A mammogram is a breast examination technique that relies on radio waves to detect medical abnormalities present in the breast. The examination uses the inspection physical examination technique, which requires scrutiny but relies much on human judgment (Ball et al., 2019). The test is a common procedure that can be administered to all women of reproductive age, and it is useful in the diagnosis of breast cancer, tumors, and cysts, way early even before the first signs and symptoms start showing (National Cancer Institute, 2016). However, while a mammogram is essential in making a diagnosis, it requires the aid of additional tests such as biopsies to ascertain the condition of the abnormality detected.
There are two types of mammogram tests, i.e., screening and diagnostic mammograms. They each have different uses, and even the patient is positioned differently when administering either of the tests. For screening mammograms, they mainly flag off unusual breast features that are usually associated with cancer development. After this, a diagnostic mammogram is then administered to ascertain the nature of the unusual breast features (National Cancer Institute, 2016). Mammograms have been used for about three decades and are vital in the diagnosis of breast conditions among women of all ages.
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In the United States, mammograms are given by various institutions like hospitals and community health centers alongside other entities equipped with mammography equipment. However, a certification by the Food and Drug Administration is quintessential in granting permission to such institutions to perform mammograms legally. Before a mammogram can be conducted, a questionnaire that discloses personal details such as current medical history is filled by the patient. Some of the details included, for example, in a woman's case include menstruation, history of breast surgeries, childbearing, and other hormonal treatments administered before. The patient is then asked to remove any clothing essentially above the waist, including jewelry, and put on a hospital gown. The technologist places a small metal marker on each nipple by the technologist to enable its viewing and use as a reference point to precisely locate the tumor.
The type of monogram exam determines the patient's position during the exam. In the craniocaudal position, the patient either sits or stands facing the mammography machine. After exposing one of her breasts, the technologist raises the cassette holder height to its level. The exposed, the patient, with the technologist's help, places it on the film with the nipple in focus. The patient then turns her head away from the x-ray angle while relaxing her shoulder. After that, her breast is pulled the furthest possible way. The compression is then lowered and compresses the breast between the film holder and the paddle. The exposure is then taken immediately, and the compression released. The compression significantly reduces the breast tissue's thickness, thus enabling a decreased radiation for the patient as well as a detailed image coupled with lower exposure time.
In the mediolateral oblique position, the technologist positions the patient sideways towards the mammography machine. After that, depending on her size or height, the film holder is angled about 30 to 60 degrees from the pectoral muscle. The machine height is then adjusted to reach the patient's armpit, where the corner of the cassette holder touches the axilla while her arm is placed at its top. An upward and backward compression lifts the breast forward, and the pressure is applied the paddle holds it firmly in its place. At this point, the breast under examination is usually in profile, and the other one is held away. A screening mammogram requires four x-rays (National Cancer Institute, 2016).
According to Breast Cancer.org (2018), mammograms provide detailed pictures of the breasts. Structures provided include calcifications, which are tiny flecks of calcium that can sometimes be indicative of early breast cancer. Calcifications cannot be felt; they are only visible on a mammogram. Depending on how they are clustered, shaped, and their numbers, the doctor may recommend further tests. Cysts are also structures shown by a mammogram. They are usually fluid-filled masses in the breasts. They are common and are rarely associated with cancer. Lastly, fibroadenomas are movable, solid rounded lumps made of healthy breast cells. They are usually not cancerous but may grow to require removal to ensure that it is not cancer. These are the most common breast mass in young women.
While mammography remains the best diagnostic tool for breast cancer, issues surrounding its validity and reliability have emerged. For instance, Hill & Robinson (2015) note that the Perfect, Good, Moderate, Inadequate (PGMI) scheme used by mammographers in the UK is flawed. In their study, the authors noted there to be differences in the schemes used by trainees and qualified mammographers, thus raising concerns over the reliability and validity of the tool. When it comes to sensitivity and specificity, Zeeshan et al. (2018) report that digital mammography has significantly bridged the gap with 97% sensitivity and about 65% specificity, thus raising the diagnostic accuracy to 89.3%. These figures are far much higher when compared to film mammography, thus warranting the move from film mammography to digital mammography.
While advancements have been made, moving over from film mammography to digital computer-aided mammography, Al-Najdawi et al. (2015) report that early detection of breast cancer is highly dependent on the radiologist's ability to read and interpret the mammograms. Human error and judgment remain the vital hindrance to mammography as a diagnostic tool. Even with the introduction of computer-aided diagnosis, the accuracy of mammograms has only improved to about 91%, meaning that there still exist cases of false positives leading to low reliability of the tool.
To improve the validity and reliability of mammograms, collaborations should be made from regulatory bodies such as the American College of Radiology and Higher education centers to ensure professional radiologists similarly interpret the films. Furthermore, this collaboration will ensure quick adoption of changes in the diagnosis scales, thus reducing the cases of false positives.
References
Al-Najdawi, N., Biltawi, M., & Tedmori, S. (2015). Mammogram image visual enhancement, mass segmentation and classification. Applied Soft Computing , 35 , 175-185.
Ball, J.W., Dains, J.E., Flynn, J.A., Solomon, B.S., & Stewart, R.W. (2019). Examination Techniques and Equipment. In Seidel’s Guide to Physical Examination: An Interprofessional Approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Breast Cancer.org. (2018). What Mammograms Show: Calcifications, Cysts, Fibroadenomas. https://www.breastcancer.org/symptoms/testing/types/mammograms/mamm_show
Hill, C., & Robinson, L. (2015). Mammography image assessment; validity and reliability of current scheme. Radiography , 21 (4), 304-307.
National Cancer Institute. (2016). Mammograms. https://www.cancer.gov/types/breast/mammograms-fact-sheet
Zeeshan, M., Salam, B., Khalid, Q. S. B., Alam, S., & Sayani, R. (2018). Diagnostic accuracy of digital mammography in the detection of breast cancer. Cureus , 10 (4).
