Is a mammogram indicated in a patient with breast cancer status post mastectomy (surgical removal of the breast)?

From the Guidelines

A mammogram is not indicated in a patient with breast cancer who has undergone a complete mastectomy, but annual mammographic screening of the contralateral breast is recommended for those with unilateral mastectomy. After mastectomy, there is no remaining breast tissue on the affected side to image with mammography, making it unnecessary for routine screening on the post-mastectomy side, as supported by the American College of Radiology Appropriateness Criteria 1. Instead, post-mastectomy surveillance typically consists of regular clinical examinations and possibly other imaging modalities like ultrasound or MRI if there are specific concerns about recurrence. However, for patients who had unilateral mastectomy, continued mammographic screening of the remaining breast is essential, as these patients have an increased risk of developing a new primary breast cancer in the contralateral breast, as recommended by the American Cancer Society/American Society of Clinical Oncology breast cancer survivorship care guideline 1. The frequency of follow-up examinations should be determined by the patient's oncologist based on their specific risk factors, type of surgery performed, and overall treatment plan. Key considerations include:

• The type of mastectomy performed, with skin-sparing or nipple-sparing mastectomies potentially leaving some breast tissue behind
• The presence of breast reconstruction, which may influence the need for limited imaging based on individual risk factors
• The importance of annual screening with 2-D mammography or digital breast tomosynthesis (DBT) for the contralateral native breast in patients with unilateral mastectomy, as recommended by the ACR Appropriateness Criteria 1.

From the Research

Mammogram Indication in Patients with Breast Cancer Status Post Mastectomy

• The indication for a mammogram in patients with breast cancer status post mastectomy is a topic of controversy among breast imagers 2.
• Some studies suggest that the yield of finding a recurrent cancer with imaging in the asymptomatic patient is too low to be beneficial, while others believe that imaging should be performed on these patients due to the risk of recurrence 2, 3.
• Mammography can be challenging in patients who have undergone mastectomy, especially in those with reconstructive surgery, due to the appearance of remaining tissue along the chest wall and reconstructed breasts 2.

Imaging Modalities for Detecting Recurrence

• Mammography, ultrasound, and magnetic resonance imaging (MRI) are commonly used imaging modalities for detecting recurrence in patients with breast cancer status post mastectomy 2, 3, 4.
• MRI has been shown to have high sensitivity and specificity for detecting recurrent disease, especially when combined with physical exam and mammography 3.
• Ultrasound has also been found to be useful in evaluating tumors in the chest wall and axilla, which may not be visible on mammograms 4.

Surveillance Protocols

• There is currently no consensus on a protocol for imaging the postoperative breast, and surveillance protocols may vary depending on the institution and patient risk factors 3.
• Some studies suggest that routine screening breast MRI may not be necessary in patients who have undergone bilateral mastectomy, especially if no residual breast tissue is identified 5.
• However, MRI can be helpful in establishing the presence of residual breast tissue and detecting locoregional recurrence in patients with highly suspicious physical findings 5.