Mammogram reports BI-RADS

The American College of Radiology (ACR) has developed a standard way of

describing mammogram findings. In this system, the results are sorted into
categories numbered 0 through 6. This system is called the Breast Imaging
Reporting and Data System (BI-RADS). Having a standard way of reporting
mammogram results lets doctors use the same words and terms and ensures
better follow up of suspicious findings. Heres a brief review of what the
categories mean:

X-ray assessment is incomplete

Category 0: Additional imaging evaluation and/or comparison to prior

mammograms is needed.

This means a possible abnormality may not be clearly seen or defined and
more tests are needed, such as the use of spot compression (applying
compression to a smaller area when doing the mammogram), magnified views,
special mammogram views, or ultrasound.

This also suggests that the mammogram should be compared with older ones
to see if there have been changes in the area over time.

X-ray assessment is complete

Category 1: Negative

Theres no significant abnormality to report. The breasts look the same (they
are symmetrical) with no masses (lumps), distorted structures, or suspicious
calcifications. In this case, negative means nothing bad was found.

Category 2: Benign (non-cancerous) finding

This is also a negative mammogram result (theres no sign of cancer), but the
reporting doctor chooses to describe a finding known to be benign, such as
benign calcifications, lymph nodes in the breast, or calcified fibroadenomas.
This ensures that others who look at the mammogram will not misinterpret the
benign finding as suspicious. This finding is recorded in the mammogram report
to help when comparing to future mammograms.

Category 3: Probably benign finding Follow-up in a short time frame is

suggested

The findings in this category have a very good chance (greater than 98%) of
being benign (not cancer). The findings are not expected to change over time.
But since its not proven benign, its helpful to see if an area of concern does
change over time.

Follow-up with repeat imaging is usually done in 6 months and regularly

thereafter until the finding is known to be stable (usually at least 2 years). This
approach helps avoid unnecessary biopsies, but if the area does change over
time, it allows for early diagnosis.

Category 4: Suspicious abnormality Biopsy should be considered

Findings do not definitely look like cancer but could be cancer. The radiologist is
concerned enough to recommend a biopsy. The findings in this category can
have a wide range of suspicion levels. For this reason, some doctors may divide
this category further:

finding with a low suspicion of being cancer

finding with an intermediate suspicion of being cancer
finding of moderate concern of being cancer, but not as high as Category 5
Not all doctors use these subcategories.

Category 5: Highly suggestive of malignancy Appropriate action should be

taken

The findings look like cancer and have a high chance (at least 95%) of being
cancer. Biopsy is very strongly recommended.

Category 6: Known biopsy-proven malignancy Appropriate action should be

taken

This category is only used for findings on a mammogram that have already
been shown to be cancer by a previous biopsy. Mammograms may be used in
this way to see how well the cancer is responding to treatment.

BI-RADS reporting for breast density

Mammogram reports can also include an assessment of breast density. BI-RADS

classifies breast density into 4 groups:

BI-RADS 1: The breast is almost entirely fat

This means that fibrous and glandular tissue makes up less than 25% of the
breast

BI-RADS 2: There are scattered fibroglandular densities

Fibrous and glandular tissue makes up from 25 to 50% of the breast.

BI-RADS 3: The breast tissue is heterogeneously dense

The breast has more areas of fibrous and glandular tissue (from 51 to 75%)
that are found throughout the breast. This can make it hard to see small
masses (cysts or tumors).

BI-RADS 4: The breast tissue is extremely dense

The breast is made up of more than 75% fibrous and glandular tissue. This can
lead to missing some cancers.

In some states, the summary of the mammogram report that is sent to patients
(sometimes called the lay summary) must contain information about breast
density. This information may be worded in lay language instead of the BIRADS
categories. Women whose mammograms show BI-RADS 3 or 4 for breast
density may be told that they have dense breasts.

Limitations of mammograms
As is the case with most medical tests, mammography has limitations.

Although breast cancer screening is the best way we have now to find cancer
early, finding cancer early does not always reduce a womans chance of dying
from breast cancer. Even though mammograms can detect breast cancers too
small to be felt, treating a small tumor does not always mean it can be cured. A
fast-growing or aggressive cancer may have already spread before its found.

The value of a screening mammogram also depends on a womans overall

health status. Detecting breast cancer early may not help prolong the life of a
woman who has other kinds of serious or life-threatening health problem such
as congestive heart failure, end-stage renal disease, or chronic obstructive
pulmonary (lung) disease. ACS screening guidelines emphasize that women
with serious health problems or short life expectancies should discuss with
their doctors whether to continue having mammograms. Our guidelines also
stress that age alone should not be the reason to stop having regular
mammograms.

False-negative results

A false-negative mammogram appears normal even though breast cancer is

present. Overall, screening mammograms miss about 1 in 5 breast cancers.

The main cause of false-negative results is high breast density. False negatives
occur more often among younger women than among older women because
younger women are more likely to have dense breasts. Breasts usually become
less dense as women age. False-negative results can delay treatment and
promote a false sense of security for the woman.

False-positive results

A false-positive mammogram looks abnormal but no cancer is actually present.

Abnormal mammograms require extra testing (diagnostic mammograms,
ultrasound, and sometimes biopsy) to find out if cancer is present.

False-positive results are more common in women who are younger, have
dense breasts, have had breast biopsies, have breast cancer in the family, or
are taking estrogen. *With annual screening, over a 10-year period the odds
that a woman will have a false-positive finding are greater than 50%. The odds
of a false-positive finding are highest for the first mammogram, and are lower
on subsequent mammograms. Women who have prior films available for
comparison reduce the odds of a false-positive finding by 50%.

False-positive mammograms can cause temporary anxiety. The extra tests

needed to be sure cancer isnt there cost time and money and also cause
physical discomfort. Still, most studies of attitudes towards false positives have
shown that women accept false positive findings as part of the process of
finding breast cancer early.

Overdiagnosis and overtreatment

While screening mammograms can find invasive breast cancer and ductal
carcinoma in situ (DCIS, cancer cells in the lining of breast ducts) that need to
be treated, its also possible that some invasive cancers and DCIS detected on
mammography will not keep growing. This means that some tumors are not
life-threatening, and never would have been detected if a woman had not
gotten a mammogram. Since doctors cant tell these cancers from those that
will grow and spread, our only hint that overdiagnosis may exist is through
statistical analysis that compares the number of cancers found by
mammography over long periods of time with the numbers of cancers that
would have been expected without screening. Overdiagnosis is a concern
because an overdiagnosed cancer still needs to be treated. This means that
some women are treated unnecessarily. These cases would be considered
overtreatment, which exposed the women to the adverse effects of cancer
therapy. Because doctors often cannot be sure which cancers and cases of DCIS
will become life-threatening, they are all treated. Although there is a wide
range of estimates of the percentage of breast cancers that might be
overdiagnosed by mammography, the most credible estimates range from 010%.

Radiation exposure

Mammograms require very small doses of radiation. The risk of harm from this
radiation is extremely low, but in theory, repeated x-rays might have the
potential to cause cancer. Still, the benefits of mammography outweigh any
possible harm from the radiation exposure.

Women should always let their health care providers and x-ray technologists
know if there is any chance that they are pregnant, because radiation can harm
a growing fetus.

Last Medical Review: 12/17/2012

Last Revised: 02/07/2013