The Benefits of Contrast-Enhanced Mammography

Roshni Rao, MD, Chief of Breast Surgery at Columbia, discusses an evolving approach to breast cancer screening, who may benefit from contrast-enhanced mammography, and all that patients should know.

We're seeing advances in breast cancer detection on several fronts, from contrast-enhanced mammography to AI research. How are these tools changing the way you think about screening?

Being able to bring contrast-enhanced mammography to Columbia has been very exciting because it seems to be better than just doing regular mammograms. And everyone knows mammograms are the best screening tests that we have. But there's an overall sense that there should be something better, right? We've been looking for that over the years.

We've tried MRI, but it can be overly sensitive. We end up getting a lot of false positives, finding a lot of things that end up being nothing. So it's not a great screening test for everyone. And even before MRI, we looked at ultrasound, but ultrasound is very labor-intensive and doesn't seem to be a great screening test either.

So over the years, we've been trying to sort out what's the best way to do this. That's why it's helpful to always be looking for the next thing. And that's what contrast-enhanced mammography is.

What does the contrast enhancement do exactly?

For patients who have dense breast tissue in particular, it allows us to sort out what's going on in areas where the breast tissue overlaps and makes things harder to see. It can pick up things that might be missed on a regular mammogram, but it's not as overly sensitive as MRI.

Is it for everyone? No. You do have to have a dose of contrast, and contrast does have some risks. Not very many, but you have to put in an IV, and the patient has to be agreeable to getting contrast. So it's certainly not perfect, but it gives us another option that we didn't have before.

Who is a good candidate for contrast-enhanced mammography, and where does it fit alongside traditional mammography and MRI?

If you're high risk, you can get MRI, and MRI is by far the most sensitive test that's out there. But mammography, especially in dense breast tissue, isn't perfect either. So contrast-enhanced mammography is something that's kind of in between.

If you don't have dense breast tissue, then probably a regular 3D mammogram is fine. It's going to be able to see through the breast tissue. But let's say your risk is 17%. The average woman's lifetime risk is around 10%, and high risk is generally considered 20% or greater. What do we do with someone who's at 17%?

You're not high risk enough to qualify for MRI, but you're above average risk and you have dense breast tissue. So let's do contrast-enhanced mammography, and you only have to do that once a year.

Before contrast-enhanced mammography, we were mostly adding ultrasound for patients who needed something beyond a regular mammogram. Was that particularly helpful? Most of the studies show it wasn't particularly helpful. We just didn't have great options.

Now we have options for what I would call the "tweeners," right? Someone who's between average and high risk but doesn't qualify for an MRI. Or some of our patients just can't get an MRI. They're too claustrophobic, or whatever it is.

So this allows us to do what we call enhanced surveillance. More screening than just a regular mammogram, but not an MRI.

Would a patient receive both a regular mammogram and a contrast-enhanced mammogram?

No, you don't do both, because there is a dose of radiation with it. Contrast-enhanced mammography would be the mammogram for that screening visit.

What should patients expect during a contrast-enhanced mammogram? Is it much different from a traditional mammogram?

It's essentially the same procedure, but you do have to get an IV and receive the contrast. So it certainly takes a little more time. I believe there is a slightly higher dose of radiation, but not a lot. Not enough that I would be worried about the radiation.

And because you're getting contrast, we need a nurse there to administer it and make sure the patient doesn't have a reaction. So there are some additional steps involved, but there's no recovery. You go home and go back about your business, or go back to work, wherever it is. You walk out and you're fine. You don't have to have someone come with you, take you home, or recover from anything like that.

Where is contrast-enhanced mammography currently available at Columbia, and are there plans to expand access?

Right now, we're offering it at HIP [Herbert Irving Pavilion]. We're planning on launching it at The One and probably also at Hudson Valley.

What about insurance coverage? Is it difficult for patients to access this type of screening?

No, not right now. We're able to offer it easily to patients who are interested.

Looking further ahead, do you think breast cancer screening will become more personalized to each woman's individual risk?

I think that's where we're going to go, because risk assessment and screening are becoming so complicated, right? It's not just one-size-fits-all, come and get your mammogram once a year. We really have to have a conversation, and there are probably going to be more options going forward.

There are some interesting studies looking at CT scans specifically for breast cancer. They're not there yet, but there's also a trial called the WISDOM trial that just published some preliminary results. That trial is trying to sort out an individual patient's risk and then really personalize their screening.

Because does every woman over the age of 50 have to have a mammogram every single year? Probably not, but we just don't know who does and doesn't.

How does your team help patients better understand their own risk and make decisions about screening?

One of the nice things is that we're now in a position at all of our sites, at HIP, The One, Hudson Valley, and NYP Westchester, where we have a nurse practitioner at each site.

They're breast specialists embedded in our department. They're not surgeons, but if patients have a question about what their actual risk is or what they need to do to figure that out, they can come in and see them. They see new patients for risk determination, and they have a fair amount of availability.

There are different models we use for risk calculation. Depending on that patient's particular factors, we can use these different calculators to really drill down into what their risks are.

And then we can sort out with them what their goals are for screening, right?

Some patients come in and say, "I'm a bit of a minimalist. I want to do only what's absolutely necessary." And some patients, for whatever personal reason, have a lot of concerns and anxiety about breast cancer. They find it more comforting to come in every six months and have some sort of screening or assessment, or even just an exam. They feel like that's going to be more helpful for them.

So our nurse practitioners can sit down with a patient and sort out not only what they're eligible for, whether that's mammography, ultrasound, contrast-enhanced mammography, or MRI, but also discuss what their goals are for screening.