Background: Little is known about factors associated with current rates of breast reconstruction after mastectomy or longer-term outcomes of different reconstructive options in diverse population-based samples. Methods: We surveyed 2245 women newly diagnosed with breast cancer and reported to the Detroit and Los Angeles SEER registries from 6/05-2/07 and merged these data to SEER. Patients were surveyed again about 4 years after diagnosis (expected n=1520). We report on a preliminary sample of 707 patients. Results: 249 patients (35.2%) had mastectomy as initial therapy. Of those, 110 (44%) received reconstruction (62% immediate, 38% delayed). One-third had autologous tissue and two-thirds had an implant (equally divided between saline and silicone) reconstruction. Less than one-quarter (22.8%) of women who received reconstruction were dissatisfied with the cosmetic results, and 28% felt the outcome did not match expectations. Women who received reconstruction were slightly more satisfied with their breast and body appearance than those who received mastectomy alone, but less satisfied than those who received BCS (5 pt scale score 3.2, 3.0, 3.5 for reconstruction, mastectomy alone, and BCS, respectively, p<.001, controlling for age). Most common reasons for not getting reconstruction were related to patient attitudes about the surgery: Half (52%) reported that they did not want more surgery or that reconstruction was not important and one-third (34%) were concerned about possible complications. Barriers to care were less commonly endorsed: 18% reported that insurance would not cover reconstruction or that they could not find a surgeon who accepted insurance (12%). 37% of those who did not get reconstruction were dissatisfied with the information they received about it. About 15% of women were still considering reconstruction at time of re-survey. Conclusions: While some women were dissatisfied with the results of breast reconstruction, overall, satisfaction with body appearance was slightly higher than for women with mastectomy alone. The majority of women who did not get reconstruction did not want it and few women continue to consider it. However, some financial and informational barriers may persist.