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Iowa is among several rural Midwestern states with the highest proportions of contralateral prophylactic mastectomy (CPM) in women 45 years of age. We evaluated the role of rurality and travel distance in these surgical patterns. Women with unilateral breast cancer (2007-2017) were identified using Iowa Cancer Registry records. Patients and treating hospitals were classified as metro, nonmetro, and rural based on Rural-Urban Continuum Codes. Differences in patient, tumor, and treatment characteristics and median travel distance (M