Mammogram – What does my callback letter mean?

So, you just received a callback letter from your screening mammogram. This is NOT the time to panic. There are many factors that could influence a radiologist’s decision to call a patient back for additional imaging. If you asked me what exams in radiology seemed the most artful, relying on skill, talent, and utilizing clinical common sense, resulting in an innate sense where something on the image causes you to perk up almost unconsciously drawing your attention. Well, the reading and interpretation of mammography and chest X-ray are at or near the top of that list.


Both these exams can have extremely subtle findings, which may not be recognized by inexperienced, much less seasoned, radiologists. Well, if you got a callback letter the radiologist must have seen something, right. Of callbacks, fewer than 1 in 10 patients are eventually diagnosed with cancer. Of that, 1 in 5 of these newly diagnosed cases ends up being ductal carcinoma in situ (DCIS). DCIS is non-invasive cancer with treatment typically including lumpectomy +/- local radiation therapy, without the need for systemic chemotherapy. So take a breath, the odds are in your favor.


That being said, why did you get a callback letter? Radiologists call patients’ back for subjectively abnormal findings on the screening mammogram, including densities, calcifications, and architectural distortion (all to be covered in a future post). Radiologists can rely on objective findings on a film. As a radiologist, I cannot stress more the importance of having comparison images. Objectively, radiologists can assess the development of a potential cancer when prior mammograms are available. Is the finding present on prior exams, or is it new? This goes to the importance of having multiple prior films. Our hanging protocol compares to the three previous mammograms, allowing me to routinely look at four years of exams. Having priors for comparison in mammography is a BIG DEAL!


What should you expect when you return for the diagnostic exam(s)? In screening mammography everyone does the same thing. There is an industry standard. We all get the same traditional four views (CC and MLO for each breast). But in diagnostic mammography the work up is up to the institution/radiologist. There is no industry standard. The one and only goal is to answer the question at hand. Some institutions start by performing only the same view that elicited the callback. If it is a mass, it is possible that a patient may go straight to ultrasound bypassing mammography altogether. But for most, it involves obtaining a traditional ML view not performed during screening mammography. Then, if is for calcifications, magnification views will often be performed. For soft tissue, compression views may be requested. There are other tricks up a radiologists sleeve like rolled views; however, I find myself utilizing these “ancillary” techniques much less since the introduction of 3D tomosynthesis.


At the end of the diagnostic exam(s), the patient should be made aware of the next step. For the vast majority of patients, it is simply a return to annual screening mammography. The workup resulted in the dissipation of the densify or possibly a completely benign finding, like a simple cyst. For the smallest percentage of callback patients, they may have to return in six months. We are almost completely certain that it is not a malignant cancer, but we don’t want to be wrong and cancer growth rates are almost always too small to have a perceptible difference in size if the patient returns sooner than six months. For a few patient’s it will mean a biopsy, and depending on the results, it could potentially be the trigger of a life changing event.


I cannot overstate this enough. Get your ANNUAL screening mammogram. I have seen cancers pop up in women who lapsed for only a single year. Sometimes a small cancer detected on screening mammogram can in retrospect be appreciated on a prior exam. That is normal. It is not due to ineptitude, negligence, or malice. It was simply too small to be perceived as a threat on the prior exam. When compared to the prior it might be seen as a 4 or 6 mm cancer, which now at 6 to 8 mm is perceptible. The clinical outcome for the patient will almost certainly be the same. This goes to my final point.


Annual screening mammography is a SUCCESS when it catches cancers. No one wants to hear that they have cancer, but when we detect small cancers on screening mammography than can be excised and the patients are cured, it is a massive win. I congratulate patients for being diligent and responsible in caring for themselves. It was their effort to keep healthy through annual screening mammogram and their commitment to treatment that led to their cure. The healthcare community just provided help and support along the way.


I hope you look forward to future posts. We will continue our foray into the world of breast imaging. I will cover what a radiologist looks for when reviewing mammograms, what the radiologist report should contain and means, and what a biopsy could entail. Come on people, sound off in the comments below and let me know what you think of this post and the future topics I listed. Is there anything else you want to learn about?




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I am an American Board of Radiology certified Diagnostic Radiologist with a certificate of additional qualification in Neuroradiology. I absolutely love my job. I have learned a tremendous amount about the human body, including its’ expected complications given our extraordinary complexity, and get to use that knowledge to help people. I personally have experienced emotional devastation and loss, which has made me compassionate and empathetic. I really care about people, and I hope I can use this site to help you. I graduated medical school in 2004 from New York Medical College. My wife and I had our first son in NY where we bought our 900 sf two bedroom one bath starter home. I stayed at Westchester Medical Center for radiology residency, where we had our second son. I obtained a neuroradiology fellowship position at Yale New Haven Medical Center commuting about an hour and a half each way for a year while we had our third boy. Upon graduation I was fortunate to return to Westchester Medical Center to work in Neuroradiology, Body Imaging, and Women’s Imaging departments, a rarity in academic medicine. Almost a decade later and I am living in a larger home in Reno working in a private practice community based outpatient radiology group which contracts with a rural hospital in Elko, Nevada. My wife and I now have four boys and gave up on the girl. We also have a male Bernese mountain Dog named Helmut and female Newfoundland named Lucy. Despite all its hardships and tremendous struggles, I have an absolutely amazing life, which is a gift I cherish. It’s down to my philosophy. I am a firm believer in teamwork. So much comes down to communication. When healthcare providers talk to each other one-on-one, the patient care is always improved, every time! We might not find an answer to your problem, but our collective knowledge sure can help improve your chances. At Yale the best conference I ever regularly attended was a head and neck tumor board. The head and neck surgeon (otolaryngologist = ENT) presented the patient’s clinical history, the radiologist showed the images, the oncologist discussed the tumor and chemotherapy options, and the patient came to the conference and we all did a physical exam looking into their mouth to directly visualize a tumor. It was incredible! Patients came from far and wide to see this highly trained, world-renowned, humble, Japanese, gentleman surgeon. It was also an epiphany. I found that when I see the patient, talk to them, listen to their story, examine them and discuss the patient with my colleagues, the patient felt better and I had a lot of fun. It’s weird but reminds me of seeing a comedy where it is always funnier in a packed theater with everyone laughing. Knowledge and compassion are both infectious and contagious. My greatest days are helping patients deal with some of their most difficult days, and I am good at it.

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