how well it accommodates the financial, cultural, and educational situations of those it needs to serve.

Breast cancer mortality rates in the United States vary by race and ethnicity, and the gap between white and African American women is striking (Figure 3-2). Although the incidence of breast cancer among white females is higher than among other racial or ethnic groups, African-American women—particularly those older than age 64—have the highest risk for mortality from breast cancer.99 (The racial and ethnic categories included in this database were white, African American, Asian/Pacific Islander, American Indian/Alaskan Native, and Hispanic.) Similarly, 88 percent of white women survive at least 5 years after diagnosis, as compared with 73 percent of African-American women. Stage-specific survival rates do not differ significantly between the two groups.28

Group disparities in mammography rates may result from a broad combination of socioeconomic and cultural influences. Low socioeconomic status is characterized by low income, higher rates of poverty, lower levels of education, lack of private health insurance, lack of transportation, and lack of access to health care. Together, these factors are associated with lower rates of cancer screening, higher probability for later stage diagnosis, lack of breast health awareness, and mistrust and misunderstanding of the health care system.28,60,61,71,91,95 Higher poverty rates among African Americans are reflected in disproportionate numbers of women lacking adequate insurance, or any insurance at all.47,90 Insurance coverage is a significant predictor of whether or not a woman will receive a mammogram.57 Uninsured women and women with Medicaid are more likely to receive a breast cancer diagnosis at a late stage of disease, and are 30 to 50 percent more likely to die of their disease than women with private insurance.57

Yet when white, African-American, and Hispanic women were provided equal access to high-quality mammographic screening, all groups had similar rates of breast cancer survival regardless of age, stage of diagnosis, and socioeconomic status.123 These circumstances are, however, far from typical (Figure 3-3).

Social factors that restrict access to health care appear to contribute to racial and ethnic differences in breast cancer mortality. Biology may also play a role; even among women who have equal access to health care, fewer African Americans than whites are diagnosed with early stage breast disease, and more African Americans are diagnosed with advanced stage cancer.123 The peak age for incidence of breast cancer among African American women is 40 to 49, while among white women it is 50 to 59.90,91 The incidence of estrogen receptor-negative and progesterone receptor-negative tumors, which tend to be aggressive, is also significantly higher among African American women than among whites.61,77,90

Social injustice, in the form of social or institutional discrimination, can

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