The World Health Organization’s definition of palliative care emphasizes its role as a quality-of-life-enhancing intervention for patients and families experiencing life-threatening illnesses, recommending its early implementation alongside curative therapies. This paradigm shift represents a fundamental evolution from traditional end-of-life care models to the proactive integration of palliative care throughout the cancer continuum. This paper examines the current evidence base for integrating early palliative care, analyzes key implementation barriers across diverse health care settings, and proposes evidence-based strategies. Furthermore, it explores innovative care delivery models, discusses the development of quality metrics for integrated care, and outlines future research priorities.
Key points
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Integration of palliative care and cancer care:
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Can be successfully achieved according to data from randomized control trials. Patients experience improved symptom control, quality of life, improved mood, in some instances improved survival.
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Enables patients to spend less time in the hospital and receive less aggressive end-of-life care as measured by markers such as reduced chemotherapy in the last 30 days of life.
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Changes the role of palliative care from an end-of-life intervention to an intervention that provides support for patients while they are getting cancer therapy.
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Abbreviations
| EAPC | European Association for Palliative Care |
| ENABLE | Educate, Nurture, Advise Before Life Ends |
| ESMO | European Society for Medical Oncology |
| PROM | patient-reported outcome measure |
| RCT | randomized controlled trial |
| SCP | standardized care pathway |
Background and context
Much criticism has been levied against oncologic care and its excessive focus on treating malignancies rather than the whole patient. The development of hospice care has served to mitigate the lack of a patient-centered focus. Over the years, hospice and palliative care became equated with end-of life care despite several redefinitions over the years. , Over time, with the evidence generated by clinical trials that palliative care can be brought in along with cancer care, palliative care has been found to be beneficial when introduced earlier in the cancer trajectory, aligning with the World Health Organization’s definition that emphasizes improving quality of life alongside curative or life-prolonging treatments.
Introduction
The current definition of palliative care according to the WHO states that “palliative care is an approach that improves quality of life for patients and their families facing the problem associated with life-threatening illness, and is applicable early in the course of disease, in conjunction with other therapies that are intended to prolong life.” For patients with cancer, this definition has evolved through recent clinical trials, which emphasize integrating palliative care with active cancer treatments, such as chemotherapy or radiation, to improve symptom management, quality of life, and overall care satisfaction. These trials also demonstrate that palliative care can be introduced earlier in the cancer journey, often referred to as “moving upstream” to better support symptom management, enhance quality of life, and increase overall satisfaction with care. This early integration has grown in importance due to the rising cancer incidence and prevalence, as well as an aging population dealing with multiple comorbidities. Studies suggest that 69% to 82% of those who die need some form of palliative care. The important challenges and frontiers of this integration are the primary focus of this paper.
Current evidence of benefit
Review of Randomized Controlled Trials on Palliative Care Integration in Oncologic Care
The following list of important randomized controlled trials (RCTs) demonstrates the benefits of integrating palliative care into oncological care.
Temel and Colleagues (2010)
Temel and colleagues’ 2010 RCT evaluated the introduction of early palliative care in patients with recently diagnosed metastatic non-small cell lung cancer receiving cancer therapy. The early palliative care group demonstrated significant improvements compared to the group receiving standard care. Key findings include the following:
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Enhanced quality of life.
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Reduced depression rates were observed.
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Increased prognostic awareness.
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Less aggressive end-of-life care (eg, reduced intensive cancer treatment).
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A surprising survival benefit was observed, with a more prolonged median survival in the early palliative care group.
This study highlights the benefits of early palliative care, establishing it as a model for the introduction of palliative care with newly diagnosed advanced cancer.
Zimmermann and Colleagues
Zimmermann and colleagues conducted a cluster-randomized trial in patients with advanced cancer who were unable to be successfully treated with palliative chemotherapy or radiotherapy. The study group received early palliative care in addition to standard oncologic care, including monthly consultations with palliative care physicians and nurses, 24/7 access to services, and discussions regarding goals, symptoms, distress, and practical needs. The control group received standard oncological care alone. Key findings include the following:
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Quality-of-life scores improved at 3 and 4 months.
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Reduced symptom severity and burden.
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Higher satisfaction with care, particularly in clinician–patient interactions.
This study is notable for its broad inclusion of various cancer types and exploration of clinician-patient dynamics, demonstrating consistent benefits across multiple outcomes, even during active anticancer therapies.
Bakitas and Colleagues (ENABLE Studies)
The ENABLE (Educate, Nurture, Advise Before Life Ends) studies by Bakitas and colleagues investigated early palliative care integration through 2 RCTs , :
ENABLE (2009)
This RCT involved 322 patients with advanced cancer at a rural comprehensive cancer center and its affiliated clinics. The intervention was a nurse-led, telephone-based psychoeducational program delivered concurrently with cancer care, comprising 4 sessions on solving problems, symptom management, advance care planning, and communication, followed by monthly follow-up phone calls. The control group received usual care. Findings include the following:
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The intervention group showed improved quality of life (QoL) and mood.
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A trend toward lower symptom intensity was observed (not statistically significant).
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Benefits were primarily observed within the first 4 months of treatment.
This study was unique for its nontraditional, limited-intervention approach, which was conducted without an interdisciplinary team, yet it showed positive effects on participants.
ENABLE III (2015)
This RCT expanded on the 2009 study by adding a family caregiver component and conducting a more comprehensive follow-up. The intervention group received early, and the control group received delayed palliative care. Key findings include the following:
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Improved 1 year survival in the early palliative care group (63% vs 48% in the delayed group).
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Lower depression scores were observed among caregivers in the early intervention group.
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No significant intergroup differences were observed in quality of life, symptom impact, or mood.
This study suggested potential survival benefits but raised questions about the mechanisms of benefit due to the lack of differences in other patient-reported outcomes.
Maltoni and Colleagues
Maltoni and colleagues’ multicenter RCT, conducted across 9 Italian centers, involved 207 patients with metastatic pancreatic cancer. The intervention group received systematic early palliative care consultations after diagnosis, along with cancer treatment, whereas the control group received on-demand palliative care (standard care). The primary and secondary outcomes included quality of life, control of symptoms, mood improvements, patient and family satisfaction with care, health care system overutilization, and the level of aggressive care at the end of life. Findings include the following:
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The early palliative care group had better QoL scores.
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The early palliative care group showed improved symptom control:
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The early intervention group spent less time in health care institutions.
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The early palliative care group received less aggressive end-of-life care, as measured by markers such as reduced chemotherapy in the last 30 days and fewer hospitalizations.
This is the first European multicenter trial to confirm the findings of Temel and Zimmermann, emphasizing the benefits in patient outcomes, health care utilization, and end-of-life care patterns, particularly for a disease-specific (pancreatic cancer) population.
Temel and Colleagues (2017)
Temel and colleagues’ (2017) RCT examined simultaneous palliative care in patients with newly diagnosed gastrointestinal and lung cancers. The intervention group showed the following results:
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Improved quality of life.
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Decreased depression.
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Better coping with prognosis.
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Enhanced communication regarding advanced directives.
This study reinforces the benefits of early palliative care for different cancer types.
Grønvold and Colleagues (2017)
Grønvold and colleagues’ RCT investigated palliative care interventions in patients with advanced cancer but was unable to find significant differences in the primary or secondary outcomes. The lack of structured palliative care visits and the short observation period likely contributed to these null findings, highlighting the importance of the intervention design.
Vanbutsele and Colleagues
Vanbutsele and colleagues’ RCT confirmed Temel’s findings, showing improvements in quality of life with early palliative care. The intervention group received monthly sessions with a palliative nurse and optional consultations with a psychologist, which differs from other studies. Despite this, the study supports the benefits of early integration of palliative care.
Summary
These RCTs collectively demonstrate that early palliative care integration improves quality of life, symptom control, and patient satisfaction with care. The variety of study designs, settings, and intervention content underscores the need for standardized palliative care approaches to ensure consistent results ( Tables 1 and 2 ).
Table 1
Summary of studies comparing usual care to usual care with palliative care
Adapted from Ref.
| Study First Author and Year (Population) | QOL | Symptoms | Anxiety/Depression | Caregiver Distress | Survival |
|---|---|---|---|---|---|
| Bakitas et al, 2009 (cancer) | Increased ( P =.02) | P =.06 | Less depressed mood ( P =.02) | NM | Longer by 5.5 mo ( P =.14 [NS]) |
| Temel et al, 2010 (lung cancer) | Increased ( P =.03) | NR | Less depression ( P =.01) | NM | Longer by 2.7 mo ( P =.02) |
| Zimmermann et al, 2014 (cancer) | Increased ( P =.05) | Equal (3 mo; P =.33) improved (4 mo; P =.05) | Equal | Improved ( P =.003) | Equal |
| Bakitas et al, 2015 (cancer) | Equal ( P =.30) | Equal ( P =.09) | Equal mood | Lower depression and stress ( P =.02 and.01, respectively) but not better QOL | Longer by 6.5 mo; 1 y OS, 63% vs 48% ( P =.038) |
| Temel et al, 2017 | Increased at week 12 ( P =.34) and at week 24 ( P =.01) | NR | Improved ( P =.048) | NR | NR |
| Groenvold et al, 2017 | No significant effect on the primary outcome (change in primary need, EORTC QLQ-C30). | No significant differences; nausea/vomiting close to significance ( P <.01 threshold) | There was no difference in emotional function. Anxiety and depression scales not reported | NR | No difference between SPC and standard care |
| Temel et al, 2024 | SPC noninferior to EPC, ( P <.001). | No significant differences were observed. | Week 24 : No significant difference; adjusted mean: SPC = 5.0 vs EPC = 5.3; difference = −0.4 (95% CI–1.3 to 0.5). | NR | NR |
| Vanbutsele et al, 2020 | At T1 (12 wk), the systematic EPC group showed improved QOL to the on-demand EPC group. TOI score (FACT-Hep, 0–128, higher better): systematic EPC mean change −0.63 (SD 10.95) vs on-demand −4.47 (SD 14.12), P =.041. T1 scores: 84.4 vs 78.1, P =.022, effect size 0.36. | At T1, systematic EPC improved pancreatic cancer-specific symptoms compared to on-demand EPC. HCS score (FACT-Hep, 0–72, higher better): mean change 0.28 (SD 6.47) vs −2.23 (SD 7.70), difference 2.51, P =.013. T1 scores: 52.0 vs 48.2, P =.008, effect size 0.42. | HADS (range 0–21, >7 indicates borderline/clinical symptoms): at T1, anxiety normal (≤7) in 64.1% systematic vs 47.7 | NR | NR |
| Jordhøy et al, 2000 | QOL NR | NR | NR | NR | Survival was not an outcome. The intervention group had more home deaths (25% vs 15%, P =.02) and fewer nursing home deaths (9% vs 21%, P <.01) than the control group. Hospital deaths were similar (68% vs 65%, respectively). |
| Vanbutsele et al, 2020 | Intervention group (early PC) scored significantly higher on the EORTC QLQ-C30 global health status/QOL scale at 6 mo prior to death | Outcomes not reported | The MQOL, which showed significant improvements in the intervention group, | NR | NR |
Abbreviation: EPC, expert palliative care; HADS, hospital anxiety and depression scale; MQOL, McGill quality of life questionaire; NR, not reported; SPC, standard palliative care; TOI, trial outcome index.
Table 2
Components of randomized controlled trials integrating palliative care with oncology
Adapted from Ref.
| Integration Component | Jordhøy et al, 2000 | Temel et al, 2010 | Zimmermann et al, 2014 | Bakitas et al, 2015 | Maltoni et al, 2016 | Temel et al, 2017 | Grønvold et al, 2017 |
|---|---|---|---|---|---|---|---|
| Clinical Component | |||||||
| Inpatient palliative care | Yes | Yes | Yes | Yes | No | Yes | Yes |
| Outpatient palliative clinic | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Community-based home palliative care | Yes | No | Yes | No | No | No | No |
| Integrative Processes | |||||||
| Multidisciplinary team | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Symptom screening(outpatient) | No | No | No | No | No | Yes | |
| Concurrent systemic chemotherapy | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| Follows palliative care guidelines | Yes | Yes | No | Yes | Yes | Yes | Yes |
| Early referral to palliative care | Yes | Yes | Yes | No | Yes | Yes | Yes |
| Clinical pathways trigger to referral | No | No | No | No | No | No | No |
| Palliative care participates in a multidisciplinary team tumor board | No | Yes | No | No | No | No | No |
| Communication between oncology and palliative care | Yes | Yes | No | Yes | Yes | No | No |
| Advanced care planning | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
Barriers to implementation
Practice Policy Gap
Despite its importance, palliative care is often underprioritized and poorly integrated into cancer care systems. Nationally, palliative care is frequently not recognized as an essential component of oncologic care but is treated as an add-on service. This lack of integration stems from insufficient willingness and capacity to prioritize palliative care within cancer care programs. The emphasis on novel tumor-directed therapies has further shifted the focus away from patient-centered care, often favoring “budget winners” such as systemic treatments, while neglecting palliative care. Consequently, palliative care referrals occur late in the disease course, often near the end of life, despite recommendations for early integration. Economic barriers, including inadequate funding and misaligned incentives, persist despite evidence that palliative care reduces costs and enhances quality of life.
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