The critical intersection of survivorship and palliative care in people with metastatic breast cancer

Introduction

An individual is considered a cancer survivor from the time of diagnosis through the entirety of their illness trajectory to the end of their life (1). However, this inclusive definition often fails to translate into practice, as individuals with de novo or recurrent metastatic cancer are frequently marginalized within survivorship discourse and service delivery (2,3). Globally, breast cancer is the most commonly diagnosed non-cutaneous malignancy, accounting for over 2.3 million new cases annually (4). Of these, approximately 6–10% of individuals present with metastatic disease at diagnosis, and a significant proportion of early-stage cases eventually recur or progress with distant metastases (5).

Although metastatic breast cancer (MBC) remains incurable, significant advances in targeted therapies, hormonal agents, and immunotherapies have led to improved disease control and prolonged survival (6-9). Many individuals with MBC alternate between active treatment and periods of stability off therapy, often living many years post-metastases (3,8), with the median overall survival increasing from approximately 1.5 years in 1988–1995 to nearly 3 years in recent studies (10-12). Consequently, individuals with MBC represent an ever-growing proportion of the breast cancer survivor community; however, literature remains insufficiently attuned to their unique needs and experiences (3,13).

As survival durations increase, the needs of individuals with MBC extend beyond oncologic management, encompassing holistic domains, such as psychosocial, financial, and existential dimensions, as visualized in Figure 1 (11,12,14,15). Krasnow et al. [2025] reported that individuals with MBC described a consistently high need for informational, psychosocial, medical, and sexual support, particularly around treatment decisions (11). These findings reinforce the importance of a multidimensional care approach that prioritizes emotional resilience, existential well-being, and quality of life (QoL) alongside conventional medical management.

Figure 1 Systemic gaps and unmet supportive care needs in people with MBC. MBC, metastatic breast cancer.

Despite the clear need for supportive care services, many patients with MBC do not fit into existing care models, and research on their long-term care experiences remains limited (14). Survivorship programs are traditionally designed to support cancer survivors by focusing on surveillance for recurrence, promoting physical and emotional recovery, and managing long-term and late effects of treatment (15).

Palliative care, by contrast, while expressly aimed at improving QoL, is often incorrectly perceived as synonymous with terminal care, limiting its uptake and accessibility in earlier stages of metastatic disease (16). This dichotomy creates a critical care gap for people with MBC whose clinical and psychosocial profiles fall between these two models. Their needs often parallel, yet remain distinct from, those of people with early-stage breast cancer (12,17,18).

Consequently, it is imperative that individuals living with MBC be formally recognized as a distinct subgroup in national and international cancer care frameworks and appropriately prioritized in supportive care planning.

Bridging this gap requires reexamining the roles and interactions between survivorship and palliative care providers. Each offers complementary strengths, yet they are often deployed in parallel rather than in partnership. This paper aims to explore how an integrated care approach, drawing on elements of both survivorship and palliative paradigms, may more effectively address the full spectrum of care needs encountered by individuals with MBC.

People with MBC who have clinical stability and minimal symptom burden may derive optimal benefit from survivorship-oriented services, whereas those experiencing disease progression, symptomatic burden, or existential distress may require the symptom management and goal-concordant care provided by palliative services. Importantly, many people exist within a fluid middle ground where a coordinated, blended approach becomes essential as elements of both survivorship and palliative care may offer meaningful benefit depending on individual needs and illness trajectory (see Table 1 for comparison of model benefits and limitations). Further guidance is needed to delineate timing, referral pathways, and interdisciplinary roles to ensure consistent, person-centered integration of this type of approach across the care continuum.

Survivorship care model

Breast cancer survivorship care includes cancer surveillance, management of treatment-related side effects, promotion of healthy lifestyle behaviors, and access to psychosocial support services (19,20). This care model supports people in managing not only their disease but also the physical, emotional, and social impacts of cancer and its treatment (20,21).

While there is no standardized criterion for when people should be referred to survivorship care, evolving guidelines increasingly recognize that survivorship includes people with metastatic disease receiving ongoing systemic treatment and having a prolonged life expectancy (22). This broader definition acknowledges that individuals living with MBC, who are clinically stable or managing well, may benefit from the structure and resources available through survivorship care.

Although literature has not yet demonstrated clear evidence that survivorship care plans improve clinical outcomes for people with metastatic disease, these people and their caregivers value and report benefits such as better adherence to medical recommendations and increased support for self-management (15,23-25). Survivorship care can support individuals with MBC by facilitating access to services beyond medical treatment, including nutrition counselling, physical activity programs, sleep and fatigue management, sexual health support, and mood or pain management services (3,26,27). Thus, for individuals who are physically stable and not currently experiencing high symptom burden, this proactive and coordinated approach can contribute to sustained QoL and emotional well-being (3)

Frameworks such as the Multinational Association of Supportive Care in Cancer (MASCC) and American Society of Clinical Oncology (ASCO) survivorship care model emphasize a multidisciplinary, team-based approach that includes clear communication, coordination between specialists, and continuous assessment of supportive care needs (15). In this context, survivorship care relies on collaborations between oncologists, primary care providers, mental health professionals, and other disciplines to address a wide range of concerns that impact well-being (15,28).

Nonetheless, existing survivorship care models often fall short in adequately serving the MBC population (10,17). A persistent barrier is the lack of a widely adopted, inclusive definition of survivorship that meaningfully includes the experiences of individuals living with incurable but treatable disease (17,29). This conceptual gap contributes to the underrepresentation of people with MBC in survivorship research, program development, and policy priorities that limit recognition and prioritization of their unique and complex needs (3,30). Another contributing factor is the fragmented structure of many healthcare systems, where services are poorly integrated (31). Consequently, the implementation of survivorship care is frequently inconsistent or delayed, particularly for these populations (31). Supportive services are often regarded as supplementary rather than integral components of comprehensive cancer management (31). Furthermore, the lack of standardized referral pathways for these services may result in delays in access, missed opportunities for timely intervention, and ambiguity regarding which healthcare provider holds responsibility for addressing specific concerns. This lack of coordination and defined accountability among care providers can leave patients uncertain about where to seek appropriate support, ultimately contributing to frustration, fragmented care delivery, and unmet clinical and psychosocial needs (31,32).

While survivorship care may be well-suited for those who are managing well, it lacks the scope to address more advanced or fluctuating needs. Therefore, for individuals whose clinical condition is changing or whose needs extend beyond wellness support, survivorship teams must be prepared to involve palliative care providers. Without this level of coordination and flexibility, survivorship models risk excluding or underserving a significant portion of the MBC population. This distinction is further detailed in Table 2.

Palliative care model

In contrast to survivorship care, the palliative care model prioritizes QoL for people with cancer and their families by preventing and relieving suffering across the physical, psychological, social, and spiritual domains (33). It is designed for individuals facing serious illness, which can be described as conditions that, while not always terminal, carry a risk of mortality and substantially affect function, well-being, or emotional health (34). Within MBC, this definition encompasses both those experiencing high symptom burden and those navigating prolonged periods of stability. As a result, palliative care may not be uniformly required at diagnosis but should be considered flexibly applied as needs evolve (33).

This model is particularly important for people with MBC who often face unique and evolving challenges, including persistent symptom burden, psychological distress, and uncertainty about the future (16). A growing body of research suggests that people with MBC have high levels of unmet needs across multiple domains of care (18,35). It has been shown that early palliative care can lead to improved QoL, reduced rates of depression, and even prolonged survival in advanced cancer populations (36). These findings highlight the critical role of palliative care in aligning treatment with patients’ values, preferences, and goals of care (36).

Despite its potential, the palliative care model has faced persistent challenges in implementation, many of which have arisen from perceptual barriers. For instance, a significant challenge is the stigma surrounding the term “palliative care”, which is driven by misconceptions equating it solely with hospice or end-of-life care (37). For individuals with MBC who continue to receive active therapy and may live for years, these perceptions can lead to hesitancy in initiating palliative referrals and clinicians may delay discussions out of concern for diminishing hope or trust (37,38). However, these barriers have been increasingly recognized as modifiable through targeted educational initiatives. For instance, programs such as the Country-led Assessment for Prioritization on Immunization (CAPACITI) pilot, a virtual training series for primary care teams, have improved clinicians’ confidence in identifying palliative needs and initiating early discussions with patients (39). Thus, by reframing palliative care as a QoL-focused service rather than end-of-life management, these educational programs can help dismantle stigma and the perceptual barriers to promote earlier, values-based integration into oncology care.

Beyond perceptual barriers, structural and institutional limitations significantly hinder access to timely palliative services. Many healthcare systems lack the infrastructure needed to support longitudinal outpatient palliative care, and existing funding models often prioritize acute or crisis-based services over long-term supportive care (40). As a result, people often access palliative care in the later stages of illness, missing the benefits of early integration such as improved symptom management and emotional support (34). Furthermore, palliative care is too often isolated from oncology and primary care teams, limiting collaboration and continuity of care (40). These fragmented systems lead to communication breakdowns and unaddressed needs of people with cancer, which ultimately reduce the quality of care delivered and satisfaction of care received (41).

Although the palliative care model demonstrates substantial strengths in managing complex symptoms, facilitating psychosocial support and aligning care with a person’s values, it remains insufficient as a comprehensive solution when employed in isolation. Consequently, individuals with MBC, who might derive considerable benefit from early and sustained palliative involvement, are often underserved during critical periods of their disease trajectory.

Blended model of care for MBC

Currently, survivorship and palliative care models vary widely across institutions and between countries, with limited guidance on how different services should interact (42). This lack of standardization creates uncertainties among healthcare providers regarding the appropriate timing for involving supportive services, how to prioritize them, and how to coordinate care across disciplines (3).

To bridge these gaps, professional organizations such as MASCC and ASCO have called for blended models of care that incorporate core elements of both palliative and survivorship care (3). A blended model capitalizes on the strengths of both approaches to provide holistic, person-centered care across the disease continuum. This relationship is illustrated in Figure 2, which presents a blended model of care for individuals with MBC. The model combines key elements of survivorship and palliative care, emphasizing person-centered care, supportive communication, care coordination, equity, ongoing needs assessment, and timely delivery of services.

Figure 2 Core components of a blended model integrating survivorship and palliative care for people with advanced and MBC. This figure outlines the key components of a blended care model that integrates both survivorship and palliative care principles for individuals with advanced and MBC. The model emphasizes: (I) person-centered & values-based approach, (II) supportive communication & destigmatization, (III) care navigation & multidisciplinary teams, (IV) equity, accessibility & cultural responsiveness, (V) early & ongoing needs assessment, and (VI) timely & coordinated care delivery. MBC, metastatic breast cancer.

An important consideration in this blended model is ensuring equitable and consistent access to high-quality services (10). These must be affordable, acceptable, available, and appropriate (43). Peer support programs, which provide emotional solidarity, reduce social isolation, and offer practical guidance, should also be embedded into this care model (15,44). Structural supports such as telehealth, hybrid care, financial counseling, culturally responsive resources, diverse care teams, and cultural humility training help ensure inclusivity and accessibility (15,45,46).

At the heart of the blended model is a person-centered philosophy. This requires shifting from reactive, provider-driven care to proactive care that aligns with each person’s values, goals, and life context. Honest and timely communication about prognosis, combined with respectful space for a person to express their preferences, is essential (3). Supportive care should be framed not as an end-of-life measure, but as an integral part of living meaningfully with MBC. It also requires ongoing collaboration, vigilant surveillance, and comprehensive support for caregivers (47). Palliative care clinicians should include caregivers in clinical conversations and care decisions alongside survivors, addressing them with the same attention to distress and anxiety, and providing culturally sensitive support that acknowledges family dynamics, bereavement needs, and the vital role caregivers play in the support system (47).

Effective implementation of a blended model hinges on seamless coordination across disciplines. This includes early involvement of multidisciplinary and interprofessional teams and proactive navigation support (3). Timely referrals to supportive services should be made in response to worsening symptoms, and a part of routine anticipatory care (48,49). Specialized survivorship nurses or patient navigators trained in MBC should be integral team members (44,50). These individuals can act as consistent points of contact, optimally facilitating communication across oncology, primary care, psychosocial services, and community resources (50,51).

While not all individuals will require intensive palliative care at diagnosis, many benefit from early, selective integration of palliative services (52). Healthcare providers must be able to recognize when patient’s needs extend beyond traditional survivorship care and respond with a more comprehensive, individualized approach. Ultimately, a blended model seeks to combine survivorship and palliative care by offering continuous, comprehensive, and person-driven support, acknowledging that living with MBC is not merely about preparing for the end-of-life, but about sustaining life with meaning, dignity, and support (3,17).

Implementing a blended care model for individuals with MBC does come with challenges. A major barrier is role ambiguity, as healthcare providers may lack clarity on leadership and coordination responsibilities when oncology, palliative, and survivorship teams intersect (53). Without a clear delineation of responsibilities, people with cancer may encounter fragmented care or inconsistent messaging across providers (53). To overcome these difficulties, the blended model must establish standardized protocols for communication, shared documentation systems, and interprofessional care plans to enhance accountability across disciplines (48). Nurse-led models have shown promise in supporting integrated care implementation and may serve as a guiding framework for operationalizing these protocols (54). Given their central role across the care continuum, nurses can act as coordinators and continuity agents, particularly in survivorship follow-up, multidisciplinary communication, and patient education (54). Another challenge is the underfunding of non-acute care services in many countries, including both survivorship and palliative care (55). Addressing this requires systemic investment in long-term supportive care infrastructure, reforms in reimbursement for these services, and the development of funding models that incentivize integrated, team-based care for MBC patients (55). Lastly, there is the risk that blended models may become overly medicalized, inadvertently sidelining patient voices. To avoid this, patients and caregivers must be engaged in co-designing care models, ensuring they remain flexible, culturally sensitive, and person-driven (56).

Conclusions

As MBC becomes an increasingly prevalent and chronic condition, healthcare systems must evolve to better meet the needs of this growing population. Survivorship care provides a framework for long-term support and empowerment, but often excludes those with incurable disease. Palliative care addresses critical symptoms and psychosocial needs but is frequently delayed and stigmatized. A blended model offers a more comprehensive, person-centered solution, integrating the strengths of both approaches to support people from diagnosis through end-of-life care. For this model to succeed, healthcare systems must prioritize implementation through clearly defined structures, interprofessional collaboration, and sustainable investment. Equally important, people with cancer and caregivers must be actively engaged in the design and delivery of care pathways to ensure services remain responsive, inclusive, and aligned with what truly matters to those living with MBC.

Acknowledgments

None.

Footnote

Peer Review File: Available at https://apm.amegroups.com/article/view/10.21037/apm-25-77/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-25-77/coif). C.B.S.II serves as the co-Editor-in-Chief of Annals of Palliative Medicine from April 2014 to April 2027. S.F.L. serves as an unpaid editorial board member of Annals of Palliative Medicine from October 2023 to September 2027. E.O. serves as an unpaid editorial board member of Annals of Palliative Medicine from December 2024 to December 2026. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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