BI-RADS 2025: A Language That Endures

Some advances in medicine arrive with fanfare. Others change practice more quietly, gradually reshaping how we think, how we speak, and ultimately how we care for patients. The story of the Breast Imaging Reporting and Data System (BI-RADS®) proves that disruption in medicine does not always require cutting-edge technology, but can simply emerge from a shared commitment to better care.

BI-RADS and I share a few things in common. The original atlas was introduced in 1993, the year I graduated from medical school and began my career as a physician. I first encountered BI-RADS as a resident at UCSF the following year, learning breast imaging at the elbow of Dr Edward Sickles, one of the system’s original architects and a true luminary in our field. In those days, BI-RADS was not yet the universal framework we now take for granted, but its authors had an ambitious vision: not merely a lexicon or reporting tool, but a foundation for clinical practice.

What began in breast imaging did not remain there. BI-RADS offered radiology a roadmap for quality, consistency, and patient- and family-centered care. Over time, the RADS framework spread across subspecialties, including LI-RADS,® PI-RADS®, TI-RADS®, Lung-RADS®, and O-RADS®. Each echoes the same essential promise that clear language, evidence-based categories, and measurable outcomes can elevate care.

More than 3 decades later, the arrival of BI-RADS 2025 feels less like a revision and more like a moment of reflection for our specialty. In this issue, Applied Radiology features the highlights of an interview with Dr Dana Smetherman, breast imager and Chief Executive Officer of the American College of Radiology, exploring why this update matters now, and how BI-RADS continues to guide breast imaging into the future. A video of the full discussion from RSNA 2025, facilitated by Editor-in-Chief Emeritus Dr Erin Simon Schwartz and Publisher Kieran Anderson, can be found on the Applied Radiology YouTube channel.

Breast imaging practice has transformed markedly since the last edition. Techniques once considered emerging, including digital breast tomosynthesis, contrast-enhanced mammography, and abbreviated MRI, are now woven into routine care. Treatment pathways have evolved as well, with neoadjuvant therapy and new surgical and minimally invasive approaches reshaping the radiologist’s role. BI-RADS has expanded to incorporate these advances while maintaining the clarity, consistency, and clinical relevance that define its value.

The 2025 transition from atlas to a living digital manual reflects more than a change in format. It signals that BI-RADS is prepared to meet the broader currents shaping modern medicine, from the rapid rise of artificial intelligence to the growing emphasis on personalized care.

For those of us who have spent our careers in breast imaging, BI-RADS is woven so completely into daily work that it can feel almost invisible. Yet its impact is present in every clear recommendation, every measurable outcome, and every patient who leaves an imaging center with understanding instead of uncertainty.

In an era of rapid change, BI-RADS endures as something rare in medicine: an approach proven across decades and adaptable enough to guide what comes next.