Although the U.S. has experienced a 27 percent decline in cancer death rates during the past 25 years, the drop has not benefited everyone equally: poor individuals and people of color have significantly higher mortality than this average.

One reason for the disparity is that people living in poverty have lower rates of routine screening, as well as a lower likelihood of getting the best possible treatment, and African-American, Native American and Hispanic people are more likely to be living in poverty than are whites and Asians. A recent study in the journal Cancer Epidemiology, Biomarkers & Prevention, for example, shows that black and Hispanic women in Chicago were less likely to be diagnosed at top-tier centers as compared with their white counterparts.

When I worked as a nurse clinician in an underserved community on Chicago’s South Side, an area known for high breast cancer mortality rates, I saw how hard it was to refer women with symptoms of breast problems to our leading academic medical centers for care. Uninsured women, in particular, were more often than not referred to our county hospital, which had fewer resources and reduced state-of-the-art diagnostic capability. Even today zip code and insurance status can influence whether or not women receive breast cancer care at centers of excellence.

And although breast cancer survival overall has improved over time, the American Cancer Society affirms that disparities remain: the five-year survival rate is 92 percent for white women but 83 percent for black women; the latter group is more likely to have more aggressive tumor types and to be diagnosed at a later stage of the illness, both of which are contributing factors to cancer outcomes. In 2015 black women were 39 percent more likely to die from breast cancer as compared with white women.

I have identified additional treatment barriers affecting women as young as 20 in my own studies with African-Americans. African-American women younger than 40 have shared with me that providers do not take them seriously when they present with breast concerns, claiming that they are too young to have breast cancer. I know from firsthand experience that young African-American women and their families are frustrated with the health care delivery system, especially if they are uninsured or underinsured.

Cancer advocates have sounded the alarm about these disparities for years. In 2007, for example, the Metropolitan Chicago Breast Cancer Task Force found a 68 percent higher death rate for black women as compared with white women. These findings helped to shape public policy and inform citywide and statewide initiatives aimed at addressing system issues such as access to high-quality mammography screening. I was thrilled to see these attempts to lower barriers in the health care system itself, rather than the traditional focus on changing behavior in patients, who should not be blamed when hospitals, doctors and insurance companies fail to provide them with good care. Because of the tremendous efforts of the task force and other partners, Chicago is leading the nation in reducing the racial gap in breast cancer mortality when compared with the other nine U.S. cities with the largest African-American population in a 2017 study. (The reduction in breast cancer mortality in the city may be attributed, in part, to the task force’s comprehensive work.)

Even though the impact is greatest for women of color, it extends to uninsured adults of every ethnic background. For example, people without insurance are more likely to postpone or forgo health care altogether—and a recent Gallup poll noted that three in 10 Americans do not seek medical care or defer treatment because of cost. And this problem is getting worse: a study by the Kaiser Family Foundation showed an increase in the number of uninsured from 2016 to 2017 of nearly 700,000—primarily in states without Medicaid expansion. Eleven percent of blacks and 19 percent of Hispanics are uninsured as compared with 7 percent of whites.

Surviving cancer should not be determined by your ethnicity or your income level. But until the gap in access to affordable good care is eliminated, that will be the prognosis.