This retrospective study assesses the presentation of breast cancer patients who died of disease. The goal was to estimate the proportion of patients whose cancer was detected by a screening mammogram, yet still proved fatal, and to characterize contemporary fatal breast cancers. Patients who died of breast cancer between 1995 and 2001 and were treated at three hospitals with complete, accessible information were identified using the Rhode Island Department of Health database and State Cancer Registry. Patients were classified as routinely screened, true interval, off-program, or unscreened. The median maximum diameter of fatal cancers was 2.5 cm. Sixty-nine percent of patients had lymph node metastases and 19% had stage IV disease. Fifty-seven percent were unscreened and 12% were routinely screened, with 2.5 cm and 1.5 cm median tumor diameters, respectively. Fifty-two percent of unscreened patients and no routinely screened patients had stage III or IV disease. Fifteen percent of fatal cancers were interval cancers. Only 27% of patients who died of breast cancer were participants in routine screening programs in Rhode Island, where 84% of women receive regular mammograms. This study complements randomized, population-based trials demonstrating a significant mortality reduction with an invitation to participate in screening.