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Riverdale, GA
University of Maryland Baltimore, MD 21201
Question
When a patient requests a screening breast sonography, what should I tell her?
Answer
Mammography is the only screening test that has been shown to decrease a woman's chances of dying from breast cancer. Where the breast tissue is dense, cancers can be hidden on mammography. Mammography is less able to show cancers in younger women, between 40 and 49 years old, than in women 50 years or older, although mammography is of benefit in both age groups. Sonography shows many cancers not seen on mammography, especially when the tissue is dense. This success has stimulated an interest in using sonography for breast cancer screening. It is not known at this time whether patients with cancers found only on sonography have the same outcome as those with cancers found on mammography or whether treating cancers found only on sonography saves lives. Most of the cancers found only on sonography are small invasive cancers. It is likely that finding such cancers is of benefit, but this has not been proven.
Screening sonography is not performed in women with predominantly fatty breast tissue. It is unlikely that cancer will be found on sonography and not on mammography if the breasts have only minimal scattered densities. It is more likely that a cancer will be found only on sonography if the tissue is mostly dense and if the woman is at high risk of breast cancer. When cancer is present in women 40–49 years old with dense tissue, two studies suggest that the cancer is more likely to be seen on sonography than on mammography [1, 2].
If a woman chooses to have screening breast sonography, she should be aware of several risks. The results of sonography depend on the skill of the individual who performs the examination. Although the results of screening sonography have been encouraging in single-center studies, it is not known that these results will be generally seen. As reviewed separately in this issue [3], additional testing may be required as a result of the screening sonogram. Approximately two to six in 100 women who undergo screening sonography will require a breast aspiration or biopsy as a result of the sonogram. Personnel interpreting breast sonography can easily perform aspiration or biopsy with sonographic guidance if needed. Only approximateley one in 10–11 of such biopsies will show cancer. Even if no aspiration or biopsy is required, in as many as one in 10 women, additional short-interval follow-up sonography (usually in 6 months) may be recommended as a result of the screening sonogram. At this time, screening breast sonography is not a benefit covered by private or public insurers, and the patient will be responsible for the cost of the examination unless the study is performed as part of a clinical trial. The cost of any procedure or follow-up needed as a result of the screening sonogram will be billed to the patient's insurance company, but the patient may be responsible for a copayment.
The patient should continue regular mammography. The earliest type of breast cancer, which is still confined to the ducts of the breast, is usually seen much better on mammography than on sonography. Even if both tests are performed, there is at least a two to four in 100 chance that cancer may still not be detected on imaging [2, 4].
References
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