Introduction from study states, “Early detection decreases deaths from breast cancer (1-5). For women of average risk, the ACR recommends annual screening mammography starting at age 40 (6). Women at higher-than-average risk should, in general, start surveillance with digital mammography (DM) at an earlier age and consider supplemental screening as well (7). As with our previous guideline on imaging women at higher-than-average risk (7), this update was developed by breast imaging experts from the ACR Commission on Breast Imaging, after extensive literature review and consideration of the ACR Appropriateness Criteria, which use robust strength-of-evidence analysis and well-established grading methodologies (8). Here we consider new data on digital breast tomosynthesis (DBT), contrast-enhanced mammography (CEM), contrast-enhanced breast MRI (CE-MRI, hereafter MRI), and re-assess breast ultrasound (US) and molecular breast imaging (MBI). Large longitudinal randomized controlled trials (RCT) are not feasible for many new modalities; in their absence, we consider interval cancer rate (ICR) – specifically its reduction – as a surrogate for mortality reduction (9).