Mammograms and Other Breast

Imaging Tests
What is a mammogram?
A mammogram is an x-ray exam of the breast thats used to detect and evaluate breast
changes.
X-rays were first used to examine breast tissue a century ago, by the German surgeon,
Albert Salomon. But modern mammography has only existed since the late 1960s, when
special x-ray machines were designed and used just for breast imaging. Since then, the
technology has advanced, and todays mammogram is very different even from those of
the 1980s and 1990s.
Todays x-ray machines used for mammograms expose the breast to much less radiation
compared with those used in the past. The x-rays do not go through tissue as easily as
those used for routine chest x-rays or x-rays of the arms or legs, which also improves the
image quality.

Whats the difference between a screening

mammogram and a diagnostic
mammogram?
Screening mammograms look for signs of cancer
Screening mammograms are x-ray exam of the breasts that are used for women who have
no breast symptoms or signs of breast cancer (like a previous abnormal mammogram).
The goal of a screening mammogram is to find breast cancer when its too small to be felt
by a woman or her doctor. Finding breast cancers early (before they have grown and
spread) greatly improves a womans chance for successful treatment.

A screening mammogram usually takes 2 x-ray pictures (views) of each breast. Some
women, such as those with large breasts, may need to have more pictures to see as much
breast tissue as possible.

Diagnostic mammograms investigate possible problems

A woman with a breast problem (for instance, a lump or nipple discharge) or an abnormal
area found in a screening mammogram typically gets a diagnostic mammogram. Its still
an x-ray of the breast, but its done for a different reason than a screening mammogram.
During a diagnostic mammogram, the images are reviewed by the radiologist while you
are there so that more pictures can be taken if need to look more closely at an area of
concern. In some cases, special images known as spot views or magnification views are
used to make a small area of abnormal breast tissue easier to evaluate. Other types of
imaging tests such as ultrasound may also be done in addition to the mammogram,
depending on the type of problem and where it is in the breast.
A diagnostic mammogram is usually interpreted in one of three ways:
It may reveal that an area that looked abnormal on a screening mammogram is
actually normal. When this happens, the woman goes back to routine yearly
screening.
It could show that an area of abnormal tissue probably is not cancer, but the
radiologist may not be ready to say that the area is normal based on these pictures
alone. When this happens its common to ask the woman to return to be re-checked,
usually in 4 to 6 months.
The results could also suggest that a biopsy is needed to find out if the abnormal area
is cancer. If your doctor recommends a biopsy, it does not mean that you have cancer.
For help understanding your mammogram report and your radiologists estimate of your
cancer risk, see the section Understanding your mammogram report BI-RADS
categories. If a biopsy is needed, you should discuss the different types of biopsy with
your doctor to decide which type is best for you. To learn more about them, please see
our document For Women Facing a Breast Biopsy.

How is a mammogram done?

When you have a mammogram, your breast is briefly compressed or squeezed between 2
plates attached to the mammogram machinean adjustable plastic plate (on top) and a
fixed x-ray plate (on the bottom). The bottom plate holds the x-ray film or the digital
detector that makes the image. The technologist compresses your breast to keep it from
moving, and to make the layer of breast tissue thinner. A thinner layer of breast tissue
allows the x-ray exposure to be reduced and makes the picture sharper. Although the

compression can feel uncomfortable and even painful for some women, it only lasts a few
seconds and is needed to get a good picture. Talk to the technologist if you have pain.
She can reposition you to make the pressure as comfortable as possible. Although the
time you are exposed to x-rays is just seconds, the entire procedure for a mammogram
takes about 20 minutes.

The x-ray device and compression plates used for mammograms

Types of mammogram machines

Mammograms produce a black and white x-ray picture of the breast tissue. Depending on
the type of machine, the picture is either on a large sheet of film or is an electronic image
that can be seen on a computer screen. These two ways of doing a mammogram are much
the same. The differences are in the way the picture is recorded, looked at by the doctor,
and stored.
Screen-film units are the machines that produce the mammogram picture on x-ray
film.
Full-field digital mammography units capture the picture in a digital format that can
be looked at on a computer screen. Most mammogram machines in use today are fullfield digital units.
Digital mammograms may be better than film mammograms at finding cancers in women
younger than 50 and in women with dense breast tissue. In the United States, most
mammograms are digital.
Its important to remember that standard film mammograms still work well. Nobody
should miss having a regular mammogram because a digital mammogram is not
available.

How mammograms are read

No matter what kind of x-ray image is taken film or electronic its interpreted (or
read) by a doctor, most often a radiologist. Radiologists are doctors who have special
training in diagnosing diseases by looking at pictures of the inside of the body produced
by x-rays, sound waves, magnetic fields, or other methods. Other doctors who treat breast
diseases may look at the mammogram, too.
Reading mammograms is challenging. The way the breast looks on a mammogram varies
a great deal from woman to woman. Some breast cancers may cause changes in the
mammogram that are hard to notice.
If youve had mammograms in the past, its very important that the radiologist has your
most recent x-ray films or digital pictures so they can be compared with the new ones.
The doctor will want to look at the actual pictures, not just the reports. Comparing the
pictures helps the doctor find small changes and detect cancer as early as possible. It can
be hard to get your older pictures, so its best to find a facility that you are comfortable
with and plan to get your regular mammograms there each year. That way, your
mammogram pictures are all in one place. If you do have to change facilities, call ahead
to find out what you will need to do in order to get your old pictures to be taken or sent to
the new place.

What to expect when you have a

mammogram
You will have to undress above the waist to have a mammogram. The facility will
give you a wrap to wear.
A technologist will position your breasts for the mammogram. You and the
technologist are the only ones in the room during the mammogram.
To get a high-quality picture, the breast must be somewhat flattened. The technologist
places the breast on the machines plate. The plastic upper plate is lowered to
compress the breast for a few seconds while the technologist takes a picture.
The whole procedure takes about 20 minutes. The actual breast compression only
lasts a few seconds.
You may feel some discomfort when your breasts are compressed, and for some
women it can be painful.
All mammogram facilities are required to send your results to you within 30 days. In
most cases, you will be contacted within 5 working days if theres a possible problem
seen on the mammogram.

 Being called back for more testing does not mean that you have cancer. In fact, less
than 10% of women called back for more tests are found to have breast cancer. Being
called back happens fairly often. It usually just means more pictures or an ultrasound
needs to be done to look at a suspicious area more carefully.
Only 2 to 4 screening mammograms of every 1,000 lead to a diagnosis of breast
cancer.
If you are a woman age 40 or over, you should get a mammogram every year. (See our
document called Breast Cancer: Early Detection for the American Cancer Society breast
cancer screening recommendations.) You can schedule the next one while you are there
at the facility. Or you can ask for a reminder to schedule it as the date gets closer. Some
women schedule the next years mammogram and ask to be reminded of the appointment
a few weeks ahead of time.

Tips for having a mammogram

These tips can help you have a good quality mammogram:
If its not posted in a place you can see it near the receptionists desk, ask to see the
FDA certificate thats issued to all facilities that offer mammograms. The FDA
requires all facilities to meet high standards of safety and quality in order to provide
mammogram services.
If you have a choice, use a facility that specializes in mammograms and does many
mammograms a day.
If you are satisfied that the facility is of high quality, continue to go there on a regular
basis so that your mammograms can easily be compared from year to year.
If youre going to a facility for the first time, bring a list of the places and dates of
mammograms, biopsies, or other breast treatments youve had before.
If youve had mammograms at another facility, try to get those mammograms to bring
with you to the new facility (or have them sent there) so that they can be compared to
the new ones.
On the day of the exam, dont wear deodorant or antiperspirant. Some of these
contain substances that can show up on the x-ray as white spots. If youre not
returning home, you may want to take your deodorant with you to put on after your
exam.
You may find it easier to wear a skirt or pants, so that youll only need to remove
your top and bra for the mammogram.

 Schedule your mammogram when your breasts are not tender or swollen to help
reduce discomfort and get a good picture. If you are still menstruating, try to avoid
the week just before your period.
Always describe any breast changes or problems you are having to the technologist
doing the mammogram. Also describe any medical history that could affect your
breast cancer risksuch as surgery, hormone use, or breast cancer in your family (or
if youve had breast cancer before). Discuss any new findings or problems in your
breasts with your doctor or nurse before having the mammogram.
Before having any type of imaging test, tell the radiologic technologist if you are
breast-feeding or if you think you might be pregnant.
If you do not hear from your doctor within 10 days, do not assume that your
mammogram was normal; call your doctor or the facility.

Where can I get help with mammogram

costs?
Medicare, Medicaid, and all private health insurance policies created after March 23,
2010 cover screening mammogram costs. The new health care law requires that health
insurance companies pay for screening mammograms. Insurance coverage is different for
diagnostic mammograms, which usually cost more than screening mammograms.
Low-cost mammograms are available in most areas. Call the American Cancer Society at
1-800-227-2345 for information about facilities in your area.
The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) also
provides breast and cervical cancer early detection testing to women without health
insurance for free or at very little cost. To learn more about this program, please contact
the Centers for Disease Control and Prevention (CDC) at 1-800-CDC INFO (1-800-2324636) or visit their website at www.cdc.gov/cancer.

How is mammography regulated?

In the United States, mammography is highly regulated. Although the overall quality of
mammography has improved since its introduction in the late 1960s, studies done in the
mid-1980s showed that quality varied greatly from place to place.
To help educate those working with mammograms, improve quality, and lower the dose
of radiation, the American Cancer Society asked the American College of Radiology
(ACR) to establish standards and criteria that would help women and doctors find those
facilities that provided high-quality screening services. In 1986, the ACR started the first
national Mammography Accreditation Program (MAP). This voluntary program raised

standards nationwide and led to better mammogram services at those sites that took part
in the program.
In 1992, Congress passed the Mammography Quality Standards Act (MQSA) to ensure
that radiology facilities offering mammography would be required to meet minimum
quality standards. Today, the US Food and Drug Administration (FDA) certifies every
facility offering mammography (except those of the Department of Veterans Affairs). In
order to be certified, the equipment, personnel, and practice of the facility must be
reviewed by an FDA-approved accreditation body, have an on-site inspection, and meet
the following criteria:
Each mammography unit has to be accredited.
Certain staff members must meet strict standards including:
- Radiologists (the doctors who interpret or read the mammograms)
- Radiologic technologists (those who actually position women for the
mammogram and take the pictures)
- Medical physicists (professionals who specialize in medical equipment and
image production)
Typical x-rays are reviewed for quality and information on radiation dose, which is
required to be very low.
If the facility meets all of the required standards, the FDA gives its certification. These
standards are outlined in the MQSA, which has been in effect since 1994. It is unlawful
to do mammograms in the United States without an FDA certificate.
The FDA has a list of all of its certified mammography facilities by state and zip code.
You can find those near you by visiting the FDAs website:
www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMQSA/mqsa.cfm.

Reporting results
Mammogram clinics must notify women in writing about the results of their
mammograms. The Mammography Quality Standards Act (MQSA) requires this.
Mammography clinics still report mammogram results to the womans doctor, too, who is
responsible for ordering more tests or treatments, if needed.
The MQSA requires clinics to mail women a separate, easy-to-understand summary of
their mammogram results within 30 daysor as quickly as possible if the results
suggest cancer is present. This means that the woman may know about the results before
her doctor calls to tell her. If the woman wants the full written mammography report,
shell need to ask for it in addition to the summary.

Radiation exposure from mammography

The modern mammography machine uses low radiation doses to produce breast x-rays
that are high in image quality. (It usually uses about 0.1 to 0.2 rads per picture; a rad is a
measure of radiation dose). Older mammography units delivered higher doses, and led to
concerns about radiation risks. These older machines are no longer used.
Strict guidelines ensure that mammography equipment is safe and uses the lowest dose of
radiation possible. Many people are concerned about the exposure to x-rays, but the level
of radiation from a mammogram today does not significantly increase the breast cancer
risk for a woman who gets regular mammograms.
To put dose into perspective, if a woman with breast cancer is treated with radiation, she
will likely get a total of several thousand rads. If she has yearly mammograms starting at
age 40 and continues until she is 90, she will get a total of 20 to 40 rads. To put it another
way, the dose of radiation that she gets during one screening mammogram is about the
same amount of radiation she would average from her natural surroundings (background
radiation) over a couple of months.
Mammograms require very small doses of radiation. The risk of harm from this radiation
is extremely low, but in theory, repeated x-rays might have the potential to cause cancer.
Still, the benefits of mammography outweigh any possible harm from the radiation
exposure.
Women should always let their health care providers and x-ray technologists know if
there is any chance that they are pregnant. Although the risk to the fetus is likely to be
low, mammograms done for screening arent done in pregnant women.

What does the doctor look for on a

mammogram?
A mammogram may show something suspicious, but by itself it cant prove that an
abnormal area is cancer. If a mammogram raises a suspicion of cancer, a tissue sample
from the suspicious area must be removed and looked at under the microscope to find out
if it is cancer. For detailed information on the types of biopsies and what you need to
know, please see our document For Women Facing a Breast Biopsy.
The doctor reading your mammogram will look for different types of changes.

Calcifications
Calcifications are tiny mineral deposits within the breast tissue. They look like small
white spots on a mammogram. They may or may not be caused by cancer. There are 2
types of calcifications.

Macrocalcifications
Macrocalcifications are coarse (larger) calcium deposits that are most likely due to
changes in the breasts caused by aging of the breast arteries, old injuries, or
inflammation. These deposits are related to non-cancerous conditions and do not require
a biopsy. Macrocalcifications are found in about half the women over 50, and in 1 of 10
women under 50.

Microcalcifications
Microcalcifications are tiny specks of calcium in the breast. Microcalcifications seen on a
mammogram are of more concern than macrocalcifications, but they do not always mean
that cancer is present. The shape and layout of microcalcifications help the radiologist
judge how likely it is that cancer is present.
In most cases, the presence of microcalcifications does not mean a biopsy is needed. But
if the microcalcifications have a suspicious look and pattern, a biopsy will be
recommended. (During a biopsy, the doctor removes a small piece of the suspicious area
to be looked at under a microscope. A biopsy is the only way to tell if cancer is really
present.)

A mass
A mass, with or without calcifications, is another important change seen on a
mammogram. Masses are areas that look abnormal and they can be many things,
including cysts (non-cancerous, fluid-filled sacs) and non-cancerous solid tumors (such
as fibroadenomas), but may sometimes may be a sign of cancer.
Cysts can be simple fluid-filled sacs (known as simple cysts) or can be partially solid
(known as complex cysts). Simple cysts are benign (not cancer) and dont need to be
biopsied. If a mass is not fluid-filled, it is of more concern and might need to be biopsied
to be sure it isnt cancer.
A cyst and a tumor can feel the same on a physical exam. They can also look the
same on a mammogram. To confirm that a mass is really a cyst, a breast ultrasound is
often done. Another option is to remove (aspirate) the fluid from the cyst with a thin,
hollow needle.
If a mass is not a simple cyst (that is, if its at least partly solid), more imaging tests
may be needed. Some masses can be watched with regular mammograms or
ultrasound, while others may need a biopsy. The size, shape, and margins (edges) of
the mass may help the radiologist determine if cancer is likely to be present.

Having your prior mammograms available for the radiologist is very important. They can
help show that a mass or calcification has not changed for many years. This would mean
that its likely not cancer and a biopsy is not needed.

Breast density
Your mammogram report will also contain an assessment of breast density. Breast
density is based on how fibrous and glandular tissue tissues are distributed in your breast,
vs. how much of your breast is made up fatty tissue.
Dense breasts are not abnormal, but they are linked to a higher risk of breast cancer. We
know that dense breast tissue can make it harder to find cancers on a mammogram. Still
experts do not agree what other tests, if any, should be done in addition to mammograms
in women with dense breasts who arent in a high-risk group (based on gene mutations,
breast cancer in the family, or other factors).

What if a breast biopsy is needed?

A suspicious area in the breast may be found by physical exam, mammogram, or another
imaging test, or by some combination of these. But no matter of how it was found, the
only way to know for sure if its cancer is to do a biopsy. This means a sample of cells or
tissue is taken from the area and looked at under the microscope. For suspicious areas
that cannot be felt (and even for most that can), imaging tests may be used to be sure the
right area is biopsied. There are several types of biopsies, and its important for you to
know which type the doctor recommends for you.
For detailed information on the types of biopsies and what you need to know, please see
our document For Women Facing a Breast Biopsy.

Understanding your mammogram report

BI-RADS categories
The American College of Radiology (ACR) came up with a standard way to describe
mammogram findings and results. In this system, the results are sorted into categories
numbered 0 through 6. This system is called the Breast Imaging Reporting and Data
System (BI-RADS). Having a standard way of reporting mammogram results lets doctors
use the same words and terms, which can help ensure better follow up of suspicious
findings. Heres a brief review of what the categories mean:

X-ray assessment is incomplete

Category 0: Additional imaging evaluation and/or comparison to prior
mammograms is needed.
This means a possible abnormality may not be clearly seen or defined and more tests are
needed, such as the use of spot compression (applying compression to a smaller area
when doing the mammogram), magnified views, special mammogram views, or
ultrasound.
This also suggests that the mammogram should be compared with older ones to see if
there have been changes in the area over time.

X-ray assessment is complete

Category 1: Negative
Theres no significant abnormality to report. The breasts look the same (they are
symmetrical) with no masses (lumps), distorted structures, or suspicious calcifications. In
this case, negative means nothing bad was found.

Category 2: Benign (non-cancerous) finding

This is also a negative mammogram result (theres no sign of cancer), but the reporting
doctor chooses to describe a finding known to be benign, such as benign calcifications,
lymph nodes in the breast, or calcified fibroadenomas. This ensures that others who look
at the mammogram will not misinterpret the benign finding as suspicious. This finding is
recorded in the mammogram report to help when comparing to future mammograms.

Category 3: Probably benign finding Follow-up in a short time frame

is suggested
The findings in this category have a very high chance (greater than 98%) of being benign
(not cancer). The findings are not expected to change over time. But since its not proven
benign, its helpful to see if the area in question does change over time.
Follow-up with repeat imaging is usually done in 6 months and regularly after that until
the finding is known to be stable (usually at least 2 years). This approach helps avoid
unnecessary biopsies, but if the area does change over time, it still allows for early
diagnosis.

Category 4: Suspicious abnormality Biopsy should be considered

Findings do not definitely look like cancer but could be cancer. The radiologist is
concerned enough to recommend a biopsy. The findings in this category can have a wide
range of suspicion levels. For this reason, some doctors divide this category further:
4A: finding with a low suspicion of being cancer
4B: finding with an intermediate suspicion of being cancer
4C: finding of moderate concern of being cancer, but not as high as
Category 5
Not all doctors use these subcategories.

Category 5: Highly suggestive of malignancy Appropriate action

should be taken
The findings look like cancer and have a high chance (at least 95%) of being cancer.
Biopsy is very strongly recommended.

Category 6: Known biopsy-proven malignancy Appropriate action

should be taken
This category is only used for findings on a mammogram that have already been shown
to be cancer by a previous biopsy. Mammograms may be used in this way to see how
well the cancer is responding to treatment.

BI-RADS reporting for breast density

Mammogram reports will also include an assessment of breast density. BI-RADS
classifies breast density into 4 groups:

The breasts are almost entirely fatty

The breasts contain little fibrous and glandular tissue, which means the mammogram
would likely detect anything abnormal.

There are scattered areas of fibroglandular density

There are a few areas of fibrous and glandular tissue in the breast.

The breasts are heterogeneously dense, which may obscure small masses
The breast has more areas of fibrous and glandular tissue that are found throughout the
breast. This can make it hard to see small masses.

The breasts are extremely dense, which lowers the sensitivity of

mammography
The breast has a lot of fibrous and glandular tissue. This can lead to missing some
cancers.
In some states, women whose mammograms show heterogeneously dense or extremely
dense breasts must be told that they have dense breasts in the summary of the
mammogram report that is sent to patients (sometimes called the lay summary). The
language used is mandated by law, and may say something like, Your mammogram
shows that your breast tissue is dense. Dense breast tissue is common and is not
abnormal. However, dense breast tissue can make it harder to evaluate the results of your
mammogram and may also be associated with an increased risk of breast cancer. This
information about the results of your mammogram is given to you to raise your
awareness and to inform your conversations with your doctor. Together, you can decide
which screening options are right for you. A report of your results was sent to your
physician.

What are the limitations of mammograms?

As is the case with most medical tests, mammography has limitations.
Although breast cancer screening is the best way we have now to find cancer early,
finding cancer early does not always reduce a womans chance of dying from breast
cancer. Even though mammograms can detect breast cancers too small to be felt, treating
a small tumor does not always mean it can be cured. A fast-growing or aggressive cancer
may have already spread before its found.
The value of a screening mammogram also depends on a womans overall health status.
Detecting breast cancer early may not help prolong the life of a woman who has other
kinds of serious or life-threatening health problem such as congestive heart failure, endstage renal disease, or chronic obstructive pulmonary (lung) disease. ACS screening
guidelines emphasize that women with serious health problems or short life expectancies
should discuss with their doctors whether to continue having mammograms. Our
guidelines also stress that age alone should not be the reason to stop having regular
mammograms.

False-negative results
A false-negative mammogram appears normal even though breast cancer is present.
Overall, screening mammograms miss about 1 in 5 breast cancers.
False negatives occur more often among women with dense breasts. Breasts usually
become less dense as women age, and so false negatives are more common among
younger women than among older women. False-negative results can delay treatment and
promote a false sense of security for the woman.

False-positive results
A false-positive mammogram looks abnormal but no cancer is actually present.
Abnormal mammograms require extra testing (diagnostic mammograms, ultrasound, and
sometimes MRI or even biopsy) to find out if cancer is present.
False-positive results are more common in women who are younger, have dense breasts,
have had breast biopsies, have breast cancer in the family, or are taking estrogen. About
half the women getting annual mammograms over a 10-year period will have a falsepositive finding. The odds of a false-positive finding are highest for the first
mammogram, and are lower on subsequent mammograms. Women who have past films
available for comparison reduce their odds of a false-positive finding by 50%.
False-positive mammograms can cause anxiety. The extra tests needed to be sure cancer
isnt there cost time and money and also cause physical discomfort.

Over-diagnosis and over-treatment

While screening mammograms can find invasive breast cancer and ductal carcinoma in
situ (DCIS, cancer cells in the lining of breast ducts) that need to be treated, its also
possible that some invasive cancers and DCIS detected on mammography will not keep
growing. This means that some tumors are not life-threatening, and never would have
been detected if a woman had not gotten a mammogram. The problem is that doctors
cant tell these cancers from those that will grow and spread.
Our only hint that over-diagnosis may exist is through statistical analysis that compares
the number of cancers found by mammography over long periods of time with the
numbers of cancers that would have been expected without screening. Over-diagnosis is a
concern because an over-diagnosed cancer will still be treated. This means that some
women are treated unnecessarily because we dont know which women fall into this
group at the time the cancer is diagnosed. These cases would be considered overtreatment, which exposed the women unnecessarily to the adverse effects of cancer
therapy. Because doctors often cannot be sure which cancers and cases of DCIS will
become life-threatening, they are all treated. Although there is a wide range of estimates

of the percentage of breast cancers that might be over-diagnosed by mammography, the

most credible estimates range from 0-10%.

Mammograms in special circumstances

Mammograms in younger women
Mammograms are more difficult to read in younger women, usually because their breast
tissue is dense and this can hide a tumor on an x-ray. Since most breast cancers occur in
older women, this is usually not a problem. Screening mammograms are not
recommended for average-risk women under age 40.
In some younger women who are at high risk for developing breast cancer (due to a gene
mutation, a strong family history, or other factors), yearly breast MRIs and mammograms
are recommended. For most of these women, screening should begin at age 30 years and
continue for as long as the woman is in good health. But because the evidence about the
best age at which to start screening is limited, this decision should be based on
discussions between patients and their health care providers, taking into account personal
circumstances and preferences.
Our document called Breast Cancer: Early Detection gives more details about the
American Cancer Society breast cancer screening recommendations. It also tells you
more about figuring out your breast cancer risk.

Mammograms after breast-conserving treatment

What is breast-conserving treatment?
Removing the entire breast (mastectomy) is one way of treating breast cancers. But
today, most breast cancers can be treated just as well with breast-conserving treatment
(BCT), which does not remove the entire breast.
Partial mastectomy (sometimes called lumpectomy) is another name for BCT. This
procedure removes the cancerous tumor and some of the surrounding normal breast
tissue.
BCT is almost always followed by radiation treatment.
A woman who has had BCT will need to continue having regular mammograms of both
breasts.

Mammogram plans after breast-conserving treatment

Most radiologists recommend that women have a mammogram of the treated breast 6
months after radiation treatment is finished. Radiation and surgery both cause changes in
the skin and breast tissues. These changes show up on the mammogram, making it harder
to read. The changes usually peak 6 months after the radiation is completed. The
mammogram done at this time serves as a new baseline for the affected breast for that
woman. Future mammograms will be compared with this one, to help the doctor follow
up on healing and check for recurrence (the cancer coming back).
Depending on the results, the next exam for that breast is often 6 months later. Experts
differ on the best follow-up plan from this point on. Some prefer a mammogram of the
treated breast every 6 months for 2 to 3 years; others suggest that yearly mammograms
are enough. Each woman should talk with her doctor about the plan that is best for her.
The opposite breast still needs yearly mammograms.

Mammograms after mastectomy

Without breast reconstruction
Total or simple mastectomy removes all of the breast tissue, including the nipple, but does
not remove underarm lymph nodes or chest muscle tissue beneath the breast. Sometimes
this surgery is done for both breasts (a double mastectomy), most often as preventive
surgery in women at very high risk for breast cancer.
Modified radical mastectomy removes the breast, skin, nipple, areola, and most of the
lymph nodes under the arm on the same side, leaving the chest muscles intact.
Radical mastectomy is surgery for breast cancer in which the breast, chest muscles, and
all of the lymph nodes under the arm are removed. This surgery is rarely used today. Its
mainly used when the cancer has spread to the chest muscles.
Women who have had total, modified radical, or radical mastectomy for breast cancer
need no further routine screening mammograms of the affected side. (If both breasts are
removed, they dont need mammograms at all.)
Mammograms are usually continued on the unaffected breast each year. This is very
important, because women who have had one breast cancer are at higher risk of
developing a new cancer in the other breast.
One type of mastectomy that does require a follow-up mammogram is the subcutaneous
mastectomy, also called skin-sparing mastectomy. In this operation, the woman keeps her
nipple and the tissue just under the skin. Enough breast tissue is left behind to require
yearly screening mammograms in these women.

Any woman who is not sure what type of mastectomy she has had or whether she needs
mammograms should ask her doctor.

With breast reconstruction

Women who have had a breast fully removed and reconstructed (rebuilt) with silicone gel
or saline implants do not need routine mammograms. If the woman has had a
subcutaneous mastectomy (discussed above), yearly mammograms are still needed.
After mastectomy, some women choose to have their breast shape rebuilt using tissue
from their own bodies. There are several types of reconstruction procedures (for
information about different flap procedures, see our document Breast Reconstruction
after Mastectomy). A patient who has had a complete (not subcutaneous) mastectomy
followed by reconstruction needs no further screening mammograms on the affected side.
But if theres an area of the reconstructed breast that is of concern on the physical exam,
a diagnostic mammogram may be done. Further imaging with ultrasound or MRI may
also be helpful.

Mammograms in women with breast implants

Women who have implants are a special challenge for mammogram screening. The xrays used for imaging the breasts cannot go through silicone or saline implants well
enough to show the breast tissue that is over or under it. This means that the part of the
breast tissue covered up by the implant will not be seen on the mammogram.
In order to see as much breast tissue as possible, women with implants have 4 extra
pictures (2 on each breast) as well as the 4 standard pictures taken during a screening
mammogram. In these extra x-ray pictures, called implant displacement (ID) views, the
implant is pushed back against the chest wall and the breast is pulled forward over it.
This allows better imaging of the front part of each breast. Implant displacement views
do not work as well in women who have had hard scar tissue form around the implants
(contractures). They are easier in women whose implants are placed underneath (behind)
the chest muscle.
Although these women do have more pictures taken at each mammogram, the guidelines
for how often women with implants should have screening mammograms are the same as
for women without them. (See Breast Cancer: Early Detection for the American Cancer
Societys breast cancer screening guidelines.)
A ruptured (burst) implant can sometimes be diagnosed on a mammogram, but a ruptured
implant will often look normal. Magnetic resonance imaging (MRI), on the other hand, is
extremely good at finding an implant rupture. MRI is the best way to check the implant
itself, while mammography is still the best test for evaluating breast tissue. See the
section Other breast imaging tests in this document for more information on MRI.

Very rarely, mammograms can cause an implant to rupture. Its important to tell the
technologist before your mammogram if you have implants.

Newer techniques for improving

mammograms
Although a mammogram is a good way to find most breast cancers when they are small
and most curable, it does not detect all breast cancers. Newer techniques are being looked
at to try to make mammograms more accurate.

Tomosynthesis (3D mammography)

This technology is basically an extension of a digital mammogram. For this test, the
breast is compressed once and a machine takes many low-dose x-rays as it moves over
the breast in an arc. The images can then be combined into a 3-dimensional picture. This
uses more radiation than most standard 2-view mammograms, but it may allow doctors to
see dense areas areas more clearly. Some studies have suggested it might lower the
chance that the patient will be called back for unnecessary tests. It may also be able to
find more cancers.
A breast tomosynthesis machine was approved by the Food and Drug Administration
(FDA) in 2011 for use in the United States, but the role of this technology in screening
and diagnosis is still not clear. Not all health insurance covers tomosynthesis, so you may
want to check with your insurance company if this is recommended for you.

When are other breast imaging tests used?

While mammograms are the most useful tests for screening and finding breast cancer
early, other imaging tests may be helpful in some cases.

MRI (magnetic resonance imaging)

MRI scans use magnets and radio waves instead of x-rays to produce very detailed, crosssectional pictures of the body. The energy from the radio waves is absorbed and then
released in a pattern formed by the type of body tissue and by certain diseases. A
computer translates the pattern into a very detailed image of parts of the body. For breast
MRI to look for cancer, a contrast liquid (called gadolinium) is injected into a vein before
or during the scan to show details better.
Breast MRI is mainly used for 2 purposes:

For women who have been diagnosed with breast cancer, to help measure the size
of the cancer and look for any other tumors in the breast. It also can be used to
look at the opposite breast, to be sure that it doesnt contain any tumors.
For certain women at high risk for breast cancer, screening MRI is recommended
along with a yearly mammogram. MRI is not recommended as a screening tool by
itself because it can miss some cancers that a mammogram would detect.

Just as mammograms are done with x-ray machines that are specially designed to image
the breasts, breast MRI also requires special equipment. Not all MRI machines are set up
to do breast MRIs.
Its important that breast MRIs be done at facilities that also can do an MRI-guided
breast biopsy. Otherwise, the entire scan will need to be repeated at another facility if a
biopsy is needed.
MRIs cost more than mammograms. Most major insurance companies pay for these
screening tests if a woman can be shown to be at high risk, but its a good idea to check
with your insurance company before having the test.
When getting ready for a breast MRI, you can eat and drink as usual. You will need to
take off clothes with metal parts such as zippers, snaps, or buttons, and put on a gown or
top. Jewelry, hairpins, safety pins, and anything else made of metal must be removed
before you go into the MRI room. The technologist will ask if you have any metal or
devices in your body, such as surgical clips, staples, implanted catheters, pacemakers,
defibrillators, artificial joints, metal fragments, tattoos, permanent eyeliner, and so on.
Some metal objects will not cause problems, but others might. Tell the staff before the
scan if you have any allergies, if you have breast implants, or if you are pregnant or
breast-feeding.
You may need to have an IV put in so you can get contrast dye to help outline the
structures of the breast. For the actual MRI, you will lie on your stomach on a padded
platform with spaces for your breasts. You will need to be very still during the test, which
can take up to an hour.

Breast ultrasound
Ultrasound, also known as sonography, uses sound waves to look inside a part of the
body. A gel is put on the skin of the breast and a handheld instrument called a transducer
is rubbed with gel and pressed against the skin. It emits sound waves and picks up the
echoes as they bounce off body tissues. The echoes are converted by a computer into a
black and white image on a computer screen. This test is painless and does not expose
you to radiation.
Breast ultrasound is sometimes used to evaluate breast problems that are found during a
screening or diagnostic mammogram or on physical exam. Breast ultrasound is not

routinely used for screening. Some studies have suggested that it may be helpful to use
ultrasound along with a mammogram when screening high risk women with dense breast
tissue (which is hard to evaluate with a mammogram). But at this time, ultrasounds
cannot replace mammograms. More studies are needed to figure out if ultrasound should
be added to routine screening mammograms for some groups of women.
Ultrasound is useful for taking a closer look at some breast masses, and its the only way
to tell if a mass is a cyst without putting a needle into it to take out (aspirate) fluid. Breast
ultrasound may also be used to help doctors guide a biopsy needle into an area of concern
in the breast. In someone with a breast tumor, it is also used to look at lymph nodes under
the arm.
There is a newer system, called a 3-dimensional automated whole breast ultrasound,
which can be used on the breast. The FDA has approved it to be used along with
mammography. The 3-D ultrasound can be done with a handheld transducer, but more
often, a larger transducer is placed over the whole breast, which can then be scanned
automatically.
Ultrasound has become a valuable tool to use along with mammograms because its
widely available, non-invasive, and costs less than other options. But the value of an
ultrasound test depends on the operators level of skill and experiencethough this is
less important with the new automated ultrasound systems. Ultrasounds arent used by
themselves for screening because they can miss some cancers seen on mammograms.
Ultrasound is less sensitive than MRI (that is, it detects fewer tumors), but it has the
advantages of costing less and being more widely available.

Ductogram (galactogram)
A ductogram, also called a galactogram, is sometimes used to help find the cause of any
worrisome nipple discharge. In this test, a very thin plastic tube is put into the opening of
a duct in the nipple that the discharge is coming from. A small amount of contrast
material is put in. It outlines the shape of the duct on x-ray and can show whether there is
a mass inside the duct.

Experimental and other breast imaging

methods
Research in the field of breast imaging is being done to
Find more cancers even before they can be felt by the patient or her doctor
Find even smaller cancers than those now detected by mammograms

 Find better ways to tell the difference between benign (not cancer) breast conditions
and breast cancers
Tests being developed for these purposes need more study before their usefulness can be
determined. Even though some of these imaging tests have been FDA approved for use
along with mammography and other proven test methods, their place in the diagnosis or
screening of breast cancer is less clear-cut.

Nuclear medicine studies

For nuclear medicine studies (also called nuclear scans) small amounts of slightly
radioactive substances are injected into the body and special cameras are used to see
where they go. Depending on the substance used, different types of abnormalities may be
found. Unlike most other imaging tests that are based on changes tumors cause in the
bodys structure, nuclear medicine scans depend on changes in tissue metabolism. A
couple of newer subtypes of nuclear medicine studies are described below under Other
experimental breast imaging tests.

Scintimammography (molecular breast imaging)

A radioactive tracer known as technetium sestamibi has been studied to help detect breast
cancer. For this test, a small amount of the radioactive tracer is put into a vein. The tracer
attaches to breast cancer cells and is detected by a special camera.
This test is not used as a screening test. Some radiologists believe this test may be helpful
in looking at suspicious areas found by mammogram. But the exact role of
scintimammography is still unclear.
Current research is aimed at improving the technology and evaluating its use in specific
situations, such as in the dense breasts of younger women. Some early studies have
suggested that it may be almost as accurate as more expensive MRI scans. More research
is needed.

Electrical impedance imaging (T-scan)

Electrical impedance imaging (EIT) scans the breast for electrical conductivity. Its based
on the idea that breast cancer cells conduct electricity in a different way than normal
cells. The test passes a very small electrical current through the breast and then detects it
on the skin of the breast. This is done using small electrodes that are taped to the skin.
EIT does not use radiation or compress the breasts.
This test is FDA approved as a diagnostic aid in helping classify tumors found on
mammogram. But at this time it has not had enough clinical testing to be used in breast
cancer screening.

Thermography (thermal imaging)

Thermography is a way to measure and map the heat on the surface of the breast using a
special heat-sensing camera. Its based on the idea that the temperature rises in areas with
increased blood flow and metabolism, which could be a sign of a tumor.
Thermography has been around for many years, but studies have shown that its not an
effective screening tool for finding breast cancer early. Although it has been promoted as
helping detect breast cancer early, a 2012 research review found that thermography was
able to detect only a quarter of the breast cancers found by mammography. In other
words, it failed to detect 3 out of 4 cancers that were known to be present in the breast.
Digital infrared thermal imaging (DITI), which some people believe is a newer and better
type of thermography, has the same failure rate. This is why thermography should not be
used as a substitute for mammograms.

Other experimental breast imaging tests

Some newer techniques are now being studied for breast imaging. These tests are in the
earliest stages of research. It will take time to see if any of these imaging tests are as good
as or better than those we use today.
Optical imaging tests pass light into the breast and then measure the light that returns or
passes through the tissue. The technique does not use radiation and does not require
breast compression. Optical imaging might be useful at some point for detecting tumors
or the blood vessels that supply them.
Molecular breast imaging (MBI) is a new nuclear medicine imaging technique for the
breast. Its being tested to see if it may be a less expensive and more specific way to
identify breast changes that have been seen on a mammogram or ultrasound. At this time
its still in the early research stages.
Positron Emission Mammography (PEM) is another newly developed imaging exam
of the breast. It uses sugar attached to a radioactive particle to detect cancer cells. The
PEM scanner is FDA approved. Working much like a PET scan, a PEM scan may be
better able to detect clusters of cancer cells within the breast. PEM may be able to show
breast cancer before it can be seen with mammograms and might prove to be as good as
or better than breast MRI. A number of studies are under way to assess this.

To learn more
More information from your American Cancer Society
The following related information may also be helpful to you. Free copies of these
materials may be ordered from our toll-free number, 1-800-227-2345, or you can read
most of them online at www.cancer.org.

More on checking women for breast cancer

Breast Cancer Early Detection (also in Spanish)
Non-Cancerous Breast Conditions (also in Spanish)
For Women Facing a Breast Biopsy (also in Spanish)

If you or someone you love has breast cancer

After Diagnosis: A Guide for Patients and Families (also in Spanish)
Breast Cancer Detailed Guide (also in Spanish)
Breast Cancer Overview (shorter and easier to read than the Detailed Guide; also in
Spanish)
Inflammatory Breast Cancer
Breast Cancer in Men Detailed Guide
Breast Cancer Dictionary (also in Spanish)
Breast Reconstruction After Mastectomy (also in Spanish)
Talking With Your Doctor (also in Spanish)

National organizations and websites*

Along with the American Cancer Society, other sources of information and support
include:
Centers for Disease Control and Prevention (CDC)
National Breast and Cervical Cancer Early Detection Program (NBCCEDP)
Toll-free number: 1-800-232-4636 (1-800-CDC-INFO)
Website: www.cdc.gov/cancer/nbccedp/

To find out more about the NBCCEDP, which provides breast and cervical cancer
early detection testing for women without coverage for free or at very little cost
National Cancer Institute
Toll-free number: 1-800-422-6237 (1-800-4-CANCER)
Website: www.cancer.gov
Offers current information about breast cancer screening, diagnosis, and treatment
as well as information on many other types of cancer
American College of Radiology (ACR)
Toll-free number: 1-800-227-5463
Website: www.acr.org
Offers information on radiology procedures, radiation safety, FAQs. and a
radiology glossary in the Patient and Family Resources section, as well as an
Accredited Facility Search
*Inclusion on this list does not imply endorsement by the American Cancer Society.

No matter who you are, we can help. Contact us anytime, day or night, for cancer-related
information and support. Call us at 1-800-227-2345 or visit www.cancer.org.

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Last Medical Review: 12/10/2013
Last Revised: 11/5/2014
2013 Copyright American Cancer Society