Breast Cancer Awareness Month: The Role of Ultrasound

As you can tell by the pink sneakers worn by NFL players, it’s Breast Cancer Awareness Month!

As such, over the course of the month, we will feature a few aspects of breast cancer diagnosis and treatment that may of interest to our readers. Today- the role of ultrasound in the diagnosis of breast cancer.

As we reported in June, former GMA host Joan Lundun was diagnosed with breast cancer. As she reported on her website, Joan Lunden’s Healthy Living:

“Two weeks ago I went for my annual mammogram as I do every year religiously, and thankfully it was all clear. That is always the moment where I feel I can breathe again. However for women who have dense fibrous breast tissue, as I do, often our doctors will recommend an ultrasound as well. My ultrasound that day revealed a tumor in my right breast.”

Everyone knows that mammography is important in the early diagnosis of breast cancer, but in this case, Joan’s mammogram was negative. Why did she have an ultrasound? What role should ultrasound play in the diagnosis of breast cancer and who should consider getting a breast ultrasound?

First, a little about breast anatomy:

the-breastsThe mature female breast is composed of essentially four structures: lobules or glands; milk ducts; fat and connective tissue.  There are 15 to 20 sections (lobes) arranged in a spoke pattern,  each lobe being made of many smaller sections (lobules). Lobules have groups of tiny glands that can make milk. After a baby is born, breast milk flows from the lobules through thin tubes (ducts) to the nipple. Fibrous tissue and fat fill the spaces between the lobules and ducts.

The glandular tissue is not uniformly distributed throughout the breast. There tends to be more glandular tissue in the upper outer portion of the breast. This is why many women complain of pain in this area just before their periods. It is also the site of about half of all breast cancers.

The consistency of the breast tissue varies from woman to woman, and even within the breasts of a single woman. The glandular portion has a firm, somewhat “nubby” feel to it, while the surrounding fat is typically soft.  It is exactly this difference in the “feel” and density of these two tissues that allow them to be differentiated on a mammogram.

The breast tissue of younger women tends to be denser, with more glandular tissue and less fat. Over time, especially after the loss of estrogen that comes with menopause, the glandular tissue shrivels (involutes) and is replaced by fatty tissue.

There is some research that suggests that women with dense breasts have a higher incidence of breast cancer, although the reasons for this are unknown at the present time.
Dense breasts make it more difficult to detect breast cancer on a mammogram. This is because dense breast tissue can look white/gray on a mammogram- the same as cancer (see diagram below).

breast densityPhoto credit: Susan B. Komen
Digital mammography– where the image is sent directly to a computer, rather than onto an x-ray film may be better for patients with dense breasts, as the images can be digitally altered to find hidden tumors.

BreastUltrasound_image1Ultrasound is another method some physicians will use to supplement mammography in women with dense breasts. Ultrasound, or sonography, uses sound waves to look inside a part of the body. An instrument called a transducer is rubbed across the skin, which is lubricated with a special ultrasound gel.  There is no radiation involved which is why it is safe to use in pregnant women.

Breast ultrasound is often used to evaluate breast problems that are found during a screening or diagnostic mammogram or on physical exam. Ultrasound can help distinguish between a cyst (fluid-filled sac) and a solid mass. Some physicians supplement the routine mammogram with an ultrasound in women with very dense breast tissue. Research has shown that it is not a good tool for mass screening for breast cancer, as there are an unacceptable rate of false negatives and positives.

The bottom line– ultrasound should not replace the mammogram for breast cancer screening. It may be used as  an additional test to tell whether a mass seen on mammogram or felt by a physician is a cyst or solid mass, or as a supplemental test for women with particularly dense breasts.

Michele R. Berman, M.D. was Clinical Director of The Pediatric Center, a private practice on Capitol Hill in Washington, D.C. from 1988-2000, and was named Outstanding Washington Physician by Washingtonian Magazine in 1999. She was a medical internet pioneer having established one of the first medical practice websites in 1997. Dr. Berman also authored a monthly column for Washington Parent Magazine.


  1. Kevin Li

    October 15, 2014 at 11:43 pm

    Promoting public awareness of important medical information can be difficult. However, using popular TV broadcasts can be useful for conveying important information in a way that is easily retained. For example, surveys have shown that an episode of the medical drama Grey’s Anatomy can increase viewers’ awareness of the improbability of mother-child HIV/AIDS transmission during childbirth. If a one-hour episode can have a significant and measurable impact on HIV/AIDS awareness, then a month-long breast cancer awareness campaign could have an enormous effect on women across the nation. For the past several years, the NFL has promoted breast cancer awareness by using pink equipment on playing fields, including pink cleats and gloves worn by the players and pink ribbons painted onto fields. This year’s motto is “A Crucial Catch”, aimed at encouraging women to seek annual mammograms. While this message promotes awareness and vigilance, it should also show that annual mammograms is not a perfect screening method, and that it could have some of the drawbacks that Dr. Berman has listed in this post.

    While mammograms have become the standard for breast cancer screening, the method comes with several limitations. In this post, Dr. Berman shows that annual mammograms cannot always offer a final diagnosis of breast cancer, due to a variety of factors. Although annual mammograms have caught early-stage breast cancer for untold numbers of women, mammograms are not a perfectly reliable screening tool. This important qualification has implications that go beyond semantics. Merely suggesting that a woman has breast cancer and not yet offering a final diagnosis can have profound psychological effects on the patient. In a written account of a Columbia University physician, a breast cancer patient shows enormous anxiety as she contemplates the possibility of a recurrence following a total mastectomy. Despite the lack of medical evidence suggesting a recurrence, that fear stays with this patient. Even without a definitive diagnosis, the idea of possibly having cancer is a terrifying thought that is not easily erased. As a result, women should go to their annual mammograms knowing what limitations this procedure can have.

    One way more women can be made more aware of the possible disadvantages of mammograms is through exposure to the media. As the NFL continues its month-long breast awareness campaign to encourage more women to seek regular mammograms, it should adjust its message to show that mammograms are not a perfect diagnostic tool, and that they also reveal things that are not cancer. Because of the psychological damage that a false-positive mammogram can cause, more women should be made aware of some of these limitations, as Dr. Berman lists here. In addition, the NFL could also better serve women by showing that additional imaging procedures can be used to either confirm or disprove a positive mammogram. This way, more women can be empowered to seek routine mammograms while arming themselves with the knowledge of what a mammogram is capable of showing and what it is not capable of proving.

  2. Hai-Uyen Nguyen

    October 16, 2014 at 11:10 am

    I recently discovered that a fitness instructor that I regularly take classes with at 24 Hour Fitness is a breast cancer survivor. For her Body Combat class this past Saturday, she asked many of the regular class-goers to wear pink for October’s breast cancer awareness month. It would be safe to say that most people in America can correctly connect the color pink with breast cancer awareness; however, I would say that many people do not actually know much about breast cancer itself, besides the fact that it affects many women. As a female that has been taught how to check for lumps that may indicate breast cancer but knows nothing more about it, reading this article taught me more about the anatomy of the breast and ways that doctors check for breast cancer.
    This article about breast cancer reminds me of the Grey’s Anatomy episode from November of 2005, which featured a woman who visited the hospital wanting to remove her ovaries and breasts. She was taking preventative measures against breast cancer since she discovered she carried the BRCA gene, which puts her at an increased risk for developing breast cancer. Hether et al. actually studied the results on the public’s perception of breast cancer after the viewing of this show as well as another recent show of E.R. that depicted breast cancer as well. As was shown in the study, watching both of these shows increased awareness of breast cancer and what can be done to prevent it. However, Grey’s Anatomy seemed to have “less of an impact on viewers’ attitudes about preventative mastectomy because it depicted more discussion among the characters as to whether surgery was the most appropriate response to a positive BRCA test” (820). Media depictions of health issues have an extremely large impact on how the general public perceives and acts towards these health issues. Even the ways in which the media depicts the issue can influence how people perceive the health issue. Therefore, our media has an eerily strong hold on the general public’s view of the world around them. For example, viewing Grey’s Anatomy was “marginally associated with behavior change” possibly because there was debate on the show as to whether getting breasts and ovaries removed would be the best response to having the BRCA gene. It is obvious that anything that is depicted on mass media will have a huge effect on our perceptions of health-related issues. However, it should not be the media’s job to educate the public. Therefore, it is very important that we, as the general public, can filter and keep the mass media depictions from swaying our perceptions.

  3. Monica Bodd

    October 16, 2014 at 6:20 pm

    The arrival of Breast Cancer Awareness month raises important questions about the use of mammograms and ultrasounds. The prescription of an annual mammogram is one of the largest preventative measures of breast cancer medicine. However, looking at the case of GMA host Joan Lundun, it is seen that this prescription was futile – only an ultrasounds later was it revealed that she had at tumor in her right breast. Does this mean that we should prescribe an annual ultrasound? What is the point of annual mammograms if they can’t catch every case of breast cancer?

    Population medicine has become a trending measure in the medical field. As Eric Topol talks about in The Creative Destruction of Medicine, the future of healthcare based in technology can imply the loss of personal diagnoses and resultant measures taken based on population research. For example, a mammogram may be prescribed to a woman because research shows that, on average, a mammogram will be able to detect breast cancer. However, the specific case of Joan Lundun was that her form of cancer could only be detected with an ultrasound, proving a mammogram futile and unnecessary radiation. Women require different forms of scans to detect breast tumors due to varying breast tissue densities and the multiple types of breast carcinomas. The rapid use of technology and its equivalent loss of personalized medicine have allowed large sample research to dictate medical measures for the entire population of women. Population medicine has taken the reins and leads healthcare systems to apply conclusions to entire populations that only apply to select groups of people, thereby causing unnecessary checkups and stress upon the patient. I guess the annual checkup mammogram isn’t as personalized and preventative as I thought.

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