Imaging services

Do I need a screening mammogram?

We understand that there are many controversies around screening mammograms. However, there is an overwhelming amount of scientific evidence that screening mammograms save the most lives when done yearly starting at the age of 40. Early detection significantly decreases the number of deaths from breast cancer by allowing for less aggressive and more effective treatment options.

At VCU Health, we recommend annual screening mammography for women 40 or older. Women with a family history of breast cancer may need to start annual screening mammography earlier, especially women who have two or more immediate family members who have had breast cancer, particularly if they have been diagnosed before menopause or have had cancer in both breasts.

Women with breast-related problems or symptoms should instead request a diagnostic mammogram, to avoid delays in addressing your concerns.

Low-dose radiation is used to capture images of each breast, using compression to keep the breasts from moving, while limiting radiation and spreading the breast tissue, in an effort to enhance the accuracy of the images. Compression can make the difference between finding and missing cancer.

• After the four images are taken, the technologist reviews your pictures to make sure they are technically acceptable and that as much tissue as possible is included on both sets of views. The study is then submitted for interpretation by one of our breast imaging radiologists.
• The procedure typically takes 20 to 30 minutes.
• We also offer 3-D mammography, FDA-approved technology that can make breast cancer easier to detect. The radiation dose is higher but still well below the limit approved by the FDA. Read about frequently asked questions for 3-D mammography.

Excellent customer service and very accommodating, even when the patient was running late. Very friendly and placed patient at ease.

–VCU Breast Imaging patient

You know the importance of having regular breast screenings. But let’s face it – no one looks forward to having a mammogram. We’re pleased to offer you this free guide – Making Your Mammo Experience Better. It contains half a dozen helpful suggestions to prepare you for your mammogram and make your screening experience as pleasant and comfortable as possible.

We interpret screening mammograms under optimal conditions, minimizing the likelihood of disruptions and distraction. We focus on looking for potential abnormalities, such as tiny deposits of calcium or masses, and comparing the current films to your prior studies.

• If your mammogram is normal or there are benign findings not related to cancer, you will receive a letter in the mail within a few days following your study.
• If a possible abnormality is detected on your screening mammogram, we will call you directly. If we are unable to reach you by phone, we will send you a certified letter requesting that a diagnostic mammogram be scheduled.

Approximately 5 percent of our patients are called back for additional studies following a screening mammogram. Most patients who are called back do not have breast cancer; in some women, breast tissue superimposes, simulating the presence of a lump on the initial images. When additional views are taken by applying a small (spot) compression paddle over the area of concern, the tissue may be characterized as normal.

Alternatively, in some women, ultrasound can be used to characterize a lump as a fluid-filled cyst.

When you return for the additional studies, one of our breast imaging radiologists will oversee your diagnostic evaluation and discuss results and recommendations with you before you leave our facility.

Although mammography is an excellent screening tool that can help identify most breast cancers, it is not a perfect test. In some women with breast cancer, mammograms may appear normal. It is for this reason that you should notify your doctor, or us, if you notice a change in your breast or if you feel a lump or an area of thickening in either breast.

We recommend a diagnostic mammography if you experience any of these symptoms:

• A lump in the breast or under the arm
• An area of thickening
• Skin changes, such as redness, dimpling or thickening
• Nipple changes, such as inversion, retraction, erosion, weeping and itching
• Nipple discharge that comes out on its own
• A change in breast size

A diagnostic mammogram may also be recommended for women who have had a possible abnormality detected during a screening mammogram. Also, for women who’ve had a lumpectomy for breast cancer since their last mammogram.

Although breast cancer is rare in men, it usually presents itself in the form of a lump, in which case a diagnostic mammogram is needed.

Along with the standard top-to-bottom and side-to-side breast images, additional images may be created using a small (spot) compression paddle, sometimes in combination with a magnification technique.

Based on the results of the diagnostic evaluation, the breast imaging radiologist will discuss findings, options and recommendations; answer your questions; and provide your results in writing before you leave our facility. If needed, an ultrasound will be done at the same visit. If a biopsy or fine needle aspiration is needed, you may be able to have it done immediately or schedule it for a later date.

If a breast biopsy is required, we typically offer results within 24 hours.

The technologist made a potentially stressful exam into an enjoyable visit. She was gentle, professional and sweet, just a gem! She kept me engaged so that my mind was not on the mechanical, which she swiftly navigated so that the exam only seemed like moments out of my day.

– VCU Breast Imaging patient

Depending on the results of the diagnostic mammogram, the radiologist monitoring your study may conduct additional studies, which could include:

• Physical examination
• Ultrasound
• Imaging guided needle biopsy
• Ductography (in patients with spontaneous nipple discharge)

Do I need a breast ultrasound?

For women age 30 or older experiencing signs or symptoms possibly related to breast cancer, our starting point is typically a mammogram. However, a breast ultrasound could be needed, to evaluate findings in the physical examination or the mammogram.

Ultrasound is used as the starting point among women who are pregnant or lactating, as well as for women under the age of 30 who have a lump. Ultrasound is useful in evaluating the axilla, or armpit, for potentially abnormal lymph nodes, particularly in patients with breast cancer. Breast ultrasound is also used to guide the radiologist during biopsies and fine needle aspirations.

Breast ultrasound studies are done by a breast imaging radiologist, trained specifically in screening for breast cancer. During a breast ultrasound study, you will lay on your back or slightly turned to one side with your arm placed comfortably under your head. Gel is applied to your breast so there are no air pockets between your skin and the transducer (the instrument used to obtain the pictures). The transducer is moved back and forth over your breast, generating images and, if an abnormality is found, images are taken for your medical record.

A physical examination of your breast is also done by the radiologist at the time of the ultrasound. Combining the ultrasound with physical findings is the equivalent of being able “to see” with our fingertips.

If the ultrasound results are normal, nothing more is usually done. However, if a breast cancer is suspected on the ultrasound, a full diagnostic mammogram is done. Ultrasound is used to characterize lumps detected on a mammogram or physical examination as:

• Fluid-filled = cysts (benign, not cancerous)
• Not fluid-filled, but likely benign
• Not fluid-filled and indeterminate
• Not fluid-filled and likely cancerous
• Areas of fatty tissue, or lobulation

Lumps identified as cysts (fluid-filled) do not require any intervention or follow-up, unless you are having symptoms or atypical features are seen on ultrasound, in which case aspiration can be done.

If the lump is determined to be non-cancerous, no follow-up may be needed. With solid, non-fluid-filled lumps, if the likelihood of malignancy is determined to be less than 2 percent based on clinical and imaging features, a six-month follow-up is usually recommended. A biopsy is suggested for those that are characterized as indeterminate or likely cancerous.

Do I need a breast MRI?

An MRI and mammogram are recommended beginning at age 30 for women considered high-risk. Those with moderately increased risk of breast cancer should talk with their doctors about the benefits and limitations of adding MRI to their yearly mammogram.

Women at high risk include those who:

• Have a known BRCA1 or BRCA2 gene mutation
• Have a first-degree relative — mother, father, brother, sister or child — with a BRCA1 or BRCA2 gene mutation and have not had genetic testing themselves
• Have a lifetime risk of breast cancer of 20 percent to 25 percent or greater, according to risk-assessment tools based mainly on a family history from both the mother and father’s sides
• Had radiation therapy to the chest when they were between the ages of 10 and 30 years
• Have a genetic disease such as Li-Fraumeni syndrome, Cowden syndrome or Bannayan-Riley-Ruvalcaba syndrome, or have first-degree relatives with one of these syndromes

Women at moderately increased risk include those who:

• Have a lifetime risk of breast cancer of 15 percent to 20 percent according to risk-assessment tools based on family history
• Have a personal history of breast cancer, ductal carcinoma in situ, lobular carcinoma in situ, atypical ductal hyperplasia or atypical lobular hyperplasia
• Have extremely dense breasts or unevenly dense breasts when viewed by mammogram.

Several risk-assessment tools, including BRCAPRO, the Claus model and the Tyrer-Cuzick model, are used to estimate a woman’s breast cancer risk. Based on different combinations of risk factors, these tools approximate estimates of breast cancer risk. Depending on the tool used, different risk estimates may be calculated for the same woman.

During the MRI, you will be asked to lie on your stomach while your breasts are positioned in a holder called the “breast coil.” You will be given a call button to press if you need to speak to us during the procedure. Most patients are able to tolerate the study. Thin (1 mm) images of the breasts are done before intravenous contrast is given. One of the nurses will test your liver function and start an IV that will be used to give you intravenous contrast. The contrast used is called gadolinium; it does not contain iodine and is different from the type of contrast used for CAT scans. Allergic reactions are rare. The images are repeated at timed intervals after the contrast is injected.

To prepare for the exam, download the MRI Preparation Checklist [PDF].

An MRI-guided biopsy may be recommended if an abnormality seen on the MRI is not visible on your mammogram or ultrasound; this requires a second MRI at least 24 hours after the first study is done.

Do I need a ductogram?

We recommend a ductogram when there is nipple discharge that comes on its own (spontaneous), regardless of its appearance. In this case, you may notice dark brown spots on your bra or night clothes, or you may notice fluid coming from your nipple after a hot bath or shower. On physical examination, fluid is obtained easily and consistently from one duct opening.

You should note that milky discharge can be seen for several years following childbirth or after breastfeeding is stopped. This type of discharge may come on its own but it is usually milky white and comes from multiple duct openings on both nipples.

During a ductogram, you are asked to lie on your back while we try to express nipple discharge so that we can identify where on your nipple the discharge is coming from. A tiny blunt-tipped needle is then advanced into the duct with the discharge and a few drops of x-ray dye are injected into this duct. Mammographic images of your breast are done so that we can evaluate the inside of the duct highlighted by the contrast material.

The most common causes of spontaneous nipple discharge include:

• Benign papilloma (approximately 50 percent of patients)
• Benign fibrocystic changes (approximately 35 percent of patients)
• Benign duct ectasia
• Breast cancer

If a lesion is identified inside the duct, we may recommend that it be surgically removed.

Nipple discharge that is seen only with expression — when you squeeze or otherwise manipulate the nipple — is not usually related to an underlying problem. It is normal for most women to have some fluid in the milk ducts. We recommend that you not try to express nipple discharge, but that when you do laundry you get in the habit of checking your bra cups and night clothes for spots that may indicate spontaneous discharge.