Mammogram Reports and BI-RADS: Categories 4 & 5

Mammogram Reports and BI-RADS: Categories 4 & 5

As a continuation of our prior posts this week on BI-RADS 1, BI-RADS 2, BI-RADS 3, today we’d like to talk about BI-RADS categories 4 and 5. Of course by now you remember that BI-RADS stands for Breast Imaging-Reporting and Data System, which is a tool developed by the American College of Radiology to simplify breast imaging reports and their recommendations. It breaks results down into categories from Zero to Six. Let’s talk about these next two categories and what they could mean for you.

Category 4, explained

BI-RADS category 4 means there is a suspicious abnormality on your breast imaging studies and a biopsy should be considered as a next step. Remember the only way to actually diagnose breast cancer is to obtain a tissue sample for evaluation by a pathologist, a doctor specializing in looking at tissue samples. A category 4 result means the radiologist has found something that needs to be further evaluated and could be cancer. Other benign, non-cancerous changes can look suspicious. It may help you to know that for this category most biopsies will turn out to be benign- only around 30% of all breast biopsies recommended on mammography, both category 4 and 5, will turn out to be cancer.  Getting benign biopsy results is both a likely and wonderful thing to know. So, take it one step at a time.

The reason you might receive a category 4 result on a mammogram can be findings like abnormal calcifications, unusual masses, or developing asymmetries in the breast tissue. You may need further imaging before getting the final category 4 result including breast ultrasound, which may detect abnormal appearing solid masses or possibly suspicious cystic masses that need biopsy. A breast MRI may be recommended and could detect abnormal masses and/or abnormalities of tissue based on the blood flow/enhancement. Any of these findings might generate the doctor’s response, “Could be nothing, but we need to be sure.”

Category 5, explained

BI-RADS category 5 means there’s a high suspicion of malignancy and that appropriate steps should be taken. The finding might be masses with or without calcifications. While microcalcifications are most often benign, there are occasions where their patterns are more worrisome. Perhaps a mass could be discovered with irregular tendrils radiating out from it, or may be the whitest thing, like a dangerous light bulb, on the backdrop of a gray and white mammogram. Further imaging is often done, possibly ultrasound and/or breast MRI. An ultrasound could show an irregular solid mass with or without blood flow. An MRI could demonstrate an abnormal mass or abnormal blood flow suspicious for cancer. As with category 4, there are other changes besides malignancy that can masquerade as a cancer. These include some infections and even some scars. So as with category 4, the only way to diagnose the finding for certain is to get a tissue sample.

One step at a time

With a category 4 or 5 result, your next steps will be guided by consulting with your doctor. Be proactive and persistent in getting the care you need. It’s very important to take a rating like this seriously but not to let fear freeze you in your footsteps. Talk to your doctors, get the recommended further testing, pursue second opinions, and trust your instincts.

You are your own greatest health advocate. Dealing with a breast biopsy is much easier to talk about than to do, so take advantage of the many support organizations available to you. One such resource is the Susan B. Komen Foundation’s Questions To Ask Your Doctor. Others before you have faced a category 5 mammogram reading and can help you know what to do next. You are not alone and you have the power to respond appropriately to what may or may not be a negative biopsy result. You can receive help no matter what the outcome.

What’s next

Hopefully this information is helpful for understanding a category 4 or 5 classification. Remember, there’s always the “contact us” button on our blog menu up top! On Monday, we will take on category 6.




Originally published 7/12/13 on