In a patient with left breast pain who is due for a screening mammogram, should I order a diagnostic (targeted) mammogram of the left breast and a routine screening mammogram of the right breast?

Order a Bilateral Diagnostic Mammogram

For a patient with left breast pain who is due for screening mammography, you should order a bilateral diagnostic mammogram, not a split approach of diagnostic on one side and screening on the other. This is the standard approach recommended by major guidelines for evaluating symptomatic patients 1, 2.

Why Bilateral Diagnostic Mammography

When a patient presents with a breast symptom (in this case, left breast pain), the evaluation shifts from screening to diagnostic imaging, regardless of being "due" for screening. The key distinction is:

• Diagnostic mammography includes additional views (spot compression, magnification) and allows the radiologist to focus on the symptomatic area while also evaluating both breasts comprehensively
• Screening mammography consists only of standard 2-view images and is designed for asymptomatic patients

The ACR Appropriateness Criteria clearly state that for women with focal, noncyclical breast pain:

• Age <30 years: Ultrasound alone is appropriate
• Age 30-39 years: Diagnostic mammography and ultrasound are both appropriate
• Age ≥40 years: Diagnostic mammography plus ultrasound is the standard approach 1, 2

Important Caveats About Breast Pain

The cancer detection rate in focal breast pain is very low (2.3-4.6% in symptomatic patients), and most imaging will be negative 1. However, when cancers are found at the site of pain, they are typically visible on both mammography and ultrasound 1. Additionally, incidental cancers unrelated to the pain site can be detected (2.3% in one study) 1.

Practical Algorithm

1. Order bilateral diagnostic mammogram (not split screening/diagnostic)
2. Add targeted ultrasound of the left breast pain site
3. The diagnostic study satisfies the screening requirement if negative
4. If positive findings emerge, follow BI-RADS assessment categories for further workup 3

Common Pitfall to Avoid

Do not order screening mammography on the asymptomatic right breast while ordering diagnostic on the symptomatic left. This creates billing confusion, may not be reimbursed appropriately, and doesn't follow standard diagnostic protocols. The bilateral diagnostic mammogram evaluates both breasts comprehensively while allowing focused attention on the symptomatic area 4.

The presence of any breast symptom converts the examination from screening to diagnostic, and this applies to the entire study, not just one breast.