Ultrasound can replace mammogram to assess breast abnormality Ultrasound is cheaper, more pleasant and reassures four in five women immediately

An ultrasound examination is a reliable first step when investigating local breast complaints such as a lump or sore. Large-scale Dutch research, coordinated by Radboud university medical center, shows that a breast radiologist can almost certainly rule out breast cancer with ultrasound. Radiologist Linda Appelman: ‘An important additional advantage is that we can immediately reassure four out of five women that they do not have breast cancer.’

Every year in the Netherlands, 70,000 women visit the hospital with a lump or other local complaint in their breast. Their first examination is now a mammogram, an X-ray of the breast. Women often experience this examination as stressful because the breasts are compressed. This mammogram rarely leads to an explanation of the complaint, which is why an ultrasound is almost always performed at the site of the complaint to reach a diagnosis.

Why not do an ultrasound first and an X-ray only if necessary? Breast radiologists Linda Appelman and Ritse Mann of the Radboudumc set up a large study to find out. They reversed the order of imaging in two thousand women with local breast complaints: first ultrasound and then mammography. Only specialized breast radiologists performed these ultrasounds, at Radboudumc in Nijmegen, Noordwest Hospital in Alkmaar and St. Antonius in Utrecht.

Reassurance

The study shows that the ultrasound is very reliable: the technique can rule out breast cancer with 99.8% certainty. Four out of five women could already be reassured during the ultrasound. They only had a benign abnormality, such as a cyst. In one in five women, ultrasound did not yet give certainty. They were given follow-up examinations and half of them eventually turned out to have a specific form of breast cancer. 

Appelman sees great advantages of ultrasound for the patient: ‘A woman has direct contact with the radiologist and the lab technician. She can better explain and point out the complaint. The radiologist can immediately tell what the cause of the complaint is based on the images. If the images on the ultrasound are not suspicious, the woman can also be reassured immediately. In addition, ultrasound is not painful and no X-rays are used.'

Resource

The question is whether ultrasound will replace the mammogram in the future. 'I think that the nature of the complaint, the ultrasound images, age and possible participation in population screening are important factors when considering whether to still have a mammogram. In many cases it will not be necessary’, Appelman says. 'A mammogram has added value mainly in breast cancer screening and when a doctor wants to look at both breasts completely when breast cancer is suspected.' 

A disadvantage of ultrasound is that the breast radiologist checks only the part of the breast with the complaint. Checking both breasts completely with ultrasound is too much work. In 0.4% of the women in the study, follow-up examinations nevertheless revealed (a preliminary stage of) breast cancer in a place other than that where the complaint was located. Appelman: ‘So these were additional findings on the mammogram, which would normally show up during breast cancer screening or when complaints arise.’

The research team created a flow chart that indicates when follow-up testing is needed after the ultrasound. This tool takes into account age, population screening participation, complaint, clinical picture and how clear the ultrasound is. 'Perform follow-up examinations anyway when in doubt’, Appelman advises. 'This could be a mammogram, but probably a biopsy will provide more clarity.' The applicability of the flow chart and the effect of actually omitting mammography will be investigated in future research.

About the publication

This study was published in Radiology: Ultrasound and DBT in women with focal breast complaints: results of the Breast UltraSound Trial (BUST). Linda Appelman, Carmen C N Siebers, Peter T M Appelman, H L Shirley Go, Mireille J M Broeders, Marja C J van Oirsouw, Peter Bult, Ritse M Mann.

• Want to know more about these subjects? Click on the buttons below for more news.

  News homepage news & media