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Mammogram scans have come a long way since the mammogram of the 1960s. Today’s digital scans look quite different, but the goal remains the same: to find breast cancer in its earliest stages and save lives. Here’s a look at the evolution of the modern mammogram.
From X-ray to Film
The 1990s and early 2000s was an exciting technological time. The way we sent mail, listened to music, and watched movies was changing – and so was the mammogram. Xeromammography had been the industry standard since the late 1960s. It involved recording an X-ray image of the breast onto a coated metal plate. At one time, this type of screening offered the highest quality breast imaging, but the scan was a tedious process. By 1990, xeromammography had fizzled out for plain film technology.
Dr. Jerome Schroeder, who directs breast imagining at SCL St. Joseph Hospital’s Breast Care Center, said the ’90s plain film had its pitfalls.
“The biggest criticisms of mammography were that in dense breasts it wasn’t sensitive enough and it could miss 30 – 40 percent of cancers,” Dr. Schroeder said, referring to the mix of fat and glandular tissue (like milk ducts and lobules) that comprise the breast.
Dense breast tissue is common, and it’s not considered abnormal. In fact, a woman’s breast density can change over her lifetime. To learn more about dense breasts, Komen has invested more than $19 million in research to study what factors affect breast density, why it increases the risk of breast cancer, and how to better screen dense breasts.
Read More about breast density and relative breast cancer risk.
Digital Takes Hold
Digital mammography soon would help to improve breast screenings.
Schroeder said the University of Colorado conducted a study, in 2003, of plain 2-D film imaging versus digital 2-D film. The results were mixed.
“They showed there was not a big difference between plain film and digital film, except in women with dense breasts. Digital did better in younger women and in denser breasts,” he said. “Digital improved things. It was an incremental step, but it wasn’t a quantum leap.”
A Quantum Leap?
Schroeder said the breakthrough came between 2009 and 2010 when researchers presented tomosynthesis, or what is called 3-D mammography.
“This started getting people excited because it set out to solve the problem of dense breasts,” Schroeder said.
Tomosynthesis is a form of mammography that takes more images of the breast at different angles instead of two images like a traditional mammogram. The x-ray machine that is stationary in a 2-D mammogram moves across the compressed breast in a 3-D mammogram.
“The 3-D scans one-millimeter [images] of the breasts,” Dr. Schroeder explained. “It takes data through the whole breast and sees through the breast as a three-dimensional object.”
While a 3-D mammogram may take a little longer, Dr. Schroeder said he gets more images to review, and a better look of the breast.
“Instead of getting four images, I might have 200 to 300 images through the breast,” he said. “No matter how dense the breast is, if I’m getting so many images, it’s going to be very difficult for cancer to hide in that density.”
Schroeder said preliminary studies of the technology have shown 3-D imaging found 40 percent more cancers that otherwise would have been missed in 2-D imaging.
“You’re getting more and doing less,” Schroeder said. “Fewer call backs. Fewer additional images. Less radiation overall and probably fewer biopsies.”
Out-of-Pocket Costs and Patient Notification
Insurance companies have been slow to classify tomosynthesis as an accepted screening tool to detect breast cancer. This means women may face out-of-pocket costs for the technology despite the Affordable Care Act and Colorado law requiring insurance plans to cover 100 percent of costs for mammograms.
As tomosynthesis has become more widespread in clinical practice, Schroeder reports more insurance carriers in Colorado cover 3-D mammograms, including Medicare. It is best to check with your insurance provider about any out-of-pocket fees associated with a 3-D mammogram.
To help women make more informed decisions about their breast health, some states have enacted legislation to require women to be notified if a mammogram finds they have dense breasts, but few states require insurance companies to cover the cost of supplemental screenings.
In April 2017, Colorado Governor John Hickenlooper signed into law the Breast Density Notification Required bill sponsored by Senator Angela Williams and Representative Jessie Danielson. The legislation requires a patient to receive a notice in their mammography report if their breast tissue is dense, as well as a statement about the increased risk of breast cancer associated with dense breasts. The notice encourages women with dense breasts to discuss screening options with their doctors. The law took effect October 1.
The 3-D Debate
Komen does not advocate for tomosynthesis over traditional 2-D digital mammography. While 3-D mammography is more widely available, studies continue to be conducted on whether it saves more lives than 2-D scans.
Learn More about the benefits and risks of mammography.
The National Comprehensive Cancer Network (NCCN) notes that the “combined use of digital mammography (two-dimensional, 2-D) in conjunction with digital breast tomosynthesis (DBT) appears to improve cancer detection and reduce false-positive call-back rates.” And the dual scans double a woman’s radiation exposure. The radiation dose, however, falls below limits set by the U.S. Food and Drug Administration.
However, the NCCN also notes there is insufficient evidence to support the use of 2-D and 3-D scans together in women with dense breasts who have no other risk factors for breast cancer. Overall, the NCCN recommends traditional mammography “with the consideration of tomosynthesis.”
The American College of Radiology (ACR) also does not endorse 3-D mammography as a clinical standard. The ACR, however, does recognize that tomosynthesis “can address some of the limitations encountered with standard mammographic views.” It recommends traditional screening or tomosynthesis for all women regardless of risk level.
While the debate continues over which type of mammogram may be most effective at screening for breast cancer, Schroeder underscored the only technology proven to reduce cancer deaths is mammography.
“By the end of the decade, 3-D will be the only study that we will do,” Schroeder predicted.
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