Abstract Significance. Surgical treatment by mastectomy or breast conserving surgery (BCS) followed by adjuvant radiotherapy is recommended for women diagnosed with breast cancer at stages I-III, and receipt of this guideline concordant care is positively associated with survival. Nearly all women with early stage breast cancer have surgical treatment. The breast cancer specific mortality disparity that exists between Black and White women is especially pronounced in certain geographic regions such as the “Black Belt” in US south including states like North Carolina, Georgia, Mississippi, Alabama and Louisiana, and within these states, Black women in rural areas have been especially burdened by high cancer morbidity and mortality. Innovation. Using a unique data linkage between cancer registry data, public and private payer insurance claims and area level social indicators, this study will be the first large scale quantitative study of the surgical treatment experience of Black women, and the first in depth investigation of cancer care delivery among rural Black women specifically. Aims. The objective is to understand patterns in surgical treatment of breast cancer and resulting costs, complications, complications, and outcomes for Black women residing in urban and rural areas in the US South. Approach. A cohort of Black women with early stage breast cancer will be derived from the UNC Cancer Information & Population Health Resource, an innovative data source that links statewide cancer registry data to multi-payer insurance claims, area level social indicators, and provider factors and covers 85% of cancers diagnosed in North Carolina between 2004-2013. Aim 1 will use Joinpoint regression to examine the temporal trends in incident mastectomy and BCS among Black women between 2004 and 2013 and will assess differences in trends for Black women residing in urban vs. rural areas. Aim 2 will assess whether the difference in prevalence of mastectomy vs BCS between urban and rural areas is mediated by distance to radiotherapy and use of low procedure volume surgeons using causal inference multiple mediation techniques. Aim 3 will calculate rate of complications defined as infection, 90-day hospital readmission for infection, wound complication, and hematoma/seroma and will estimate the costs associated with complications following surgery. Study Impact. This study integrates several sources of data to identify multi- level contributors to geographic variation in cancer care outcomes. Greater insight into breast cancer care delivery for Black women, particularly those in in rural areas, promotes equity in health services delivery. The long term goal of this study is to identify modifiable systems factors to foster efficient delivery of healthcare, facilitate the provision of high quality care, and improve patient safety in a vulnerable population especially burdened by breast cancer.