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Contrast-Enhanced Mammography at UPMC: From Evidence Generation to Clinical Implementation

July 23, 2026

8 Minutes

UPMC and University of Pittsburgh breast imaging researchers and clinicians have spent more than 10 years evaluating contrast-enhanced mammography (CEM), leading the field to define where the modality fits in diagnostic breast imaging, image-guided biopsy, and emerging screening applications. With CEM now in routine diagnostic clinical use at UPMC Magee-Womens Hospital and five UPMC Magee breast imaging centers in the greater Pittsburgh region as of May 1, 2026, the Breast Imaging Program at UPMC has entered a new phase, translating years of prospective investigation into day-to-day clinical practice.

Image of Margarita Zuley, MD, FACR, FSBI.“For much of the past decade, the scientific question was whether contrast-enhanced mammography could deliver clinically meaningful information,” says Margarita Zuley, MD, FACR, FSBI, professor, Department of Radiology; vice chair, Quality, Breast Imaging Division; chief, Breast Imaging Division; director, UPMC Quality in Breast Imaging. “Today, the question is how to implement it thoughtfully, identify the patients who benefit most, and use it to improve the accuracy and efficiency of breast imaging to detect cancer and when found, influence how we treat it.”

Dr. Zuley is part of a multidisciplinary, collaborative group of UPMC and University of Pittsburgh breast imaging and breast cancer specialists whose research has helped define the clinical applications of CEM. That work has progressed from proof-of-concept studies through investigations of disease extent, image-guided biopsy, screening, and diagnostic performance. As the data have accumulated, the focus on CEM is shifting toward translation and implementation and how to incorporate the modality into clinical workflows while improving patient care, preserving limited imaging resources, and expanding access across a large health system.

Moving from a Proof of Concept to Clinical Utility

CEM combines conventional mammography with iodinated contrast. The examination produces low-energy images that retain the structural information of standard mammography, as well as contrast-enhanced images that identify areas of enhancement within the breast.

Early prospective work at UPMC compared CEM with breast magnetic resonance imaging (MRI), molecular breast imaging, and ultrasound for evaluating disease extent. Subsequent research has examined diagnostic performance, biopsy decision-making, and the use of CEM to guide tissue sampling.

“The question has been how to obtain the most useful diagnostic information with the least amount of intervention possible,” Dr. Zuley says. “If a more accurate examination can distinguish patients who need additional testing from those who do not, it can improve the care experience without compromising the ability to identify clinically important disease.”

The current clinical program builds on that work. CEM is being used now diagnostically, rather than as a routine screening examination, while Dr. Zuley and colleagues continue to study its potential in more universal screening applications and other scenarios.

A More Efficient Diagnostic Pathway

Patients recalled after screening mammography for an indeterminate or confounding finding may undergo additional mammographic views, ultrasound, biopsy, MRI, or several sequential examinations before the diagnostic question at hand is answered. Each step may be appropriate, but serial testing can also increase travel, time away from work, cost, and uncertainty.

“Breast imaging has historically relied on a series of examinations to resolve many diagnostic questions,” Dr. Zuley says. “CEM allows us to ask whether more definitive information can be obtained earlier in that process, reducing the number of downstream studies for patients who do not need them.”

CEM is not intended to replace every ultrasound, MRI examination, or biopsy. Instead, it may help breast imaging teams identify patients who can safely avoid additional testing and patients who need biopsy or further evaluation.

“Cancer detection is only one part of the responsibility,” Dr. Zuley says. “We also need to address the burden created by recalls, low-suspicion findings, and procedures that ultimately do not identify cancer. Improved diagnostic accuracy can help us address both sides of that equation.”

The approach also has implications for imaging capacity. Reducing unnecessary follow-up examinations may allow breast imaging programs to direct resources toward patients with new or more urgent diagnostic needs.

“Our goal is to make the diagnostic process as precise as possible,” Dr. Zuley says. “That means reducing unnecessary MRI, ultrasound, and biopsy when the information from CEM allows us to do so, while ensuring that patients who need additional care receive it promptly.”

Developing CEM-Guided Biopsy

One area of study at UPMC has been CEM-guided biopsy. Some enhancing lesions cannot be targeted with ultrasound or conventional mammographic guidance and have historically required MRI-guided biopsy.

MRI-guided biopsy remains an important option, but it depends on specialized equipment and limited procedural capacity. Dr. Zuley and colleagues worked with an imaging vendor to develop a CEM-guided strategy for selected MRI-detected lesions that can be localized with contrast mammography.

“When a lesion identified on MRI can also be localized with CEM, contrast-guided biopsy can provide an alternative pathway to tissue diagnosis,” Dr. Zuley says. “That may reduce delays associated with MRI biopsy scheduling and provide a more accessible option for selected patients.”

Research Questions in Biopsy Reduction and Screening

UPMC Magee’s CEM research program continues to examine questions that will shape broader use of the modality. An NIH R01-supported study has completed enrollment and is now in the analytic phase. The study examined if CEM can reduce biopsy among women without breast cancer by improving characterization of suspicious imaging findings.

“Our R01 study addresses the practical clinical question of whether CEM can help us avoid biopsy in women whose imaging findings appear suspicious but are ultimately benign,” Dr. Zuley says. “Improving specificity in that setting could have a meaningful effect on patient care.”

Dr. Zuley and colleagues are also studying CEM in screening populations, including women with a personal history of breast cancer. Screening applications require evidence beyond diagnostic performance, including cancer detection, false-positive findings, biopsy rates, interval cancers, patient acceptance, cost, and access.

“CEM has potential in screening, but the evidence and regulatory environment must continue to develop before it becomes part of routine screening practice,” Dr. Zuley says. “Our current clinical use is focused on diagnostic care, where the modality can provide additional information for patients who need further evaluation.”

Implementing CEM Across the UPMC System

Moving CEM from research into clinical practice required more than adding software to a mammography unit. Breast imaging centers need protocols for contrast screening and reactions, IV placement, renal-function assessment when indicated, nursing and technologist training, radiologist interpretation, and revised scheduling workflows.

“Implementation of this program required extensive operational planning and training for staff,” Dr. Zuley says. “Breast centers have traditionally been designed around a short mammography visit. Adding contrast requires changes in workflow, including IV placement, safety screening, staff training, and time for the examination. That sounds simple, but the practical reality is different.”

Dr. Zuley and colleagues are evaluating how to expand CEM across its clinical network, including communities where MRI capacity may be limited. The objective is to increase access to contrast-based breast imaging while preserving MRI for patients for whom it remains the preferred examination.

“CEM gives us greater flexibility across our system,” Dr. Zuley says. “Expanding the diagnostic options available to breast imaging teams can improve access to timely evaluation and reduce pressure on MRI resources, particularly in communities where those resources are limited.”

More Information

Learn more about Contrast Enhanced Mammography and the full spectrum of breast imaging modalities at UPMC. You can also call 888-604-4013 for more information about UPMC Imaging Services or find an imaging location.

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