Radiology

Both conventional (analog) and digital mammograms are still in use, but in major cities most facilities that do a lot of mammograms (and state-of-the-art imaging) have switched to digital. Similar to you photos at home, there is a great deal of benefit to being able to post-process or adjust the images for better contrast, magnification, etc. Also viewing on a computer moniter is beneficial. That being said, a large scale study was performed by Dr. Etta Pisano when digital first came out. The study determined that digital mammograms will benefit women with dense breast tissue, and those who are under age 40. So, if you are not in these categories then it is OK to get an analog study.

My personal opinion, yes, digital mammograms are the norm for NYC, where I practice. Both conventional (analog) and digital mammograms are still in use, but in major cities most facilities that do a lot of mammograms (and state-of-the-art imaging) have switched to digital. Similar to you photos at home, there is a great deal of benefit to being able to post-process or adjust the images for better contrast, magnification, etc. Also viewing on a computer moniter is beneficial. That being said, a large scale study was performed by Dr. Etta Pisano when digital first came out. The study determined that digital mammograms will benefit women with dense breast tissue, and those who are under age 40. So, if you are not in these categories then it is OK to get an analog study.

My personal opinion, yes, digital mammograms are the norm for NYC, where I practice.

BI-RADS stands for Breast Imaging Reporting and Data System. The American College of Radiology, AMA, and other medical organizations have agreed upon a reporting system that standardizes how radiologists describe findings on a mammogram, and more importatly how they make their recommendations so that the recommendation is clear, for the referring physician.

BI-RADS-1: NEGATIVE
This means no findings, nothing on which to comment.

BIRADS-2: BENIGN FINDINGS
This means that there is a normal finding such as a cyst or coarse (benign) calcification. No further intervention is indicated.

BIRADS-3: PROBABLY BENIGN FINDING, SHORT INTERVAL FOLLOW-UP IS SUGGESTED
This is used when there is finding that is most likely benign, but the radiologist cannot say so for certain. A radiologist will only use this category when they believe the finding has less than 2% risk of malignany. This may be used for example, for something such as a lymph node, which has a characteristic appearance and location, but is not definitvely fulfillling criteria of such. Or for calcifications that look very benign, but this is the first time they are appearing. The six month follow-up is to establish stability. The radiologist does not expect this finding to change during the follow-up interval.
Unfortunately, some gynecologists and patients have a hard time accepting this category. They think "what does the radiologist mean by "probably" it does not sound very scientific," but indeed it is the official term of the BIRADS lexicon. Some patients will push for a biopsy of a finding in this category, it is technically an option, but usually overkill. If radiologists recommended biopsy on all of these "probably benign" findings we would really be doing a disservice and an inordinant number of biopsies on benign entities.

BIRADS-4: SUSPICIOUS FINDING, BIOPSY SHOULD BE CONSIDERED
This is used for a finding that is not definitively benign and requires biopsy. This includes lesions that the radiologist believes are likely to be benign, such as fibroadenomas, as well as cancers. To differentiate, some people divide this category into 4A and 4B, low degree of suspicion and higher degree of suspicion. If your report has this category you can ask your doctor to elaborate if the findings has features highly suggestive of cancer, or not. The radiologist usually knows. Statistically, most nodules in this category turn out to be benign (fibroadenomas).

BIRADS-5: HIGHLY SUGGESTIVE OF MALIGNANCY-APPROPRIATE ACTION SHOULD BE TAKEN
These lesions have a high probablility (greater than 95%) of being cancer. Honestly, many radiologists do not use this category since BIRADS4 is already recommending biopsy. But it is true that often a finding is so characteristic that the radiologist knows it is cancer, but still nothing gets treated without a biopsy first.

BIRADS-6: KNOWN MALIGNANCY
This is used when the patient has a biopsy proven cancer, but additional imaging is still needed. A common scenario of this, is the MRI that is done when cancer has been diagnosed but we are looking if there are any additional sites of cancer (extent of disease work-up).

BIRADS-O: NEEDS ADDITIONAL IMAGING (OR OLD FILMS)
This is basicaly saying that the work-up is incomplete and a final interpretation cannot be given. This is used in a screening situation. In most facilities four images are taken by the technologist and the radiologist interprets the study at a later time. If there is a finding, the radiologist will often require additional views (compression spot views or magnification views) to clarify the finding. The patient will be notified that they need to return to the radiology office. Statistically, most of these call backs will be normal, the patient will not end up having any abnormality or require biopsy. In a small percentage, a biopsy might be ordered, but most of these will still turn out to be benign. BI-RADS stands for Breast Imaging Reporting and Data System. The American College of Radiology, AMA, and other medical organizations have agreed upon a reporting system that standardizes how radiologists describe findings on a mammogram, and more importatly how they make their recommendations so that the recommendation is clear, for the referring physician.

BI-RADS-1: NEGATIVE
This means no findings, nothing on which to comment.

BIRADS-2: BENIGN FINDINGS
This means that there is a normal finding such as a cyst or coarse (benign) calcification. No further intervention is indicated.

BIRADS-3: PROBABLY BENIGN FINDING, SHORT INTERVAL FOLLOW-UP IS SUGGESTED
This is used when there is finding that is most likely benign, but the radiologist cannot say so for certain. A radiologist will only use this category when they believe the finding has less than 2% risk of malignany. This may be used for example, for something such as a lymph node, which has a characteristic appearance and location, but is not definitvely fulfillling criteria of such. Or for calcifications that look very benign, but this is the first time they are appearing. The six month follow-up is to establish stability. The radiologist does not expect this finding to change during the follow-up interval.
Unfortunately, some gynecologists and patients have a hard time accepting this category. They think "what does the radiologist mean by "probably" it does not sound very scientific," but indeed it is the official term of the BIRADS lexicon. Some patients will push for a biopsy of a finding in this category, it is technically an option, but usually overkill. If radiologists recommended biopsy on all of these "probably benign" findings we would really be doing a disservice and an inordinant number of biopsies on benign entities.

BIRADS-4: SUSPICIOUS FINDING, BIOPSY SHOULD BE CONSIDERED
This is used for a finding that is not definitively benign and requires biopsy. This includes lesions that the radiologist believes are likely to be benign, such as fibroadenomas, as well as cancers. To differentiate, some people divide this category into 4A and 4B, low degree of suspicion and higher degree of suspicion. If your report has this category you can ask your doctor to elaborate if the findings has features highly suggestive of cancer, or not. The radiologist usually knows. Statistically, most nodules in this category turn out to be benign (fibroadenomas).

BIRADS-5: HIGHLY SUGGESTIVE OF MALIGNANCY-APPROPRIATE ACTION SHOULD BE TAKEN
These lesions have a high probablility (greater than 95%) of being cancer. Honestly, many radiologists do not use this category since BIRADS4 is already recommending biopsy. But it is true that often a finding is so characteristic that the radiologist knows it is cancer, but still nothing gets treated without a biopsy first.

BIRADS-6: KNOWN MALIGNANCY
This is used when the patient has a biopsy proven cancer, but additional imaging is still needed. A common scenario of this, is the MRI that is done when cancer has been diagnosed but we are looking if there are any additional sites of cancer (extent of disease work-up).

BIRADS-O: NEEDS ADDITIONAL IMAGING (OR OLD FILMS)
This is basicaly saying that the work-up is incomplete and a final interpretation cannot be given. This is used in a screening situation. In most facilities four images are taken by the technologist and the radiologist interprets the study at a later time. If there is a finding, the radiologist will often require additional views (compression spot views or magnification views) to clarify the finding. The patient will be notified that they need to return to the radiology office. Statistically, most of these call backs will be normal, the patient will not end up having any abnormality or require biopsy. In a small percentage, a biopsy might be ordered, but most of these will still turn out to be benign.

Breast density is something that we as radiologists are always aware of. We always mention in our mammography reports whether the breasts are very dense, moderately so, or not very dense. There are actually 4 categories. The problem is that the information is not always communicated to the patients. We are required by MQSA to provide every patient with the results of their mammogram in writing. Some folks mail these results while others, like myself, usually provide it to the patient when she has completed her exam. We are now attempting to include information about density in those results. Our mammography technologists will answer any questions that the patient may have, and frequently I will also speak with them myself. I don't really have an opinion about whether legislation is the way to handle this. Breast density is something that we as radiologists are always aware of. We always mention in our mammography reports whether the breasts are very dense, moderately so, or not very dense. There are actually 4 categories. The problem is that the information is not always communicated to the patients. We are required by MQSA to provide every patient with the results of their mammogram in writing. Some folks mail these results while others, like myself, usually provide it to the patient when she has completed her exam. We are now attempting to include information about density in those results. Our mammography technologists will answer any questions that the patient may have, and frequently I will also speak with them myself. I don't really have an opinion about whether legislation is the way to handle this.

I’d worry less about the performance of the mammography than about the read of the actual image. The actual mechanics of performing the mammography, while important, are less important than having a well-qualified radiologist. A good radiologist will know both whether the mammography was set up correctly in the first place just by looking at the image (and will re-order another one if not), and whether it’s being read and interpreted correctly. I’d worry less about the performance of the mammography than about the read of the actual image. The actual mechanics of performing the mammography, while important, are less important than having a well-qualified radiologist. A good radiologist will know both whether the mammography was set up correctly in the first place just by looking at the image (and will re-order another one if not), and whether it’s being read and interpreted correctly.

Hi AK:

Good question. Short answer: it varies. Long answer:

For newly diagnosed breast cancer, radiation is most often used after surgery. As a result, there is nothing objectively measurable left of the tumor. Unless physical exam gives reason to suspect a recurrence before radiation has begun, usually no testing is performed. CT scans used to plan radiation therapy can identify the postoperative area but can't distinguish tumor from normal breast tissue.

In some other tumors, like lung cancer, it's clearer that the tumor appears abnormal on chest x-ray, CT or PET scan. However, imaging alone is usually not enough and biopsy is needed to confirm. Hi AK:

Good question. Short answer: it varies. Long answer:

For newly diagnosed breast cancer, radiation is most often used after surgery. As a result, there is nothing objectively measurable left of the tumor. Unless physical exam gives reason to suspect a recurrence before radiation has begun, usually no testing is performed. CT scans used to plan radiation therapy can identify the postoperative area but can't distinguish tumor from normal breast tissue.

In some other tumors, like lung cancer, it's clearer that the tumor appears abnormal on chest x-ray, CT or PET scan. However, imaging alone is usually not enough and biopsy is needed to confirm.