There was a continued outcry from radiologists and from women's groups, and the NCI withdrew its recommendation, adding that they would leave the decision up to the individual woman. Subsequent studies have shown a significant increased survival in 40-to-50-year old patients who have annual mammograms. The issue, however, remains a controversial one.

How Mammography Works

In the screening situation, the breast is positioned on a small platform, compression is applied, and an x-ray is taken. Generally, two views of each breast are obtained. The medial-lateral oblique (MLO) is more or less a side view of the breast with the top being close to your neck and the bottom being down toward the belly. The other view is the craniocaudad (CC) view, which takes a picture through the breast placed flat on a platform and compressed. This is a top-to-bottom view of the breast, as if you were standing above it looking down.

The cathode ray tube and electronics that generate the x-rays are designed for high resolution of soft tissue structures, while the films and the screens placed next to the films are designed to make the most of this specially designed high resolution x-ray light. What radiologists are looking for is a film with a sharp image and just the right amount of contrast that makes the tissue stand out the most.

Mammograms need to be viewed on the proper sort of view box, preferably one that is designed exclusively for mammograms. Part of the job of interpreting mammograms is comparing the current study to available prior studies. The room should be quiet, with just the right amount of light coming through from the view box. The radiologist will also use a magnifying glass to scan the films for microcalcifications.

What does breast cancer look like? Imagine the mammogram as a picture of a cloud formation, one on the left and a very similar one on the right. First, the radiologist must see if one doesn't look a lot like the other. Radiologists call this "architectural distortion," and it may indicate that something is wrong. Sometimes the cancer is obvious and looks like a round, crablike structure with strands of tissue coming off an irregular central mass. But more often than not, cancers are not so obvious.

There are some problems inherent in mammography. First is the density of the breast tissue. When a woman is young, the tissue generally is quite dense because it has many functioning milk gland cells. As a woman ages, the milk cells diminish and are replaced by fat cells. Since cancers are white, they are much harder to see in the white background composed of breast tissue than in the black background of a fatty breast. Women under 50 have relatively dense breasts, and it may be very difficult to detect a lesion.

The radiologist may want to get additional information by looking at more views in various positions or with different levels of compression. The radiologist may also want to have an ultrasound to unravel a large, soft tissue clump on one side. You may get called back to have additional tests. The vast majority of cases that need additional screening turn out to be nothing serious, so if you get called back, you should not be overly apprehensive.

Calcifications are an entire subject by themselves. These tiny dots of various shapes, brightly outlined on a field of gray, can be benign in places like the lymph nodes, small arteries, and along the ducts. Sometimes, breast cancers produce these tiny calcifications; in which case they have a somewhat distinctive appearance. This is good news because it means that radiologists have another way to pick up cancer. In addition to looking for the mass itself, they can look for these characteristic calcifications. Nonetheless, sometimes it is difficult to tell whether a given calcification is benign or malignant.

The calcifications can appear as irregularities in the cloud formation or as tiny, punctation dots. Chances are that they are benign. Now there are three options: (1)wait about six months to see if the mass enlarges or the calcifications increase in number, both of which are suggestive signs of malignancy; (2) biopsy; or (3) biopsy and removal. This is an area where the art and science of radiology come together. Which route to take depends on many factors that the patient should discuss with all the members of the health care team. These factors include:

• Patients who should be followed up in six months are generally those who radiologists consider very low risk for cancer.
   
• Cancer grows more slowly as the patient ages, so older women may choose to wait to see what happens since there is less urgency.
   
• Suspicious cases are biopsied.
   
• The vast majority of biopsies turn out to be benign.
   
• Ultrasound-guided or stereotactic biopsies are well tolerated by outpatients.
• There are many other factors that vary from case to case that need to be discussed among everyone involved.

What is mammography like?

With low-dose x-rays to the breasts, no needles, and no dye, a mammogram is not a horrible procedure. Aside from waiting in exam rooms that might be a bit cold, along with answering a slew of questions asked by the technologist, you will be subjected to four inconveniences. First, you will not be able to wear any deodorant on the day of the study because it may make the films less clear. Next, you will have to disrobe completely from the waist up, even though you may be supplied a johnny top. The good news is mammography technologists are almost exclusively women. Third, your breast will be subjected to compression by the mammography machine, which pinches, sometimes very hard. You may deal with this intrusion by negotiating with your mammography technologist who hopefully is sympathic to your plight. The mammo technologist’s goal is to turn in good, diagnostic films without causing you an unreasonable amount of discomfort. You need to understand, however, that mammography does involve a certain amount of discomfort because of the need for compression of the breast tissues. Finally, mammograms are generally obtained in the standing position. To get your breast to lie flat on a small platform (craniocaudad view) or in between two plates (lateral view), your body must be bent every which way to accomplish this. Despite all this, mammograms should not be too unpleasant an experience.

What is it like afterwards?