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Beth Israel Deaconess Medical Center and Harvard Medical School Boston, MA 02215
The article by Houssami et al. [1] concludes that rather than mammography "sonography is more accurate than mammography in symptomatic women 45 years of age and may be an appropriate initial imaging test in those women." These authors correctly point out that "if the sonographic result is positive, most clinicians would agree that mammography is indicated.... However, if the sonographic findings are negative, the benefit of mammography is related to the remaining breast cancer prevalence."
I agree with the gist of the recommendations by Houssami et al. [1] and commend them for addressing a subject on which there is so little evidence-based data. Indeed, these authors seem to set up a straw man in their introduction with the statement that "experts suggest that women younger than 35 years old be examined with sonography, and women 35 years and older be examined with mammography, as the primary breast imaging modality." The single reference for this statement is a book chapter [2] and, as the authors point out, is not supported by any data.
Unfortunately, Houssami et al. [1] do not tell us how often the 480 symptomatic women in their study were referred for a palpable mass, nipple discharge, or breast pain. If referral was for a palpable abnormality, it would be interesting to know how often the finding was felt only by the patient and not confirmed by the referring physician, radiologist, or other experienced health practitioner.
In my department, sonography is usually the recommended imaging examination for palpatory abnormalities in woman younger than 40. Symptomatic women older than 40 usually have had a recent screening mammography or are scheduled for one in the near future and would undergo the equivalent of this screening examination at the time of breast sonography. Hence, unless there is a high index of clinical suspicion, or the woman is at high risk for breast cancer, I would choose age 40 as the usual cutoff age to perform concomitant mammography, rather than age 45 as suggested by Houssami et al. [1].
In my practice, a woman with a self-diagnosed breast lesion is often referred directly for imaging before being seen by her primary physician or surgeon. This arrangement usually is an efficient use of resources because even if no abnormality has been confirmed by the physician, confirmatory imaging is still performed. This approach relates in part to the medicolegal climate in this country and may be less applicable in Australia. Also, at the time of breast sonography, many palpatory abnormalities cannot be identified by the radiologist, sonographic technologist, or even the patient. Performing additional mammography in these women makes even less sense.
Besides the added cost and relative lack of benefit, there is a third reason for reluctance in performing mammography in symptomatic women before the age of 40. Younger women have relatively dense breast parenchyma requiring increased radiation to penetrate the tissues, and these tissues are more sensitive to radiation than those of older individuals. Therefore, mammography is generally less accurate and more dangerous.
In conclusion, I concur with the recommendations of Houssami et al. [1], although in patients above the age of 40 years and depending on the specific symptoms and the level of clinical suspicion, mammography might generally be considered in addition to breast sonography. When both these examinations are performed, I would favor initially performing mammography as a potential guide for the subsequent targeted sonography.
References
The University of Sydney and Westmead Hospital Westmead, NSW 2145,
Australia
University of Sydney NSW 2006, Australia
Royal North Shore Hospital NSW 2065, Australia
We thank Dr. Hall for his interest in our article and our recommendations [1]. We agree that this is an area in which there has been little evidence-based data to assist clinical practice (before the findings reported in our study). This accounts for the variations in the age used to decide first-line breast imaging in clinically referred women (or "cutoff" age, as Hall refers to it). We are pleased that in Hall's practice, age 40 is the usual cutoff age, which is closer to age 45 (the cutoff age indicated by the evidence from our study) than recommendations that use age 35 as the cutoff age [2]. Our data on the age-related accuracy of the two imaging tests [1] provide an opportunity for all radiologists and clinicians responsible for treating women with breast symptoms to review current practice and should facilitate evidence-based clinical policy.
We point out that our article provides the frequency and description of presenting symptoms in all 480 subjects in our table 1 [1]. We agree with Hall that even if a symptomatic woman has no clinical abnormality, imaging is still warranted as a key component in breast diagnosis. We also agree with Hall's reluctance to perform mammography in young symptomatic women, for all the reasons he has stated, and support his approach of selectively considering mammography "depending on the specific symptoms and the level of clinical suspicion."
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  D. B. Kopans, N. Houssami, L. Irwig, and S. Blome Breast Imaging and the Symptomatic Patient: Enough with the "Diagnostic" Mammography Am. J. Roentgenol., November 1, 2003; 181(5): 1423 - 1424. [Full Text] [PDF]
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