The Kaiser score reliably excludes malignancy in benign contrast-enhancing lesions classified as BI-RADS 4 on breast MRI high-risk screening exams.

• The Kaiser score shows high diagnostic accuracy in identifying malignancy in contrast-enhancing lesions in patients undergoing high-risk screening for breast cancer. • The application of the Kaiser score may avoid > 45% of unnecessary breast biopsies in high-risk patients. • The Kaiser score aids decision-making in high-risk breast cancer MRI screening programs.