The American College of Radiology (ACR) Appropriateness Criteria provide guidelines for the initial workup and surveillance of asymptomatic women with stage I breast cancer. For newly diagnosed stage I breast cancer, imaging is generally not recommended to rule out bone, thoracic, abdominal, or brain metastases due to low yield and lack of clinical benefit. Guidelines from ASCO, NCCN, ESMO, and others advise against routine imaging for asymptomatic patients, as it does not improve survival or quality of life and may lead to unnecessary testing and delays in treatment. For surveillance of asymptomatic women with stage I breast cancer, imaging is also not recommended to detect distant metastases. However, for local recurrence, either diagnostic bilateral mammography, diagnostic digital breast tomosynthesis (DBT), screening mammography, or screening DBT is appropriate. These procedures are equivalent alternatives for detecting local recurrences. The ACR Appropriateness Criteria emphasize that imaging should be used judiciously, considering the potential risks and benefits. Radiation exposure is a key factor in selecting imaging modalities, with relative radiation level (RRL) indications provided for each procedure. For asymptomatic women with a history of stage I breast cancer, imaging is not recommended for detecting distant metastases, but mammography and DBT are appropriate for detecting local recurrences. The guidelines also highlight the importance of patient education and shared decision-making in follow-up care.The American College of Radiology (ACR) Appropriateness Criteria provide guidelines for the initial workup and surveillance of asymptomatic women with stage I breast cancer. For newly diagnosed stage I breast cancer, imaging is generally not recommended to rule out bone, thoracic, abdominal, or brain metastases due to low yield and lack of clinical benefit. Guidelines from ASCO, NCCN, ESMO, and others advise against routine imaging for asymptomatic patients, as it does not improve survival or quality of life and may lead to unnecessary testing and delays in treatment. For surveillance of asymptomatic women with stage I breast cancer, imaging is also not recommended to detect distant metastases. However, for local recurrence, either diagnostic bilateral mammography, diagnostic digital breast tomosynthesis (DBT), screening mammography, or screening DBT is appropriate. These procedures are equivalent alternatives for detecting local recurrences. The ACR Appropriateness Criteria emphasize that imaging should be used judiciously, considering the potential risks and benefits. Radiation exposure is a key factor in selecting imaging modalities, with relative radiation level (RRL) indications provided for each procedure. For asymptomatic women with a history of stage I breast cancer, imaging is not recommended for detecting distant metastases, but mammography and DBT are appropriate for detecting local recurrences. The guidelines also highlight the importance of patient education and shared decision-making in follow-up care.