What type of mammogram is recommended for a patient with a history of breast cancer who has undergone a mastectomy?

Mammography After Mastectomy

No routine mammography should be ordered for the mastectomy side in asymptomatic patients with a history of mastectomy. 1

Surveillance Recommendations for the Mastectomy Side

There is no evidence to support screening or diagnostic mammography of the mastectomy side in asymptomatic women. 1 The ACR Appropriateness Criteria explicitly states that mammography—whether screening, diagnostic, or digital breast tomosynthesis—should not be used to evaluate for recurrence after mastectomy in asymptomatic patients. 1

Clinical Surveillance Instead of Imaging

• ASCO recommends clinical surveillance with physical examination and history every 3 to 12 months for the first 5 years after mastectomy, followed by annual clinical breast examination thereafter. 1
• Locoregional recurrence after mastectomy is typically detected clinically rather than by imaging. 1
• Recurrence rates after mastectomy are approximately 1% to 2% annually, with overall recurrence between 2% to 15% depending on initial cancer type, stage, and follow-up period. 1

Limited Role for MRI in High-Risk Cases

• High-risk women with mastectomies may benefit from MRI surveillance of the mastectomy side, though evidence is limited. 1
• One small study found a cancer detection rate of 10 per 1,000 in the asymptomatic mastectomy side, with sensitivity of 66.7% and specificity of 99.2%. 1
• These cancers would have otherwise been undetected until symptomatic since screening mammography is not performed after mastectomy. 1
• Larger studies are needed to assess the utility of surveillance MRI in the mastectomy setting. 1

Surveillance of the Contralateral Breast

Annual screening mammography (2-D or digital breast tomosynthesis) IS recommended for the contralateral native breast. 1, 2

• This follows standard breast cancer screening guidelines for women with a personal history of breast cancer. 2
• Annual mammography provides mortality reduction in women with a history of breast cancer. 2
• The most common presentation of recurrent or second breast cancer is an abnormal mammogram in an otherwise asymptomatic patient. 2

Enhanced Surveillance for High-Risk Features

Consider annual breast MRI for the contralateral breast if the patient has:

• Dense breasts AND personal history of breast cancer 1, 3
• Diagnosis before age 50 1, 3
• Lifetime risk ≥20% 1, 3

When to Image the Mastectomy Side

Only order imaging of the mastectomy side if the patient develops symptoms or clinical findings suspicious for recurrence. 1

In symptomatic cases:

• Diagnostic mammography or digital breast tomosynthesis can be used for evaluation of suspected local recurrence. 1
• MRI breast with and without IV contrast may be appropriate depending on clinical findings. 1
• Ultrasound has limited evidence but may be considered. 1

Common Pitfall to Avoid

Do not order routine surveillance mammography of the mastectomy side "just to be safe"—this is not evidence-based and is explicitly not recommended by ACR guidelines. 1 Focus surveillance efforts on clinical examination and imaging of the contralateral breast.