This study aimed to improve the diagnostic accuracy of breast diseases by combining breast imaging-reporting and data system (BI-RADS) with the enhancement intensity and pattern of contrast-enhanced spectral mammography (CESM) (this combination of BI-RADS and CESM was designated as BaC).BI-RADS was used to evaluate low-energy CESM images. Spearman nonparametric correlation analysis was performed to analyze the correlation between the enhancement intensity of CESM subtraction images and the pathological results. Odds ratio (OR) values were calculated to determine whether the enhancement pattern of CESM subtraction images is a risk factor for benign and malignant lesions. The diagnostic efficacies of BI-RADS, CESM, and BaC scores for benign and malignant breast diseases were analyzed using the receiver operating characteristic (ROC) curve.Lesions with a high enhancement intensity were more likely to be malignant than those with low enhancement intensity. Lesions with heterogeneous enhancement tended to be malignant, whereas those with homogeneous enhancement tended to be benign. No significant correlation was observed between ring enhancement and the benignity or malignancy of lesions. The area under the ROC curve of BaC was higher than that of BI-RADS or CESM, and the difference was statistically significant.The diagnostic efficacy of BI-RADS combined with CESM enhancement was superior to that of either method alone.