Background: The process of shared decision-making in the surgical management of breast cancer is complex. Many women eligible for breast conservation therapy (BCT) still choose total mastectomy (TM), and little is known about the factors responsible for their decision. We conducted a pilot, qualitative study in order to determine factors influencing the selection of TM over BCT, and to improve our understanding of patient’s concerns and priorities in their decision-making process for breast cancer surgery. Methods: Data were collected from a four-year, prospective Breast Cancer Surgical Quality Database. Study participants included female patients with invasive carcinoma who, despite being eligible for BCT, elected to undergo TM. Eligibility criteria included women with no contraindications to BCT, tumor size <2cm, and no evidence of extensive microcalcifications. Patients with tumor recurrence, multicentric disease, scleroderma, and lupus were excluded. Patients were contacted by phone and administered a survey designed to elicit the specific factors affecting their decision to undergo TM. Results: Out of 670 patients treated for IDC/ILC between 2003 and 2007, 12 met eligibility criteria and were subsequently interviewed. 10 patients identified fear of recurrence as the prevailing factor in their decision to undergo TM, and 5 patients identified availability of breast reconstruction as a moderate to strong influence in their decision to undergo TM. Time away from work and transportation during radiation therapy had minimal or no influence. Conclusions: Our results indicate that patients with small, invasive breast cancers who chose TM for their surgical treatment, despite being eligible for BCT, were primarily influenced by fear of recurrence. These decision factors persisted despite treatment at a multidisciplinary center, where patients are informed of equivalent survival and minimal difference in recurrence with appropriate BCT. These results highlight the need for further assessment of patient education and comprehension, as well as greater awareness of emotional factors which may influence a patient’s decision regarding the surgical management of her breast cancer.