AI image analysis as the basis for risk-stratified screening

Artificial intelligence (AI) has emerged as a transformative tool in breast cancer screening, with two distinct applications: computer-aided cancer detection (CAD) and risk prediction. While AI CAD systems are slowly finding its way into clinical practice to assist radiologists or make independent reads, this review focuses on AI risk models, which aim to predict a patient's likelihood of being diagnosed with breast cancer within a few years after negative screening. Unlike AI CAD systems, AI risk models are mainly explored in research settings without widespread clinical adoption. This review synthesizes advances in AI-driven risk prediction models, from traditional imaging biomarkers to cutting-edge deep learning methodologies and multimodal approaches. Contributions by leading researchers are explored with critical appraisal of their methods and findings. Ethical, practical, and clinical challenges in implementing AI models are also discussed, with an emphasis on real-world applications. This review concludes by proposing future directions to optimize the adoption of AI tools in breast cancer screening and improve equity and outcomes for diverse populations.