Mammography remains the ‘gold standard’ in the early detection of breast cancer. Dr Malcolm Crockford, consultant radiologist at The Radiology Clinic, explains how mammography can detect breast cancer long before a lump develops.

Mammography has developed dramatically over the last 40 years and has now become a sophisticated digital test which requires minimal amounts of radiation (less than we receive from the sun each year) to identify cancer at its earliest, that is when it is around 2 to 4mm.

It is at this stage that treatment becomes relatively simple with no serious side effects and an almost certain chance of normal life expectancy afterwards.

The breast is made of mainly glandular and fatty tissues with a varying proportion in different women. The younger breast has more glands and tends to be denser while the more mature breast is mainly fatty. Glandular dense tissues show as white on the mammogram while fatty tissues are dark.

Breast cancer in its early stage develops small fragments of calcium which are clustered together over a small area with a diameter of 2mm upwards. The calcium is like a little ‘stone’ and it is only digital mammography that can detect it. At this stage the woman or doctor would not be able to detect a breast lump and it would often take around 12 to 18 months before it can be felt manually.

The radiologist will need to use techniques of ultrasound guidance to biopsy or help with removal of these non-palpable lesions.

Cancer may however also produce a white density on a mammogram. Typically this is irregular in outline and produces distortion of the surrounding breast tissue that is identified mammographically.

These ‘spiculated’ lesions are typical of cancer of the breast ducts and sometimes are associated with micro-calcification. These white densities at their earliest can remain hidden even on a good-quality digital mammogram and so ultrasound techniques are now being used to complement the mammographic examination in dense breasts.

Ultrasound of the breast is a very operator-dependent technique and the actual test is carried out in real time with the trained radiologist’s eyes focused on the moving image on the screen. Ultrasound is excellent at distinguishing between fluid and solid structures, with fluid structures (cysts) in the breasts being of no clinical significance. Most of the solid structures are also of no importance but there are certain signs that should alert the radiologist and recommend biopsy to better assess the situation.

Biopsies are now carried out much more accurately with the aid of ultrasound.

The radiologist usually attempts to obtain samples from different parts of the area being biopsied for a more representative and accurate sample. The specimen is sent for analysis to the Pathology Department and the result is issued within a couple of days.

In the case of a cancerous outcome, the radiologist interacts with the breast surgeon who sees the patient with all her imaging and biopsy results, examines the breasts and discusses with her the options available for treatment.

Mammography does not hurt and there are no issues relating to radiation

This can vary from a simple lumpectomy with removal of a small ‘focus’ of breast (usually less than 5mm) to a part removal of breast or a full mastectomy (total removal of breast and lymph glands).

The decision depends on a number of issues that relate to the aggression of the cancer and the age of the patient and, most importantly, how early it is detected.

Women should not hesitate to do the test. Mammography does not hurt and there are no issues relating to radiation.

It needs to be carried out when a patient feels well to obtain its full value as patients who come for mammograms already feeling a lump have often had cancer for around one to two years.

That’s why the interval between one mammogram and another should be around 18 months.

Remember that contrary to what one often hears, breast cancer is much more common in the more mature woman, peaking around 70 years of age.

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