Diagnostic mammograms

One in eight women in the UK will develop breast cancer at some point in life (Breast Cancer Care – February 2015). Mammography is a technique for taking x-ray images (mammograms) of the breasts that can show breast cancers at an early stage. Mammograms are used in the NHS Breast Screening Programme to look for breast changes in women (aged 50-70) who have no symptoms of breast cancer. These are called screening mammograms. The NHS Breast Screening Programme is being gradually extended in England to women aged 47 to 49, as well as to those aged 71 to 73 as part of a trial.
In the past the NHS Breast Screening Programme did not include women under fifty because mammograms are less effective in pre-menopausal women, and because the density of the breast tissue in younger women makes it more difficult to detect problems. The incidence of breast cancer is also lower in younger women (see Healthtalk Breast screening site).The average age of the menopause in the UK is 52. The NHS Breast Screening Programme is currently extending the age range for breast screening in England to include women aged 47-73. Age extension will mean that women in England will receive their first screening invitation by the time they turn 50.
Studies have shown that digital mammography is better for screening younger women (under fifty) and women with denser breasts, and is equally effective as film mammography in older women (see ‘Diagnostic mammograms in the UK’ and the DMIST study). Younger women (under 47) who develop breast symptoms – pain, skin thickening, nipple discharge, or a change in breast size or shape – can be referred to a breast clinic by their GP where they may be given a mammogram. A mammogram used to diagnose breast disease in women of any age with breast symptoms is called a diagnostic mammogram. Breast symptoms can include:
  • A painless lump in the breast
  • a change in the size or shape of a breast
  • dimpling of the skin of the breast
  • a thickening in the breast tissue
  • a nipple becoming inverted (turned in)
  • a lump or thickening behind the nipple
  • a rash (like eczema) affecting the nipple
  • a bloodstained discharge from the nipple (this is very rare)
  • a swelling or lump in the armpit

A doctor explains why screening and diagnostic mammograms are taken.

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I am Dr Michael Michell and I am a radiologist based at King’s College Hospital, and I direct the screening programme for South East London. And the Screening Programme covers a target population of around 150,000 women aged between 50 and 70 years.

So the role of the radiologist is to look very carefully at the routine screening mammograms that are taken and we are looking for any signs that there might be a cancer present.The role of the radiographer, the next person in the team, is to take very high quality pictures so that we can be sure that we have the best chance of seeing any abnormality that is present. And the radiographers and the radiologists and for that matter all of the other members of the multi disciplinary team in screening, all undergo specialist training so that they can do their jobs to the very highest standard.

Could you explain why a woman might have a screening mammogram and why a woman might have a diagnostic mammogram?

Sure. The screening mammogram is a routine test carried out on well women who in most cases have no symptoms of breast disease at all, and the screening mammogram is offered by the National Health Service as a routine test every three years starting from the age of 50. We invite regularly, every three years up until the age of 70 currently, and after that age women are able to self refer for screening mammograms for as long as they wish.

We are currently implementing an extension to the screening programme in this country and that will mean that all women will be invited for their first mammogram before they’re 50, and we will be inviting them up until the age of 73.

And diagnostic mammograms? Why would women go for a diagnostic mammogram?

So the diagnostic mammogram is part of the test that I used routinely to investigate women with symptoms of breast disease. So, for example, if a woman presents to her doctor with a lump,and she is aged 35 or over, when she goes to the breast clinic she will have of course a consultation and an examination, and then the investigations will involve a mammogram, but will also involve probably other tests such as an ultrasound, possibly a needle biopsy. So the mammogram is part of that diagnostic work up for symptoms.

Right. And how often do you give diagnostic mammograms a year, say, compared to screening mammograms?

Okay, so a diagnostic mammogram is done as part of the work up for investigation of symptoms, when a women presents to the breast clinic, referred usually by her general practitioner. In most cases doing the whole work up, we are able to make a definite diagnosis and then if treatment is needed then of course we give that treatment. But there would be no follow up after that, so we would aim to get to a definite diagnosis and then act accordingly.

Diagnostic mammograms are not part of the NHS Breast Screening Programme, which uses a routine call and recall system to invite well women. However, the same techniques are used in both breast screening clinics and hospital breast clinics for diagnosing breast cancer and many staff work in both settings.

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Some women we spoke with said they’d had diagnostic mammograms before they were eligible for routine breast screening. They had had breast symptoms and, after seeing their GP, were referred for a mammogram and, a few women, for other tests. Many women have a breast problem at some time in their lives. Most breast problems are not caused by cancer (see ‘Benign breast problems‘ on the Healthtalk Breast Screening site).

Sue found a lump when she was in her early thirties which turned out to be a cyst.

Age at interview 50

Gender Female

Age at diagnosis 49

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About 13, 14 years ago I found a small lump in my breast, which I went to the doctor. She was sure it was nothing to worry about but I was referred to the breast care clinic within a couple of weeks. They did find that I had a small cyst and the clinic I was referred to did all the tests on the day. And I had a mammogram then and also ultrasound and the cyst was actually aspirated on the day. And after that they said I shouldn’t have any more problems. Unfortunately the cyst did fill up again and I had it aspirated again but from then until August last year, when I was called for the routine screening with the NHS, I never had any problems at all.

How old were you at that time?

Thirty-three, thirty-four. My daughter was only eighteen months old. And to find a lump with a child so young, that was really devastating.

Yeah. Did you have any idea what it could be at that point?

No, nothing at all. I just thought the worst. I thought a lump, it’s got to be cancerous. Because unfortunately I’ve known a few younger friends who had had something that turned out not to be so good.

Yeah. So you went to your GP first?

Yes. And they had the screening programme in [place name], they will see you within six weeks. And because she could actually feel the lump I was seen with two weeks. But as the clinic at that time was a one-stop shop, they did everything there. They actually analysed even the fluid on the day that they took out of the cyst to make sure there was nothing nasty in that as well.

So you had a mammogram that day, ultrasound scan?

Yes mammogram, ultrasound, and the I can’t remember the word now. When they aspired the cyst as well.

Yeah. So you found there and then it was just a cyst?

Yes.

And they aspirated it so the lump went?

That’s right. But unfortunately it came back the next day. They told me I’d never have a lump there again. But the next day I could feel it. I went back to my GP and she aspirated it that day for me in the surgery. And after that it never came back again.

Yeah. And then you got a letter through the post when you were forty-nine and a half?

That’s right. And just for routine screening because they do it, I don’t know if it’s the same in every area, but between fifty and fifty-three you have the first routine screening for a mammogram.

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Jane had surgery to remove two benign lumps well before she was invited for routine screening.

Age at interview 50

Gender Female

Age at diagnosis 49

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When I was about thirty, just after I had my second baby, I had a cyst on the left breast, which I had to go into hospital and had that removed. And then about four or five years after that I had a lump in my right breast, which was benign. But it was taken out.

Was the cyst removed or aspirated with a syringe, or you actually had it removed surgically?

Yes, yes. I did, had it removed surgically yes. So no concerns as to I think I’m going to get breast cancer’, just normal cysts and a benign lump.

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One woman said that, when she had breast pain she was particularly concerned because her mother had had breast cancer. She was referred to a breast clinic and given a diagnostic mammogram, which showed that the breast pain was harmless. Another woman said her father had had breast cancer so she was given her first mammogram at forty. She then had her next one at the age of 51 when she was invited in the NHS Breast Screening Programme.
Some of the younger women we spoke with had diagnostic mammograms for breast symptoms that turned out to be DCIS.

Bleeding from Jos nipple was dismissed by doctors when she was pregnant and later when she was…

Age at interview 42

Gender Female

Age at diagnosis 42

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The very first problem was, I was pregnant with my second child and because I’d had problems with my first child with mastitis, which is a bit lumpy, you know, in the breast, I sort of had a similar sort of feeling. You usually get it after you’ve given birth but I’d a similar feeling just, I can’t remember, I think I was in the last month or last two months of the pregnancy, so slightly lumpy. And so I expressed, because you tend to with mastitis, you express the milk out because you’re getting milk even before you’ve given birth. And blood came out.

When you expressed?

When I expressed, and obviously it was a bit of a shock because obviously throughout the first child, when I’d expressed many times because of mastitis, nothing like that had happened, only milk would come out. So I immediately went to the doctor, a bit worried. And they immediately sent me up to the breast clinic. You know, within a day or so, and I saw someone and they said, You haven’t got any lumps, it’s just pregnancy So that was it. I was quite relieved, gave birth, breast-fed. And, of course, you don’t notice really anything because everything that’s coming from your breast goes straight into the baby [laughs], you know. So I didn’t notice anything. And sometimes you can, people say you might get bleeding anyway with breast feeding because of whatever. But I didn’t anyway notice anything.

And then about, well it would have been, it was just, let me think, it would have been almost two years later, two and half years later almostlood again. Oh my goodness, what’s going on? So I ring my doctor and I say, Look I’ve got this bleedingnd she said, No, don’t worry, you’ve been checked out, no problem

So I waited and it was two years actually since, and then I waited another six months because I thought she, no, I’ve been to the Centre of Excellence, they surely know what they are doing. I’m very busy with my children that I haven’t really got time for that anyway. And the doctor’s reassured me. So I went another six months and I just thought actually, and then when I was feeding, the blood, you know, he was slightly spitting it out. And I’m thinking, this is so wrong. This is so much blood coming out. It can’t be right.

So I did actually go back. But a different doctor. I said, Look, probably nothing but I’d really, I’ve got to go back to these people And she said, Yeah, it’s probably nothing And there was a very quick slippery slope to having a mammogram, having another mammogram, having a, what’s the next stage, a
Did you have an ultrasound?

ultrasound, having a biopsyAnd then, yes, you’ve got DCIS.

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Tests to find out why Felicity was having breast pain led quickly to a diagnosis of DCIS.

Age at interview 43

Gender Female

Age at diagnosis 41

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It started with a constant, I was getting a constant ache in my left breast and that’s quite interesting and I’ll come onto that later but it was just a constant ache, a very heavy dull ache. So when I took my bra off at night I would kind of feel it, a very deep ache. And I just ignored it because you do. And then I went to get a new bra fitted at a department store in [place name] and there was a big poster on the wall of the changing room that said, If you have any of the following symptoms, you should go and get checked And one of them was constant breast pain. And that’s what alerted me to go along and see if there was anything there.

I had in fact, before I had my second child, gone to the breast consultant for something similar and that kind of came to light later on, I’d forgotten about it. And I was told it was just hormonal and to take evening primrose oil. And then I had my second child and it had come, it reoccurred and then.

So I went to the doctor who gave me a breast examination, the local, my GP, and immediately referred me. But I was never sure if she actually found lumps or not but I assume she felt something that shouldn’t have been there. And I didn’t really think anything of it. I just took it all as a routine thing because I hadn’t felt any lumps and I think what I understand now is that they only give you as much information as they have really. They don’t give you any assumptions or thoughts that they might have on it. Which is fine [laughs]. And I went along to get a mammogram at the breast clinic. I was referred very, very quickly.

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Women’s experiences of having diagnostic mammograms at the breast clinic are similar to those of women attending for screening mammograms. However, women presenting with symptoms may be more anxious because they are expecting to find something wrong.

Kath was anxious because her breast felt different, but wondered whether she was just imagining…

Age at interview 48

Gender Female

Age at diagnosis 47

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Well I was suffering depression last year. And I ended up thinking that I could feel a different area in the breast, not a lump. Just, it just felt a little bit denser I would say. Kind of like a line of it. And I spoke to my partner. Got him to check. I got my best friend, we’ve been friends since we were thirteen. Sounds a bit strange but I got my friend to check as well. Nobody else could feel anything, only me.

So I’d convinced myself that I was just being paranoid, you know, because I was thinking a lot of black thoughts at that point in time anyway. But I got to the point where it wasn’t just checking like every week, it got to be every day in the shower. And then it got to be sitting watching television with my hand [laughs] up my jumper, checking it out. Still, you know, just got to the point where that was it.

I went to the doctor to get the repeat prescriptions for my depression medication. Mentioned to my GP at the time who was actually a locum, I didn’t know the girl at all, quite a young woman. So she checked me out. I says it’s probably nothing but She couldn’t feel anything but she did refer me for a mammogram. Now, in [place name] what they do is, you get referred quite quickly. So this was through the NHS. And went for the mammogram a couple of weeks later. Didn’t tell anybody, my partner, friends, family, anybody. Went for the mammogram. I got called back into the room and they did both breasts again.

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Some women find mammograms uncomfortable or painful (see the Healthtalk Breast Screening site). One woman presenting with symptoms, though, said she did not care about the discomfort of the mammogram because she just wanted to know what was wrong.
More experiences of diagnostic mammograms can be found on the Healthtalk Breast Screening site.

Referral to an assessment clinic

After having a routine mammogram in the NHS Breast Screening Programme, most women receive a results letter about two weeks later. About 95 per cent...