From the Guidelines
If a patient refuses a mammogram, the most appropriate alternative breast cancer screening test is breast ultrasound, particularly for women with dense breasts, as it uses sound waves to create images of breast tissue and can detect cancer when mammography is less effective. According to the American College of Physicians guidance statement from 2019 1, breast ultrasound is a viable alternative for women who refuse mammograms or have dense breasts, as it can reduce recall rates and increase cancer detection compared to conventional mammography.
Alternative Screening Options
Other alternative breast cancer screening options include:
- Breast MRI: provides detailed images using magnetic fields and is recommended for high-risk patients, though it's more expensive and may produce more false positives 1.
- Molecular breast imaging: uses a radioactive tracer to identify cancer cells but involves radiation exposure.
- Clinical breast exams: performed by healthcare providers can detect palpable abnormalities but miss smaller lesions.
Considerations for Choosing an Alternative Screening Method
The best choice of alternative screening method depends on the patient's risk factors, breast density, and reason for mammogram refusal. Patients should discuss these options with their healthcare provider to determine the most appropriate screening method for their individual circumstances, as mammography remains the gold standard for breast cancer screening with the strongest evidence for reducing mortality 1.
Key Points to Consider
- Breast density can affect the accuracy of mammography, and alternative screening methods may be more effective for women with dense breasts.
- The American Cancer Society recommends shared decision-making for women at increased risk of breast cancer to determine the best screening strategy.
- Alternative screening methods vary in sensitivity, specificity, cost, and availability, and the choice of method should be individualized based on patient factors.
From the Research
Alternative Breast Cancer Screening Tests
If a patient refuses a mammogram, there are alternative breast cancer screening tests that can be used. These include:
- Magnetic Resonance Imaging (MRI) 2, 3, 4
- Ultrasound 2, 3, 5
- Digital breast tomosynthesis 3
- Contrast-enhanced mammography 3
Recommendations for Alternative Screening Tests
The use of alternative screening tests depends on the patient's risk level and breast density. For example:
- High-risk women and women with extremely dense breast tissue should use MRI for supplemental screening or ultrasound if MRI is not available 3
- Women with dense breast tissue may benefit from screening breast sonography as an adjunct to screening mammography 5
- The addition of MRI to mammography in high-risk groups has the greatest potential to detect additional mammographically occult cancers 2
Effectiveness of Alternative Screening Tests
Studies have shown that:
- Adding MRI to mammography provides a highly sensitive screening strategy, especially for young women at high risk of breast cancer 4
- Ultrasound can detect small breast cancers that are not detected on mammography or clinical breast examination, especially in women with dense breast tissue 5
- Digital breast tomosynthesis and contrast-enhanced mammography have also shown potential to further increase diagnostic performances, but more evidence is needed to support their use 3