What are the current guidelines for screening mammography and evaluating new calcifications?

From the Guidelines

Current screening mammography guidelines recommend that women at average risk begin annual mammograms at age 40, continuing as long as they are in good health with a life expectancy of at least 10 years. Some organizations suggest the option of biennial screening for women aged 55 and older. For women with higher risk factors such as family history or genetic mutations (BRCA1/2), screening may begin earlier, typically at age 30, often with supplemental MRI. When new calcifications are detected on mammography, they should be evaluated based on their morphology and distribution. Suspicious calcifications (those that are pleomorphic, linear, or segmentally distributed) require further assessment with magnification views and possibly biopsy. Benign-appearing calcifications (round, smooth, diffusely scattered) may only need routine follow-up. The BI-RADS classification system guides management: BI-RADS 2 calcifications (benign) need routine screening, BI-RADS 3 (probably benign) require short-interval follow-up at 6 months, while BI-RADS 4-5 (suspicious or highly suspicious) warrant biopsy. These guidelines aim to balance early detection of breast cancer with minimizing unnecessary procedures, recognizing that calcifications represent one of the earliest detectable signs of breast cancer, particularly ductal carcinoma in situ.

Key Points

• Annual screening mammography for women 40 to 84 years of age decreases mortality by 40% (12 lives per 1,000 women screened) 1.
• Biennial screening mammography for women 50 to 74 years of age only decreases mortality by 23% (7 lives per 1,000 women screened) 1.
• Women should continue screening mammography as long as they remain in overall good health and are willing to undergo the examination and subsequent testing or biopsy, if an abnormality is identified 1.
• The BI-RADS classification system guides management of detected calcifications, with suspicious calcifications requiring further assessment and benign-appearing calcifications needing routine follow-up 1.

Evaluation of New Calcifications

When new calcifications are detected on mammography, they should be evaluated based on their morphology and distribution.

• Suspicious calcifications require further assessment with magnification views and possibly biopsy.
• Benign-appearing calcifications may only need routine follow-up.

Screening Recommendations

• Women at average risk should begin annual mammograms at age 40.
• Women with higher risk factors may begin screening earlier, typically at age 30, often with supplemental MRI.
• Biennial screening may be considered for women aged 55 and older.

These guidelines are based on the most recent evidence, including the 2023 update from the American College of Radiology 1.

From the Research

Current Guidelines for Screening Mammography

The current guidelines for screening mammography and evaluating new calcifications are based on several studies, including those published in 2008 2, 2009 3, and 2010 4. These studies provide evidence-based recommendations for the evaluation of microcalcifications detected at screening mammography.

Evaluation of Microcalcifications

• The study published in 2008 2 found that ultrasound (US) findings can be helpful in differentiating benign and malignant lesions in patients with microcalcifications with low concern of malignancy on screening mammography.
• The study published in 2009 3 found that US-guided 11-G vacuum-assisted biopsy can retrieve calcifications from 71% of lesions, and that successful calcification retrieval is related to the visibility of associated masses or dilated ducts by US, and to lesion depth, size, and distribution, and level of suspicion at mammography.
• The study published in 2001 5 found that short-term follow-up of nonpalpable probably benign lesions, including calcifications, can be effective in identifying a few low-stage carcinomas, but progression in probably benign calcifications is usually unrelated to malignancy.

Recommendations for Screening Mammography

• The American College of Radiology (ACR) Appropriateness Criteria published in 2010 4 provide recommendations for the evaluation of nonpalpable mammographic findings, excluding calcifications.
• The ACR recommends an evidence-based approach to the evaluation of findings detected at screening mammography, including the use of additional diagnostic mammographic views, breast ultrasound, breast MRI, and percutaneous biopsy when necessary.

Newer Guidelines

Compared to the 1992 study 6, the newer guidelines published in 2008 2, 2009 3, and 2010 4 provide more detailed recommendations for the evaluation of microcalcifications detected at screening mammography, including the use of ultrasound and biopsy. However, it is essential to note that guidelines may continue to evolve, and it is crucial to consult the most recent recommendations and expert opinions for the evaluation of screening mammography findings.