Mammography

Mammography is a type of breast cancer screening that uses low-dose X-rays to detect cancer early. It is used to test healthy people before any symptoms of breast cancer are present. Its aim is to detect cancer at an early stage, when it is most treatable. Mammography can also diagnose breast disease in women experiencing symptoms such as a lump, pain, skin dimpling or nipple discharge.

Mammography is considered the gold standard for breast cancer screening, offering an effective way of detecting breast cancer early.

Thanks to advances in medical technology, Cleveland Clinic Abu Dhabi is able to offer advanced breast cancer screening and diagnostic tools such as digital mammography with computer-aided detection and breast tomosynthesis, making mammography more effective than ever before. 3D mammography (tomosynthesis), which is not widely available in the UAE, combines multiple X-rays to create a detailed, three-dimensional image of the breast. This makes it easier to detect even very small cancers and reduces the number of false positives.

What is mammography?

Mammography is specialized medical imaging that uses a low-dose X-ray system to see inside the breasts. A mammography exam, called a mammogram, aids in the early detection and diagnosis of breast diseases in women.

An X-ray is a non-invasive medical test that helps doctors diagnose and treat medical conditions. Imaging with X-rays involves exposing a part of the body to a small dose of ionizing radiation to produce pictures of the inside of the body. X-rays are the oldest and most frequently used form of medical imaging.

Digital mammography, also called full-field digital mammography (FFDM), is a mammography system in which the X-ray film is replaced by electronics that convert X-rays into mammographic pictures of the breast. These systems are similar to those found in digital cameras and their efficiency enables better pictures with a lower radiation dose. These images of the breast are transferred to a computer for review by the radiologist and for long-term storage.

Breast tomosynthesis, also called three-dimensional (3-D) mammography and digital breast tomosynthesis (DBT), is an advanced form of breast imaging where multiple images of the breast from different angles are captured and reconstructed (synthesized) into a three-dimensional image set. In this way, 3-D breast imaging is similar to computed tomography (CT) imaging in which a series of thin ‘slices’ are assembled together to create a 3-D reconstruction of the body.

Although the radiation dose for some breast tomosynthesis systems is slightly higher than the dosage used in standard mammography, it remains within the FDA-approved safe levels for radiation from mammograms. Some systems have doses very similar to conventional mammography.

Breast tomosynthesis may also result in:

• Earlier detection of small breast cancers that may be hidden on a conventional mammogram
• Fewer unnecessary biopsies or additional tests
• Greater likelihood of detecting multiple breast tumors
• Clearer images of abnormalities within dense breast tissue
• Greater accuracy in pinpointing the size, shape and location of breast abnormalities.

Computer Aided Detection is a form of artificial intelligence and assists in the detection and diagnosis of suspicious features on the mammogram, supporting the radiologist and increasing detection rates of breast cancer in some cases.

When is a mammogram used?

Mammograms are used as a screening tool to detect early breast cancer in women experiencing no symptoms. They can also be used to detect and diagnose breast disease in women experiencing symptoms such as a lump, pain, skin dimpling or nipple discharge.

Screening mammography

Mammography plays a central part in early detection of breast cancers because it can show changes in the breast years before a patient or doctor can feel them. The Department of Health – Abu Dhabi recommends that women should get mammogram screening every 2 years from the age of 40, or earlier if breast cancer runs in the family.

If you are at high risk for breast cancer, you may need to obtain a breast MRI in addition to your annual mammogram. It is also common to undergo an Ultrasound exam as part of breast imaging services especially if you're under the age of 40 or the mammogram indicates dense breast tissue or further clarification is required.

Diagnostic mammography

Diagnostic mammography is used to evaluate a patient with abnormal clinical findings, such as a breast lump or nipple discharge . Diagnostic mammography may also be done after an abnormal screening mammogram in order to evaluate the area of concern on the screening exam.

How should I prepare for a mammogram?

Before scheduling a mammogram, we recommend that you discuss any new findings or problems in your breasts with your doctor. In addition, inform your doctor of any prior surgeries, hormone use, and family or personal history of breast cancer.

Do not schedule your mammogram for the week before your menstrual period if your breasts are usually tender during this time. The best time for a mammogram is one week following your period. Always inform your doctor or X-ray technologist if there is any possibility that you are pregnant. Do not wear deodorant, talcum powder or lotion under your arms or on your breasts on the day of the exam. These can appear on the mammogram as calcium spots.

Describe any breast symptoms or problems to the technologist performing the exam. Obtain your prior mammograms and make them available to the radiologist if they were done at a different location. This is needed for comparison with your current exam and can often be obtained on a CD.

What does mammography equipment look like?

A mammography unit is a rectangular box that houses the tube in which X-rays are produced. The unit is used exclusively for X-ray exams of the breast, with special accessories that allow only the breast to be exposed to the x-rays. Attached to the unit is a device that holds and compresses the breast and positions it so images can be obtained at different angles.

Breast tomosynthesis is performed using digital mammography units, but not all digital mammography machines are equipped to perform tomosynthesis imaging.

How does the procedure work?

X-rays are a form of radiation like light or radio waves. X-rays pass through most objects, including the body. Once it is carefully aimed at the part of the body being examined, an x-ray machine produces a small burst of radiation that passes through the body, recording an image on photographic film or a special detector. Different parts of the body absorb the X-rays in varying degrees. Dense bone absorbs much of the radiation while soft tissue, such as muscle, fat and organs, allows more of the X-rays to pass through them. As a result, bones appear white on the X-ray, soft tissue shows up in shades of grey and air appears black.

Most X-ray images are digital files that are stored electronically. These stored images are easily accessible for diagnosis and disease management.

In conventional film and digital mammography, a stationery X-ray tube captures an image from the side and an image from above the compressed breast. In breast tomosynthesis, the X-ray tube moves in an arc over the breast, capturing multiple images from different angles.

How is the procedure performed?

Mammography is performed on an outpatient basis.

During mammography, a specially qualified radiologic technologist will position your breast in the mammography unit. Your breast will be placed on a special platform and compressed with a clear plastic paddle. The technologist will gradually compress your breast.

Breast compression is necessary in order to:

• Even out the breast thickness so that all of the tissue can be visualized
• Spread out the tissue so that small abnormalities are less likely to be hidden by overlying breast tissue
• Allow the use of a lower x-ray dose since a thinner amount of breast tissue is being imaged
• Hold the breast still in order to minimize blurring of the image caused by motion
• Reduce x-ray scatter to increase sharpness of picture.

You will be asked to change positions between images. The routine views are a top-to-bottom view and an angled side view. The process will be repeated for the other breast. Compression is still necessary for tomosynthesis imaging in order to minimize motion, which degrades the images. During screening breast tomosynthesis, two-dimensional images are also obtained or created from the synthesized 3-D images. You must hold very still and may be asked to keep from breathing for a few seconds while the x-ray picture is taken to reduce the possibility of a blurred image. The technologist will walk behind a wall or into the next room to activate the x-ray machine.

When the examination is complete, you may be asked to wait until the radiologist determines that all the necessary images have been obtained.

The examination process should take about 30 minutes.

What will I experience during and after the procedure?

You will feel pressure on your breast as it is squeezed by the compression paddle. Some women with sensitive breasts may experience discomfort. If this is the case, schedule the procedure when your breasts are least tender. Be sure to inform the technologist if pain occurs as compression is increased. If discomfort is significant, less compression will be used. Always remember compression allows better quality mammograms.

Who interprets the results and how do I get them?

A radiologist, a doctor specifically trained to supervise and interpret radiology examinations, will analyze the images and send a signed report to your primary care or referring doctor, who will discuss the results with you. Follow-up exams may be needed. If so, your doctor will explain why. Sometimes a follow-up exam is done because a potential abnormality needs further evaluation with additional views or a special imaging technique. A follow-up exam may also be done to see if there has been any change in an abnormality over time.

What are the benefits of mammography versus the risks?

Benefits

Screening mammography reduces the risk of death due to breast cancer. It is useful for detecting all types of breast cancer, including invasive ductal and invasive lobular cancer.

Screening mammography improves a doctor’s ability to detect small tumors. When cancers are small, the woman has more treatment options. The use of screening mammography increases the detection of small abnormal tissue growths confined to the milk ducts in the breast, called ductal carcinoma in situ (DCIS).

No radiation remains in a patient's body after an X-ray examination. X-rays usually have no side effects in the typical diagnostic range for this exam.

Risks

There is always a slight chance of cancer from excessive exposure to radiation. However, the benefit of an accurate diagnosis far outweighs the risk. The effective radiation dose for this procedure varies.

What are the limitations of MRI-guided breast biopsy?

While mammography is the best screening tool for breast cancer available today, mammograms do not detect all breast cancers. This is called a false negative result. On the other hand, when a mammogram looks abnormal and no cancer is present, this is called a false-positive result.

Screening mammographic images themselves are often not enough to determine the existence of a benign or malignant disease with certainty. If there are abnormalities, your radiologist may recommend further diagnostic studies.

It is very important to realize that not all breast cancers can be seen on mammography. Interpretations of mammograms can be difficult because a normal breast looks different for each woman. Because some breast cancers are hard to visualize, a radiologist may want to compare the image to views from previous examinations.

Breast implants can also impede accurate mammogram readings because both silicone and saline implants are not transparent on X-rays and can block a clear view of the tissues around them, especially if the implant has been placed in front of, rather than beneath, the chest muscles. Experienced technologists and radiologists know how to carefully compress the breasts to improve the view without rupturing the implant.