Purpose: Breast magnetic resonance imaging (MRI) is a highly sensitive screening modality for early breast cancer detection; however, associated recall and biopsy rates require monitoring to minimise unnecessary anxiety and intervention. This audit evaluated recall, biopsy, and cancer detection rates following breast MRI surveillance of asymptomatic moderate- and high-risk women at Royal Perth Hospital (RPH) and compared outcomes with published benchmarks. Methodology: A retrospective audit was conducted of asymptomatic moderate- and high-risk women who underwent screening breast MRI at RPH between January 2017 and December 2023 under Medicare item number MR464. Eligibility included high-risk genetic mutations, personal history of breast cancer before age 50, prior mantle radiation therapy, or a calculated lifetime breast cancer risk >30% or 10 year risk >5%. Outcomes were assessed at the examination level. Results: A total of 726 breast MRI examinations were performed in 307 women, comprising 221 prevalent and 505 incident screening examinations. Recall for further assessment occurred in 173 examinations (23.8%). Seventy-two biopsies were performed, corresponding to a biopsy rate of 9.9% of examinations. Six breast cancers were detected, yielding a cancer detection rate of 8.3 per 1000 MRI examinations, representing 3.5% of recalls and 8.3% of biopsies. Recall rates were highest in the earlier years and decreased over time. Most cancers were early stage, with no lymph node involvement on final surgical histopathology, and 66.7% met criteria for minimal cancer. Two interval cancers were identified. Conclusion: Breast MRI surveillance in moderate- and high-risk women demonstrated biopsy and cancer detection rates comparable to published benchmarks, with cancers predominantly detected at an early stage. Recall rates decreased over time, consistent with transition from prevalent to incident screening.