The American College of Radiology (ACR) Appropriate Use Criteria have just made notable advancements in their recommendations for supplemental breast cancer screening beyond traditional mammography for those with dense breast tissue. Among the key updates, two stand out:

1. For individuals with extremely dense breast tissue and an average lifetime risk of breast cancer, both abbreviated and full protocol contrast-enhanced breast MRI are now classified as “usually appropriate” for supplemental screening.

2. Those with heterogeneously dense breast tissue at intermediate lifetime risk are now also candidates for MRI screening with a “usually appropriate” rating.

Previously, breast MRI was generally limited as “usually appropriate” to individuals at high, at least 20%, lifetime risk of breast cancer, regardless of breast density. This update represents a big step in making MRI accessible to more individuals at different risk levels.

Potential Increase in MRI Access and Insurance Coverage: This expanded “usually appropriate” rating from the ACR could make MRI screenings accessible to a greater number of individuals with dense breast tissue. Typically, insurers cover procedures rated “usually appropriate” by the ACR, but this will test their willingness to cover the high-cost breast MRI exams.

Here are some immediate takeaways and questions raised by these new guidelines:

• Broadening Access: Many advocates hope for comprehensive supplemental screening for all individuals with dense breast tissue. While this update is a step in that direction, those with heterogeneously dense tissue and only average risk still may lack access to screenings beyond traditional 2D or 3D mammography—a significant gap that needs addressing.

• Alternatives to MRI: Where do ultrasound, contrast-enhanced mammography (CEM), and molecular breast imaging (MBI) fit? ACR rates ultrasound as only “may be appropriate,” reflecting its modest improvement in cancer detection over mammography alone, though ultrasound remains widely used. MRI detects far more cancers, aligning with the goal of maximizing early detection, yet cost, availability, and accessibility are major hurdles for some patients.

• The Potential for CEM and MBI: CEM and MBI could play crucial roles in supplemental screening as new data emerges. CEM is seen as a particularly promising alternative, potentially offering both mammography and supplemental screening in a single, potentially cost-effective procedure. CEM is now rated as “may be appropriate” for several supplemental screening uses. As research confirms CEM’s performance, insurers may increasingly embrace it as a lower-cost MRI alternative, which could expand access significantly. In my view, MBI remains undervalued by the ACR and deserves at least a "may be appropriate" rating for supplemental screening.

Finally, legislation such as the Find It Early Act, which has bipartisan support in Congress, aims to mandate coverage for ultrasound, MRI, CEM, and MBI as supplemental screenings regardless of individual breast cancer risk levels. While this Act would be a big win if passed, the ACR’s new recommendations provide meaningful support for improved screening access in the meantime.

For a more in-depth comparison of these dense breast screening modalities, take a look at my recent peer-reviewed publication, Maximizing Breast Cancer Detection Through Screening: A Comparative Analysis of Imaging-Based Approaches where the combination of breast MRI with mammography yields the highest cancer detection rates—albeit at a higher expense.

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