(Reuters Health) – Lung cancer patients at public hospitals, which serve a greater proportion of poor and disadvantaged people, are less likely to receive adequate treatment for pain and other symptoms than patients treated at a cancer center, according to a new study.

Patients at public hospitals were nine times more likely than the cancer center patients to come in with more-severe symptoms to begin with.

“I think it’s been noted…for the last couple of decades” that cancer “is less well managed in what we consider underserved patients,” said Dr. Charles Cleeland from MD Anderson Cancer Center in Houston, who led the study.

Underserved patients tend to be poor, single, unemployed, non-white, and receiving public assistance health insurance. They also tend to have low levels of formal education.