Image quality in mammography is affected by the shape, size, and x-ray absorption properties of the anatomic part or lesion to be radiographed in addition to x-ray beam quality, geometric unsharpness, and the resolution, characteristic curve, and noise properties of the recording system. The authors review x-ray energy spectra, modulation transfer functions. Wiener spectra, characteristic and gradient curves, and radiographs of a breast phantom and a resected breast specimen containing microcalcifications; these factors, and the complex relationship between them, affect image quality and patient radiation exposure. Evaluation of the best system or technique for obtaining a breast image is discussed in terms of the compromise between diagnostic certainty and cost or risk.