Sentinel lymph node biopsy (SLNB) for breast cancer is now performed routinely in many U.S. medical centers. The acceptance of SLNB in the community and in rural medical centers, however, has not been accurately defined. The purpose of this study was to assess how surgeons in Kentucky, a predominantly rural state, have incorporated SLNB into practice. General surgeons in the state of Kentucky were identified by registration with the state medical association. All general surgeons (n=272) in the state were mailed the questionnaire, with 93% (n=252) responding. Overall, 172 defined themselves as rural surgeons. Among the rural surgeons, 87% perform breast cancer operations and 54% perform SLNB. In comparison, 74% of nonrural surgeons perform breast cancer operations and 80% perform SLNB. A majority of nonrural surgeons (73%) have performed SLNB for more than 2 years when compared to rural surgeons (73% versus 37%, respectively; p<0.0001). Planned backup axillary node dissection was stopped by both rural (26%) and community (39%) surgeons after 10 cases (14% rural, 19% nonrural) or 11--20 cases (12% rural, 20% nonrural). Surgeons reported using SLNB for the following diagnoses: invasive cancer (98%), ductal carcinoma in situ (DCIS) (43%), and lobular carcinoma in situ (LCIS) (11%). The majority of surgeons (87%) reported a greater than 90% SLN identification rate. SLNB has become widely accepted by surgeons in both rural and nonrural medical centers in Kentucky. However, there has been considerable variability in the number of training cases surgeons have performed prior to abandoning routine axillary dissection. This indicates a need for continuing educational efforts aimed at quality assurance.