Getting called back for further imaging after a screening mammogram is a frequent occurrence, particularly for individuals undergoing their first mammogram. According to Dr. Ainel Sewell, a breast radiologist at Houston Methodist, “Mammograms help us find breast cancers when they are tiny, which is why this screening technique is the gold standard.”
Dr. Sewell explains that breast tissue can appear similar to breast cancer on a mammogram, and vice versa, making interpretation challenging. She emphasizes the importance of having screening mammograms performed at specialized breast imaging centers with fellowship-trained, board-certified radiologists who focus exclusively on breast imaging. “Rather than a general radiologist that dabbles in multiple disciplines, a breast radiologist focuses solely on mammograms and detecting subtle changes in breast tissue,” she says. “This level of sub-specialization is critical for early detection.”
Despite specialized care, callbacks still occur. Dr. Sewell notes, “When we see something unusual, it’s not that we think it’s definitely breast cancer. It’s that additional imaging is needed to take a more detailed look. The goal is to make sure we don’t miss a tiny tumor forming, because that’s when breast cancer is easiest to treat.”
The likelihood of being called back is higher after a first mammogram since there are no previous images for comparison. “Your breast tissue is that unique and looks completely different from everyone else’s,” Dr. Sewell states. She likens the first screening to establishing a baseline or “fingerprint” of normal tissue.
Common reasons for callbacks include dense breast tissue, asymmetry between breasts, distortions or calcifications, and cysts or fibrocystic changes. Dense tissue, present in about half of women, appears white on mammograms—the same as many abnormalities—making it harder to distinguish issues. “Think of dense breast tissue as snow and breast cancer as a snow bunny,” Dr. Sewell says.
Asymmetry can also prompt additional imaging, especially when prior images are unavailable for comparison. Distortions may signal disruptions in normal architecture due to benign conditions or may require further evaluation if they raise concern. Calcifications are often harmless but can sometimes indicate early cancer depending on their pattern.
Cysts and fibrocystic changes are common and usually benign but can appear suspicious without prior images for reference. Ultrasound is often used to confirm the nature of these findings.
During a callback appointment, follow-up imaging such as ultrasound or diagnostic mammogram may be performed based on initial findings. Dr. Sewell explains, “If I think I’m looking at cysts, I might go straight to an ultrasound. The same goes for very dense breast tissue… Or we might get a diagnostic mammogram done first and then, depending on what we see, perform an ultrasound or not.”
After the workup, results and next steps are discussed during the same visit.
Dr. Sewell acknowledges the anxiety associated with callbacks: “Everyone in our breast care centers — from desk attendants to nurses to mammogram technologist and ultrasound technologists — know how anxiety-provoking it is to be faced with the idea that something could be wrong with you. It’s why our goal is to schedule you to come back in quickly and help get your questions answered.”
She offers advice for those who receive a callback: do not panic; schedule follow-up appointments promptly; ask questions; and remain consistent by using the same breast center each year. “The power of mammography really comes from doing that exam at the same place year, after year, after year,” adds Dr. Sewell.
