Screening Mammography for Breast
Cancer
Introduction:
Breast cancer is the most frequently
diagnosed cancer & is the second
leading cause of potentially avoidable
cancer mortality among women.
Breast cancer is largely found in older
women. The cancer survival is
influenced by the size of the lesion &
the status of the axillary lymph nodes.
Breast screening is a method of
detecting cancer at a very early stage.
The key to curing breast cancer is
early detection & prompt treatment. A
physical examination, mammography
& breast self examination make up the
conventional early detection approach.
A mammogram is a special picture of
breast. It can detect small changes in
breast tissue which may indicate
cancers which are too small to be felt
either by self examination or by a
doctor.
Outcome of Screening:
Population based mammography
screening aims to reduce morbidity &
mortality from breast cancer by early
detection & treatment of occult
Dr. B. Lohani,
Dept. of Radiology & Imaging
TU Teaching Hospital,
Maharajgunj.
malignancies. As the cancer survival
depends on the stage of the disease
small tumors with negative axillary
nodes are detected more often in
mammography than with physical
examination. It was found that
annual/biennial screening has led to
significant reduction in mortality from
cancer (30% in 50 – 69 yrs age group).
The sensitivity of mammography is 75
– 95% with specificity of 90 – 95% for
detection of cancer with positive
predictive value (PPV) of 20% for less
than 50 yrs & 60 – 80% for 50 – 69 yrs.
Detection of cancer at early stage also
has the benefit of less disfiguring &
less toxic treatments as small tumors
are amenable to breast conserving
surgery which is very important form
patients' perspective.
Screening Guidelines:
The screening guidelines are provided
by the American Cancer Society,
American College of Radiology &
American College of Obstetricians &
Gynecologists. The recommendations
include screening mammography
every 1 – 2 year for 40 – 49 yrs age &
 annually after the age of 50 yrs. High
risk group should seek expert advice
of physician for regular screening
before the age of 40. It is stated that
the outcome of well established
screening program should detect more
than 50% cancer at the minimum (non
invasive or invasive with less than 1
cm size with no nodes) & more than
80% of the detected cancers should be
node negative at surgery/ pathology.
The false negative mammograms are
due to non inclusion of palpable mass
in the film, dense breast, technical
inadequacy etc.
Radiation Risk:
An increased susceptibility to breast
cancer has been documented among
women exposed to high doses of
radiation (1 to 20 Gy). The

radiation dose for a standard two-view examination of both breasts is approximately

4.5 mGy. A risk–benefit calculation in the UK has established that the benefits of
screening far outweigh the risk of inducing a cancer, with the ratio of lives saved to
lives lost calculated as approximately 100:1.The latest follow-up data from the
Japanese atomic bomb survivors have shown progressively decreasing radiation risk
with increased age at exposure. Women who were exposed in their youth and teens
suffered the highest increase in risk. No increased risk was demonstrable for women
aged 40 or older at exposure.

Technical Consideration:

Because both high contrast and high spatial resolution are needed standard
radiographic equipment cannot be utilized for this examination. Mammography is
performed in dedicated mammography units which provide greater contrast between
soft tissue structures. All mammographic units are equipped with compression paddles
that squeeze the breast against the film holder. Compression has the advantages of a)
spreading of overlapping structure (differentiation of the masses vs. summation
shadows), b) immobilization (prevents image blurring), c) providing uniform thickness
of breast & d) reduced radiation dose.

Though mammography can be performed while standing or sitting, standing is

preferred as more breast tissue can be included for examination. Screening is
accomplished with standard two views i.e. MLO (medio-lateral oblique) and CC
(craniocaudal) views.

MLO view:

The breast is compressed in supero-medial direction. This is the most useful view as
greatest amount of breast tissue is along with the pectoralis major muscle and
inframammary fold.

CC view: For craniocaudal view breast is compressed in horizontal direction. The

pectoralis major muscle is visible in about 30% of patients.

Full field digital mammography has advantage of higher contrast resolution with
increased conspicuity of the lesions.
Interpretation:

For correct interpretation detailed clinical information relevant to breast health and
cancer risk should be provided along with patient's history and any previous surgical
biopsies or HRT. The mammographic findings should be correlated with physical
examination.

For interpretation, CC and MLO mammograms should each be viewed together in a

mirror-image configuration which allows the radiologist to scan the breasts for
symmetry

A magnifying lens should be used to examine each film thoroughly. All visible
parenchyma should be scanned systematically with magnification. This will allow
visualization of tiny microcalcifications and will ensure that the radiologist has
examined all parts of the breast in detail.

Analyzing the mammogram:

1) Normal mammogram:

MLO View CC View

2) Benign lesion: Mammographic features of typical benign lesion include a

well defined circumscribed mass with convex borders with increasing density
toward the center. The “halo sign,” which is a partial or complete radiolucent
ring surrounding a mass suggest benignity. A benign lesion has normal
 surrounding breast parenchyma without distortion of normal breast
architecture.

Benign Lesion on MLO View Benign Lesion on CC View

3) Indeterminate mammogram: Further evaluation should be done with

additional mammographic views or ultrasonography. Spot compression and
magnification views in mammogram helps in further characterization of the
lesion providing finer detail and accurate assessment of morphology of
microcalcifications and the border of masses.

Spot Compression view for Calcification

4) Breast Cancer: Clustered pleomorphic microcalcifications with or without

an associated soft tissue mass is the primary mammographic sign of breast
cancer which is seen in more than 50% of all mammographically discovered
cancers. About 1/3rd non palpable cancers manifest by calcifications without
associated mass. When breast cancer presents as mass it classically appears
as a spiculated mass on mammogram (<20% on non palpable cancers). Most
spiculated masses are infiltrating ductal carcinoma. The cancer may also
present as a round mass with indistinct or ill defined microlobulated borders,
increasing density towards the center or distortion of surrounding
parenchyma.
Malignant lesion Rt breast on MLO view Malignant lesion Rt breast on CC view

Computer Aided Detection (CAD):

It is a computer software system designed to aid the film reader by placing prompts
over areas of concern which reduces observational oversight. It is highly sensitive
for detecting cancers on screening mammograms. It prompts around 90% of all
cancer, 86-88% of all masses and 98% of microcalcifications. However there is no
concensus in the literature as to whether CAD improves film reader performance.

Conclusion:
Breast cancer represents a significant health problem. Early detection with
screening mammography is the only proved way to lower mortality. The challenge
for the radiologist is to maintain the highest standards of quality in performance and
interpretation of imaging studies and to encourage all women to take regular
advantage of these life saving techniques.