The American College of Radiology (ACR) has developed appropriateness criteria for the initial workup and surveillance of local recurrence and distant metastases in asymptomatic women with newly diagnosed Stage I breast cancer. The criteria are based on a review of the literature and expert panel discussions. For newly diagnosed asymptomatic women with Stage I breast cancer, imaging is not recommended to rule out bone, thoracic, abdominal, or brain metastases. Similarly, for surveillance of asymptomatic women with Stage I breast cancer, imaging is not recommended to rule out bone, thoracic, abdominal, or brain metastases. However, diagnostic bilateral mammography, diagnostic digital breast tomosynthesis (DBT), screening mammography, or screening DBT are generally appropriate for surveillance to rule out local recurrence. These procedures are considered equivalent alternatives, and only one will be ordered to provide the necessary clinical information for effective patient care. The criteria emphasize the importance of early detection of locoregional or contralateral recurrence, which is correlated with improved survival, rather than detecting asymptomatic metastatic cancer.The American College of Radiology (ACR) has developed appropriateness criteria for the initial workup and surveillance of local recurrence and distant metastases in asymptomatic women with newly diagnosed Stage I breast cancer. The criteria are based on a review of the literature and expert panel discussions. For newly diagnosed asymptomatic women with Stage I breast cancer, imaging is not recommended to rule out bone, thoracic, abdominal, or brain metastases. Similarly, for surveillance of asymptomatic women with Stage I breast cancer, imaging is not recommended to rule out bone, thoracic, abdominal, or brain metastases. However, diagnostic bilateral mammography, diagnostic digital breast tomosynthesis (DBT), screening mammography, or screening DBT are generally appropriate for surveillance to rule out local recurrence. These procedures are considered equivalent alternatives, and only one will be ordered to provide the necessary clinical information for effective patient care. The criteria emphasize the importance of early detection of locoregional or contralateral recurrence, which is correlated with improved survival, rather than detecting asymptomatic metastatic cancer.