E.U.

Screening. “Diagnostic” mammography is monitored by the radiologist during the appointment and “screening” mammography is not. Indications for diagnostic mammography, rather than screening, include, but are not limited to, signs and symptoms of breast cancer such as a lump, bloody or spontaneous clear nipple discharge, skin or nipple retraction. If additional targeted imaging or follow-up is needed for an abnormality seen on the most recent prior breast imaging, a “diagnostic” appointment is also appropriate. In diagnostic breast imaging, additional views or ultrasound may be performed at the same visit if they are needed. The radiologist will interpret the breast imaging during the examination and the woman will leave with her results after a diagnostic mammogram. Women with a personal history of breast cancer can have their routine annual mammograms performed as diagnostic or screening examinations at many facilities. Diagnostic mammography is typically covered by insurance but subject to deductible and copay.

“Screening” mammography is fully covered by insurance under the Affordable Care Act for women over the age of 40 in the United States and may be covered for younger women, if recommended by her physician, depending on the insurance policy. Typically, screening mammograms are interpreted in a quiet, uninterrupted environment with the full benefit of prior examinations. Cancers are better detected and fewer unnecessary additional views (with associated radiation exposure) are recommended in the screening setting. Results are usually sent by mail to the patient within a few days to a week (by law not later than 30 days) after the appointment.

Depending on the patient’s age, risk level (for further explanation see section on Risk Assessment Tools) breast density, and available imaging modalities, additional screening tools, such as MRI, contrast-enhanced mammography (CEM), or ultrasound may be recommended in addition to mammography. In some centers, molecular breast imaging (MBI) may be an option. Each of these modalities improves cancer detection in dense tissue compared to standard mammography/tomosynthesis alone (see Table: Summary of Cancer Detection Rates by Screening Method). Note: CEM is not yet FDA-approved for screening.

For evidence-based screening recommendations designed to optimize cancer detection in individuals in different risk categories, including dense breasts, see our Screening Decision Support Tool. For a comparison of screening guidelines for individuals determined to be at high/increased risk, see our High/Increased-Risk Screening Guidelines page. For a comparison of screening guidelines for individuals with dense breasts and no other risk factors, see our and Dense Breast Screening Guidelines page.

In the U.S., the answer depends on the type of screening, patient’s insurance, risk factors, the state you practice in, and whether or not a law is in effect requiring insurance coverage for additional screening. In Illinois, for example, if ordered by a physician, a woman with dense breasts can receive an ultrasound without a copay or deductible. In New York as of January 1, 2017 all supplemental screening and diagnostic breast imaging are required to be fully covered (no copay/no deductible), though exceptions do exist. Generally, in other states, an ultrasound will be covered if ordered by a physician – but is subject to the copay and deductible of an individual health plan. In New Jersey, insurance coverage is provided for additional testing if a woman has extremely dense breasts. An MRI will generally be covered if the patient meets “high-risk” criteria*. In Michigan, at least one insurance company will cover a screening MRI for normal-risk women with dense breasts at a cost which matches the copay and deductible of a screening mammogram (which in most cases is zero). It is important for the patient to check with her insurance carrier prior to having an MRI. For insurance billing codes for additional breast screening, click here.

In Europe, national breast screening programs for women of average risk are offered free in nearly all European countries adhering to standards laid out in the European Guidelines for Quality Assurance in Breast Cancer Screening and Diagnosis. Variations do exist on the ages and risk factors of women invited to participate in routine screening, screening intervals, coverage and supplemental screening modalities utilized. Opportunistic mammography exists in some countries either as the sole screening system or in addition to the national breast screening program. Part of the cost is out of pocket payment or reimbursed by private insurance.

*For more information on high-risk criteria, see American Cancer Society guidelines: https://www.cancer.org/cancer/types/breast-cancer/screening-tests-and-early-detection/american-cancer-society-recommendations-for-the-early-detection-of-breast-cancer.html

Compared to standard digital mammography, 3D mammography (tomosynthesis) does improve the chance of finding cancer in most breasts. However, in women with extremely dense breasts, studies have shown mixed results as to whether 3D mammograms find more cancers than 2D mammograms. 3D does reduce the chance of having to return for additional diagnostic imaging for a false positive finding (false alarm).

Studies indicate there is benefit from screening ultrasound even after 3D mammography. Four large-scale studies [1-4] showed that ultrasound significantly improved detection of cancer even after the combination of 2D and 3D mammography in dense breasts. However, on average, ultrasound will also show more areas which need follow-up than does mammography. Some of those “finds” will be cancer, but the vast majority of these additional findings, determined after further imaging or biopsy, will be false positives.

If a patient has dense breasts, the answer is yes. In several large studies [1-4], including the ASTOUND [1] prospective multicenter trial in Italy, ultrasound significantly improved detection of cancer even after tomosynthesis (3D mammography) or the combination of 2D and 3D mammography in women with dense breasts. A 2020 prospective multicenter study [5] of abbreviated (“fast” or “mini”) MRI in 1444 women with dense breasts found an overall 3D mammography cancer detection rate of 6.2/1000 women screened vs. an overall abbreviated MRI cancer detection rate of 15.2/1000, a difference of 9/1000. If a patient has been recommended to have MRI screening because of her risk factors, she would still have MRI even if tomosynthesis is performed, regardless of her breast density. If screening MRI is performed, then screening ultrasound is not needed.

The American College of Radiology (ACR) [1] recommends all women, but especially Black women and women of Ashkenazi Jewish descent, undergo risk assessment and possible genetic testing by age 25 to identify those at higher risk who can then be counseled to begin earlier and more aggressive screening for breast cancer. All women benefit most from starting screening at least by age 40, and many women will meet current guidelines for supplemental screening MRI based on consideration of risk factors including age, mammographic breast density, family history of breast cancer, and breast biopsy history. Insurance coverage for screening MRI and risk criteria vary by state.

Gadolinium, a heavy metal, is injected intravenously as a contrast agent to help see breast cancer on MRI examinations. Most of the gadolinium is cleared by the kidneys. There are data showing that small amounts of gadolinium can accumulate in parts of the brain, especially after multiple MRI examinations. The importance of this finding is unknown and has not been linked to any known negative health effects in patients with normal kidney function. There appears to be more gadolinium retained by the body with certain types of contrast agents (so-called “linear” compounds) than with those that are more like a cage around the gadolinium (so-called “macrocyclic” compounds). When kidney function is less than normal, the dose of contrast used may be reduced. Gadolinium contrast should not be used in a patient who is pregnant or who may be pregnant. The Food and Drug Administration has concluded that the benefit of all approved gadolinium-based contrast agents far outweighs any hypothetical risks. Experts on our Medical Advisory Board agree, and we continue to recommend annual contrast-enhanced MRI for women at high risk. For further information, please see: https://www.fda.gov/Drugs/DrugSafety/ucm589213.htm.