Abstract Though breast-conserving therapy (BCT) was first recommended as the preferred treatment for women with early-stage breast cancer in 1990, little is known about the factors influencing or limiting the use of BCT in rural women. We retrospectively surveyed all surviving patients (227) referred to the Roger Maris Cancer Center over a 2-year period. Disease characteristics were verified by the tumor registry and random chart review. Responses were obtained from 171 patients (75%), a median of 26 months from diagnosis. The majority of patients were from rural areas; only 32% resided in towns with a population greater than or equal to 15,000. Thirty-five percent of those patients meeting published criteria had BCT. Patients who underwent BCT were younger (mean age 56.8 vs. 62.5, P = 0.01), more likely to have benign axillary lymph nodes (82% vs. 64%, P = 0.008), and more likely to be employed away from the home (66% vs. 44%, P = 0.01) than patients who underwent mastectomy (MRM). Distance from the nearest radiation facility did not affect treatment decisions (mean: 59.5 miles BCT vs. 52.6 miles MRM). Most patients (83%) ranked their surgeon as the most important source of information about treatment options. Perceived surgical recommendations were generally followed. Only three patients who felt their surgeon recommended MRM underwent BCT; eleven patients chose MRM though they believed their surgeon recommended BCT. The choice of local therapy is predominantly a surgeon-driven process; logistical barriers unique to a rural population had little impact. Unfortunately, many surgeons continue to apply much more stringent criteria when recommending BCT than those in published guidelines.