African American women have a lower overall incidence of breast cancer but a higher overall mortality than do white women. African American women with breast cancer present for medical care at an earlier age, with more advanced stage disease, and with higher-risk tumor biology. While the advanced stage at presentation and higher-risk tumor biology appear to account for much of the excess mortality in African American women, differences persist even after controlling for these factors. This paper discusses the factors that may contribute to differences in survival and differences in stage at diagnosis between African American and white women.