Mammography is foundational to breast cancer screening, but clinicians now have many more imaging options for patients whose risk factors, breast density, symptoms, or imaging findings need a closer look. Digital breast tomosynthesis (3D mammography), contrast-enhanced mammography (CEM), ultrasound, breast MRI, and artificial intelligence (AI)-supported breast imaging can provide more information that physicians can rely on. These tools add clinical value, particularly when caring for Black women, who are often confronted with diagnoses at younger ages and have an incidence of death from the disease much higher than their white counterparts. The American College of Radiology (ACR) suggests Black women should begin breast cancer assessments by age 25 and stay vigilant about detection throughout their lives.
Understanding which breast imaging tools are available can help guide patients in getting the right screening to identify any breast abnormalities.
Mammography produces a two-dimensional image that analyzes three-dimensional tissue for abnormal shapes, sizes, or density. It has its limitations. While a self-exam helps women feel in control of their own health, feeling a lump is not the same as identifying a cancerous tumor in the breast. Additionally, conducting regular exams may not detect hidden irregularities in breast tissue, which may hide cancer inside otherwise normal tissue.
Luckily, medical technology and science have evolved beyond putting the onus upon women to feel around for cancer. Instead, digital breast tomosynthesis, introduced in 2011, captures multiple images from different angles and reconstructs them into thin visual slices, allowing radiologists to examine the breast layers and to improve early cancer detection.
“Think about looking at a book with all the pages stacked on top of each other,” said Monique Gary, DO, breast surgical oncologist and Chief Medical Officer of Bexa, a company building early detection solutions for breast cancer patients. “Sometimes normal breast tissue can overlap and hide a cancer, especially in women with dense breasts.”
It is important to realize that 3D mammography feels to patients like simply a better version of the same test. The patient experience is generally the same. But the findings are more sophisticated and can help physicians make better determinations. Annual screening beginning at age 40 is prudent guidance, but risk and family history can affect the timing and procedural guidance for earlier screening.
Dr. Gary explained that “Every breast imaging tool answers a slightly different question,” but patients may need education on what each tool does and does not show.
“Mammography is particularly good at finding tiny calcifications that can be an early sign of breast cancer,” she said. But ultrasounds help determine what a lump actually looks like inside, particularly whether it is solid or fluid-filled.
That matters because a patient can have a normal mammogram while reporting a new lump in their manual breast exam. As a clinician, it is important to determine the limitations of the diagnostic tools and explain to patients that there is no single breast cancer detection test to put one’s mind at ease. Instead, it may be an iterative process that uses different diagnostic tools.
Senayet Agonafer, MD, a breast radiologist at Lenox Hill Radiology, explained that “AI is increasingly becoming part of breast imaging, and we will continue to see it play an important role in the future. At my imaging center, we use an AI-powered tool called Enhanced Breast Cancer Detection (EBCD). The radiologist reads the mammogram first, and the AI serves as a second set of eyes, flagging areas that need a closer look.
If there’s a discrepancy, meaning it flags something the radiologist may have missed, the case gets escalated to an expert breast imaging radiologist for another look.” This helps reduce bias and errors at the physician level, and ensures each patient gets the time and attention their results merit.
“MRI is our most sensitive breast imaging tool,” Dr. Gary said. “It uses contrast to show areas of abnormal enhancement and can uncover cancers that are difficult to see on mammography.” But it may also cause false positives that require additional imaging or biopsies for a final determination.
Ultrasound and mammography are helpful tools, added Kimberly Beavers, MD, a board-certified breast imaging radiologist. “Breast ultrasound is useful for identifying small masses that may be obscured by dense breast tissue on mammography,” she explained. “Additionally, breast ultrasound can also be helpful for identifying and classifying abnormal findings seen on mammograms or MRI.”
Radiologists also play a major role in determining the diagnosis. “If there’s a discrepancy, meaning it flags something the radiologist may have missed, the case gets escalated to an expert breast imaging radiologist for another look,” she explained.
Individualized imaging is meaningful for Black patients, especially Black mothers, daughters, and aunts who are approximately twice as likely to develop triple-negative breast cancer (TNBC).
Clinical communication is also a concern within our realm of control. Patients often feel like their only option is to feel for lumps and wait for annual exams. Both provide imperfect information about abnormalities that may, in fact, be cause for concern: inconsistent breast pain, discharge, or a rash change should affect a patient’s willingness to screen. Screening applies to patients with and without symptoms. But once a symptom is present, the clinical question changes and patient reluctance may kick in.
“A new lump, persistent focal breast pain, nipple or skin change, or spontaneous nipple discharge should be evaluated regardless of when the last mammogram was performed,” Dr. Gary said. “Screening is for people without symptoms. A symptom changes the conversation.”
Awareness of breast imaging options should improve disparities in testing and patient outcomes. Knowing patients’ lifetime cancer risk or their Tyrer-Cuzick (or IBIS) results is also important. Physicians can use risk assessment, breast density, family history, symptoms, personal habits, and prior test results to determine whether a patient needs additional imaging or specialized treatment.
Primary care physicians, OB/GYNs, and other clinicians who routinely counsel women should be proactive about preventive care. Ask when the patient last had a mammogram and refer them for one if it has been too long since their last diagnostic visit.
The goal is not to order more tests but to get better answers. It is to make sure the right patient receives the right imaging at the right time. For Black women, whose breast cancers are more likely to occur at younger ages and have aggressive characteristics, that individualized approach can save lives.
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