BACKGROUND: Disparities in breast cancer outcomes are prevalent in rural areas, exacerbated by barriers in access to care. We sought to identify factors associated with advanced-stage breast cancer presentation in the National Cancer Database. STUDY DESIGN: Patients with breast cancer residing in rural areas were selected from the National Cancer Database between 2004 and 2021. We used multinomial logistic regression to evaluate clinicopathologic factors associated with stage at diagnosis. RESULTS: Among 52,287 rural patients with breast cancer analyzed, 7,111 (13.6%) were diagnosed at advanced stages. Non-Hispanic Black patients had a significantly higher risk of later-stage diagnosis compared with non-Hispanic White patients (stage 2: odds ratio [OR] 1.4 [95% CI 1.26 to 1.55]; stage 3: OR 1.58 [95% CI 1.38 to 1.82]; and stage 4: OR 1.29 [95% CI 1.07 to 1.54]). Hispanic patients had increased risk of stage 3 breast cancer compared with non-Hispanic patients (OR 1.5, [95% CI 1.03 to 2.20]). Uninsured patients had a progressively higher risk of advanced-stage diagnosis than insured patients (stage 2: OR 1.37 [95% CI 1.12 to 1.68]; stage 3: OR 2.06 [95% CI 1.61 to 2.64]; stage 4: OR 3.88 [95% CI 2.94 to 5.11]). Significant geographic differences were observed, with patients in the East South Central (OR 1.28 [95% CI 1.07 to 1.52]) and West South Central (OR 1.33 [95% CI 1.03 to 1.70]) regions having a significantly higher likelihood of stage 4 breast cancer compared with patients in the West North Central region. CONCLUSIONS: Significant geographical differences exist in the diagnosis of late-stage breast cancer in rural populations, which are further exacerbated by demographic factors including race and insurance status.