Mammogram

(Mammography, Breast X-ray)

Procedure Overview

What is a mammogram?

A mammogram is an x-ray examination of the breast. It is used to detect and diagnose breast disease in women who either have breast problems such as a lump, pain, or nipple discharge, as well as for women who have no breast complaints. The procedure allows detection of breast cancers, benign tumors, and cysts before they can be detected by palpation (touch).

Mammography cannot prove that an abnormal area is cancer, but if it raises a significant suspicion of cancer, tissue will be removed for a biopsy. Tissue may be removed by needle or open surgical biopsy and examined under a microscope to determine if it is cancer.

Mammography has been used for about 30 years, and in the past 15 years technical advancements have greatly improved both the technique and results. Today, dedicated equipment, used only for breast x-rays, produces studies that are high in quality but low in radiation dose. Radiation risks are considered to be negligible.

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The recent development of digital mammography technology shows promise for improved breast imaging, in particular, for women less than 50 years of age, women with dense breast tissue, and women who are premenopausal or perimenopausal. Digital mammography provides electronic images of the breasts that can be enhanced by computer technology, stored on computers, and even transmitted electronically in situations where remote access to the mammogram is required. The procedure for a digital mammography is basically performed the same way as a standard mammogram.

What are the different types of mammograms?

According to the National Cancer Institute:

• screening mammogram
  A screening mammogram is an x-ray of the breast used to detect breast changes in women who have no signs of breast cancer. It usually involves two x-rays of each breast. Using a mammogram, it is possible to detect a tumor that cannot be felt.
• diagnostic mammogram
  A diagnostic mammogram is an x-ray of the breast used to diagnose unusual breast changes, such as a lump, pain, nipple thickening or discharge, or a change in breast size or shape.
  
  A diagnostic mammogram is also used to evaluate abnormalities detected on a screening mammogram. It is a basic medical tool and is appropriate in the workup of breast changes, regardless of a woman's age.

What is an x-ray?

X-rays use invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs on film. Standard x-rays are performed for many reasons, including diagnosing tumors or bone injuries.

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X-rays are made by using external radiation to produce images of the body, its organs, and other internal structures for diagnostic purposes. X-rays pass through body structures onto specially-treated plates (similar to camera film) and a "negative" type picture is made (the more solid a structure is, the whiter it appears on the film).

Anatomy of the Breasts

Each breast has 15 to 20 sections, called lobes, which are arranged like the petals of a daisy. Each lobe has many smaller lobules, which end in dozens of tiny bulbs that can produce milk.

The lobes, lobules, and bulbs are all linked by thin tubes called ducts. These ducts lead to the nipple in the center of a dark area of skin called the areola. Fat fills the spaces between lobules and ducts.

There are no muscles in the breast, but muscles lie under each breast and cover the ribs.

Each breast also contains blood vessels and vessels that carry lymph. The lymph vessels lead to small bean-shaped organs called lymph nodes, clusters of which are found under the arm, above the collarbone, and in the chest, as well as in many other parts of the body.

Reasons for the Procedure

Mammography may be used either for screening or to make a diagnosis. Women older than 25 years should undergo diagnostic mammography if they have symptoms such as a palpable lump, breast skin thickening or indentation, nipple discharge or retraction, erosive sore of the nipple, or breast pain.

A mammogram may be used to evaluate breast pain when physical examination and history are not conclusive. Women with breasts that are dense, “lumpy,” and/or very large may be screened with mammography, as physical examination may be difficult to perform.

Women who are at high risk for breast cancer or with a history of breast cancer may be routinely screened with mammography.

There may be other reasons for your physician to recommend a mammography.

Who should get a screening mammogram?

The American Cancer Society recommends the following screening guidelines for early detection of cancer in women who have no symptoms:

• Annual mammograms starting at age 40. The age which screening should be stopped is considered on an individual basis according to potential risks and benefits of screening based on a woman's individual overall health status. 
• A clinical breast exam should be part of a regularly scheduled health examination about every three years in a woman's twenties and thirties and every year for a woman in her forties and older.
• Women should know how their breasts normally feel and report any breast change right away to their health care provider. Breast self-exam is an option for women beginning in their twenties.
• Women who are at an increased risk (family history, genetic tendency, past breast cancer) should talk with their physicians about the benefits and limitations of starting mammography screening earlier, having additional tests (breast ultrasound, MRI), or having more frequent exams.

In addition, the following guidelines by age are recommended:

• National Cancer Institute Guideline for Screening Mammography:
  Women in their 40s and older should have a screening mammogram on a regular basis, every one to two years.
• American Cancer Society Guideline for Screening Mammography:
  Women 40 years of age and older should have a screening mammogram every year.

Consult your physician regarding the screening guidelines that are appropriate for you.

Risks of the Procedure

You may want to ask your physician about the amount of radiation used during the procedure and the risks related to your particular situation. It is a good idea to keep a record of your past history of radiation exposure, such as previous scans and other types of x-rays, so that you can inform your physician. Risks associated with radiation exposure may be related to the cumulative number of x-ray examinations and/or treatments over a long period of time.

If you are pregnant or suspect that you may be pregnant, you should notify your physician. Radiation exposure during pregnancy may lead to birth defects. If it is necessary for you to have a mammogram, special precautions will be made to minimize the radiation exposure to the fetus.

Mammograms may be more difficult to interpret in women younger than 30 years of age, due to the increased density of their breast tissue.

Some discomfort may be felt as the breast is compressed against the x-ray plate during the procedure. This compression will not harm the breast, however.

There may be other risks depending upon your specific medical condition. Be sure to discuss any concerns with your physician prior to the procedure.

Certain factors or conditions may interfere with a mammogram. These include, but are not limited to, the following:

• talcum powder, deodorant, creams, or lotions applied under the arms or on the breasts
• breast implants, as they may prevent complete visualization of the breast
• previous breast surgery
• breast changes which may occur during menstruation. The best time to undergo a mammogram is one week after your menstrual period ends.

Before the Procedure

• Your physician will explain the procedure to you and offer you the opportunity to ask any questions that you might have about the procedure.
• You may be asked to sign a consent form that gives permission to do the procedure. Read the form carefully and ask questions if something is not clear.
• No fasting or sedation is required before the procedure.
• If you are pregnant or suspect that you may be pregnant, you should notify your physician.
• Notify your physician of all medications (prescribed and over-the-counter) and herbal supplements that you are taking.
• Notify your physician if you have breast implants or if you are breastfeeding.
• Dress in clothes that permit access to the area to be tested or that are easily removed.
• Comparison with old mammograms is very important. If you are having a mammogram performed at a new facility, you may be asked to retrieve your previous mammograms from the previous facility.
• Avoid using deodorant, perfume, powders, or ointment on the breast or underarm area on the day of the mammogram. It may interfere with the reading.
• Patients with painful breasts may be asked to refrain from caffeinated food and beverages for five to seven days before testing.
• Based upon your medical condition, your physician may request other specific preparation.

During the Procedure

Mammogram

A mammogram may be performed on an outpatient basis or as part of your stay in a hospital. Procedures may vary depending on your condition and your physician's practices.

Generally, a mammogram follows this process:

1. You will be asked to remove any clothing, jewelry, or other objects that might interfere with the procedure.
2. You will be asked to remove clothing from your waist up, and will be given a gown to wear.
3. The technologist will ask you if you have noticed any lumps or other changes in either breast. If so, an adhesive marker will be placed on the spot(s) prior to the procedure.
4. You will stand in front of a mammography machine and one breast will be placed on the x-ray plate. In order to position the breast for optimal imaging, the technologist may examine and/or palpate the breast before placing it on the plate. An adhesive marker may be applied to any moles, scars, or other spots that might interfere with the breast image.
   
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5. A separate flat plate, often made of plastic, will be brought down on top of the breast to compress it gently against the x-ray plate. Compression of the breast is required in order to minimize the amount of radiation used and to ensure optimal visualization of the breast tissue. You may feel some discomfort during this time.
6. You will be asked to hold your breath while the image is being taken.
7. The radiologic technologist will step behind a protective window while the image is taken.
8. Two pictures at different angles will be taken of each breast, requiring the breasts to be repositioned between pictures.
9. After the x-rays have been taken, you will be asked to wait while the films are examined by the radiologist to ensure that the films are clear and that no additional films are needed. If there is a question about any of the films, you may be asked to have additional films taken.

While the mammogram itself causes no pain, the manipulation and compression of the breast being examined may cause some discomfort or pain, particularly in the case of a recent injury or invasive procedure such as surgery. The radiologic technologist will use all possible comfort measures and complete the procedure as quickly as possible to minimize any discomfort or pain.

After the Procedure

Generally, there is no special type of care following a mammogram. Your physician may give you additional or alternate instructions after the procedure, depending on your particular situation.