Age-Specific Predictive Value of Ultrasound, Mammography, and Magnetic Resonance Imaging for Breast Malignancy in Baghdad, Iraq

Background: Breast cancer is the most prevalent malignancy among women worldwide and in Iraq. The rising incidence and mortality are mostly attributed by late diagnosis and inadequate screening. Although mammography, ultrasound, and magnetic resonance imaging are essential for early detection, their diagnostic performance varies by age, breast density, and population characteristics. Most available guidelines are based on Western populations and may not be fully applicable to younger Iraqi women with dense breasts, particularly in resource-limited settings. Methods: This prospective comparative study was carried out from January 2023 to December 2024 at two teaching hospitals in Baghdad. A total of 485 symptomatic women (25–80 years) underwent the three imaging modalities, with histopathological confirmation. Breast density was classified using the Breast Imaging Reporting and Data System, and patients were stratified into four age categories (<40, 40–49, 50–59, and ≥60 years). Findings categorized as 4 or 5 were considered positive. Diagnostic accuracy (sensitivity, specificity, positive predictive value, and negative predictive value) was evaluated overall and by age groups. Results: Dense breasts were observed in 65.6% of participants, especially in women under 40 years (87.3%). Ultrasound showed higher sensitivity in women <40 years (92.3% vs. 78.5% for mammography), while mammography performed best in women aged 50–59 years (94.2%). Magnetic resonance imaging had the highest sensitivity (91.4%) but the lowest specificity (78.5%), particularly in younger women (73.0%). Mammography had the highest false-negative rate in women <40 years (21.5%), whereas magnetic resonance imaging showed higher false-positive rates (26.8%). Dense breasts reduced mammographic sensitivity but had limited impact on ultrasound and magnetic resonance imaging. Conclusions: Imaging performance in Iraqi women is age- and density-dependent. Ultrasound is most suitable for women under 40 years, mammography for those aged 50–59 years, and magnetic resonance imaging for high-risk cases. These findings support age-adapted imaging strategies in Iraq.