A look back at the history of mammography

July 20, 2018
by Sean Ruck, Contributing Editor
Long before mammography became a topic of debate about guidelines and the benefits of tumor identification versus false-positives, it was just another technology that seemed to be a curiosity for some and a revelation for others.

The precursor to mammograms were the radiography studies performed in 1913 by Dr. Robert Salomon on breast tissue that had been collected through mastectomies. Through his research, Salomon discovered that there were different types of breast cancer. And while he was able to use radiography to show the role the axillary lymph nodes played in the dissemination of cancerous tumors, holding the claim to fame as the first to perform a mammogram was not to be his lot, possibly due to not realizing or caring about the benefits it could bring to women or possibly due, in part, to the disruption of his work caused by the rise of Hitler, which resulted in his being ousted from his faculty position at the University of Berlin. Salomon was later placed in a concentration camp for several months before ultimately landing in Holland by 1939, where he would spend the rest of his life.

Regardless of the reasons Salomon didn’t pursue his work further, others picked up the baton. Another German researcher, Walter Vogel, detailed how X-rays could help medical professionals differentiate between healthy and cancerous breast tissue. His guidelines, created nearly a century ago, were so well-crafted, that they’re still used today. However, to get to the first mammogram with a patient, a leap of a few years to 1930 is required.

It was in 1930 that Stafford Warren became an associate professor of medicine at University of Rochester School of Medicine. It was also that year that he published his work, “A Roentgenologic Study of the Breast.” Like Salomon, Warren developed images of cancer tissue gathered via mastectomy – more than 3,000 images in all. Unlike Salomon, Warren continued his research and created methods to capture images of living breast tissue by repurposing available X-ray equipment. The mammograms performed by Warren required his patients to lie on their side with one arm raised. According to the book “Diagnosis of Diseases of the Breast,” by Lawrence Bassett and Valerie Jackson, out of a patient pool of 119 women who were set to undergo surgery, Warren accurately diagnosed cancer in 54 of the 58 cases he labeled as positives.

These findings were significant because they elevated radiography of breast tissue from a research pursuit to a method of improving patient health by reducing the need for invasive procedures. An ironic side note to Warren’s impressive career is the fact that he was part of the Manhattan Project, meaning he helped harnass the power of radiation to potentially save lives as well as to take them away.

While Warren holds the honor of performing the first mammograms, that historical note may require an asterisk. Warren performed his procedures on women who were already seeking medical treatment for some type of breast disease, so while there was value in the work, it didn’t ultimately change the fact that those women would be operated on. That’s where Dr. Jacob Gershon Cohen comes into the story.

During the 1950s, Cohen built on the work of his predecessors to act on the logical next step – the imaging and screening of women who were deemed healthy in order to head off instances where cancer had gone unnoticed. That early warning gave doctors the ability to head it off before it spread, thereby improving outlooks for women diagnosed with breast cancer. It was during Cohen’s time that some of the early controversy regarding mammography emerged. At the time of his early work, X-rays delivered relatively high radiation doses, creating a concern among some medical professionals that regular use of X-ray for screening could actually exacerbate the occurrences of breast cancer. The introduction of better film, which needed lower dosage, eased much of the concern and by 1969, the first X-ray equipment specifically manufactured for breast imaging was on the market.

Another challenge arose in the 1970s after the National Cancer Institute released findings based on a four-year study they conducted from 1973 to 1977. The study, which included the review of more than a quarter of a million U.S. women, concluded that a significant number had undergone surgical procedures after a mammogram turned up small, benign growths. The report’s findings led to the NCI issuing its first set of guidelines surrounding breast screening, and those guidelines are still being updated and debated today.