Changing emphasis in breast diagnosis: the surgeon's role in evaluating mammographic abnormalities

The increasing number of mammograms performed has resulted in a substantial increase in surgical referral for mammographic abnormalities with or without clinically apparent change. This increase challenges surgeons to examine their criteria for biopsy.

I performed a retrospective review of data from 2,936 women referred for breast assessment. Data from women younger or older than 50 years who were clinically normal or who had a clinically apparent lesion were evaluated to determine the effect of mammographic diagnosis on the biopsy rate, rate of carcinoma diagnosed per biopsy performed, and prevalence of carcinoma in the categories of mammographic results.

Although the rates of biopsy and detection of carcinoma were different in younger and older women, the influence of mammographic diagnosis was similar. Regardless of age and presence or absence of a clinical abnormality, few breast carcinomas were detected in women whose mammograms showed normal breasts or benign lesions. Mammograms that showed malignant changes, even among women assessed as clinically normal, significantly influenced the rate of biopsy and the diagnoses of breast carcinoma.

Women who are assessed as clinically normal and have mammograms that show benign lesions and women who have a breast problem judged clinically as benign and mammographic results that are normal or show a benign lesion can be observed with confidence that the risk of breast carcinoma is low. By careful selection, 40 percent of women who are assessed as clinically normal and younger than 50 years and 20 percent of women older than 50 years can be observed rather than undergo biopsy, even though the mammogram is considered to show malignant changes. A clinical abnormality combined with a mammographic finding of malignancy almost always requires performance of a biopsy. Because of the large number of women referred for surgical evaluations who have normal results on a mammogram or whose mammograms show a benign problem, a conservative approach is appropriate to reduce the number of biopsies performed in women of all ages.