Supplemental Breast Cancer Screening Law Renders Majority of High-Risk Black Women Ineligible

The Pennsylvania Act 1 of 2023, which eliminated costs for supplemental breast cancer screenings based on certain criteria, leaves many Black women ineligible and does not sufficiently detect false negatives, a new study published in the JAMA Network Open found.¹ Although introduced with good intent, it disproportionately affects Black women, who already experience more aggressive cancers and higher rates of false negatives.

"Given lower density and lifetime risk estimates, few Black women met criteria for insurance coverage in Pennsylvania, and the criteria had poor sensitivity for identifying Black women with false-negative mammograms," the authors wrote. "Additionally, using the current breast density criteria for magnetic resonance imaging may not accurately reflect breast cancer risk in Black women."

Supplemental breast cancer screenings criteria leaves Black women ineligible despite high percentage of false-negative mammograms. | Image Credit: breastcancerscreening-H_Ko.jpeg

The act—which came in response to growing evidence pointing to benefits of a supplemental MRI—requires health insurance companies to cover all costs for up to one supplemental breast cancer screening each year if the woman is established at risk for breast cancer by personal history, family history, genetic predispositions, prior radiation therapy, or heterogeneously dense breast tissue.² The Dense Tissue and Early Breast Neoplasm Screening (DENSE; NCT01315015) trial showed that women with extremely dense breast tissue had 50% lower false-negative rates after undergoing one round of MRI screening after a negative mammogram. Despite the ethical motivation to make early diagnosis and detection of breast cancer in women more accessible, researchers found that Black women were less likely to meet the criteria for the supplemental screenings despite prior evidence stating Black women are 40% more likely to die from breast cancer than White women, thus exacerbating preexisting disparities in breast cancer diagnosis and screenings.^1,3

“If fewer Black women are being recommended for supplemental screening, this may reflect an effort to reduce unnecessary harm—particularly if additional screening does not significantly improve survival or detection rates,” the study authors noted. “Ultimately, screening guidelines must balance benefits with potential harms, and more research is needed to refine strategies that ensure equitable, evidence-based care tailored to individual risk profiles.”

Breast tissue density is measured using the Breast Imaging and Reporting Data System (BI-RADS) and categorized into 4 tiers, each increasing in density: almost entirely fatty (BI-RADS A), scattered areas of fibroglandular density (BI-RADS B), heterogeneously dense fatty (BI-RADS C), and extremely dense fatty (BI-RADS D). Women with dense breast tissue are at a 5 times higher risk of breast cancer than women with non-dense breasts and also have higher rates of false-negative mammograms, as dense tissue can sometimes mask tumors on screenings.

Breast Tissue Density in Black Women vs White Women

The total study population consisted of 68,478 women (39,397 Black women and 30,081 White women) between 40 and 74 years of age. Based on the BI-RADS categorization, there were more cases of White women with extremely dense breast tissue than Black women (561 [2.1%] vs 1464 [5.8%]; P = .02). There was also a smaller portion of Black women that had a Breast Cancer Risk Assessment (BCRAT) lifetime risk greater than 20% (257 [0.7%] vs 1905 [6.4%]; P = .04). Due to the characterization of the BI-RAD criteria, Black women were less likely to be eligible for supplemental screenings under the Pennsylvania law than White women (523 [1.6%] vs 2081 [8.4%]; P = .02).

In the analysis, 16% (10,951) of women were missing BRACT scores in their electronic health records. After researchers adjusted for age and BI-RADS density, White women were still 11 times more likely than Black women to be eligible for a supplemental screening under the Pennsylvania law, even with missing BRACT scores (OR, 11.32; 95% CI, 8.79-14.94; P = .001). White women also had a higher percentage of sensitivity (the percentage of false-negative mammograms correctly identified as eligible for supplemental screenings) and lower specificity (the percentage of true-negative mammograms not eligible for supplemental screening) under this law when compared with Black women. The stipulations of this law, which characterized which women were eligible for supplemental screenings, resulted in 1 in 3 false negatives identified in White women (29% [95% CI, 14%-45%]), while Black women had a sensitivity of 0%.

Previous studies have shown Black women are more likely to go undiagnosed due to false-positive results when compared with White women, despite having the highest rates of false negatives among racial and ethnic groups.¹ However, when only measuring criteria based on BI-RADS categories of heterogeneously and extremely dense breast tissue, White women had a sensitivity of 74% (95% CI, 57%-87%) and specificity of 60% (95% CI, 24%-80%) for false negatives compared to the 53% sensitivity (95% CI, 29%-77%) and 80% specificity (95% CI, 48%-96%) for false negatives in Black women.

“Our results suggest that expanding supplemental screening eligibility to all women with heterogeneously or extremely dense breasts would identify more false negatives. However, given that approximately half of screening-aged women have dense breasts, most of whom will never develop breast cancer, offering supplemental screening to all would greatly increase the number of MRIs or ultrasonographic screenings performed,” the study authors explained. “This expansion would lead to high costs and limited, delayed access for those who need it most, making this approach currently unfeasible due to capacity constraints.”

Although the Pennsylvania law’s eligibility criteria for supplemental screening were based on BI-RADS and BCRAT lifetime risk, it did not include BMI adjustments, nor did the study account for menopausal status, BMI, or age at menarche.

“Proactive evaluation of the potential impacts of new policies on various patient populations is needed to help prevent new practices from inducing and/or exacerbating existing disparities in breast cancer, mainly as Black women are less likely to qualify for supplemental screening, despite their greater risk of breast cancer diagnosis and death using the BI-RADS breast density definitions,” the story authors suggested.

References

1. Mahmoud MA, Ehsan S, Ginzberg SP, Domchek SM, Nathanson KL, Conant EF, et al. Racial differences in screening eligibility by breast density after state-level insurance expansion. JAMA Netw Open. 2025;8(8): e2525216. doi:10.1001/jamanetworkopen.2025.25216

2. Pennsylvania General Assembly. Act 1 of 2023, P.L. 1, No. 1: An Act amending the Insurance Company Law of 1921—Coverage for Mammographic Examinations and Diagnostic Breast Imaging and Coverage for BRCA-Related Genetic Counseling and Genetic Testing. May 1, 2023. Accessed August 5, 2025. https://www.legis.state.pa.us/WU01/LI/LI/US/HTM/2023/0/0001..HTM?6=

3. Torres JM, Sodipo MO, Hopkins MF, Chandler PD, Warner ET. Racial differences in breast cancer survival between Black and White women according to tumor subtype: a systematic review and meta-analysis. J Clin Oncol. 2024;42(32):3867-3879. doi:10.1200/JCO.23.02311