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Agency for Health Care Policy and Research (US). AHCPR Quick Reference Guides. Rockville (MD): Agency for Health Care Policy and Research (US); 1992-1996.

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13High-Quality Mammography: Information for Referring Providers

Quick Reference Guideline Number 13

Created: .

Attention Clinicians

The Clinical Practice Guideline on which this Quick Reference Guide for Clinicians is based was developed by a multidisciplinary, non-Federal panel comprising health care professionals and consumer representatives. Panel members were:

  • Lawrence W. Bassett, MD (Co-chair)
  • R. Edward Hendrick, PhD (Co-chair)
  • Tamsen Lynn Bassford, MD
  • Priscilla Butler, MS
  • Darryl Carter, MD
  • Marydale DeBor, JD
  • Carl J. D'Orsi, MD
  • Carol Garlinghouse, MSN, RN
  • Richard F. Jones, III, MD
  • Amy S. Langer, MBA
  • J. Leonard Lichtenfeld, MD
  • Janet Osuch, MD
  • Lynda Reynolds, BS, RT
  • Ellen Shaw de Paredes, MD
  • Richard E. Williams, MD

For a description of the guideline development process and information about the sponsoring agency, the Agency for Health Care Policy and Research (AHCPR), see Quality Determinants of Mammography, Clinical Practice Guideline No. 13 (AHCPR Publication No. 95-0632). Copies of the Clinical Practice Guideline are available through the Government Printing Office. To receive single copies of this Quick Reference Guide for Clinicians (AHCPR Publication No. 95-0633) and How To Get High-Quality Mammograms: A Woman's Guide (AHCPR Publication No. 95-0634), call toll-free 800-358-9295 or write the AHCPR Publications Clearinghouse,P.O. Box 8547, Silver Spring, MD 20907.Single copies of the Clinical Practice Guideline and bulk copies of this publication are available for sale from the Government Printing Office, Superintendent of Documents,Washington, D.C. 20402.Call (202) 512-1800 for ordering information.

AHCPR invites comments and suggestions from users for consideration in development and updating of future guidelines. Please send written comments to Director, Office of the Forum for Quality and Effectiveness in Health Care, AHCPR, Willco Building, Suite 310, 6000 Executive Boulevard, Rockville, MD 20852.

Note: This Quick Reference Guide for Clinicians presents information on mammography of interest to health care providers who refer women for mammography. The Clinical Practice Guideline is intended for the entire spectrum of health care professionals involved in mammography services: the referring health care provider, the interpreting physician, the radiologic technologist, and the medical physicist. Additional information is provided for the mammography facility, the facility scheduler and receptionist, the equipment service person, and the woman who goes for mammography. The Clinical Practice Guideline provides more detailed analysis and discussion of the available research, health care decisionmaking, critical evaluation of the assumptions and knowledge of the field, considerations for women with special needs, and references. Decisions to adopt particular recommendations from any publication must be made by practitioners in light of available resources and circumstances of individual cases.

High-Quality Mammography: Information for Referring Providers

Purpose and Scope

Mammography is the most sensitive method for the detection of breast cancer. It is estimated that 1 woman in 8 will have breast cancer during her lifetime and about 1 in 33 will die from breast cancer. The probability of developing breast cancer increases with age. Mammography, either in combination with clinical breast examination or alone, has been demonstrated to reduce breast cancer mortality, particularly in older women.

This Quick Reference Guide is directed to the physician or other health care provider who is responsible for referring women for screening or diagnostic mammography. It is derived from portions of the Clinical Practice Guideline on Quality Determinants of Mammography. Providers who want a more global perspective and health care professionals who supply mammography services should consult the Clinical Practice Guideline.

Mammography is used for two purposes. Screening mammography is used to screen women for breast cancer in the absence of signs or symptoms of the disease. Diagnostic mammography (also called problem-solving mammography or consultative mammography) is performed on women or men (termed patients) with signs or symptoms, abnormal screening mammograms, or special characteristics such as breast implants. Because mammography is performed mainly on women, the term "woman" and female pronouns are used throughout the guideline.

In developing the guideline, the panel took a broad perspective of mammography services, starting when a woman or her health care provider calls to schedule mammography and ending with tracking, monitoring, and followup of the screened woman or patient. The panel took this comprehensive approach because mammography, especially screening mammography, is different from many other medical examinations. Medical systems generally treat acutely or chronically ill patients; however, mammography often is performed on healthy women who want to stay healthy. As is the case with any screening or diagnostic examination, mammography has limitations, and screening can result in adverse consequences. Mammography screening may fail to detect breast cancer, resulting in delay of appropriate care when there are clinical signs. Other possible problems are inaccurate interpretation of mammograms; results not being received or recommendations not followed; or a painful mammography experience, discouraging women from future participation in regular screening. Because of such problems, this guideline addresses the entire system of screening and diagnostic mammography so that women receive accurate screening and followup for effective breast care.

The question of when asymptomatic women should begin mammography screening for breast cancer and the frequency of such screening intentionally was not addressed in this guideline. Such topics were determined to be beyond the scope of the panel developing the guideline. Instead, the focus is on identifying elements associated with the highest quality mammography, both screening and diagnostic, regardless of the age at which screening mammography begins or the frequency with which it is performed.

This guideline was developed on the basis of existing scientific evidence. When only partial evidence addressed a particular question, the panel chose either to supplement the evidence with panel consensus or to address only the aspects of the question for which evidence existed. When no evidence existed to address a particular question, the panel chose either to address the question by consensus or to note the need for research in that area without attempting to resolve the question.

The guideline statements are ranked by the panel as follows:

  • Strong recommendations are guideline statements that deal with elements of mammography that the panel considers essential to good practice.
  • Recommendations are statements that deal with elements of mammography that the panel considers attainable in most but not all mammography facilities.
  • Options are statements of a less compelling nature that cannot be justified as recommendations.

The characterization of guideline statements as strong recommendations, recommendations, or options is based on the panel's opinion of how essential these steps are to achieve high-quality mammography.

Each guideline statement is rated for strength of evidence, as indicated by a letter code:

  • A means the statement is supported by strong or extensive research-based evidence.
  • B means the statement is supported by some research-based evidence and by panel expert opinion.
  • C means the statement is based on panel experience and expert opinion.

Expert opinion was arrived at by consensus as to the guideline statement, its ranking, and its strength of evidence rating.

Key Points

The purpose of this guideline is to identify the elements of high-quality mammography. Key points in the Quick Reference Guide include the following:

  • Screening for breast cancer is best done by including both mammography and clinical breast examination in the screening process. Imaging modalities other than x-ray mammography are not appropriate screening tools for breast cancer.
  • Health care providers are responsible for referring women for screening mammography on a regular, ongoing basis. Women are responsible for getting regular screening mammograms. When a problem is identified through screening or diagnostic mammography, women are responsible for working with a health care provider to get appropriate followup care.
  • The referring provider, interpreting physician, and woman should form a partnership to communicate and follow through with recommendations.
  • Mammography results should always be communicated as quickly as possible to the referring provider and to the screened woman or mammography patient.
  • Women and patients must have the opportunity to ask questions and express concerns, and responses must be conveyed to them as clearly as possible, with a sensitivity to cultural and ethnic diversity and language.
  • Mammography is not perfect. A negative mammogram (a mammogram that shows no apparent problem) should never delay further evaluation or prevent care for a physical finding such as a breast lump, skin change, or spontaneous nipple discharge.
  • The purpose of mammography for patients with a palpable breast lump is to further define the lump and to rule out the presence of unexpected nonpalpable breast cancer in the ipsilateral or contralateral breast.
  • Quality mammography results when physicians interpret mammograms obtained by qualified radiologic technologists using dedicated equipment that is monitored through regular quality control.
  • By law, beginning October 1, 1994, all mammography facilities in the United States except Veterans Health Administration facilities must be certified by the Food and Drug Administration.

Breast Cancer Screening and Diagnosis

Strong Recommendation: Inform women that they should have both a clinical breast examination and mammography as part of the breast cancer screening process. (C)

Strong Recommendation: Be aware that mammography is the most sensitive and specific screening test for breast cancer currently available. (A)

Referring providers should ensure that women have routine mammography as well as clinical breast examination (CBE). Mammography can detect breast cancer when it is too small to be detected by CBE. However, screening for breast cancer is best done by having mammography and a thorough CBE. Mammography in combination with CBE has resulted in a higher breast cancer detection rate and decrease in mortality than is the case for mammography or CBE used alone. The survival rate of women with nonpalpable breast cancer detected by mammography alone is greater than the survival rate of women whose cancer is palpable.

Recommendation: If possible, women should be scheduled for screening mammography when they are not experiencing cyclic breast tenderness or conditions that increase breast density. (C)

Discomfort during the examination is among the reasons cited by women for not adhering to recommended guidelines for screening mammography. For this reason, screening mammography should be avoided during the week prior to menses if a woman has breast pain during this time. Breast tenderness can impair the technologist's ability to achieve optimal breast compression. However, diagnostic mammography should be scheduled as soon as possible.

Strong Recommendation: Screening and diagnostic mammography differ in terms of purpose, views taken, and presence of the interpreting physician on site. When referring women for mammography, specify whether screening or diagnostic mammography is requested. (B)

Screening mammography is an x-ray examination to detect unsuspected breast cancer at an early stage in asymptomatic women; it usually consists of two views of each breast. The interpreting physician may or may not be on site for screening mammography. Diagnostic mammography is an x-ray examination used to evaluate a patient with a breast mass or masses, other breast signs or symptoms (spontaneous discharge from the nipple, skin changes, etc.), an abnormal or questionable screening mammogram, a history of breast cancer with breast conservation, or special characteristics such as augmented breasts. The diagnostic mammogram should be correlated with known physical findings and symptoms. Diagnostic mammography may require additional views of the breast to better visualize the area of concern; it may also include the use of other breast imaging modalities, such as ultrasonography. The interpreting physician usually should be on site during performance of diagnostic mammography. Although online interpretation is desirable for diagnostic mammography, it may not be possible in all clinical settings (for example, in rural areas).

Because diagnostic mammography generally takes more time to perform and usually requires the presence of the interpreting physician, it is important for the referring provider to specify at the time of referral whether diagnostic or screening mammography is being requested.

Disability usually does not preclude screening or diagnostic mammography. It is important to communicate special patient needs or disabilities such as severe scoliosis to the mammography facility before the examination.

Recommendation: Tell women whether they are being referred for screening or diagnostic mammography and how they will be informed of results. If the referral is for diagnostic mammography, tell the patient why it is needed, what to expect at the examination, and the necessity of followup. (B)

Recommendation: Be aware that although breast pain is a relatively uncommon presentation of breast cancer, its presence does not exclude the diagnosis of malignancy. (B)

Breast pain is the most common symptom associated with the breast. When breast cancer presents as breast pain, it is almost always associated with a palpable mass, nipple retraction, or other physical signs. Therefore, women presenting with localized breast pain should have a thorough CBE as part of their initial evaluation.

Recommendation: Women who have had breast-conserving surgery should have regular clinical breast examination and diagnostic mammography. (C)

Recommendation: Women with breast signs or symptoms, such as a breast mass, skin changes, or unilateral spontaneous nipple discharge, should be scheduled for diagnostic rather than screening mammography. (A)

In two retrospective series, malignancy was diagnosed in 4 percent of women evaluated for spontaneous nipple discharge. Malignancy may be associated with serous, sanguineous, or serosanguineous discharge. Nonspontaneous nipple discharge is common, especially in premenopausal women, and should not be considered a sign of malignancy. The etiology of unilateral, spontaneous nipple discharge should be addressed regardless of mammography results.

Diagnostic Mammography

Recommendation: When diagnostic mammography is appropriate, because of either an abnormal physical finding or an abnormal screening mammogram, every effort should be made to accomplish this in a timely manner. In general, the diagnostic mammogram should be performed as soon as possible. (C)

One month was considered a reasonable timeframe in which to accomplish diagnostic mammography, although there are no data to support it. The reason always to perform a diagnostic examination in a timely fashion is for the best care of the patient. Delay in the diagnosis of breast cancer is the reason for a high percentage of malpractice litigation and claims paid.

Strong Recommendation: Communicate abnormal clinical breast examination results in writing to the mammography facility before the mammography examination. Specify the location of any palpable abnormalities as to breast (left or right) and quadrant (upper outer, upper inner, lower outer, and lower inner). Also provide information about whether any previous breast surgeries or recent needle aspirations have been performed and, if so, their exact location. (C)

Option: A graphic representation of the breast showing the approximate location of the abnormality may be used to assist in this communication. (C)

An example of a graphic representation is shown in Figure 1.

Figure 1. Graphic representation of breast.

Figure

Figure 1. Graphic representation of breast. Note: The referring provider may use a diagram like this to denote the location of a palpable mass.

Recommendation: Aspiration of a palpable breast abnormality may cause a hematoma in the breast tissue, which can decrease the accuracy of subsequent mammography for at least 1 week. If aspiration is attempted before mammography, the referring health care provider should communicate this information to the mammography facility. (B)

Aspiration of a suspected cyst is often the initial step in the diagnostic workup of a palpable breast mass. The decision to attempt aspiration of a suspected breast cyst will probably be based on several factors, including size of lump and ease of access, the strength of the clinician's suspicion that a mass is a cyst, the availability of mammography, the availability of breast ultrasonography, and cost considerations. Two case series indicate a number of false-positive mammograms based on artifact from presumed hematoma formation after fine-needle aspiration biopsy (FNAB), all within 1 week of the aspiration. Therefore, if mammographic or sonographic findings following aspiration are confusing, the mammography examination can be repeated after 2 weeks, when the findings secondary to hematoma should have resolved. Alternatively, the mammogram could be delayed for 2 weeks following aspiration.

Strong Recommendation: Referring health care providers, interpreting physicians, and patients should understand the purpose of mammography for patients with a palpable breast lump. (B)

The purpose of mammography for patients with a palpable breast lump is to further define the lump and to rule out the presence of unexpected nonpalpable breast cancer in the ipsilateral or contralateral breast. The purpose of mammography is not to delay the biopsy of a clinically suspicious abnormality.

Strong Recommendation: Inform women that mammography has limitations as well as strengths. A negative mammogram does not rule out malignancy in the presence of a palpable mass or other breast abnormality. Inform women that a negative mammogram should not delay the clinical evaluation, including a possible biopsy, of a breast lump or other suspicious clinical finding. (B)

Strong Recommendation: A lump or other abnormal clinical finding that develops after a negative screening examination should be evaluated as soon as possible and not delayed until the next screening examination. (B)

Recommendation: Explain to patients that a correlative breast examination is often done as part of the mammographic examination of a patient with a reported palpable abnormality to make sure that the area of interest is included on the mammogram. The correlative breast examination, performed at the mammography facility, should never be considered a substitute for a complete clinical examination of both breasts, usually performed by the referring health care provider and intended for the detection of unsuspected breast cancer. (C)

In a correlative breast examination, a radiopaque marker (BB) is placed directly over the palpable abnormality to indicate its exact location. The BB directs attention to the area of concern and enables the interpreting physician to determine whether abnormal mammography findings match the location of the palpable abnormality. If the palpable abnormality does not appear on the films, additional views may be taken.

After the mammograms have been done, the interpreting physician may conduct another correlative breast examination to better understand the clinical findings and to properly correlate them with the findings on the mammogram. Subtle changes on the mammogram may have more significance when the clinical findings suggest a possible breast cancer.

Women With Breast Implants

Recommendation: Women who have had implants for breast augmentation should have mammograms for the detection of nonpalpable cancer at the usual recommended intervals. Although mammography should be performed, it is less effective in detecting cancers in women with implants. (B)

There are now no published data showing an increase in risk of breast cancer among women with implants.

Recommendation: Mammography of women with breast implants should always be considered diagnostic mammography, even if women are asymptomatic. Diagnostic mammography of women with implants requires special handling and positioning: four views of each breast, rather than two, should be taken whenever possible. (B)

Although unsuspected breast cancer can be detected on mammograms of women with implants, mammography is more difficult to perform. Mammography has not been proven useful for breast cancer detection when implants have been used for breast reconstruction after total mastectomy; regular CBE should be performed in these cases.

Mammography of asymptomatic women with breast implants should include both implant-included and implant-displaced views whenever possible. In the implant-displaced views, the radiologic technologist manually displaces the implant toward the chest wall while bringing breast tissue forward so that it can be adequately compressed. This maneuver results in an improved image of the anterior breast tissue.

Views, Compression, and Positioning

Recommendation: Be aware that screening mammography consists of two standard views of each breast: the mediolateral oblique and craniocaudal views. For the workup of a clinical or mammographic abnormality (diagnostic mammography), a large number of additional techniques are available. (B)

The primary goal of positioning for screening mammography is to show all of the breast tissue on the two standard views. The most commonly used additional views for diagnostic mammography are "spot compression" and "magnification," which are intended to better define a possible mammographic abnormality.

Spot compression involves the use of a smaller compression device to optimize compression over a local area of concern and to displace overlying tissues away from the area of concern. Magnification is used to improve the visibility of the details of the margins of a mass or to better see and characterize microcalcifications.

Recommendation: Be aware that positioning of the breast for mammography has undergone considerable changes in recent years and that positioning should be done by experienced radiologic technologists who have been trained in the most recent advances in mammography. (B)

Recommendation: Inform women that breast compression is necessary for good-quality mammography and lowers the x-ray dose needed. Inform women that compression may be uncomfortable and that they should tell the radiologic technologist if it is painful. (B)

Proper compression is essential for high-quality mammography. Compression involves pressing the breast between a clear-plastic, movable plate (the compression device) and the platform holding the film during mammography. Compression:

  • Reduces breast thickness, thus improving the visualization of structures within the breast that may be indicative of breast cancer, enhancing image contrast (by decreasing scattered radiation), and lowering radiation dose.
  • Immobilizes the breast, thus preventing motion that can blur the image of breast structures.
  • Spreads the tissues in the breast, thus reducing the possibility that a lesion might be obscured by overlying tissues and therefore missed.

Women who have significant breast pain may be advised to take a mild over-the-counter analgesic, such as acetaminophen, salicylates, or nonsteroidal anti-inflammatory agents, about 1 hour before undergoing mammography. Studies have shown that women are more likely to have pain if they expect it. Women should be reassured that adequate compression can usually be accomplished without pain. Most women tolerate compression well and would not defer future mammograms because of pain or discomfort. Women who have preexisting pain are less likely to tolerate compression.

Mammography in Women of Different Ages

Mammography in Women 50 and Over

Strong Recommendation: Be aware that the incidence of breast cancer increases with age. There is general consensus that screening mammography decreases mortality from breast cancer in women 50 and over. (A)

Mammography in Women 40-49

Recommendation: Be aware that there is a range of opinion about the value of screening mammography in asymptomatic women ages 40-49.

Mammography in Women Under 40

Recommendation: Be aware of the risks and limitations of mammography for women under 40 years of age, as well as special indicators for mammography in this age group. (B)

Routine screening mammography is not generally recommended for asymptomatic women under age 40. In general, the risk of developing breast cancer is lower for women in this age group than for older women. For women under 40, decisions to perform screening mammography and selection of intervals between examinations should be made on a case-by-case basis. Referring providers should directly contact the interpreting physician when scheduling mammography for women under 30.

Breast density is widely believed to decrease the discriminatory capability of mammography in women under 40, who are likely to have denser breasts. Both lower prevalence of breast cancer and decreased sensitivity of screening mammography in this age group would be expected to reduce the potential benefits of mammography in asymptomatic women. Based on several small case studies, false-negative rates in symptomatic women appear to be higher for women under 40. An indicated biopsy should not be delayed because of a negative mammogram.

Pregnancy and lactation can increase breast density. Resumption of menses is currently one of the markers for scheduling a screening mammogram in post partum or lactating women. By 24 weeks post partum, 85 percent of nursing mothers and 90 percent of nonnursing mothers will have resumed menstruation.

Women with a first-degree relative (mother, daughter, or sister) who was diagnosed with breast cancer have an increased relative risk of breast cancer. Relative risk is defined as the rate of breast cancer incidence in women who have the risk factor of a first-degree relative with breast cancer divided by the rate of breast cancer incidence in women who do not have the risk factor. Higher risks have been reported for some subgroups, such as women who have first-degree relatives with premenopausal or bilateral breast cancer. Many protocols for managing these patients suggest beginning mammographic screening at an earlier age, usually at or before the age of the relative at diagnosis.

Communication Results

Communication of mammography results is an important component of clinical practice. Various members of the panel, who represented referring providers, interpreting physicians, and consumers, realize that this issue is controversial and there are a variety of ways communication is accomplished. However, the guideline that was developed has as its goal the method of communication most likely to ensure that the woman receives her results, so that the outcome is reduced mortality from breast cancer.

Recommendation: The referring health care provider and the interpreting physician should be sensitive, supportive, and appropriate in communicating results, as well as prompt and accurate. (B)

Communicating normal results directly to women as soon as possible eliminates anxiety, reinforces the woman's role as a responsible participant in the process, reminds her of the importance of regular screening, and is a quality assurance safeguard. Effective communication is most crucial when results are abnormal and additional imaging is required.

Strong Recommendation: Be aware that failure to communicate results can lead to delay in diagnosis and treatment of breast cancer. Failure to communicate results in a timely fashion can lead to unnecessary anxiety in women. (B)

Many women believe that mammography results are normal if they are not contacted after their examination. This impression that "no news is good news" can have serious adverse consequences for women with an abnormal examination. The interpreting physician, the provider, and the woman are all responsible for ensuring that mammography results are communicated in an effective and timely manner and that recommendations are carried out. Timely communication is necessary whether results are normal or abnormal.

A communication lag may delay treatment and reduce treatment options. Problems in communicating abnormal results have included confusion concerning the appropriate steps to be taken; inappropriate or insensitive communication, resulting in avoidable anxiety and confusion; delay in receipt of results; and failure to communicate results to the woman at all-for example, when reports are misfiled or filed unread.

Recommendation: The primary responsibility for communicating a recommendation for short-interval followup, diagnostic mammography, or adjunctive diagnostic procedures rests with the referring health care provider. (B)

Strong Recommendation: The referring health care provider is responsible for the followup, monitoring, and tracking of women whose results are abnormal, including those for whom a biopsy is recommended. (B)

Recommendation: The referring health care provider should establish with the facility protocols to ensure that the communication loop is closed and that the roles of the referring health care provider and the facility in communicating results and tracking compliance are understood by all parties. (B)

The communication loop includes the referring provider, the facility, and the woman. The responsibility for communicating results is shared by the woman's referring provider and the mammography facility.

The interpreting physician's responsibility for communication of mammography results should vary depending on the presence of clinical findings in the breast, as shown in Table 1. The panel recommends clear and timely communications from the facility. In particular, facility personnel should undertake the following:

  • Inform all women of the time period in which they will receive their results. The woman will be instructed to call her health care provider or the mammography facility if she does not receive her results within the stated time period.
  • Use their best efforts to report results as soon as possible, usually within 10 business days. The reporting period should not exceed 30 days.
  • Send the health care provider a written report documenting the specific findings, followup recommendations, and interpreting physician.
  • Give the woman written results of her mammography and other breast imaging, either on site or by mail. The results should be in simple language, identify the interpreting physician, be given in a timely fashion, and include further steps to be taken.
  • Contact the health care provider with information about the need for additional views and adjunctive diagnostic imaging procedures. Sometimes, due to prior agreements with the referring provider, the facility will schedule these procedures directly with the woman or perform them immediately.
  • Directly telephone the referring provider if the result is suspicious for cancer.
  • Offer the woman the option of having abnormal results explained in person or by telephone. Information should not be left on an answering machine or given to another individual without the woman's express prior permission.
  • If scheduling and tracking recommended followup breast imaging examinations, notify the referring provider if the woman does not comply with the followup recommendation.

Table 1. Reporting of results by mammography facility.

Table

Table 1. Reporting of results by mammography facility.

Option: Referring health care providers or interpreting physicians may telephone women directly to explain abnormal findings, their significance, and recommended next steps. (B)

This telephone communication is in addition to written results given to the woman.

An increasing number of mammography facilities have begun to report both normal and abnormal results directly to women. This can be accomplished without disrupting a woman's relationship with her referring provider. Studies have shown that direct communication of results to women by mammography facilities produces a dramatic improvement in compliance with followup recommendations.

Option: Women may be sent a reminder before their next appropriate screening date. (B)

This reminder may be communicated by the health care provider or by the mammography facility, according to prearranged protocols. Computerized monitoring and tracking systems may be used to automatically generate the reminder. The primary concern in monitoring and tracking women with normal results is compliance with regular screening guidelines. It is important that mammography screening occur on a regular basis. The responsibility for that effort should lie with the woman's health care provider and with the woman herself.

Recordingkeeping

Strong Recommendation: Keep in the woman's chart the mammography report and any associated direction, action, or communications with the woman. (C)

The usual repository for mammography reports is the patient's general medical record. The health care provider's records system may be manual, automated, or computerized, but its design should address durability, security, confidentiality, storability, and retrievability.

Recommendation: Referring health care providers should have an in-office method to ensure prompt reading of mammography reports so that appropriate action and followup are taken. (C)

The referring provider's records should include:

  • Reason for the mammography examination.
  • The mammography report from the interpreting physician.
  • All followup records and communications with the woman (by telephone or in writing).
  • Information for comparison when future mammography studies are done, such as facility name and location and date of examination.

Recommendation: Use and maintain an effective medical records system that allows integration of mammography reports and related data with the patient's other medical records and demographic information. (C)

The records can be used for a patient mammography reminder system and can also provide documentation for insurance claims and legal action.

Possible Adverse Consequences and Other Problems

Recommendation: Be aware of the possible adverse consequences of mammography, the likelihood of each, and procedures to lower their likelihood. (C)

Excessive biopsies are a possible adverse consequence of mammography. There is also a low probability of breast cancer induction due to radiation exposure. Other problems associated with mammography include inadequate communication of results, the need to return for additional or repeat views, the inconvenience of scheduling mammography, pain or discomfort, false reassurance, delay in diagnosis and treatment, and cost.

Recommendation: Women may have substantial anxiety when they have to return for additional views or repeat views. These extra views should be done as soon as feasible to reduce anxiety. Mammography facility staff should be supportive and available to answer any questions the woman may have. (B)

Recommendation: Be aware that the risk of breast cancer induction from annual screening mammography beginning at age 40 or 50 is negligible. The estimated risk of breast cancer induction increases in women who are younger at the time of exposure. (A)

The average radiation dose to the breasts from two-view screening mammography is 2.0-4.0 mGy. This is comparable with the natural background radiation dose received by every person in the United States annually.

The latest and most thorough estimate of the risk of breast cancer induction from radiation exposure found that the risk of radiation-induced breast cancer starts 5-10 years after exposure, with the probability of radiation-induced breast cancer incidence peaking at 15 years after exposure and the probability of mortality from radiation-induced breast cancer peaking at 20 years after exposure. Risk of radiation-induced breast cancer is strongly dependent on age at exposure, with younger women having a higher but still small risk of radiation-induced breast cancer. The lifetime risk of breast cancer death due to radiation from a two-view screening mammogram at age 45 is approximately equal to the risk of death caused by traveling 450 miles by car (accident) or smoking three cigarettes (lung cancer).

Recommendation: In the process of detecting as many early breast cancers as possible, a certain number of biopsies will be done for benign mammographic abnormalities. Be aware that the positive predictive value of biopsied mammographic abnormalities (number of cancers detected/number of biopsies recommended) can vary significantly from one facility to another and that the positive predictive value and stage of disease found must be considered together. (A)

The wide variation in the yield of cancers from biopsies reflects differences in the population of women studied (e.g., the age of the women), the experience of the physicians interpreting the mammograms, and the philosophies of the interpreting and referring physicians concerning the percentage of biopsies that should yield breast cancer. Benign biopsies result from CBE as well as from mammography, and overall, the cancers found by mammography are detected at earlier stages.

Mammography Standards

Recommendation: Be aware that quality has varied among mammography facilities. On October 1, 1994, all mammography facilities in the United States except Veterans Health Administration facilities must be certified by the Food and Drug Administration (FDA) to provide mammography services. Continued certification will require annual inspection and compliance with Federal quality standards. (A)

A 1990 study of mammography sites by the General Accounting Office revealed significant variations in quality assurance among sites. As of October 1, 1994, the Mammography Quality Standards Act (MQSA) requires that mammography facilities in the United States be certified by FDA according to standards for equipment, personnel, and recordkeeping. Certification requires being accredited by an FDA-approved accreditation body. In addition, all facilities have annual inspections by qualified MQSA inspectors. Certification lasts for 3 years, the time period of accreditation, or for an interim 6-month period while the facility is in the process of receiving accreditation. Facilities must display the FDA certificate. However, Veterans Health Administration facilities have their own mammography quality assurance program that parallels MQSA, and they do not require FDA certification. The 800-4-CANCER number-the National Cancer Institute's Cancer Information Service-will provide information on local certified mammography facilities.

Other Breast Imaging Modalities

Modern mammography has been demonstrated to have high sensitivity and specificity for breast cancer detection and low radiation risk. Other modalities have been introduced and evaluated for the detection of breast cancer. As screening tools for breast cancer, thermography and light scanning (diaphanography or transillumination) have not been shown to be of value. Ultrasonography is less sensitive than mammography as a screening tool for breast cancer but has a valuable diagnostic role in distinguishing cysts from solid masses in previously detected masses. This modality is also useful in evaluating clinically palpable masses not visible on mammography, especially in younger women. Xeroradiography has been shown to have sensitivity and specificity comparable to that of screen-film mammography but has higher radiation doses and greater maintenance problems. Newer modalities, such as breast magnetic resonance imaging and digital mammography, are currently being developed and evaluated for diagnostic use.

Abstract

This Quick Reference Guide for Clinicians contains highlights from Quality Determinants of Mammography, Clinical Practice Guideline No. 13 of interest to health care providers who refer women for mammography. The Quality Determinants of Mammography Guideline Panel, a private-sector panel of health care professionals and consumers, developed the Guideline after comprehensively analyzing the research literature and current scientific knowledge concerning elements necessary for high-quality mammography.

Specific recommendations are made in the following areas:

  • Components of complete breast cancer screening.
  • Responsibilities of women, mammography facilities, and referring providers as to screening and followup care.
  • Communication of results.
  • Limitations of mammography.
  • Certification of mammography facilities.

This document is in the public domain and may be used and reprinted without special permission. AHCPR appreciates citation as to source, and the suggested format is provided below:

Bassett LW, Hendrick RE, Bassford TL, et al.High-Quality Mammography: Information for Referring Providers. Quick Reference Guide for Clinicians No. 13.AHCPR Publication No. 95-0633.Rockville, MD Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services. October 1994.

Bibliography

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  2. American College of Obstetricians and Gynecologists (ACOG). Report of Task Force on Routine Cancer Screening [ACOG committee opinion No. 128]. Washington: ACOG; 1993.
  3. Bassett LW, Ysrael M, Gold RH, Ysrael C. Usefulness of mammography and sonography in women less than 35 years of age. Radiology. 1991 Sep;180(3):831–5. [PubMed: 1871302]
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  5. Colditz GA, Willett WC, Hunter DJ, Stampfer MJ, Manson JE, Hennekens CH, Rosner BA, Speizer FE. Family history, age, and risk of breast cancer. JAMA. 1993 Jul 21;270(3):338–43. [PubMed: 8123079]
  6. Feig SA, Hendrick RE.Risk, benefit, and controversies in mammography. In: Haus AG, Yaffe MJ, editors. Syllabus: a categorical course in physics; technical aspects of breast imaging. Oak Brook [IL]: RSNA Publications; 1992. p. 103-18.
  7. Hendrick RE. Quality assurance in mammography: accreditation, legislation and compliance with quality assurance standards. Radiol Clin North Am. 1992 Jan;30(1):243–55. [PubMed: 1732931]
  8. Langlands AO, Tiver KW. Significance of a negative mammogram in patients with a palpable breast tumor. Med J Aust. 1982 Jan 9;1(1):30–1. [PubMed: 7062882]
  9. Mann BD, Giuliano AE, Bassett LW, Barber MS, Hallauer W, Morton DL. Delayed diagnosis of breast cancer as a result of normal mammograms. Arch Surg. 1983 Jan;118(1):23–4. [PubMed: 6848070]
  10. Marchant DJ, Sutton SM. Use of mammography in the United States, 1990. MMWR Morb Mortal Wkly Rep. 1990 Sep 14;39(36):621, 627–30.
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AHCPR Publication No. 95-0633.

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