OBJECTIVES: Personalized breast cancer screening aims at identifying the best screening strategy depending on the individual risk level of each woman. At the same time, existing screening programs have low participation and adherence rates. Research has shown that the perception of risk information may influence screening behavior. Cost-effectiveness of personalized screening thus has to be evaluated with respect to risk-dependent screening adherence. This study uses an established simulation model to evaluate the effects of risk-dependent adherence behavior in women with personalized risk perception. METHODS:  Adherence scenarios are formulated in the light of recent findings. A validated Markov microsimulation model is adapted to evaluate the effects of these different adherence scenarios. RESULTS:  Three adherence scenarios could be identified: a positive relation between high perceived risk and screening adherence, a negative relation or a curvilinear relationship, which describes positive effects of moderate risk, but negative effects of low and high risk perception. Cost-effectiveness is calculated for routine and personalized screening strategies, as suggested by earlier studies. CONCLUSIONS:  Economic evaluations of personalized screening are heavily influenced by the perception of risk and risk-dependent adherence of women at risk. Non-adherence decreases the cost-effectiveness of routine and personalized screening strategies. Depending on the nature of the adherence relation (positive, negative, curvilinear), the cost-effectiveness of personalized breast cancer screening strategies is especially affected. Future economic evaluations need to take into account, if personalized risk information would strengthen or weaken adherence behavior and accommodate risk-dependent screening adherence.