Breast Imaging 101
Clinically Correlating
Screening and diagnostic breast imaging involves several modalities, each with specific indications and performance characteristics.
Mammography (including digital mammography [DM] and digital breast tomosynthesis [DBT]) remains the primary screening tool for average-risk women. DBT offers improved cancer detection and reduced recall rates compared to DM, and is preferred for women with dense breasts, though its sensitivity is still limited in extremely dense tissue.[1-5] The American College of Radiology (ACR) recommends DBT or DM as first-line screening for average-risk women.[3-4]
Ultrasound is primarily used as a supplemental screening tool, especially in women with dense breasts or those at intermediate risk who cannot undergo MRI. It increases cancer detection but is associated with higher false-positive rates and operator dependence. Its role is more prominent in diagnostic workup of palpable abnormalities or inconclusive mammographic findings.[1][4-7]
Magnetic Resonance Imaging (MRI), particularly with contrast, provides the highest sensitivity for breast cancer detection. It is recommended by the ACR for high-risk women (e.g., BRCA mutation carriers, strong family history) and is increasingly considered for women with extremely dense breasts or intermediate risk. Abbreviated MRI protocols are emerging to improve accessibility and cost-effectiveness, with comparable diagnostic accuracy to full protocols.[3-8] MRI is not routinely used for average-risk women due to increased false positives and cost.[2][8]
Contrast-enhanced mammography (CEM) is a newer modality with sensitivity comparable to MRI and higher than DM or DBT, but with lower specificity. It is promising for diagnostic assessment of recalled lesions and for supplemental screening in dense breasts, though further validation is needed before widespread adoption.[1][7][9]
In summary, mammography (DM/DBT) is first-line for screening, with ultrasound and MRI reserved for supplemental screening in higher-risk or dense breast populations, and CEM is an emerging option for diagnostic workup and supplemental screening. The ACR guidelines provide the most up-to-date consensus for modality selection.[3-4]
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References
Screening Algorithms in Dense Breasts: AJR Expert Panel Narrative Review.
Berg WA, Rafferty EA, Friedewald SM, Hruska CB, Rahbar H. AJR. American Journal of Roentgenology. 2021;216(2):275-294. doi:10.2214/AJR.20.24436.
Breast Cancer Screening Using Mammography, Digital Breast Tomosynthesis, and Magnetic Resonance Imaging by Breast Density. Stout NK, Miglioretti DL, Su YR, et al. JAMA Internal Medicine. 2024;184(10):1222-1231. doi:10.1001/jamainternmed.2024.4224.
Patient-Friendly Summary of the ACR Appropriateness Criteria®: Female Breast Cancer Screening: 2024 Update. Aziz A, Bhole S. Journal of the American College of Radiology : JACR. 2025;22(5):615. doi:10.1016/j.jacr.2024.09.017.
ACR Appropriateness Criteria Breast Cancer Screening. Mainiero MB, Lourenco A, Mahoney MC, et al. Journal of the American College of Radiology : JACR. 2016;13(11S):R45-R49. doi:10.1016/j.jacr.2016.09.021.
Breast Density Implications and Supplemental Screening. Vourtsis A, Berg WA. European Radiology. 2019;29(4):1762-1777. doi:10.1007/s00330-018-5668-8.
Comparison of Abbreviated Breast MRI vs Digital Breast Tomosynthesis for Breast Cancer Detection Among Women With Dense Breasts Undergoing Screening. Comstock CE, Gatsonis C, Newstead GM, et al. JAMA. 2020;323(8):746-756. doi:10.1001/jama.2020.0572.
Opportunities in Cancer Imaging: Risk-Adapted Breast Imaging in Screening.
Gilbert FJ, Hickman SE, Baxter GC, et al. Clinical Radiology. 2021;76(10):763-773. doi:10.1016/j.crad.2021.02.013.
Contrast-Enhanced MRI for Breast Cancer Screening. Mann RM, Kuhl CK, Moy L. Journal of Magnetic Resonance Imaging : JMRI. 2019;50(2):377-390. doi:10.1002/jmri.26654.
Akwo J, Hadadi I, Ekpo E. Cancers. 2024;16(20):3505. doi:10.3390/cancers1620350.