Background: The benefits of NAC for breast cancer are multifaceted, providing insight into chemosensitivity, facilitating breast conservation, and providing prognostic information. However, little is known about NAC use across patient demographic factors and health care settings, or trends in surgical procedures after NAC. Methods: Women diagnosed with Stage I-III breast cancer in California, 1998-2012 were identified from the California Cancer Registry. Use of NAC, adjuvant chemotherapy (aCTx) and type of surgery (breast conserving surgery (BCS), bilateral mastectomy (BLM), unilateral mastectomy (ULM)) were examined as a function of clinical, pathological, and sociodemographic and hospital factors. Results: Among 236,797 patients, 34.9% received aCTx, 5.2% NAC and 59.9% no chemotherapy (NoCTx). NAC use nearly tripled over this time period (3.5%-10.8%). Among chemotherapy recipients, NAC use was higher with stage (Stage I, 3.7%; Stage III, 29.1%), was highest for women age < 40 (20.0%) and fell to 13.8% for 40-49 years, 11.8% for 50- 64 years and 10.3% for age ≥ 65. On multivariable analysis, predictors of NAC use included higher stage (III) and grade (3), younger age ( < 40 years), Hispanic (H) ethnicity [versus non-H White, odds ratio (OR) 1.10, 95% confidence interval (CI) 1.05-1.16], and care at a National Cancer Institute (NCI)-designated cancer center (OR 1.70, CI 1.58-1.82). 54.1% of NAC recipients had ULM; 31.6% had BCS and 14.3% BLM. By comparison, lower rates of BLM, 7.4% and 4.3% were recorded among aCTx and NoCTx recipients, respectively. Both BCS and BLM use after NAC increased over time, except for BCS among women < 50 years. The only independent predictor of BCS use after NAC was care at a cancer center (OR 1.70, CI 1.58-1.82). For BLM after NAC, age < 40 (vs. 50-64, OR 2.59, CI 2.21-3.03) or high socioeconomic status neighborhood (vs. low, OR 2.10, CI 1.67-2.64) were the only predictive factors. Conclusions: Although NAC use nearly tripled over time, it remains low, albeit more prevalent in cancer centers. In parallel, BLM use quadrupled after NAC, and was less common after aCTx or NoCTx. High BLM use after NAC warrants investigation, with regard to treatment intent and quality of care.