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Breast
Imaging
Breast Imaging Overview
Screening Mammography
Screening Mammography
Amy M. Fowler, MD, PhD; Wendie A. Berg, MD, PhD, FACR, FSBI
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KEY FACTS

  • Imaging

    • Clinical Issues

      • Diagnostic Checklist

        TERMINOLOGY

        • Definitions

          • Mammographic screening: Periodic imaging of both breasts using digital mammography ± digital breast tomosynthesis (DBT) in asymptomatic women to detect breast cancer
            • Earlier detection → ↓ node-positive invasive cancers → ↓ breast cancer mortality and morbidity
          • Mammography Quality Standards Act (MQSA) (USA)
            • Federal law (1992) with stringent quality standards for all stages and personnel involved
            • Governed by FDA &/or state with required regular QA process and annual inspections
            • Images interpreted by Mammography Quality Standards Act (MQSA)-certified breast imager (USA) or equivalent
            • Must be supported by accurate diagnostic assessment, expert image-guided needle biopsy, breast pathology, treatment
          • Online screening: Interpretation at time of examination with immediate provision of results
          • Offline screening: Mammograms batch-read, either later or remotely, by 1 or more radiologists
            • Postal (or phone call) recommendation to return for additional investigation
          • Results: Breast Imaging Reporting and Data System (BI-RADS) 1 (negative), 2 (benign), or 0 (incomplete, additional imaging needed, recall)
          • Recall rate = abnormal interpretation rate, i.e., percentage of women screened with recommendation for further testing prior to next routine mammogram
            • BI-RADS 0 (incomplete) recommended for additional evaluation
            • BI-RADS 3 assessment not to be used on screening mammography but would be considered recall
            • Includes BI-RADS 4 (suspicious) and BI-RADS 5 (highly suggestive of malignancy), but use of these is typically reserved for diagnostic setting
            • Excludes BI-RADS 1 or 2 assessment, even if therapeutic (but not diagnostic) cyst aspiration will be performed
            • Excludes technical recalls (e.g., motion, poor positioning)
          • Screening interval: Recommended time between screening exams
            • USA: American College of Radiology (ACR), National Comprehensive Cancer Network (NCCN): Every year beginning at age 40 and continuing as long as in good health
              • American Cancer Society (ACS): Offer at age 40-44; recommend at age 45; yearly for ages 40-54, biennial or annual for age ≥ 55; as long as life expectancy ≥ 10 years
              • National Cancer Institute (NCI): Every 1-2 years
              • US Preventive Services Task Force (USPSTF): Women aged 40-49 should discuss with their physicians; every 2 years from age 50-74
              • If high risk, screening recommended by age 25-30 (see guidelines for MR)
            • Canadian Task Force on Preventive Health Care: Every 2-3 years from age 50-74
            • European Society of Breast Imaging (EUSOBI): Every 2 years from age 50-69; extension to age 73-75 and from age 40-45 to 49 also encouraged
            • United Kingdom National Health Service: Every 3 years from age 50-70; in some parts of England, from age 47-73
            • Swedish program: Variable, every 18-24 months from age 40-50 to age 69 or 74
            • Austrian program: Every 18 months from age 45-54; every 2 years age 55-74 years
            • Dutch, Norwegian, Canadian, Australian, and New Zealand screening programs: Every 2 years from age 50-69
            • Japanese Breast Cancer Society: Start at age 40; do not specify interval or duration
          • True-positive: Tissue diagnosis of breast cancer within screening interval (typically 365 days in USA) after abnormal (positive) screening mammogram
            • Positive test: BI-RADS 0, 3, 4, 5 on screening (use of BI-RADS 3, 4, and 5 is discouraged for screening exams)
          • False-negative: Tissue diagnosis of breast cancer within screening interval after negative mammogram (BI-RADS 1 or 2 on screening or technical recall only)
          • Positive predictive value (PPV)
            • PPV1 = PPV of abnormal screening exams (# true-positive exams divided by # of all positive screening exams)
            • PPV2 = PPV of biopsies recommended (# true-positive exams divided by # of screening exams recommended for biopsy after full work-up)
            • PPV3 = PPV of biopsies performed (# true-positive exams divided by # of screening exams with biopsies actually performed after full work-up)
          • Cancer detection rate (CDR): # diagnosed with breast cancer per 1,000 screening examinations
            • Prevalent cancers are found on initial, baseline screening mammogram
            • Incident cancers are found on subsequent screening exam performed at or close to recommended screening interval
            • Interval cancers are diagnosed during time between recommended screening exams, typically due to clinical symptoms, after negative mammogram
          • Minimal cancer: Invasive cancer ≤ 1 cm or DCIS
          • Most audits performed at patient level (i.e., screening examination level), though can be performed at breast level
            • If patient recalled for finding other than area proven to be cancer within screening interval, this is still considered true-positive
            • Note: If patient diagnosed with cancer because of new screening examination performed prior to screening interval (e.g., 360 days after negative screen) and diagnosis of cancer made because of new finding on new mammogram, this is still considered false-negative for original negative screening mammogram even if cancer cannot be seen in retrospect

        IMAGING

        • Imaging Anatomy

          • Anatomy-Based Imaging Issues

            PATHOLOGY

            • Staging, Grading, & Classification

              CLINICAL ISSUES

              • Demographics

                • Natural History & Prognosis

                  DIAGNOSTIC CHECKLIST

                  • Consider

                    • Reporting Tips

                      Selected References

                      1. Skaane P et al: Digital mammography versus digital mammography plus tomosynthesis in breast cancer screening: The Oslo Tomosynthesis Screening Trial. Radiology. 182394, 2019
                      2. Helvie MA et al: Screening mammography for average-risk women: the controversy and NCCN's position. J Natl Compr Canc Netw. 16(11):1398-1404, 2018
                      3. Klarenbach S et al: Recommendations on screening for breast cancer in women aged 40-74 years who are not at increased risk for breast cancer. CMAJ. 190(49):E1441-E1451, 2018
                      4. Lee CS et al: Harmonizing breast cancer screening recommendations: metrics and accountability. AJR Am J Roentgenol. 210(2):241-245, 2018
                      5. Mango V et al: Commentary ACOG practice bulletin July 2017: Breast cancer risk assessment and screening in average-risk women. Br J Radiol. 91(1090):20170907, 2018
                      6. Tabár L et al: The incidence of fatal breast cancer measures the increased effectiveness of therapy in women participating in mammography screening. Cancer. 125(4):515-523, 2018
                      7. Lehman CD et al: National performance benchmarks for modern screening digital mammography: update from the Breast Cancer Surveillance Consortium. Radiology. 283(1):49-58, 2017
                      8. Monticciolo DL et al: Breast cancer screening for average-risk women: recommendations from the ACR commission on breast imaging. J Am Coll Radiol. 14(9):1137-1143, 2017
                      9. Sardanelli F et al: Position paper on screening for breast cancer by the European Society of Breast Imaging (EUSOBI) and 30 national breast radiology bodies from Austria, Belgium, Bosnia and Herzegovina, Bulgaria, Croatia, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Italy, Israel, Lithuania, Moldova, The Netherlands, Norway, Poland, Portugal, Romania, Serbia, Slovakia, Spain, Sweden, Switzerland and Turkey. Eur Radiol. 27(7):2737-2743, 2017
                      10. Siu AL et al: Screening for breast cancer: U.S. Preventive Services Task force recommendation statement. Ann Intern Med. 164(4):279-96, 2016
                      11. Tozaki M et al: The Japanese Breast Cancer Society clinical practice guidelines for screening and imaging diagnosis of breast cancer, 2015 edition. Breast Cancer. 23(3):357-66, 2016
                      12. Oeffinger KC et al: Breast cancer screening for women at average risk: 2015 guideline update from the American Cancer Society. JAMA. 314(15):1599-614, 2015
                      13. Friedewald SM et al: Breast cancer screening using tomosynthesis in combination with digital mammography. JAMA. 311(24):2499-507, 2014
                      14. Kerlikowske K et al: Outcomes of screening mammography by frequency, breast density, and postmenopausal hormone therapy. JAMA Intern Med. 173(9):807-16, 2013
                      15. Sickles EA et al: Breast Imaging Reporting and Data System, BI-RADS: Mammography. 5th ed. Reston: American College of Radiology, 2013
                      16. Hendrick RE et al: Mammography screening: a new estimate of number needed to screen to prevent one breast cancer death. AJR Am J Roentgenol. 198(3):723-8, 2012
                      17. Nishikawa RM et al: Clinically missed cancer: how effectively can radiologists use computer-aided detection? AJR Am J Roentgenol. 198(3):708-16, 2012
                      18. Hubbard RA et al: Cumulative probability of false-positive recall or biopsy recommendation after 10 years of screening mammography: a cohort study. Ann Intern Med. 155(8):481-92, 2011
                      19. Tabár L et al: Swedish two-county trial: impact of mammographic screening on breast cancer mortality during 3 decades. Radiology. 260(3):658-63, 2011
                      20. Carney PA et al: Identifying minimally acceptable interpretive performance criteria for screening mammography. Radiology. 255(2):354-61, 2010
                      21. Nelson HD et al: S. Preventive Services Task Force. Screening for breast cancer: an update for the U.S. Preventive Services Task Force. Ann Intern Med. 151(10):727-37, W237-42, 2009
                      22. Hogben RK: Screening for breast cancer in England: a review. Curr Opin Obstet Gynecol. 20(6):545-9, 2008
                      23. Rosenberg RD et al: Performance benchmarks for screening mammography. Radiology. 241(1):55-66, 2006
                      24. Berry DA et al: Effect of screening and adjuvant therapy on mortality from breast cancer. N Engl J Med. 353(17):1784-92, 2005
                      25. Burnside ES et al: The use of batch reading to improve the performance of screening mammography. AJR Am J Roentgenol. 185(3):790-6, 2005
                      26. D'Orsi C et al: Current realities of delivering mammography services in the community: do challenges with staffing and scheduling exist? Radiology. 235(2):391-5, 2005
                      27. Hendrick RE et al: Community-based mammography practice: services, charges, and interpretation methods. AJR Am J Roentgenol. 184(2):433-8, 2005
                      28. Pisano ED et al: Diagnostic performance of digital versus film mammography for breast-cancer screening. N Engl J Med. 353(17):1773-83, 2005
                      29. Smith RA et al: The randomized trials of breast cancer screening: what have we learned? Radiol Clin North Am. 42(5):793-806, v, 2004
                      30. Elmore JG et al: International variation in screening mammography interpretations in community-based programs. J Natl Cancer Inst. 95(18):1384-93, 2003
                      31. Tabar L et al: Mammography service screening and mortality in breast cancer patients: 20-year follow-up before and after introduction of screening. Lancet. 361(9367):1405-10, 2003
                      32. Yen MF et al: Quantifying the potential problem of overdiagnosis of ductal carcinoma in situ in breast cancer screening. Eur J Cancer. 39(12):1746-54, 2003
                      33. Walter LC et al: Cancer screening in elderly patients: a framework for individualized decision making. JAMA. 285(21):2750-6, 2001
                      34. Elmore JG et al: Ten-year risk of false positive screening mammograms and clinical breast examinations. N Engl J Med. 338(16):1089-96, 1998
                      35. Wilson TE et al: Patient satisfaction with screening mammography: online vs off-line interpretation. Acad Radiol. 5(11):771-8, 1998
                      36. Hendrick RE et al: Benefit of screening mammography in women aged 40-49: a new meta-analysis of randomized controlled trials. J Natl Cancer Inst Monogr. (22):87-92, 1997
                      Related Anatomy
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                      Related Differential Diagnoses
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                      References
                      Tables

                      Tables

                      KEY FACTS

                      • Imaging

                        • Clinical Issues

                          • Diagnostic Checklist

                            TERMINOLOGY

                            • Definitions

                              • Mammographic screening: Periodic imaging of both breasts using digital mammography ± digital breast tomosynthesis (DBT) in asymptomatic women to detect breast cancer
                                • Earlier detection → ↓ node-positive invasive cancers → ↓ breast cancer mortality and morbidity
                              • Mammography Quality Standards Act (MQSA) (USA)
                                • Federal law (1992) with stringent quality standards for all stages and personnel involved
                                • Governed by FDA &/or state with required regular QA process and annual inspections
                                • Images interpreted by Mammography Quality Standards Act (MQSA)-certified breast imager (USA) or equivalent
                                • Must be supported by accurate diagnostic assessment, expert image-guided needle biopsy, breast pathology, treatment
                              • Online screening: Interpretation at time of examination with immediate provision of results
                              • Offline screening: Mammograms batch-read, either later or remotely, by 1 or more radiologists
                                • Postal (or phone call) recommendation to return for additional investigation
                              • Results: Breast Imaging Reporting and Data System (BI-RADS) 1 (negative), 2 (benign), or 0 (incomplete, additional imaging needed, recall)
                              • Recall rate = abnormal interpretation rate, i.e., percentage of women screened with recommendation for further testing prior to next routine mammogram
                                • BI-RADS 0 (incomplete) recommended for additional evaluation
                                • BI-RADS 3 assessment not to be used on screening mammography but would be considered recall
                                • Includes BI-RADS 4 (suspicious) and BI-RADS 5 (highly suggestive of malignancy), but use of these is typically reserved for diagnostic setting
                                • Excludes BI-RADS 1 or 2 assessment, even if therapeutic (but not diagnostic) cyst aspiration will be performed
                                • Excludes technical recalls (e.g., motion, poor positioning)
                              • Screening interval: Recommended time between screening exams
                                • USA: American College of Radiology (ACR), National Comprehensive Cancer Network (NCCN): Every year beginning at age 40 and continuing as long as in good health
                                  • American Cancer Society (ACS): Offer at age 40-44; recommend at age 45; yearly for ages 40-54, biennial or annual for age ≥ 55; as long as life expectancy ≥ 10 years
                                  • National Cancer Institute (NCI): Every 1-2 years
                                  • US Preventive Services Task Force (USPSTF): Women aged 40-49 should discuss with their physicians; every 2 years from age 50-74
                                  • If high risk, screening recommended by age 25-30 (see guidelines for MR)
                                • Canadian Task Force on Preventive Health Care: Every 2-3 years from age 50-74
                                • European Society of Breast Imaging (EUSOBI): Every 2 years from age 50-69; extension to age 73-75 and from age 40-45 to 49 also encouraged
                                • United Kingdom National Health Service: Every 3 years from age 50-70; in some parts of England, from age 47-73
                                • Swedish program: Variable, every 18-24 months from age 40-50 to age 69 or 74
                                • Austrian program: Every 18 months from age 45-54; every 2 years age 55-74 years
                                • Dutch, Norwegian, Canadian, Australian, and New Zealand screening programs: Every 2 years from age 50-69
                                • Japanese Breast Cancer Society: Start at age 40; do not specify interval or duration
                              • True-positive: Tissue diagnosis of breast cancer within screening interval (typically 365 days in USA) after abnormal (positive) screening mammogram
                                • Positive test: BI-RADS 0, 3, 4, 5 on screening (use of BI-RADS 3, 4, and 5 is discouraged for screening exams)
                              • False-negative: Tissue diagnosis of breast cancer within screening interval after negative mammogram (BI-RADS 1 or 2 on screening or technical recall only)
                              • Positive predictive value (PPV)
                                • PPV1 = PPV of abnormal screening exams (# true-positive exams divided by # of all positive screening exams)
                                • PPV2 = PPV of biopsies recommended (# true-positive exams divided by # of screening exams recommended for biopsy after full work-up)
                                • PPV3 = PPV of biopsies performed (# true-positive exams divided by # of screening exams with biopsies actually performed after full work-up)
                              • Cancer detection rate (CDR): # diagnosed with breast cancer per 1,000 screening examinations
                                • Prevalent cancers are found on initial, baseline screening mammogram
                                • Incident cancers are found on subsequent screening exam performed at or close to recommended screening interval
                                • Interval cancers are diagnosed during time between recommended screening exams, typically due to clinical symptoms, after negative mammogram
                              • Minimal cancer: Invasive cancer ≤ 1 cm or DCIS
                              • Most audits performed at patient level (i.e., screening examination level), though can be performed at breast level
                                • If patient recalled for finding other than area proven to be cancer within screening interval, this is still considered true-positive
                                • Note: If patient diagnosed with cancer because of new screening examination performed prior to screening interval (e.g., 360 days after negative screen) and diagnosis of cancer made because of new finding on new mammogram, this is still considered false-negative for original negative screening mammogram even if cancer cannot be seen in retrospect

                            IMAGING

                            • Imaging Anatomy

                              • Anatomy-Based Imaging Issues

                                PATHOLOGY

                                • Staging, Grading, & Classification

                                  CLINICAL ISSUES

                                  • Demographics

                                    • Natural History & Prognosis

                                      DIAGNOSTIC CHECKLIST

                                      • Consider

                                        • Reporting Tips

                                          Selected References

                                          1. Skaane P et al: Digital mammography versus digital mammography plus tomosynthesis in breast cancer screening: The Oslo Tomosynthesis Screening Trial. Radiology. 182394, 2019
                                          2. Helvie MA et al: Screening mammography for average-risk women: the controversy and NCCN's position. J Natl Compr Canc Netw. 16(11):1398-1404, 2018
                                          3. Klarenbach S et al: Recommendations on screening for breast cancer in women aged 40-74 years who are not at increased risk for breast cancer. CMAJ. 190(49):E1441-E1451, 2018
                                          4. Lee CS et al: Harmonizing breast cancer screening recommendations: metrics and accountability. AJR Am J Roentgenol. 210(2):241-245, 2018
                                          5. Mango V et al: Commentary ACOG practice bulletin July 2017: Breast cancer risk assessment and screening in average-risk women. Br J Radiol. 91(1090):20170907, 2018
                                          6. Tabár L et al: The incidence of fatal breast cancer measures the increased effectiveness of therapy in women participating in mammography screening. Cancer. 125(4):515-523, 2018
                                          7. Lehman CD et al: National performance benchmarks for modern screening digital mammography: update from the Breast Cancer Surveillance Consortium. Radiology. 283(1):49-58, 2017
                                          8. Monticciolo DL et al: Breast cancer screening for average-risk women: recommendations from the ACR commission on breast imaging. J Am Coll Radiol. 14(9):1137-1143, 2017
                                          9. Sardanelli F et al: Position paper on screening for breast cancer by the European Society of Breast Imaging (EUSOBI) and 30 national breast radiology bodies from Austria, Belgium, Bosnia and Herzegovina, Bulgaria, Croatia, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Italy, Israel, Lithuania, Moldova, The Netherlands, Norway, Poland, Portugal, Romania, Serbia, Slovakia, Spain, Sweden, Switzerland and Turkey. Eur Radiol. 27(7):2737-2743, 2017
                                          10. Siu AL et al: Screening for breast cancer: U.S. Preventive Services Task force recommendation statement. Ann Intern Med. 164(4):279-96, 2016
                                          11. Tozaki M et al: The Japanese Breast Cancer Society clinical practice guidelines for screening and imaging diagnosis of breast cancer, 2015 edition. Breast Cancer. 23(3):357-66, 2016
                                          12. Oeffinger KC et al: Breast cancer screening for women at average risk: 2015 guideline update from the American Cancer Society. JAMA. 314(15):1599-614, 2015
                                          13. Friedewald SM et al: Breast cancer screening using tomosynthesis in combination with digital mammography. JAMA. 311(24):2499-507, 2014
                                          14. Kerlikowske K et al: Outcomes of screening mammography by frequency, breast density, and postmenopausal hormone therapy. JAMA Intern Med. 173(9):807-16, 2013
                                          15. Sickles EA et al: Breast Imaging Reporting and Data System, BI-RADS: Mammography. 5th ed. Reston: American College of Radiology, 2013
                                          16. Hendrick RE et al: Mammography screening: a new estimate of number needed to screen to prevent one breast cancer death. AJR Am J Roentgenol. 198(3):723-8, 2012
                                          17. Nishikawa RM et al: Clinically missed cancer: how effectively can radiologists use computer-aided detection? AJR Am J Roentgenol. 198(3):708-16, 2012
                                          18. Hubbard RA et al: Cumulative probability of false-positive recall or biopsy recommendation after 10 years of screening mammography: a cohort study. Ann Intern Med. 155(8):481-92, 2011
                                          19. Tabár L et al: Swedish two-county trial: impact of mammographic screening on breast cancer mortality during 3 decades. Radiology. 260(3):658-63, 2011
                                          20. Carney PA et al: Identifying minimally acceptable interpretive performance criteria for screening mammography. Radiology. 255(2):354-61, 2010
                                          21. Nelson HD et al: S. Preventive Services Task Force. Screening for breast cancer: an update for the U.S. Preventive Services Task Force. Ann Intern Med. 151(10):727-37, W237-42, 2009
                                          22. Hogben RK: Screening for breast cancer in England: a review. Curr Opin Obstet Gynecol. 20(6):545-9, 2008
                                          23. Rosenberg RD et al: Performance benchmarks for screening mammography. Radiology. 241(1):55-66, 2006
                                          24. Berry DA et al: Effect of screening and adjuvant therapy on mortality from breast cancer. N Engl J Med. 353(17):1784-92, 2005
                                          25. Burnside ES et al: The use of batch reading to improve the performance of screening mammography. AJR Am J Roentgenol. 185(3):790-6, 2005
                                          26. D'Orsi C et al: Current realities of delivering mammography services in the community: do challenges with staffing and scheduling exist? Radiology. 235(2):391-5, 2005
                                          27. Hendrick RE et al: Community-based mammography practice: services, charges, and interpretation methods. AJR Am J Roentgenol. 184(2):433-8, 2005
                                          28. Pisano ED et al: Diagnostic performance of digital versus film mammography for breast-cancer screening. N Engl J Med. 353(17):1773-83, 2005
                                          29. Smith RA et al: The randomized trials of breast cancer screening: what have we learned? Radiol Clin North Am. 42(5):793-806, v, 2004
                                          30. Elmore JG et al: International variation in screening mammography interpretations in community-based programs. J Natl Cancer Inst. 95(18):1384-93, 2003
                                          31. Tabar L et al: Mammography service screening and mortality in breast cancer patients: 20-year follow-up before and after introduction of screening. Lancet. 361(9367):1405-10, 2003
                                          32. Yen MF et al: Quantifying the potential problem of overdiagnosis of ductal carcinoma in situ in breast cancer screening. Eur J Cancer. 39(12):1746-54, 2003
                                          33. Walter LC et al: Cancer screening in elderly patients: a framework for individualized decision making. JAMA. 285(21):2750-6, 2001
                                          34. Elmore JG et al: Ten-year risk of false positive screening mammograms and clinical breast examinations. N Engl J Med. 338(16):1089-96, 1998
                                          35. Wilson TE et al: Patient satisfaction with screening mammography: online vs off-line interpretation. Acad Radiol. 5(11):771-8, 1998
                                          36. Hendrick RE et al: Benefit of screening mammography in women aged 40-49: a new meta-analysis of randomized controlled trials. J Natl Cancer Inst Monogr. (22):87-92, 1997