Breast cancer is the most common noncutaneous malignancy and the second most lethal form of cancer among women in the United States. Mortality from breast cancer has declined since the late 1980s, but this decline has been steeper among white women compared with black women. As a result, the black:white mortality rate ratio has increased over the last two decades. Other ethnic minorities also suffer from disproportionately high breast cancer mortality rates. This review discusses the causes of racial and ethnic disparities in breast cancer mortality and describes the most common approaches to reducing these disparities. The literature suggests that outcome disparities are related to patient-, provider-, and health system-level factors. Lack of insurance, fear of testing, delay in seeking care, and unfavorable tumor characteristics all contribute to disparities at the patient level. At the provider level, insufficient screening, poor follow-up of abnormal screening tests, and nonadherence to guideline-based treatments add to outcome disparities. High copayment requirements, lack of a usual source of care, fragmentation of care, and uneven distribution of screening and treatment resources exacerbate disparities at the health system level. Although pilot programs have increased breast cancer screening among select populations, persistent disparities in mortality suggest that changes are needed at the policy level to address the root causes of these disparities.

The authors conduct a systematic review of the literature to identify interventions designed to enhance breast cancer screening, diagnosis, and treatment among minority women. Most trials in this area have focused on breast cancer screening, while relatively few have addressed diagnostic testing or breast cancer treatment. Among patient-targeted screening interventions, those that are culturally tailored or addressed financial or logistical barriers are generally more effective than reminder-based interventions, especially among women with fewer financial resources and those without previous mammography. Chart-based reminders increase physician adherence to mammography guidelines but are less effective at increasing clinical breast examination. Several trials demonstrate that case management is an effective strategy for expediting diagnostic testing after screening abnormalities have been found. Additional support for these and other proven health care organization-based interventions appears justified and may be necessary to eliminate racial and ethnic breast cancer disparities. Keywords breast cancer; screening; diagnosis; treatment; race; ethnicity; interventionBreast cancer is the most common noncutaneous malignancy and the second most common cause of cancer death among U.S. women (Ries et al. 2005). With over 200,000 cases diagnosed each year, the lifetime risk of breast cancer among U.S. women is 1 in 8 (American Cancer Society 2005). Although breast cancer mortality declined by 2.3% per year between 1990 and 2002, racial and ethnic disparities increased during that time, primarily due to a greater decline in breast cancer mortality among white women compared to minority women (Jemal et al. 2004;Ries et al. 2005). Five-year female breast cancer survival is currently 87.5% among whites, 75.0% among blacks, 83.0% among Hispanics/Latinos, 89.4% among Asians/Pacific Islanders, and 79.6% among American Indians/Alaska Natives (Jemal et al. 2004).Disparities in breast cancer survival may be related to racial and ethnic differences at each stage of detection and management, including screening, timeliness of diagnostic testing after abnormal screening, quality of care during breast cancer treatment, and follow-up upon completion of breast cancer therapy (Aziz and Rowland 2002;McWhorter and Mayer 1987). No single element of care explains all of the mortality disparities. For example, breast cancer mortality remains higher among black women compared to white women despite evidence that screening mammography rates have been similar in these two groups since about 1993 ( Figure 1). In addition, compared to white women, Hispanic/Latino women have lower mammography rates and lower 5-year breast cancer survival, while Asian/Pacific Islander women have lower mammography rates and higher 5-year breast cancer survival (National Center for Health Statistics 2005;Jemal et al. 2004 (McPhee et al. 2002), these results suggest that screening mammography is only one of several factors important to racial/ethnic differen...

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Dramatic changes in health care have stimulated reform of undergraduate medical education. In an effort to improve the teaching of generalist competencies and encourage learning in the outpatient setting, the Society of General Internal Medicine joined with the Clerkship Directors in Internal Medicine in a federally sponsored initiative to develop a new curriculum for the internal medicine core clerkship. Using a broad-based advisory committee and working closely with key stakeholders (especially clerkship directors), the project collaborators helped forge a new national consensus on the learning agenda for the clerkship (a prioritized set of basic generalist competencies) and on the proportion of time that should be devoted to outpatient care (at least one third of the clerkship). From this consensus emerged a new curricular model that served as the basis for production of a curriculum guide and faculty resource package. The guide features the prioritized set of basic generalist competencies and specifies the requisite knowledge, skills, and attitudes/values needed to master them, as well as a list of suggested training problems. It also includes recommended training experiences, schedules, and approaches to faculty development, precepting, and student evaluation. Demand for the guide has been strong and led to production of a second edition, which includes additional materials, an electronic version, and a pocket guide for students and faculty. A follow-up survey of clerkship directors administered soon after completion of the first edition revealed widespread use of the curricular guide but also important barriers to full implementation of the new curriculum. Although this collaborative effort appears to have initiated clerkship reform, long-term success will require an enhanced educational infrastructure to support teaching in the outpatient setting.