Contrast-Enhanced Mammography and What Providers Need to Know About The Imaging Modality at UPMC Magee-Womens Hospital

The UPMC breast imaging program has studied contrast-enhanced mammography (CEM) for more than a decade. The program is now using the technology in routine diagnostic practice for select patients at UPMC Magee-Womens Hospital and five UPMC Magee breast imaging centers across the greater Pittsburgh region. The move from research into clinical use was built on years of study and clinical trials by a multidisciplinary team evaluating the efficacy of CEM in diagnostic breast imaging, image-guided biopsy, and its future potential for use in routine screening. The research continues.

For health care providers, the new availability of CEM in diagnostic or follow-up situations raises practical questions. When is CEM recommended? How does it differ from conventional mammography or breast MRI? Which patients are appropriate candidates? And what should clinicians tell patients when they have questions about an examination that may be unfamiliar to many outside of the breast imaging world?

In this interview, Margarita Zuley, MD, FACR, FSBI, professor, Department of Radiology, vice chair, Quality; chief, Breast Imaging Division; director, UPMC Quality in Breast Imaging, discusses how CEM is currently being used in diagnostic breast imaging at UPMC, what it offers patients, and why provider understanding and support are important to its successful implementation for patient care.

Q: For providers who may be unfamiliar with CEM, what is it and what does the examination involve?

A: Contrast-enhanced mammography combines a standard diagnostic mammogram with an intravenous injection of iodinated contrast, the same type of contrast one might have with a CT scan. It’s that simple. From the patient's perspective, the examination is very similar to a routine mammogram, with the addition of an IV before the images are obtained.

What makes the imaging findings different is that the contrast allows us to evaluate not just the structure of the breast seen on the mammogram, but also areas of increased blood flow that may be associated with breast cancer. In many ways, we're obtaining physiologic information similar to what we look for with breast MRI.

It's helpful to think of CEM as another diagnostic tool rather than a replacement for conventional mammography or MRI. A standard diagnostic mammogram continues to provide detailed anatomic information, while the contrast-enhanced images add another layer of information that can help us determine if an area of concern warrants additional evaluation.

Patients are often surprised when they hear the words "contrast" and "mammogram" together because most have never encountered the examination before. That's understandable. CEM has been available primarily in research settings until recently, and many referring physicians haven't yet had occasion to discuss it with patients.

When our breast imaging team recommends CEM, it's because we believe the additional information it gives us can help answer a specific diagnostic question. In some patients, that may reduce the need for additional imaging or help us reach a diagnosis more efficiently. In others, it helps clarify findings that remain indeterminate after conventional diagnostic imaging.

Q: Which patients are candidates for CEM today at UPMC?

A: Right now, we're using CEM as a diagnostic examination rather than a screening examination. In most cases, that means a patient has already had a screening mammogram or has presented with a breast concern that requires further evaluation.

The examination can be particularly helpful when conventional diagnostic mammography and ultrasound don't completely answer the clinical question. It also has an important role in evaluating the extent of disease after a breast cancer diagnosis and, in selected patients, may provide information that otherwise would require breast MRI.

Q: How can CEM reduce the burden of diagnostic care for women?

A: Historically, the diagnostic evaluation of a breast abnormality has often been a stepwise process. A patient has a screening mammogram, returns for additional mammographic views, undergoes an ultrasound, may need an MRI, and in some cases has a biopsy. Every step may be appropriate, but it can also mean multiple appointments, additional time away from work, added expense, and weeks of uncertainty for the patient.

One of the questions we've been asking is whether we can obtain more definitive diagnostic information earlier in that process. If we can answer the clinical question sooner, we may be able to reduce the number of additional imaging examinations some patients require and therefore improve access for more patients overall.

That doesn't mean CEM eliminates the need for ultrasound, MRI, or biopsy. Those remain essential tools in breast imaging. What CEM gives us is another way to evaluate a patient when additional physiologic information may help clarify what we're seeing. In some cases, that may allow us to avoid additional imaging or help us move more confidently and efficiently toward biopsy or treatment.

Q: How does CEM compare with breast MRI? Is it intended to replace MRI?

A: CEM has been shown to be comparable to MRI. Still, Breast MRI is an essential part of breast imaging, and there are many situations where it continues to be the gold standard. The question isn't if one technology is better than the other. The question is which imaging study is most appropriate for a particular patient and clinical scenario.

MRI provides exceptional sensitivity and remains indispensable for many high-risk screening patients and for a variety of complex diagnostic questions. At the same time, MRI isn't always the most practical or accessible option. Not every community has the same MRI capacity, scheduling delays can occur, and some patients are unable to undergo MRI because of claustrophobia, implanted devices, or other contraindications.

Contrast-enhanced mammography expands the options available to breast imaging specialists. In selected patients, it can provide the additional physiologic information we need without requiring an MRI. That has the potential to improve access to contrast-based breast imaging while allowing MRI resources to remain available for patients in whom MRI is clearly the preferred examination. Our objective isn't to replace one technology with another, but instead to use each of them where they can contribute most effectively to patient care.

Q: You're asking other physicians to become familiar with CEM. Why is that so important?

A: Successful implementation of any new technology depends on more than the physicians using it. It also depends on the clinical teams who care for those patients before and after they come through our breast imaging program. That's why it's so important for groups like primary care doctors, advanced practice providers, and nurses to understand the basics of CEM.

When we recommend CEM, many patients have never heard of it. We’ve just started using it clinically in May 2026. They understand what a mammogram is and they may have heard of breast MRI, but an examination that combines mammography with intravenous contrast is unfamiliar. Naturally, they're going to have questions, and many of them will reach out to the health care provider they know and trust, which is usually their primary care provider or gynecologist.

When patients hear consistent messages from all of their health care providers, they're generally more comfortable moving forward with the recommended evaluation. That shared understanding helps reduce uncertainty and keeps the diagnostic process moving efficiently, allowing us to answer important clinical questions as quickly and accurately as possible.

What we value most is collaboration. Breast imaging doesn't happen in isolation. Other health care providers play an essential role in helping patients understand their diagnostic evaluation, and that partnership becomes even more important as new technologies like CEM become part of routine clinical practice.

Q: What questions are patients asking when CEM is recommended?

A: The first question is usually, "Why do I need this test?" Patients are familiar with mammograms, and many have heard of breast MRI, but contrast-enhanced mammography is new to most. When they hear that they need intravenous contrast for a mammogram, it's natural for them to wonder why another exam is needed.

We explain that CEM has been recommended because we believe it can provide additional information that will help answer a specific diagnostic question. Every patient is different, and the imaging evaluation is tailored to the clinical situation. Just as we choose between ultrasound, MRI, or biopsy based on the question we're trying to answer, we're selecting CEM because we believe it's the most appropriate examination for that patient.

Patients also ask what to expect during the examination. We tell them that, aside from placement of a small IV to administer the contrast, the experience is very similar to a standard diagnostic mammogram. The examination itself is straightforward, takes 5-10 minutes to perform in the breast center and most patients tolerate it very well.

Another common question is whether recommending CEM means they're more likely to have cancer. The answer is no. CEM is a diagnostic imaging study that has a higher sensitivity and higher accuracy than routine mammography for cancer detection. It's being used to gather more information so we can better characterize a finding and determine the most appropriate next step. Sometimes that means we can reassure a patient that no additional evaluation is needed. Other times, it helps us identify patients who should undergo biopsy or additional imaging. The purpose is to improve diagnostic accuracy so that patients receive the care they need and avoid the care they don't.

Q: What would you like other health care providers to understand about CEM as they begin seeing more patients offered this examination?

A: I would encourage providers to think of CEM as another evidence-based diagnostic option that has become available to help answer important clinical questions. It's not replacing mammography, ultrasound, or breast MRI. It's expanding our ability to tailor the diagnostic evaluation to the patient.

I also hope clinicians will continue reaching out to us with questions. Breast imaging works best when it's collaborative. Whether it's discussing why CEM was recommended, reviewing imaging findings, or talking through the next steps in a patient's evaluation, those conversations help ensure we're providing coordinated, patient-centered care.

Patient Referrals, Questions, Further Reading

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.