the radiatin expsure. Nevertheless, wmen shuld talk with their health care prviders abut the need fr each x- ray. In additin, they shuld always let their health care prvider and the x-ray technician knw if there is any pssibility that they are pregnant, because radiatin can harm a grwing fetus. 5. Where can I find current recmmendatins fr screening mammgraphy? Many rganizatins and prfessinal scieties, including the United States Preventive Services Task Frce (which is cnvened by the Agency fr Healthcare Research and Quality, a federal agency), have develped guidelines fr mammgraphy screening. All recmmend that wmen shuld talk with their dctr abut the benefits and harms f mammgraphy, when t start screening, and hw ften t be screened. Althugh NCI des nt issue guidelines fr cancer screening, it cnducts and facilitates basic and translatinal research that infrms standard clinical practice and medical decisin making that ther rganizatins may use t develp their guidelines. 6. What is the best methd f detecting breast cancer as early as pssible? Getting a high-quality screening mammgram and having a clinical breast exam n a regular basis are the mst effective ways t detect breast cancer early. Checking ne s wn breasts fr lumps r ther unusual changes is called a breast self-exam, r BSE. This type f exam cannt replace regular screening mammgrams r clinical breast exams. In clinical trials, BSE alne was nt fund t help reduce the number f deaths frm breast cancer. Althugh regular BSE is nt specifically recmmended fr breast cancer screening, many wmen chse t examine their wn breasts. Wmen wh d s shuld remember that breast changes can ccur because f pregnancy, aging, r menpause; during menstrual cycles; r when taking birth cntrl pills r ther hrmnes. It is nrmal fr breasts t feel a little lumpy and uneven. Als, it is cmmn fr breasts t be swllen and tender right befre r during a menstrual perid. If a wman ntices any unusual changes in her breasts, she shuld cntact her health care prvider. 3

4 7. What is the Breast Imaging Reprting and Database System (BI-RADS )? The American Cllege f Radilgy (ACR) has established a unifrm way fr radilgists t describe mammgram findings. The system, called BI-RADS, includes seven standardized categries, r levels. Each BI-RADS categry has a fllw-up plan assciated with it t help radilgists and ther physicians apprpriately manage a patient s care. Breast Imaging Reprting and Database System (BI-RADS) Categry Assessment Fllw-up 0 Need additinal imaging evaluatin Additinal imaging needed befre a categry can be assigned 1 Negative Cntinue regular screening mammgrams (fr wmen ver age 40) 2 Benign (nncancerus) finding Cntinue regular screening mammgrams (fr wmen ver age 40) 3 Prbably benign Receive a 6-mnth fllw-up mammgram 4 Suspicius abnrmality May require bipsy 5 Highly suggestive f malignancy (cancer) Requires bipsy 6 Knwn bipsy-prven malignancy (cancer) Bipsy cnfirms presence f cancer befre treatment begins 8. Hw much des a mammgram cst? Fr mst wmen with private insurance, the cst f screening mammgrams is cvered withut cpayments r deductibles, but wmen shuld cntact their mammgraphy facility r health insurance cmpany fr cnfirmatin f the cst and cverage. 4

5 Medicare pays fr annual screening mammgrams fr all female Medicare beneficiaries wh are age 40 r lder. Medicare will als pay fr ne baseline mammgram fr female beneficiaries between the ages f 35 and 39. There is n deductible requirement fr this benefit. Infrmatin abut cverage is available n the Medicare website r thrugh the Medicare Htline at MEDICARE ( ). Fr the hearing impaired, the telephne number is Hw can uninsured r lw-incme wmen btain a free r lw-cst screening mammgram? Sme state and lcal health prgrams and emplyers prvide mammgrams free r at lw cst. Fr example, the Centers fr Disease Cntrl and Preventin (CDC) crdinates the Natinal Breast and Cervical Cancer Early Detectin Prgram. This prgram prvides screening services, including clinical breast exams and mammgrams, t lw-incme, uninsured wmen thrughut the United States and in several U.S. territries. Cntact infrmatin fr lcal prgrams is available n the CDC website r by calling CDC INFO ( ). Infrmatin abut free r lw-cst mammgraphy screening prgrams is als available frm NCI s Cancer Infrmatin Service at CANCER ( ) and frm lcal hspitals, health departments, wmen s centers, r ther cmmunity grups. 10. Where can wmen get high-quality mammgrams? Wmen can get high-quality mammgrams in breast clinics, hspital radilgy departments, mbile vans, private radilgy ffices, and dctrs ffices. The Mammgraphy Quality Standards Act (MQSA) is a Federal law that requires mammgraphy facilities acrss the natin t meet unifrm quality standards. Under the law, all mammgraphy facilities must: 1) be accredited by an FDA-apprved accreditatin bdy; 2) be certified by the FDA, r an agency f a state that has been apprved by the FDA, as meeting the standards; 3) underg an annual MQSA inspectin; and 4) prminently display the certificate issued by the agency. Mre infrmatin abut MQSA is available frm the FDA. Wmen can ask their dctrs r staff at a lcal mammgraphy facility abut FDA certificatin befre making an appintment. Wmen shuld lk fr the MQSA certificate at the mammgraphy facility and check its expiratin date. MQSA regulatins als require that mammgraphy facilities give patients an easy-t-read reprt f their mammgram results. Infrmatin abut lcal FDA-certified mammgraphy facilities is available thrugh NCI s Cancer Infrmatin Service at CANCER ( ). Als, a searchable list f these facilities can be fund n the FDA website. 5

6 11. What shuld wmen with breast implants d abut screening mammgrams? Wmen with breast implants shuld cntinue t have mammgrams. (A wman wh had an implant fllwing a mastectmy shuld ask her dctr whether a mammgram f the recnstructed breast is necessary.) It is imprtant t let the mammgraphy facility knw abut breast implants when scheduling a mammgram. The technician and radilgist must be experienced in perfrming mammgraphy n wmen wh have breast implants. Implants can hide sme breast tissue, making it mre difficult fr the radilgist t detect an abnrmality n the mammgram. If the technician perfrming the prcedure is aware that a wman has breast implants, steps can be taken t make sure that as much breast tissue as pssible can be seen n the mammgram. A special technique called implant displacement views may be used. 12. What is digital mammgraphy? Hw is it different frm cnventinal (film) mammgraphy? Digital and cnventinal mammgraphy bth use x-rays t prduce an image f the breast; hwever, in cnventinal mammgraphy, the image is stred directly n film, whereas, in digital mammgraphy, an electrnic image f the breast is stred as a cmputer file. This digital infrmatin can be enhanced, magnified, r manipulated fr further evaluatin mre easily than infrmatin stred n film. Because digital mammgraphy allws a radilgist t adjust, stre, and retrieve digital images electrnically, digital mammgraphy may ffer the fllwing advantages ver cnventinal mammgraphy: Health care prviders can share image files electrnically, making lng-distance cnsultatins between radilgists and breast surgens easier. Subtle differences between nrmal and abnrmal tissues may be mre easily nted. Fewer fllw-up prcedures may be needed. Fewer repeat images may be needed, reducing the expsure t radiatin. T date, there is n evidence that digital mammgraphy helps t reduce a wman s risk f dying frm breast cancer cmpared with film mammgraphy. Results frm a large NCI-spnsred clinical trial that cmpared digital mammgraphy with film mammgraphy fund n difference between digital and film mammgrams in detecting breast cancer in the general ppulatin f wmen in the trial; hwever, digital mammgraphy appeared t be mre accurate than cnventinal film mammgraphy in yunger wmen with dense breasts (2). A subsequent analysis f wmen aged 40 thrugh 79 wh were underging screening in U.S. cmmunity-based imaging facilities als fund that digital and film mammgraphy had similar accuracy in mst wmen. Digital screening had higher sensitivity in wmen with dense breasts (3). 6

7 Sme health care prviders recmmend that wmen wh have a very high risk f breast cancer, such as thse with a knwn mutatin in either the BRCA1 r BRCA2 gene r extremely dense breasts, have digital mammgrams instead f cnventinal mammgrams; hwever, n studies have shwn that digital mammgrams are superir t cnventinal mammgrams in reducing the risk f death fr these wmen. Digital mammgraphy can be dne nly in facilities that are certified t practice cnventinal mammgraphy and have received FDA apprval t ffer digital mammgraphy. The prcedure fr having a mammgram with a digital system is the same as with cnventinal mammgraphy. 13. What is 3D mammgraphy? Three-dimensinal (3D) mammgraphy, als knwn as breast tmsynthesis, is a type f digital mammgraphy in which x-ray machines are used t take pictures f thin slices f the breast frm different angles and cmputer sftware is used t recnstruct an image. This prcess is similar rt hw a cmputed tmgraphy (CT) scanner prduces images f structures inside f the bdy. 3D mammgraphy uses very lw dse x-rays, but, because it is generally perfrmed at the same time as standard twdimensinal (2D) digital mammgraphy, the radiatin dse is slightly higher than that f standard mammgraphy. The accuracy f 3D mammgraphy has nt been cmpared with that f 2D mammgraphy in randmized studies. Therefre, researchers d nt knw whether 3D mammgraphy is better r wrse than standard mammgraphy at aviding false-psitive results and identifying early cancers. 14. What ther technlgies are being develped fr breast cancer screening? NCI is supprting the develpment f several new technlgies t detect breast tumrs. This research ranges frm methds being develped in research labs t thse that are being studied in clinical trials. Effrts t imprve cnventinal mammgraphy include digital mammgraphy, magnetic resnance imaging (MRI), psitrn emissin tmgraphy (PET) scanning, and diffuse ptical tmgraphy, which uses light instead f x-rays t create pictures f the breast. Selected References 1. Mandelblatt JS, Crnin KA, Bailey S, et al. Effects f mammgraphy screening under different screening schedules: mdel estimates f ptential benefits and harms. Annals f Internal Medicine 2009;151(10): [PubMed Abstract] 2. Pisan ED, Gatsnis C, Hendrick E, et al. Diagnstic perfrmance f digital versus film mammgraphy fr breast-cancer screening. New England Jurnal f Medicine 2005; 353(17): [PubMed Abstract] 3. Kerlikwske K, Hubbard RA, Migliretti DL, et al. Cmparative effectiveness f digital versus filmscreen mammgraphy in cmmunity practice in the United States: a chrt study. Annals f Internal Medicine 2011;155(8): [PubMed Abstract] 7

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