The Midwest is often referred to as America’s heartland, and is home of the so-called bellwether states whose voting patterns have consistently predicted the outcome for national elections. Patients with breast cancer and breast cancer surgeons are also voters, and it is therefore reasonable to question whether these political patterns can be generalized to oncology practice patterns. If so, then the study by Nash et al1 in this issue of JAMA Surgery indicates that we have not yet seen a peak in the rising rates of contralateral prophylactic mastectomy (CPM) that have been observed among patients in the United States with unilateral breast cancer.