PURPOSE: To examine whether mammographic assessments and recommendations are linked as expected, based on the Breast Imaging Reporting and Data System (BI-RADS), for the evaluation of women with signs and symptoms of breast disease. MATERIALS AND METHODS: Eight mammography registries from the Breast Cancer Surveillance Consortium contributed mammographic data from 1996 through 1997 for women 25 years of age or older, with signs or symptoms of breast cancer. The association of assessments and recommendations and the relationship of self-reported symptoms to assessments are described. RESULTS: A total of 51,673 diagnostic mammograms were included in the analyses and the expected management recommendation was provided 85%-90% of the time for mammograms classified as assessment categories 1, 2, 4, or 5. Category 3 ("probably benign finding") had the most variability in associated management recommendations, with only 40% (2,998 of 7,423) of cases associated with the recommendation for short interval follow-up. Of the 1,648 category 0 mammograms ("needs additional imaging") that did not have a final assessment, 64% were recommended for additional imaging, while another 20% of the cases were recommended for either a consultation or biopsy. The number of women who reported a lump as a symptom decreased with age but was associated with higher BI-RADS assessments. CONCLUSION: BI-RADS assessment categories were generally used as intended for all categories but 0 and 3. Additional education about the use of these categories may be warranted. The inconsistencies between assessment category and management recommendations may present difficulties in conducting outcome audits.