By Erin Steigleder, MSW, Director of Programs
When it comes to breast cancer screening, you may be surprised to know that mammography isn’t the only game in town. We’re going to highlight six imaging tests that can be used in breast cancer screening and, spoiler, why you might end up sticking with mammography. Screening is different from diagnostic testing, and the imaging tests below can be used in different ways and have different cost implications when it comes to diagnostics, so the descriptions below only apply to how the tests are used in breast cancer screening. You are undergoing breast cancer screening if you have no symptoms of breast cancer and you are just going in for an annual check, but it becomes diagnostic testing if you report a possible sign or symptom of breast cancer or if you are fewer than five years out from a breast cancer diagnosis, because those who have recently been treated for breast cancer need to have more involved testing.
On this front, however, we have some exciting news. After three years of work from the Virginia Breast Cancer Foundation and our partners, Virginia’s governor signed a bill requiring that diagnostic imaging for breast cancer be provided at no out-of-pocket cost for women with certain insurance plans. We’ll be putting out more information on this in the coming weeks and months, so be sure you are signed up for our email newsletter to keep up with the latest information.
Mammograms
Mammography is the tried and true breast cancer screening test. It’s been in common use since the 1980s, and though the technology has advanced quite a bit since then, the test itself is largely the same. A mammogram is an x-ray of the breast. During a mammogram, the breast is placed between two plates and squeezed to spread out the tissue, and the process is repeated on the other breast. The technologist will take two different “views” of each breast at different angles, so expect to take about 4 different pictures in all. The breasts are exposed to a small amount of radiation, about the same amount as what you experience flying cross-country in an airplane. The entire process doesn’t take very long and after you are finished your technologist will let you know their process for how they get you the results from the radiologist, a medical doctor specially trained to interpret x-rays and other imaging tests. Either they will call you within a few days if you need to come back for further imaging, or you will receive a note in your electronic medical chart or through the mail that your test results are all clear. But rest assured, if you get called back, it doesn’t automatically mean you have cancer. About 10% of patients return for what most commonly turns out to be non-cancerous, benign changes related to hormones, aging, or overlap of normal breast tissue.
Insurance
If you have health insurance, they will most likely cover one “baseline” screening mammogram between the ages of 35-39 and then an annual mammogram starting at the age of 40. If you report a symptom, even though it might be your usual time to get a screening, your mammogram may be coded as diagnostic, as additional x-ray views and/or an ultrasound may be needed to thoroughly evaluate your symptoms. This means you may need to pay a co-pay or coinsurance when you receive your test,
Pros and Cons
The main pros about using a mammogram for breast cancer screening is that it is the recommended first-line test and is covered by insurance at no cost. They are quick, non-invasive, and catch most breast cancers at a low cost to the medical system as a whole. Of all the tests out there, mammograms have the most scientific evidence behind them with regard to saving lives through early detection: when done yearly starting at 40, mammograms have lowered the death rate from breast cancer by > 40%. In large part, this is through showing the earliest, stage 0 cancers that other tests are not as good as finding. There is also the Every Woman’s Life program that covers the cost of breast screening and diagnostics for women who are uninsured.
A few minor cons about mammograms are that they can be uncomfortable because they require the breast tissue to be squeezed between two plates, from the underarm to the nipple. If you experience discomfort during a mammogram, imaging centers will sometimes recommend taking ibuprofen/Advil ahead of your appointment, or scheduling at a certain time of the menstrual cycle if possible, when the breasts may be less tender, but check with your doctor and imaging center staff to be sure what is right for you. For those with dense breast tissue, a mammogram alone may not be enough to diagnose breast cancer, as it may miss a small cancer or “lump” that is hiding in dense tissue that is the same shade of gray.
Where Does it Rank?
Mammograms really are the gold standard in breast cancer screening for women of average risk for developing the disease. Relatively quick, accurate, and inexpensive as far as medical tests go and widely available. Even 3D mammograms, or breast tomosynthesis, a relatively new mammography technology, is widely available now, which is especially beneficial for people with dense breast tissue. If you need a breast cancer screening, the mammogram is the right first choice for most people.
Mammogram with Contrast (Contrast Enhanced Mammography, CEM)
A mammogram with contrast, as one might imagine, shares a lot of similarities with the standard mammogram but with one big difference: the addition of contrast. The contrast is an iodine-based dye that is given to the patient through an IV before the mammogram begins. This dye helps to light up potentially cancerous tissue on a mammogram because the dye follows the blood flow. The greater the blood flow to an area, the brighter that area will show up on a black and white mammogram image, and areas with greater than normal blood flow can indicate cancerous tissue.
Insurance
Contrast-enhanced mammography is a relatively new technique and is not yet covered in full by most insurance plans. There is not yet sufficient evidence to show that the addition of contrast provides enough benefit to warrant insurance coverage, so if you are considering this option please be sure to contact your insurance plan ahead of time to learn more about what your payment obligation might be.
Pros and cons
The pros and cons of contrast-enhanced mammography are largely the same as mammography without contrast. The pro of adding contrast to mammography is that the dye could draw more attention to potentially cancerous tissue, which could be a benefit to those with dense breast tissue and can help radiologists to see problems that may hide in a standard mammogram. This could mean fewer missed cancers in women with dense breast tissue. However, there are also more cons with contrast-enhanced mammography. The test is likely not covered by insurance so it will cost more, not many imaging centers are offering the test because it is not covered by insurance, and it is minimally-invasive due to the introduction of the iodine-based dye through an IV. Whenever a test becomes invasive there is a greater risk of complications. Complications for this test range from bruising due to IV insertion to an allergic reaction to the dye, which may particularly be a problem for people who are allergic to shellfish. It also uses more radiation than a standard mammogram. And, because it is still a mammogram, it still uses compression, requires two views of each breast, and has the same “blindspots” as a standard mammogram. If you are considering a contrast-enhanced mammogram, please be sure to cover the benefits and risks thoroughly with your doctor so you can determine if potentially increased accuracy is worth the additional risk for your unique circumstances.
Where Does it Rank?
A contrast-enhanced mammogram is not the first choice for your standard breast cancer screening and in many cases, may not offer any additional benefit compared to a standard mammogram and, therefore, is not worth the additional risk. However, it is a potential tool in the toolbox if you have dense breast tissue or high lifetime risk of breast cancer, want a more detailed test, and an MRI is either inaccessible or unappealing to you. If you’re curious about this test, please talk to your doctor about if this might be an option for you or not.
Thermography
Thermography is another noninvasive imaging test that is sometimes used for breast cancer screening. It measures heat in the breast and maps out which areas are reading hotter than normal, which could be an indicator of potentially cancerous tissue. Thermography uses infrared technology rather than the small amounts of radiation used in mammography, and there is also no tissue compression as part of the test. The theories behind how it works is similar to the use of contrast mammography, more heat in an area means more blood flow and that extra blood flow could mean cancerous tissue. We wrote a blog a while back solely on thermography, so if you want more information you can give that a read.
Insurance
Thermography is not covered by most insurance, and that is because there is not yet sufficient evidence that it provides adequate screening for breast cancer. Because the screening is not better than mammography, most health insurance companies won’t cover it.
Pros and cons
Some pros about thermography are that it uses infrared technology instead of small amounts of radiation like mammography and there is no tissue compression. The lack of radiation and compression can make some patients feel more mentally and physically comfortable with receiving a breast cancer screening test. Thermography is also more accessible for people who live in areas around the world without regular access to mammography because the technology is easier to make portable.
The cons about thermography are that it is not as thorough as a mammogram, and it costs money because insurance doesn’t cover it for free like mammograms. Thermography is good at identifying invasive breast cancer, but does not do a good job at identifying Stage 0 or in situ breast cancers or calcifications. Some stage 0 breast cancers can become invasive so when they are found in a mammogram, surgery to remove them is generally prescribed. If these tumors are missed at the noninvasive stage, they have time to grow and spread and become more difficult to treat in the future. Calcifications are also an indicator of breast health that could cause your radiologist to recommend further screening or a follow-up visit in 6 months instead of a year, and if those calcifications aren’t seen then they cannot be watched. Lastly, an abnormal thermogram still requires a mammogram and/or ultrasound to follow up and guide tissue sampling (needle biopsy), since those are the gold standards to diagnose a breast cancer.
Where Does it Rank?
Thermography is not recommended as a screening tool for breast cancer. The technology is not yet good enough to justify its use in place of or alongside a mammogram. A mammogram does not use enough radiation to be harmful, even across decades of screening, and thermography can miss more small cancers or potential problems, meaning there is no real benefit conveyed by using thermography over mammography, and may actually be harmful in some cases.
Ultrasound
An ultrasound is a test that uses sound waves to map out the internal tissues of the breast. Ultrasounds can show fluid in tissue, which is helpful in determining whether a mass is a benign, non-cancerous fluid-filled cyst or a more solid mass or “lump” of tissue that is cause for further testing. Because of this they are usually used as supplemental testing after an initial mammogram. The radiologist can use the ultrasound to take a closer look, in a different way, at any areas from the mammogram that looked potentially concerning. This is particularly helpful for women who have dense breasts because their mammography images are often difficult to decipher on their own. We sometimes get the question “why can’t I just have an ultrasound instead of having to do the mammogram first? I always end up with an ultrasound anyway.” The rest of this section will deal with that question.
Insurance
Insurance will not “sub in” an ultrasound for a screening mammogram, so many people will end up paying at least a portion of the cost for the ultrasound as it is considered diagnostic or supplemental imaging.
Pros and Cons
A pro of getting an ultrasound as your only screening for breast cancer is that there is no tissue compression, which can make some women uncomfortable; or radiation. An ultrasound will also allow a closer look at cysts and other lumps and bumps that you can feel and may find some that you can’t. The major con with an ultrasound is that it can miss early, stage 0 cancers that show up as calcifications only be seen on mammograms.
An ultrasound only looks at one area of the breast at a time, and its quality can depend on the skill of the person performing it. This is why the ultrasound is best used after a mammogram has been performed. The mammogram provides a map for the ultrasound to follow by highlighting potential areas of concern. The person operating the ultrasound then goes on a mission to find those same areas with the ultrasound in order to get a clearer picture of what is happening. Because they know there is something there to find, they will work to manipulate the wand or maneuver the breast tissue until they find what they are looking for. The mammogram guides the ultrasound. Without that map provided by the mammogram, they don’t know there is something to find and could easily not have the wand or the breast tissue in the right position. Some facilities use an automated breast ultrasound machine, or ABUS, to ensure the entire breast is covered uniformly throughout the scan, however these too can result in more false alarms and so are best interpreted in conjunction with, rather than a substitute for mammograms.
Where Does it Rank?
Ultrasound is a very helpful tool in breast cancer screening, but only in conjunction with a mammogram. Ultrasound alone would miss too many potential cancers when they are early and small, meaning treatment would begin at later stages, which can mean more surgery and a longer time in treatment. Getting an ultrasound after a mammogram, if recommended by a radiologist, is the right way to go. Women with dense breast tissue, and/or at high risk for breast cancer especially benefit from getting screening ultrasounds to supplement their screening mammograms.
Magnetic Resonance Imaging (MRI)
Magnetic Resonance Imaging, or MRI, is the most detailed way to screen for breast cancer. MRIs use magnetic and radio waves to map the inside of the breast. The test involves the patient being injected with a dye containing gadolinium and laying on their belly on a platform. The platform has a cutout in which the patient’s breasts are inserted so that the tissue hangs down. The platform then moves inside the MRI tube, and the test begins. MRIs can take a while, from 30 minutes to an hour.
Insurance
Insurance coverage of a breast MRI can be difficult. MRIs, in general, are a very expensive test, and breast MRIs are no different in that respect. Some health insurance plans will partially cover the cost of the test; some won’t cover it at all if they don’t agree with your breast cancer risk assessment (more on that later). Thankfully, breast MRIs are part of Virginia’s new law on diagnostic breast imaging coverage, so beginning in 2026, many people will be able to access it without any out-of-pocket cost. If you are interested in getting a breast MRI or your doctor recommends that you get one, call your insurance company first to see what is covered under your plan.
Pros and Cons
The main pro of an MRI is that it is the most detailed image you can get, even for people with dense breasts. An MRI will see everything that is happening inside the breast tissue and the surrounding area because it is a “360 degree” view of both breasts, the armpits, and chest wall. This is especially beneficial for people with dense breast tissue and people who are at a higher risk of breast cancer due to their genetics or other reasons.
Unfortunately, the level of detail is also related to a small con of breast MRIs: they see everything, even things that are benign, not cancerous, and likely won’t cause problems. These are called incidental findings, things that a test discovered “on accident” that warrant further testing even if they are not the presenting problem. Yes, you do get more information about what’s going on inside your body from incidental findings, but you might also spend extra money and time learning about what the finding means. Also, as mentioned above, MRIs can be difficult to get insurance to cover, so you and your doctor may be spending some time on the phone trying to convince them that you need it.
MRIs also pose some additional risk compared to mammograms because of the use of injected dye. Additionally, MRIs can be an unpleasant experience. The test usually involves loud noise and being encased in a tube for 30 minutes to an hour, which can be difficult for someone who gets claustrophobic, and the proper positioning may be difficult for some people to hold for an extended period of time. Patients with kidney failure or pacemakers/defibrillators may also not be able to have an MRI. The kidneys need to be able to eliminate the dye from the body. And any metal can affect the quality of the images. These are important things to discuss with your doctor ahead of getting an MRI; CEM or ultrasound may be good alternatives if you have dense tissue or are at high risk and need additional screening.
Where Does it Rank?
A breast MRI is the highest quality breast imaging you can get, but that doesn’t mean it is right for everyone. If you are of average risk for developing breast cancer and you don’t have dense breasts, an MRI is likely overkill. But, if you are high risk and/or you have very dense breast tissue, your doctor may recommend getting an MRI as a part of your breast cancer screening routine. Some people have an MRI every few years, some every year, and some every six months, depending on their personal risk and medical recommendations. If you are high risk for developing breast cancer or you have dense breast tissue, talk to your doctor to see if you should get a breast MRI.
“Fast” MRI
A “fast” or abbreviated MRI is the same as a regular MRI, except it takes fewer images, and so it only takes about 10 minutes.
Insurance
Insurance does not yet cover a fast MRI for breast cancer screening, so it is likely the patient will pay a portion out of pocket. However, facilities may charge a flat fee that might actually be cheaper than an insurance copay, so be sure to check with both the facility and your insurance company in advance.
Pros and Cons
A fast MRI has similar pros to a traditional MRI in that it takes more detailed images than a mammogram. A fast MRI is also a quick test, so it won’t take as much time as a traditional MRI. This can also make it easier for people with claustrophobia or trouble holding the correct positioning to get through the test. The cons of the fast MRI are also similar to that of a traditional breast MRI because a gadolinium-based dye is still used, insurance coverage is a challenge, and the test is loud. Another con of the fast breast MRI is that it is not yet widely available, putting it in the same boat as contrast-enhanced mammography.
Where Does it Rank?
A fast MRI might be a good option for you if you are at a higher risk of developing breast cancer and/or have dense breasts, but due to the cost and limited availability, it may be hard to access compared to mammography or a traditional breast MRI. If you are interested, mention it to your doctor and see if they think it is a good fit and if there is a facility near you that provides the test.
In Conclusion
So, there you have the current screening imaging tests for breast cancer. To sum up, for most people, the mammogram, particularly the 3D mammogram or tomosynthesis, is the right choice. If you think you might be high risk or you have dense breasts, talk to your doctor about if an MRI, either traditional or “fast”, might be a good option for you as well. Ultrasound is a great tool to be used as part of breast cancer screening, but the technology is not a suitable replacement for mammography. Thermography is also not advanced enough to be a useful tool for catching breast cancer in its earliest, most treatable form.
Remember, to stay informed about how the new Virginia law on breast diagnostic imaging works, please sign up for our newsletter! As a result of this law, many people will have these tests covered by their insurance at no out-of-pocket cost. We’ll be releasing some guides in the coming months on how to determine if your health insurance plan falls under this new law, so stay tuned!
