How Contrast-enhanced Mammography Improves Cancer Detection

It’s a well-established statistic: one in eight women will develop breast cancer in her lifetime.

With odds like that, women who meet certain criteria or have breast tissue that is difficult to examine with routine mammograms deserve extra reassurance.

By taking mammography technology to the next level, contrast-enhanced mammography (CEM) can provide peace of mind. As a radiologist, Monica Yepes, M.D., knows that (CEM) can make a real difference in a patient’s diagnosis. Dr. Yepes is chief of Breast Imaging and director of Breast Imaging Services at Sylvester Comprehensive Cancer Center.

She recalls a high-risk patient who had multiple masses in her breast tissue. Her situation was difficult for doctors to monitor. Using CEM, which is almost as sensitive as a breast MRI, her doctors were able to closely follow her condition.

“It gave her a great sense of security,” Dr. Yepes says.

In another instance, a person who works with Dr. Yepes also had breast tissue that was difficult to screen. Her routine mammogram had highlighted several areas that seemed suspicious. The contrast-enhanced mammography revealed no cause for concern.

A third patient’s routine mammogram suggested the need for a breast biopsy. She avoided that procedure after her contrast-enhanced images showed no signs of cancer. Another high-risk patient with dense breast tissue could not have an MRI. Her CEM detected a small cancer not found on her regular mammogram.

In patients with a recently diagnosed breast cancer who may not be candidates for MRI, “A contrast-enhanced mammogram helps us find additional areas of concern that don’t show up on a regular mammogram. And it’s less likely to produce a false-positive result than an MRI. This is part of staging the breast,” Dr. Yepes says.

Staging is a process that helps doctors determine how much cancer is present, which helps them to decide on the appropriate treatment.

 In a study of 611 women, contrast-enhanced mammography was “significantly more sensitive than standard digital mammography in detecting breast cancer.”

Although CEM has existed for more than a decade and was approved by the Food and Drug Administration (FDA) several years ago, it only recently came into wider use. Sylvester began using this diagnostic tool two years ago and remains one of the few South Florida facilities to offer this technology.

What to expect with CEM

How does contrast-enhanced screening differ from a conventional mammogram? It’s similar, with one distinct difference.

Contrast iodine is administered into the patient’s arm through an IV. There is a two-minute wait to allow the contrast to get into the breast tissue. Our technologist then performs a mammogram, taking four views of each breast: two in each position (which only feels like one because they are taken within the same breath-hold).

Through special technology, four of these images are taken so that the contrast is not visible. The other four demonstrate the contrast.

Within 10 minutes, it’s done. A radiologist reviews the images immediately to see if additional images are needed, and directs the technologist accordingly.

Do I need a contrast-enhanced mammogram?

It depends.

Women with a very high risk of breast cancer such as those listed below need to be closely monitored. In these patients, a yearly MRI, in addition to an annual mammogram, is recommended.

Breast cancer risk factors:

• Having the BRCA1 or BRCA2 gene.
• A personal or family history of breast cancer
• Chest radiation therapy before age 30
• A lifetime risk assessment higher than 20%

If you don’t meet these criteria but are still at high risk or have dense breast tissue or significant scar tissue because of past surgeries, your doctor may recommend more advanced screenings such as ultrasound, contrast-enhanced mammography, or MRI.

Contrast-enhanced mammography also proves helpful if you can’t undergo an MRI because you have:

• Claustrophobia
• Implanted metal devices
• An allergy to gadolinium (the dye used during an MRI to show detail)
• Obesity (some patients are too large to fit comfortably inside an MRI)

When is it better to get a routine mammogram?

Shouldn’t every woman have CEM, given the extra clarity and information it provides? “We’re not to the point of recommending them for everyone at this time,” Dr. Yepes says.

She notes that some patients should avoid contrast mammograms. “We screen patients for contraindications,” adding that it is best to avoid contrast-enhanced mammography if you have:

• Renal (kidney) disease or problems
• Severe hypertension (high blood pressure)
• Breast implants
• Allergies to iodine-based contrast dye
• High risk of anaphylaxis

The problem with procrastination

Pandemic-related repercussions affected every aspect of our lives, including routine cancer screenings. “We are very concerned that patients are postponing mammograms. Almost two years into this pandemic, we are finding a lot of advanced cancers due to postponement,” Dr. Yepes says.

Dr. Yepes believes patients have more to fear by putting off a mammogram than by going into the Breast Imaging Center. “We never stopped our safety precautions. All patients are screened before entering. Most of our staff are vaccinated, and everyone wears personal protective equipment (PPE). We haven’t had a single patient become infected with COVID because they were here with us, and no patients have infected our doctors or staff. We’re actually much safer in a hospital than in our communities.”

When scheduling a screening, “Wait four to six weeks after a COVID vaccination before getting a mammogram. The vaccine may inflame the lymph nodes – that’s your body creating a healthy response to the vaccine. It can confuse the radiologist reviewing your mammogram, as the swollen lymph node may appear suspicious, when it’s just inflammation. However, if you feel a lump in your breast or see any suspicious changes, don’t wait. Come in as soon as possible and tell the technologist if you were recently vaccinated.”

For now, contrast-enhanced mammography is only available at Sylvester Comprehensive Cancer on the main campus of UHealth and at the Lennar Foundation Medical Center. “We’re working on expanding this service to our satellite facilities,” Dr. Yepes says. Whichever mammogram you need, her message is the same. “We are here for you. Please come in.”

Preparing for Your Mammogram

To have a more successful screening experience:

• Minimize caffeine consumption a few days before getting screened. (Caffeine makes breast tissue more sensitive and can make a mammogram more uncomfortable.)
• Don’t wear deodorant, powders, or lotions on your upper body the day of your appointment.
• If mammograms are painful for you, take a mild pain reliever such as ibuprofen (Advil) or acetaminophen (Tylenol) unless your doctor has told you to avoid these medications.
• If you haven’t gone through menopause, schedule your mammogram during the first half of your menstrual cycle, when your breasts are less likely to be tender.
• If you were screened at another facility, bring your prior reports and images with you to your Sylvester appointment.
• Ask your insurance provider whether they cover 3D mammograms and CEM. Currently, Dr. Yepes says that mammograms are billed separately from the contrast portion of the procedure.

To ease discomfort during your mammogram:

• Relax your upper body so your muscles aren’t tight. Let out a sigh just before your technologist positions your breast.
• When the technologist tells you to hold your breath, stop breathing. Taking in a big breath tenses your body and can make you pull away from the machine.

Nancy Moreland is a regular contributor to UMiami Health News. She has written for several major health care systems and the CDC. Her writing also appears in the Chicago Tribune and U.S. News & World Report.

Tags: breast cancer detection, cancer care in Miami, contrast-enhanced mammograms, mammogram, mammography