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Background: For patients with breast cancer who decline recommended treatments, available data examining survival outcomes are sparse. We compared overall survival and relapse-free survival outcomes between patients with breast cancer who declined recommended primary treatments and those who received recommended primary treatments. Methods: Using data from the BreastSurgANZ Quality Audit database, a retrospective cohort study was performed for patients diagnosed with breast carcinoma (stage 0-IV) between 2001 and 2014 who were treated in our integrated cancer centre. A propensity score-matched analysis was performed to compare overall survival and relapse-free survival between patients who either declined or received the standard recommended treatment. Results: A total of 56/912 (6.1%) patients declined one or more recommended therapies. Five-year overall survival for those who declined or received treatment as recommended was 81.8% versus 88.9% (P = 0.17), respectively. Ten-year survival was 61.3% versus 67.8% (P = 0.22), respectively. For patients who declined treatments, 5-year relapse-free survival was 72.4%, compared to 87.4% for those who received them (P = 0.005). Ten-year relapse-free survival was 61.0% versus 80.6% (P = 0.002), respectively. On adjusted Cox regression analysis, treatment refusal was associated with poorer relapse-free survival (adjusted hazard ratio 2.76 (95% confidence interval 1.52-5.00), P < 0.001). Conclusion:In conclusion, patients who declined recommended treatment for breast cancer had poorer relapse-free survival compared to those who received them. These data may help clinicians assist patients with breast cancer in their decision-making.