Is additional breast imaging needed after a negative mammogram?

Researchers from the Columbia University Medical Center have found additional breast imaging with ultrasound technology may be unnecessary after a patient receives a negative mammogram and has experienced symptoms of breast pain alone, according to a recent study published in Current Problems in Diagnostic Radiology. 

"Our study aimed to determine the diagnostic value of added ultrasound following a normal mammogram in the initial investigation of breast pain; we hypothesized that the annual mammogram is sufficient to rule out malignancy and further ultrasound investigation is unnecessary," said lead author of the study Eralda Mema, MD, from the department of radiology at Columbia University Medical Center. "Our aim was to provide a balanced approach to the imaging of mastalgia with the goal of identifying the small number of cancers present in patients with breast pain, while avoiding overuse."  

Mema and her colleagues asserted that if additional symptoms occur with breast pain (mastalgia), further ultrasound testing should be considered for identifying mammographically occult tumors.  

In total, 8,085 women were recruited for the study and underwent ultrasound evaluation for breast pain in 2013. The median age of the participants was 46 years old. Additionally, of the 8,085 women, 559 had mammograms before the ultrasound examination.  

The patient's age, type of mammogram (screening or diagnostic), breast density, type of breast, additional breast symptoms, mammogram/ultrasound findings, final breast imaging reporting and data system (BIRADS) assessment and follow-up imaging and biopsy results were recorded, according to study methods.  

Study results after ultrasound testing included the following:  

  • 29.8 percent of patients were recalled from negative screening mammogram. 
  • 70.2 percent of patients had a preceding negative diagnostic mammogram. 
  • The BIRADS breast density (BD) distribution was BD1: 5.5 percent, BD2: 39.9 percent, BD3: 46.0 percent, BD4: 8.6 percent.  
  • Final BIRADS assessments were BIRADS 1/2 (79 percent), BIRADS3 (12.9 percent), BIRADS 4 (8.1 percent), BIRADS 5 (0 percent).  
  • Majority (66.9 percent) of the patient had breast pain alone.  
  • Additional breast symptoms were also noted as follows: palpable concern (24 percent), nipple discharge (3.9 percent), kin changes/other (5.2 percent).  
  • On follow-up evaluation, 26 findings were recommended for tissue sampling, which yielded malignancies in two patients. 
  • A negative mammogram with clinical symptoms of breast pain alone yielded no malignances (NPV, 100 percent) and was not impacted by breast density. 
  • In patients with additional symptoms accompanying pain, malignancies were present despite negative mammogram in two patients; nipple discharge (4.5 percent) and palpable concern (0.7 percent).  

"Justification for this approach include the improved ability of ultrasound to identify additional benign lesions, which may theoretically identify malignant findings in a larger representative sample, as well as value in reassurance to the patient and referring physicians," Mema concluded. "We believe that obtaining an ultrasound examination in these patients may increase the number of follow-ups of probably benign (BIRADS 3) lesions and subsequently increase the rate of benign biopsies."