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Mammography for Breast Cancer

Mammography is a special type of X–ray imaging used to create detailed images of the breast. Mammography uses low dose X–ray, high contrast, high–resolution film, and an X–ray system designed specifically for imaging the breasts. Successful treatment of breast cancer depends on early diagnosis. Mammography plays a major role in early detection of breast cancers.

Mammography can show changes in the breast well before a woman or her physician can feel them. Once a lump is discovered, mammography can be the key in diagnosing the lump to determine if it is cancerous. If an abnormality is found, image guided biopsy and other types of diagnostic imaging such as breast ultrasound can be used to help confirm breast cancer. Biopsy (sampling of tissue for laboratory testing) of an abnormality can be done to determine if the tissue is cancerous (malignant tissue) or not cancerous (benign tissue). Stereo–tactic mammography or ultrasound can be used to guide the biopsy of the lump (see section on breast biopsy for more information).

There are two types of mammography exams, screening and diagnostic:
Screening
Screening mammography is an X–ray examination of the breasts in a woman who is asymptomatic (has no complaints or symptoms of breast cancer). The goal of screening mammography is to detect cancer when it is still too small to be felt by a woman or her physician. Early detection of small breast cancers by screening mammography greatly improves a woman’s chances for successful treatment. Screening mammography is recommended on a periodic schedule (typically every year) based on a woman’s age and risk profile for breast cancer. Screening mammography is available at a number of clinics and locations.

Diagnostic
Diagnostic mammography is an X–ray examination of the breast in a woman who either has a breast complaint (for example, a breast lump found during self–examination or nipple discharge) or has had an abnormality found during screening mammography. Diagnostic mammography is more involved and time–consuming than screening mammography and is used to determine the exact size and location of breast abnormalities and to image the surrounding tissue and lymph nodes.

Typically, several additional views of the breast are imaged and interpreted during diagnostic mammography. Thus, diagnostic mammography is more expensive than screening mammography. Diagnostic mammography should only be done under the direct guidance of a radiologist.

Women with breast implants or a personal history of breast cancer will usually require the additional views used in diagnostic mammography.

Procedure of Mammography
During mammography, the technician will position the patient and image each breast separately. One at a time, each breast is carefully positioned on a special film cassette and then gently compressed with a paddle (often made of clear Plexiglas or other plastic). This compression flattens the breast so that the maximum amount of tissue can be imaged and examined.

To “Take” an X–ray mammogram, the X–ray source is turned on and X–rays are radiated through the compressed breast and onto a film cassette positioned under the breast. The X–rays hit a special phosphor coating inside the cassette. This phosphor glows in proportion to the intensity of the X–ray beams hitting it, thus exposing the film with an image of the internal structures of the breast. Highly sensitive film and special X–rays are used for mammography to create the highest quality images at the lowest exposure.

The resulting “Exposed film” inside the cassette is then developed in a dark room much like a regular photograph is developed. It is the special energy and wavelength of the X–rays that allow them to pass through the breast and create the image of the internal structures of the breast. As the X–rays pass through the breast, they are attenuated (weakened) by the different tissue densities they encounter.

Fat is very dense and absorbs or attenuates a great deal of the X–rays. The connective tissue around the breast ducts and fat is less dense and attenuates or absorbs far less X–ray energy. It is these differences in absorption and the corresponding varying exposure level of the film that create the images which can clearly show normal structures such as fat, fibro–glandular tissue, breast ducts, and nipples. Further, abnormalities such as micro–calcifications, masses, and cysts are also visible.

The developed mammography films are then interpreted by a radiologist, who compares the new images of a woman’s breast to each other and to previous mammograms a woman has had. The radiologist will look for shadows and patterns of tissue density to detect any abnormalities.

A mammogram is like a fingerprint, the appearance of the breast on a mammogram varies tremendously from woman to woman, and no two mammograms are alike. It is extremely helpful for the radiologist to have films (not just the report) available from previous examinations for comparison purposes. This will help the doctor to recognize small changes that occur gradually over a period of time and detect a cancer as early as possible.

The breast is made of fat, fibrous tissue and glands. Breast masses (these include benign and malignant lesions) appear white on mammogram. Fat appears black on a mammogram. Everything else (glands, connective tissue, tumors and other significant abnormalities such as micro–calcifications) appear as levels of white on a mammogram.

Breast Compression During Mammography
Breast compression is necessary to flatten the breast so that the maximum amount of tissue can be imaged and examined. Breast compression may cause some discomfort, but it only lasts for a brief time during the mammography procedure. Patients should feel firm pressure due to compression but no significant pain. If you feel pain, please inform the technologist. During the mammography examination, breast compression should only be applied two to four times per breast for a few seconds each time (see below for description of views taken during screening and diagnostic mammography).

Breast compression is necessary during mammography in order to:
Flatten the breast so there is less tissue overlap for better visualization of anatomy and potential abnormalities. For example, inadequate compression can lead to poor imaging of micro–calcifications, tiny calcium deposits that are often an early sign of breast cancer. Allow the use of a lower X–ray dose since a thinner amount of breast tissue is being imaged.

Special Mammography Techniques
In some cases, special mammography techniques are used to make a small area of breast tissue or a suspected abnormality easier to evaluate. Depending on the type of abnormality and its location in the breast, one of these special mammography techniques (spot compression and magnification views) may be used.

The Benefits of Mammography
Early detection of small breast cancers by screening mammography greatly improves a woman’s chances for successful treatment. If breast cancer is caught and treated while it is still confined to the breast ducts (DCIS: ductal carcinoma in situ), the cure rate is close to 100%.

Breast cancers found by screening mammography of women in their forties were smaller and at an earlier stage (with less spread to lymph nodes or other organs) than cancers found in women not undergone mammography.

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