Palliative and Supportive Care: Time for Recognition of Critical Relevance

One can summarize the message of the following commentary by recalling the profound words of the great American philosopher, Yogi Berra: “When you come to a fork in the road, take it.”

Although many may disagree with this conclusion, this commentator would argue that it is time for the oncology community to fully embrace the concepts of palliative and supportive care, whichever terminology is used at a particular center, as a true core component of cancer care and not merely a “nice to have” add-on.

One can provide several historical reasons, as well as the major evolution of cancer care over the last half century, to explain the current status of efforts directed at the cancer itself (surgery, radiation, antineoplastic chemotherapy) vs strategies focused on management of cancer and treatment-related toxicities as well as attempting to optimize quality of life (QOL).

In days past, treatment of cancer (except perhaps early-stage disease) was often difficult, stressful, and ultimately frequently unsuccessful. Curative treatment, when it was a realistic aim of disease management, may have been highly morbid, such as the routinely employed radical mastectomy for localized breast cancer or limb amputation for extremity sarcomas. Other than antibiotics, necessary preoperative and postoperative medical specialty consultation (eg, pulmonologist, cardiologist, nephrologist) and (hopefully) short-term opioids for pain control, there was limited need for a “specialist” focused on general cancer-related symptoms.

Far more common, and outside the narrow range of curative therapy for early-stage disease, was the need for a rational approach to end-of-life care, which understandably focused on the provision of adequate pain control. Efforts in this area also included the role of hospice care, both inpatient and, more importantly, strategies to manage the dying patient with cancer for as long and comfortably as possible at home.

The landmark writings of Elisabeth Kübler-Ross (On Death and Dying), which described in elegant detail for a lay audience the previously largely hidden psychological and emotional aspects associated with the dying process, and the unique needs of the patient approaching death, emphasized the relevance of a focus on this aspect of cancer management.

And it is here that the palliative care physician played a major role in a “hand-off” from the cancer-treating physician when it was determined that future therapy directed at removing/killing the cancer was futile. Nothing wrong here, except for the fact that end-of-life care unfortunately became essentially synonymous with palliative care.

The ramifications of this association between end-of-life care and palliative care continue to the present. A recent commentary in JAMA, remarkably entitled “Why good palliative care clinicians get fired,” emphasizes the issue.¹ The manuscript describes why patients made the decision to remove palliative care physicians from their care teams due to conflicts between what the physicians saw as their responsibility to an individual patient’s welfare and divergent views of some patients, families, and treating oncologists. Somehow, in these difficult conversations, the palliative care physician may be seen as being less than essential to the efforts of the oncology team. After all, they are around to assist in end-of-life care when others decide this is the appropriate next step.

But now we turn to the current reality of cancer care. Yes, therapeutics for, and overall survival of cancer have vastly improved. And in many settings, a reduction in the associated morbidity of treatment has been an even more impressive outcome. Again, consider the dramatic changes in local breast cancer management or the application of limb-sparing surgery.

However, along with this success has come the recognition that although many negative aspects of treatment have been reduced or eliminated, other toxicities (eg, fatigue, painful peripheral neuropathy and arthralgias, low-grade emesis, dyspnea, etc) have become evident.

And although survival has improved, this has not necessarily been translated into “cure.” Rather, many conditions have been converted into more chronic disease processes where continuous treatment to maintain remission or a successful intervention at the time of relapse/progression are currently the standard of care. These adverse effects can result in modest to severe impacts on an individual patient’s QOL.

Who should be responsible for monitoring, managing, or possibly preventing these frequently multidimensional and distressing symptoms? The treating oncologist?

It is here that the transition from palliative care to supportive care becomes evident. Depending on the available organizational resources, this may be the same or a different specialist. But like the question of the appropriate timing for palliative care intervention, the role of supportive care remains less than optimally defined and their relevant services clearly underutilized.²

It is recognized that the palliative or supportive care physician, whether an oncologist or other medical specialty by training, receives payment for cognitive activities, rather than for the performance of procedures or administering chemotherapy. Further, many consultations are complex, and the required decision-making time is consuming. As a result, direct financial support for initiating, supporting, and growing a focused palliative or supportive care program may be problematic, particularly in an era of reduced health care dollars.

However, in the opinion of this commentator, it is increasingly essential to appreciate the critical importance of clinicians whose direct focus is on the QOL of individual patients with cancer, to help manage problematic symptoms of the cancer and its therapy.

Consider, for example, the use of opioids in cancer management. In a concerning report examining the administration of narcotic analgesia among more than 9000 opioid-naive US veterans undergoing curative cancer surgery (stages 0-III), 10.6% experienced persistent opioid use.³ Were opioids in these individuals being optimally managed? Would the experience be different if postsurgical patients with cancer have been counseled and at least partially managed by a supportive care physician?

The second report examined the recent use of opioids at a single tertiary cancer center from 2016 to 2021 among patients who were initially referred to the palliative care clinic for consultation regarding cancer pain management.⁴ The study reported that oncologists’ use of long-acting opioids had decreased from 26% to 12%, along with a decrease in the total morphine-equivalent daily dose, or even the administration of any opioid product. Again, the question to be asked is whether this was optimal symptom management.

Finally, it is relevant to note that evolving data support the role of palliative/supportive care to enhance timely hospice referrals,⁵ reduce the costs of advanced cancer hospitalization,⁶ and favorably impact complex curative inpatient hospitalizations (eg, stem cell transplantation).⁷

Are we ready to “take that fork in the road” and move palliative/supportive care into routine cancer care?

References

1. Rosenberg AR, Rabinowitz E, Arnold RM. Why good palliative care clinicians get fired. JAMA. 2025;333(21):1864-1865. doi:10.1001/jama.2025.4353
2. Wardill HR, Lustberg MB, Davies A, et al. Supportive care in what? Myths and misconceptions that prevent the provision of excellent cancer care. JCO Glob Oncol. 2026;12(6):e2600087. doi:10.1200/GO-26-00087
3. Schapira MM, Chhatre S, Dow PM, et al. The impact of opioid use associated with curative-intent cancer surgery on safe opioid prescribing practice among veterans: an observational study. Cancer. 2025;131(18):e70009. doi:10.1002/cncr.70009
4. Admane S, Bramati PS, Fellman B, et al. Trends in outpatient opioid prescriptions for cancer pain between 2016 and 2021. JCO Oncol Pract. 2025;21(11):1656-1664. doi:10.1200/OP-24-00782
5. Singh R, Fadul CE, Kopp E, et al. Palliative care and quality outcomes in patients with brain metastases and poor prognosis: a multi-institutional analysis. JCO Oncol Pract. Published online February 23, 2026. doi:10.1200/OP-25-00882
6. Lu S, Rakovitch E, Hannon B, et al. Palliative care as a component of high-value and cost-saving care during hospitalization for metastatic cancer. JCO Oncol Pract. 2025;21(2):252-260. doi:10.1200/OP.23.00576
7. El-Jawahri A, LeBlanc TW, Kavanaugh A, et al. Multisite randomized trial of inpatient palliative care intervention for patients undergoing hematopoietic stem cell transplantation. J Clin Oncol. 2025;43(24):2700-2711. doi:10.1200/JCO-25-00378