On this page you will find best practice breast screening and imaging appropriateness criteria for the following:

• Screening Mammography
• Diagnostic Mammography
• Digital Breast Tomosynthesis (DBT)
• Breast Ultrasound
• Breast MRI
• Image-guided Breast Biopsy
• Ultrasound-guided Cyst Aspiration
• Breast Imaging FAQs
  

Screening mammography

Screening mammography should be performed annually starting at age 40 for all women. Patients do not need an order or referral from their doctor to schedule a screening mammogram. Patients can select date, time, and location for screening mammograms online through MyChart and results are released automatically to MyChart.

For patients who have had a unilateral mastectomy for breast cancer and therefore require unilateral breast cancer screening, use IMG8078 (right) or IMG8079 (left).

Diagnostic mammography

 

Indications for diagnostic mammography include:

• Breast symptoms (i.e. palpable breast lump, focal breast pain, suspicious nipple discharge)
• Callback from screening mammography
• Short term follow up for a finding seen on a prior diagnostic mammogram
• Annual surveillance in patients with recent history of breast cancer

A diagnostic mammography appointment may include additional mammographic views and/or a breast ultrasound. Patients will receive their results at the end of the appointment.

If a patient is over 30 and has not had a bilateral mammogram in over six months, please order a bilateral exam even if symptoms are unilateral.

Digital breast tomosynthesis (DBT)

Digital breast tomosynthesis (DBT) is a quasi-3D mammogram which allows radiologists to see more details of the breast tissue. With DBT, breast radiologists can find more breast cancers and call back fewer patients for additional imaging. DBT is beneficial to all women but is most beneficial in women with dense breast tissue. Both screening mammography and diagnostic mammography can be performed with DBT.

Breast ultrasound

Breast ultrasound is typically used in combination with mammography. Breast ultrasound is used as a first imaging modality in young patients (<30 years) with breast symptoms.

Screening breast ultrasound can be used as a supplemental screening modality with mammography. This slightly increases cancer detection, but also a high false positive rate. Screening ultrasound is recommended for high risk women who are unable to have breast MRI.

Breast MRI

Indications for breast MRI include

• High risk screening
• Extent of disease evaluation in newly diagnosed breast cancer
• Evaluate response to neoadjuvant chemotherapy
• Suspected occult breast cancer (for example, patients with axillary metastases)
• Pathologic nipple discharge without abnormality on mammogram/ultrasound
• Silicone implant integrity evaluation

High risk patients include women with a BRCA gene mutation and their untested first degree relatives, women with chest irradiation between 10 to 30 years of age, and women with >20% lifetime risk of breast cancer.

Patients with silicone implants should be screened for silent implant rupture at 5-6 years after surgery and then every 2-3 years afterwards.

Image guided breast biopsies

When a suspicious finding is seen on breast imaging, a biopsy should be performed. The biopsy is performed using the modality that best visualizes the finding (mammogram, ultrasound, or MRI). All biopsies are performed using a local anesthetic. Breast biopsies are very safe. Prior to a breast biopsy, the radiologist will explain the procedure in detail to the patient and answer any questions.

Ultrasound guided cyst aspiration

Most breast cysts can be safely assessed as benign and do not require an aspiration. However, if a patient has a symptomatic breast cyst or a suspected breast abscess, an ultrasound guided aspiration can be performed. This can be both therapeutic and diagnostic.

Frequently asked questions

Q: What should I order for my patient who presents with a palpable breast lump?

A: Diagnostic mammogram and ultrasound.

Q: My patient feels a breast lump. How likely is this to be breast cancer?

A: Most palpable breast lumps are benign. However, a new palpable mass can be a presenting symptom of breast cancer. All new palpable breast lumps should be further evaluated with diagnostic mammogram and ultrasound.

Q: What should I order for my patient with bilateral cyclical diffuse breast pain?

A: Patients with bilateral cyclical diffuse breast pain typically do not require nonroutine breast imaging.

Q: At what age should I start ordering screening mammograms for my patients who have average lifetime risk of breast cancer?

A: Age 40. The American College of Radiology, Society of Breast Imaging, and USPSTF all agree that mammographic screening for average risk women should begin at age 40.

Q: Should I order screening mammograms with digital breast tomosynthesis?

A: Yes. Screening mammograms performed with digital breast tomosynthesis allow radiologists to find more breast cancers and call back fewer patients.

Q: My patient wants to have screening ultrasound instead of screening mammogram. Is that okay?

A: No. Mammography is the only screening modality proven to decrease breast cancer mortality. We recommend annual screening mammography for all women starting at the age of 40. Screening ultrasound can be used as a supplement screening modality in some subsets of patients.

Q: My patient has had silicone implants for 10 years and suddenly developed a contour irregularity on one side. What test should I order?

A: Breast MRI without contrast.

Q: My patient had a suspicious finding on a recent mammogram and a biopsy was recommended. How do I know which kind of biopsy to order?

A: The radiology report will specifically state which type of biopsy is being recommended. Options are ultrasound-guided, stereotactic/tomosynthesis-guided, and MRI-guided.

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