In one of our previous articles, we wrote that mammography (MMG) is a screening diagnostic method for breast cancer. Today, we would like to expand on this topic and have invited a specialized specialist to share information about MMG and the current mammogram screening guidelines being used.

This article was written by Y. Timovskaya, Ph.D., doctor oncologist of the highest category, Member of ESMO with the help of A Galishyna, head of the diagnostic department of the Specialized Breast Center, a doctor of radiation diagnostics, member of ESR, EUSOBI. This article was last modified on 10 August 2021.

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At the same time, it is necessary to take into account the patient’s age, complaints, anamnesis, clinical examination data, and the results of previous medical tests.

Ultrasound Breast Screening and Mammogram: definition

✔ Mammography (MMG) is an X-ray method for breast examination, which is the gold standard for diagnosing breast cancer. It perfectly detects microcalcifications, one of the early signs of breast cancer. The most important thing when using MMG is the fact that even standard views allow you to visually assess the full volume of an organ.

✔ Ultrasound – ultrasound examination of breast tissue, an additional diagnostic method. Suitable for patients with increased density of breast tissue (women under 35-40 years old). Therefore, it may be more appropriate for patients under 35-40 years of age to have an ultrasound scan rather than mammography (MMG). It is also the best method for fragmentary assessment of breast tissue. It is also used for the differential diagnosis of some formations. These, for example, include formations with a clear outline, identified on mammography.

Each of these methods has advantages and disadvantages. There are no absolute contraindications to their implementation.

How to Choose Diagnostic Methods

As we wrote above, each clinical case requires an individual approach in the selection and examination sequence.

So, for example, if a patient has complaints, her examination is diagnostic in nature. In this case, the doctor’s task is to choose the most appropriate diagnostic method. The aim will be to find out the reason for the complaints, the nature of the process, and the extent to which it has spread.

It’s worth saying that a multimodal approach is often used. In such cases, a combination of several methods is used (MMG + ultrasound, MMG + MRI, using interventional techniques). It is also important to note that doctors sometimes need to apply special techniques within the same research method. For example, in the case of MMG, these are spot view, magnification view(s), Cleopatra’s view, etc¹.

But in any case, the doctor is responsible to choose the appropriate diagnostic methods and techniques. Therefore, it is very important to contact specialists who can use the entire arsenal of diagnostic methods.

Is it possible to avoid examinations if there are no complaints from the breast?

The American Society of Breast Surgeons says that all women over the age of 25 must have a formal breast cancer risk assessment. You can do it yourself, or go through the risk assessment according to the NCCN guidelines in Healsens (below there will be links to download the app). After such an assessment is made, categories of patients without complaints should undergo screening. If a woman is not at risk, then such examinations can be started from the age of 40+. But we’ll talk more about mammogram screening guidelines below. If the risk of breast cancer is above average, then annual screening mammograms should be started at an earlier age, and in addition to mammography, additional examinations may be required.

Mammogram vs Ultrasound

It is worth pointing out what the limitations are for each diagnostic method. Thus, it will become more obvious what is decisive when choosing a diagnostic method. So, for ultrasound, the following limits are distinguished:

• the predominance of adipose tissue in the structure of the mammary gland in patients over 40 years of age with symptoms of fibrous-fatty involution of the breast tissue (age-related changes);
• the presence of large skin lesions. For example, with skin diseases and inflammatory processes.

Since ultrasound assesses the gland tissue fragmentarily, section by section, for patients with large breast sizes, this method is also not very suitable. This is due to the fact that there is a high risk of missing small formations.

Mammography is not recommended without direct indications (suspected cancer) during pregnancy and lactation. In addition, in young patients, the diagnostic value of MMG decreases. This is due to the fact that young women have a higher density of breast tissue. And finally, we add that MMG is also ineffective in the presence of inflammatory diseases of the mammary glands.

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Mammogram screening guidelines

At the moment, medical guidelines aim for an individualized approach, taking into account personal risks. Generally, the higher the risk of breast cancer, the earlier and more often screenings are recommended. So, for example, the American Cancer Society divides women into risk groups.

For Women at Increased Risk of Breast Cancer

✔ It’s recommended annual MMG from age 30 for women at increased risk of breast cancer². This group includes patients with mutations in the BRCA1 or BRCA2 genes. And also if it is known that mutations in these genes have been identified in first-line relatives.

In addition, other mammogram screening guidelines distinguish the medium-risk group of women who have been treated for ovarian cancer³ or bowel cancer before age 35⁴. Similarly, this risk zone includes women who have close relatives who have had breast cancer and ovarian cancer.

Some sources suggest starting screening MMG for women from this group no later than 10 years before the age at which breast cancer was detected in 1st or 2nd line relatives⁵. These are sisters, mothers, aunts, grandmothers (both on the mother’s side and on the father’s side). But screening should be started not earlier than 25 years old.

As you can see, everything is very individual.

For example, if the patient’s mother had breast cancer at the age of 36 when her daughter needs to undergo annual examinations, starting at the age of 26. The choice of the method for these annual examinations should be made by the physician, depending on the findings of the clinical examination.

For Women with Low Risk of Breast Cancer

For women with an uncomplicated medical history, it is recommended to carry out screening MMG from 40 years according to the scheme²:

• once every 2 years from 40 to 50 years old and after 70 years old,
• once a year at the age of 50-70 years old.

Therefore, all women over 40 should be offered MMG, with possible additional research. In all other cases, the approach to the diagnostic method should be completely individualized.

And in conclusion, adherence to the indicated intervals allows for the most effective detection of breast cancer in the early, often preclinical stages. The main problem remains the low awareness of general practitioners and patients about the problem of breast cancer, as well as the need to perform screening MMGs.

What you need to tell the doctor to determine the research method

Before taking the examination, it is recommended to inform the doctor about the following problems, if any:

1. A history of oncological diseases (such as breast cancer, ovarian cancer and colon cancer) in the patient or relatives.
2. Previous breast surgery and past trephine biopsies.
3. The presence of chronic diseases (especially endocrinological and gynecological) and the constant intake of drugs, especially contraceptives and hormone replacement therapy drugs.
4. Menstruation (age of onset of menstruation, duration of menopause, regularity of the menstrual cycle), number of pregnancies and childbirth, duration and nature of lactation.
5. The presence of complaints from the mammary glands (cyclical changes before the onset of menstruation and their severity, pain outside the menstrual cycle, discharge from the nipples, induration).
6. Results from previous breast studies.

After analyzing the patient’s survey data, the doctor will choose the best diagnostic method. The decisive factors here are the age and timing of previous studies. Because compliance with them allows you to correctly assess dynamic changes.

👉 And finally, the information received on time is the most important!

FURTHER READING

1. Mammography views
2. American Cancer Society Recommendations for the Early Detection of Breast Cancer
3. Breast Cancer Survivors at Increased Risk for Ovarian Cancer
4. Secondary Breast, Ovarian, and Uterine Cancers After Colorectal Cancer
5. Breast Cancer Screening Guidelines