Research · for Cancer charities, support groups & hospices

Late and Unequal: Who Receives Palliative Care for Cancer, and When

Published 2026-11-02 · Updated 2026-11-03

Even in countries with well-developed hospice services, specialist palliative care usually begins only weeks before death. Across 64 UK hospices, the median time from referral to death in 2015 was 48 days, and it was shorter for older people and for people with illnesses other than cancer[1]. Trials show that starting palliative care earlier, alongside cancer treatment, modestly improves quality of life. Worldwide, most people who need palliative care never receive it at all[2].

Palliative care is often pictured as care for the last days of life. The research on cancer describes something wider: a team that eases pain and other symptoms, talks through what matters to the person, supports the family, and works alongside oncology from the point an illness is known to be incurable. Whether people get that care, and how early, depends partly on where they live, what illness they have, how old they are and which hospital treats them. This study sets out, at population level, how late referral typically comes, what the trials of early palliative care found, who is referred later or not at all, and how large the gap is worldwide. The gaps it describes are gaps in services and systems, not failings of the people who need care or of the families who look after them.

48 daysmedian time from referral to death among 42,758 adults referred to 64 UK hospices who died in 2015; 53 days for people with cancer and 27 days for other conditions[1]
70%of the 12,879 adults who died of cancer in Finland in 2019 had no contact with specialist palliative care[3]
About 14%of the worldwide need for palliative care is being met by specialist services, according to the Global Atlas of Palliative Care (3rd edition, 2026): over half of the need in high-income countries, 4.4% in low- and middle-income countries[4]

Specialist palliative care often begins in the last weeks of life

The largest UK study of hospice referral timing collected data from 64 hospices on every adult with advanced illness who had been referred to them and died in 2015: 42,758 people in all. The median time from referral to death was 48 days: 53 days for people with cancer and 27 days for people with other conditions. It fell steadily with age, from 78 days for people under 50 to 39 days for people aged 75 and over. The authors concluded that people were being referred "very late in their illness trajectory"[1].

Median days from referral to death, 64 UK hospices, 2015Among 42,758 adults referred to 64 UK hospices who died in 2015, the median time from referral to death was 48 days overall: 53 days for people with cancer and 27 days for people with other conditions; 78 days for people under 50, 59 days for people aged 50 to 74 and 39 days for people aged 75 and over.020406080All decedents48 daysCancer53 daysNon-cancer conditions27 daysAged under 5078 daysAged 50 to 7459 daysAged 75 and over39 days
Adults (over 17) with advanced illness who had been referred to a hospice specialist palliative care service (inpatient, community or outpatient) and died between 1 January and 31 December 2015; 42,758 people across 64 UK hospices. A median means half of people had less time than this. Source: Allsop et al., Palliative Medicine, 2018.

National register data from Finland add the group never seen at all. Of all 12,879 adults who died of cancer in Finland in 2019, 20% had their first specialist palliative care contact more than 30 days before death, 10% in their last 30 days, and 70% had no specialist palliative care contact. People first seen more than 30 days before death had fewer hospital admissions than those with no contact (26% against 53%), an observational association rather than proof of cause[3].

When specialist palliative care first began, adults who died of cancer in Finland, 2019Of 12,879 adults who died of cancer in Finland in 2019, 20% had their first specialist palliative care contact more than 30 days before death, 10% in the last 30 days of life, and 70% had no specialist palliative care contact.0%25%50%75%100%First contact more than 30days before death20%First contact in the last30 days10%No specialist palliativecare contact70%
All 12,879 adults who died of cancer in Finland in 2019, identified from the national Causes of Death Register and linked registers. Specialist palliative care only; people may still have had palliative care from their own oncology, hospital or primary care teams. Source: Nåhls et al., BMC Cancer, 2026.

In the United States, among 366 people in the Houston area who died of advanced cancer in 2009-2010 after a palliative care consultation, a third (33%) had been referred more than three months before death. Earlier referral was linked to fewer emergency visits (39% against 68%), fewer hospital admissions (48% against 81%) and fewer hospital deaths (17% against 31%) in the last 30 days of life[5]. At a comprehensive cancer centre in Maryland (study published 2021), the median time people with cancer spent in hospice was 14.5 days before a quality-improvement project, and a third (33.3%) stayed seven days or fewer, which the authors call "a marker of poor quality care"[6].

Trials show early palliative care improves quality of life; the effect on survival is uncertain

The trial most often cited is Temel and colleagues' study in the New England Journal of Medicine in 2010. It randomly assigned 151 people with newly diagnosed metastatic non-small-cell lung cancer, attending as outpatients, to early palliative care integrated with their oncology care or to oncology care alone. The primary outcome was the change in quality of life at 12 weeks. People in the early palliative care group reported better quality of life (a mean score of 98.0 against 91.5 on a lung cancer quality-of-life scale running from 0 to 136) and fewer had depressive symptoms (16% against 38%). Fewer received aggressive care at the end of life (33% against 54%)[7].

The same paper reported a longer median survival in the early palliative care group: 11.6 months against 8.9 months. This finding is often quoted, but survival was not the trial's primary outcome, it came from a single, fairly small trial, and later pooled analyses have not confirmed a survival benefit. It is best read as reassurance that early palliative care did not shorten life, not as evidence that it extends it[7].

Later trials tested the approach in other cancers and health systems, with more mixed results.

TrialDesign and populationMain result
Zimmermann et al., Toronto, Canada (2014)[8]24 oncology clinics cluster randomised; 461 people with advanced cancer and an expected prognosis of 6 to 24 monthsPrimary outcome (a quality-of-life score at 3 months) did not differ significantly; satisfaction with care and a second quality-of-life measure were better at 3 months; at 4 months every measure favoured palliative care, all but one significantly
ENABLE III, Bakitas et al., United States (2015)[9]207 people with advanced cancer randomised to palliative care starting soon after enrolment or 3 months laterNo significant differences in quality of life, symptoms or mood; one-year survival 63% (early) against 48% (delayed)
Temel et al., United States (2017)[10]350 people with newly diagnosed incurable lung or non-colorectal gastrointestinal cancerNo significant difference in quality of life at 12 weeks (primary outcome); better quality of life and less depression at 24 weeks; benefits concentrated in lung cancer
Vanbutsele et al., Belgium (2018)[11]186 people with advanced solid tumours, in a system where psychosocial support was already part of standard careQuality of life at 12 weeks higher with early, systematic palliative care (61.98 against 54.39 on the trial's quality-of-life scale)

Two meta-analyses pool this evidence. A Cochrane review of seven randomised trials with 1,614 participants found that early palliative care improved quality of life with a small effect (standardised mean difference 0.27) and reduced symptom intensity slightly, with low-certainty evidence. Data on survival from four trials (800 participants) showed no clear difference (hazard ratio 0.85, 95% confidence interval 0.56 to 1.28; very low certainty)[12]. A wider meta-analysis of 43 trials in people with any life-limiting illness, not only cancer, found palliative care was linked to better quality of life, more advance care planning and less use of health services, but not to survival (hazard ratio 0.90, 0.69 to 1.17)[13]. On this evidence, the American Society of Clinical Oncology's 2017 guideline says that people with advanced cancer "should receive dedicated palliative care services, early in the disease course, concurrent with active treatment"[14].

Older people and people with illnesses other than cancer are referred later

In the UK hospice study, increasing age remained a significant predictor of fewer days of hospice care after adjusting for other factors, as did being male, having a non-cancer diagnosis and, notably, having no recorded ethnicity[1].

People with cancer are, by comparison, the group palliative services reach earliest. In Ontario, among 145,709 adults who received palliative care in their last year of life and died in 2010-2017, care began more than 90 days before death for 28.9% of people who died of cancer, against 15.9% of people who died of chronic organ failure (such as heart failure or lung disease) and 15.3% of people with dementia[15]. Even so, fewer than three in ten people with cancer in that cohort started palliative care more than three months before death.

Palliative care started more than 90 days before death, by cause of death, Ontario 2010-2017Among 145,709 adults in Ontario who received palliative care in their last year of life and died in 2010-2017, palliative care began more than 90 days before death for 28.9% of people who died of cancer, 15.9% of people who died of chronic organ failure and 15.3% of people who died with dementia.0%10%20%30%40%Cancer28.9%Chronic organ failure15.9%Dementia15.3%
Adults in Ontario, Canada, who received any palliative care in their last year of life and died between 2010 and 2017 (110,622 died of cancer, 21,054 of chronic organ failure, 14,033 of dementia). People who received no palliative care at all are not included. Source: Quinn et al., JAMA Network Open, 2021.

The Global Atlas of Palliative Care (2nd edition) estimates that although cancer is the largest single disease group among adults who need palliative care, "over 70% of the need is for other conditions"[2]; its 3rd edition puts cancer (excluding leukaemia) at 27.9% of adult need[4]. Hospice care grew up around cancer; the gap now is reaching people with other conditions as early.

Deprivation, ethnicity and rural living shape who is reached

Deprivation

The clearest population data on deprivation come from Ontario, Canada. Among 729,290 adults of all causes who died between 2009 and 2016, the gap between the most and least deprived neighbourhoods in palliative home visits in the last 30 days of life was 6.8 percentage points in 2016 (a relative gap of 26.3%), and the authors conclude that key measures of end-of-life care "are not achieved equally across socioeconomic groups"[16]. Among 173,915 people who died with cancer in Ontario between 2015 and 2021, 57.8% received specialist palliative care in their last 30 days; when COVID-19 restrictions began in March 2020, home deaths rose less in the most deprived areas than in the least deprived (6.1% against 11.4%), which the authors describe as amplified socioeconomic disparities[17]. In England, among 737 people aged 50 and over who died of any cause, greater wealth was linked to a lower likelihood of dying in hospital[18]. A UK review of 29 studies, though, found "not a consistent or clear narrative" on whether socioeconomic position affects receipt of palliative care in the UK, and identified gaps in the evidence on how need is assessed[19]. More is in our study of deprivation and cancer.

Ethnicity

In the United States, a study of 601,680 people with metastatic prostate, lung, colon or breast cancer in the National Cancer Database (diagnosed 2004-2015) found that 21.7% had palliative care recorded: 22.5% of non-Hispanic white people, 20.0% of Black people and 15.9% of Hispanic people. After adjustment, the difference by ethnicity was no longer significant, but being treated at a minority-serving hospital (the tenth of hospitals with the highest share of Black and Hispanic patients) was linked to lower odds of palliative care (adjusted odds ratio 0.67), which points to the site of care[20]. Among 318,549 Medicare decedents aged over 65 with poor-prognosis cancers (2007-2019), Black and Hispanic people were less likely than white people to receive any opioid near the end of life (by 4.3 and 3.6 percentage points) and received lower daily doses, and adjusting for socioeconomic factors did not reduce these gaps[21].

Elsewhere, the data are often too thin to say. A Scottish study of 117,467 cancer deaths (2001-2009) noted that palliative care reviews had "limited ability to demonstrate equal access due to incomplete or unreliable ethnicity data"[22], and in the UK hospice study a missing ethnicity record was itself linked to shorter hospice care[1]. Ethnic inequality in cancer care more broadly is covered in our study of ethnicity and cancer.

Rural and remote living

In a population-based cohort of people who died of cancer in Ontario in 2007-2012, people living in rural areas of the north were less likely to receive palliative care (adjusted odds ratio 0.90), and people who did not receive it were more likely to have aggressive end-of-life care and to die in an acute hospital[23].

Worldwide, most people who need palliative care do not receive it

The Global Atlas of Palliative Care (Worldwide Hospice Palliative Care Alliance) estimated in its 2nd edition (2020) that over 56.8 million people needed palliative care in 2017, including 25.7 million in their last year of life; palliative care was needed for 45.3% of all deaths that year, and 76% of the need was in low- and middle-income countries[2]. The 3rd edition (2026), with estimates updated to 2023 and an expanded method, puts the need at more than 73.5 million people a year, including 27.6 million near the end of life; 72.9% of adults in need live in low- and middle-income countries[4]. Both editions use the concept of serious health-related suffering pioneered by the Lancet Commission on Global Access to Palliative Care and Pain Relief; because the method changed, the totals are not a simple trend[2][4].

How much of that need is met? The 2nd edition's foreword set the roughly 7 million people then served by about 25,000 services against the 56.8 million in need: "this is only about 12% of the need being met"[2]. By 2025, the 3rd edition estimates, 33,720 services cared for over 10.4 million people, yet "only an estimated 14% of the total global need for palliative care, not including most primary palliative care, is being met"[4]. A 2025 analysis by palliative care researchers[24] and WHO's fact sheet[25] also give about 14%, the figure used in our companion study of end-of-life care. These are rough estimates of specialist provision against modelled need; each says that only around one person in seven who needs palliative care receives it.

The need is growing. An update to the Lancet Commission's work, using a revised method, estimated that serious health-related suffering rose by 74% between 1990 and 2021 to almost 73.5 million people, 80% of them in low- and middle-income countries[26]. A projection combining WHO mortality forecasts with symptom data estimated that by 2060, 48 million people a year will die with serious health-related suffering, with cancer deaths accounting for 16 million of them (a 109% increase on 2016)[27]. These are modelled estimates, not counts. Place of death is covered in our study of where people with cancer die.

What the evidence asks of us

  • Make early, integrated palliative care routine in cancer services. The trial evidence for quality of life and symptoms is consistent enough that ASCO recommends palliative care early in the course of advanced cancer, alongside active treatment, with referral to interdisciplinary teams[14][12]. Outpatient palliative care clinics matter: in the Houston study, people first seen as outpatients had less aggressive end-of-life care (adjusted odds ratio 0.42)[5].
  • Measure timing, not only reach. Median days from referral to death, and the share of people seen only in their last 30 days, show the gap more clearly than counts of people referred[1][3].
  • Monitor equity by age, diagnosis, deprivation, ethnicity and place, and record ethnicity completely, since missing data hide the very gaps services need to find[22][16].
  • Extend the hospice model to people without cancer and to rural areas, where referral is later and less common[15][23].
  • Close the global gap. Recommendations include codifying palliative care in every country's national health policy, basic palliative care training for all non-specialist health workers, community involvement, and making essential palliative care medicines available[24].

Language: this piece says "people with cancer" and "people living with and after cancer", and describes the illness and its treatment plainly, without combat metaphors. Statistical terms such as "median", "odds ratio" and "hazard ratio" are used in the sense the cited source defines them.

Why we're publishing this

Many people reach hospices and palliative care teams late, and some never reach them at all. This study, part of our cancer research library, gathers the published evidence on how late, for whom, and what the trials say about starting earlier, so that services, commissioners and funders can see the pattern in one place and make the case for change. The case is theirs, and that of the people and families they care for.

How to read this data

The timing figures come from a few high-income countries and are not directly comparable: each counts a different kind of palliative care over a different period. Links between earlier referral and less hospital care are observational. The trial results are stronger evidence of cause, but the trials were mostly small, run in specialist cancer centres in North America and Europe, and the Cochrane review rated the evidence as low to very low certainty. The ethnicity evidence is mostly from the United States, and elsewhere is limited by incomplete recording. Global need figures are modelled estimates for a stated year using the serious health-related suffering method; they are not counts of people, and the two Atlas editions are not directly comparable.

Use this data

Free to cite with attribution to Better Health For Everyone. Charities, campaigners and journalists are welcome to reuse these figures and charts. For the underlying figures as a spreadsheet, get in touch.

Suggested citation: Better Health For Everyone (2026). Late and Unequal: Who Receives Palliative Care for Cancer, and When. https://www.betterhealthforeveryone.org/research/cancer-palliative-care-access

Important: This article summarises published research for general information. It is not medical advice and cannot be used to diagnose, treat or predict anything about an individual. If you have concerns about your own or someone else's health, please speak to a qualified health professional.

Sources

  1. Allsop MJ, Ziegler LE, Mulvey MR, Russell S, Taylor R, Bennett MI. Duration and determinants of hospice-based specialist palliative care: a national retrospective cohort study. Palliative Medicine, 2018;32:1322-1333. europepmc.org/article/MED/29874525
  2. Connor SR, ed. Global Atlas of Palliative Care, 2nd edition. Worldwide Hospice Palliative Care Alliance, 2020. thewhpca.org/resources/global-atlas-of-palliative-care-2nd-ed-2020/
  3. Nåhls NS, Lehto HR, Ahtiluoto S, et al. Timing of specialist palliative care and acute healthcare utilization at the end of life among adults who died of cancer: a nationwide cohort study. BMC Cancer, 2026;26:748. europepmc.org/article/PMC/PMC13267208
  4. Connor SR, Rosa WE, eds. Global Atlas of Palliative Care, 3rd edition. Worldwide Hospice Palliative Care Alliance, 2026. thewhpca.org/wp-content/uploads/2026/10/WHPCA_-Global-Atlas-Third-Edition_DIGITAL_FinalCopy-1.pdf
  5. Hui D, Kim SH, Roquemore J, Dev R, Chisholm G, Bruera E. Impact of timing and setting of palliative care referral on quality of end-of-life care in cancer patients. Cancer, 2014;120:1743-1749. europepmc.org/article/PMC/PMC4073257
  6. Sedhom R, Gupta A, Smith TJ. Short hospice length of service in a comprehensive cancer center. Journal of Palliative Medicine, 2021;24(2):257-260. europepmc.org/article/PMC/PMC7840298
  7. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. New England Journal of Medicine, 2010;363:733-742. europepmc.org/article/MED/20818875
  8. Zimmermann C, Swami N, Krzyzanowska M, et al. Early palliative care for patients with advanced cancer: a cluster-randomised controlled trial. Lancet, 2014;383:1721-1730. europepmc.org/article/MED/24559581
  9. Bakitas MA, Tosteson TD, Li Z, et al. Early versus delayed initiation of concurrent palliative oncology care: patient outcomes in the ENABLE III randomized controlled trial. Journal of Clinical Oncology, 2015;33:1438-1445. europepmc.org/article/MED/25800768
  10. Temel JS, Greer JA, El-Jawahri A, et al. Effects of early integrated palliative care in patients with lung and GI cancer: a randomized clinical trial. Journal of Clinical Oncology, 2017;35:834-841. europepmc.org/article/MED/28029308
  11. Vanbutsele G, Pardon K, Van Belle S, et al. Effect of early and systematic integration of palliative care in patients with advanced cancer: a randomised controlled trial. Lancet Oncology, 2018;19:394-404. europepmc.org/article/MED/29402701
  12. Haun MW, Estel S, Rücker G, et al. Early palliative care for adults with advanced cancer. Cochrane Database of Systematic Reviews, 2017;(6):CD011129. europepmc.org/article/MED/28603881
  13. Kavalieratos D, Corbelli J, Zhang D, et al. Association between palliative care and patient and caregiver outcomes: a systematic review and meta-analysis. JAMA, 2016;316:2104-2114. europepmc.org/article/PMC/PMC5226373
  14. Ferrell BR, Temel JS, Temin S, et al. Integration of palliative care into standard oncology care: American Society of Clinical Oncology clinical practice guideline update. Journal of Clinical Oncology, 2017;35(1):96-112. europepmc.org/article/MED/28034065
  15. Quinn KL, Wegier P, Stukel TA, Huang A, Bell CM, Tanuseputro P. Comparison of palliative care delivery in the last year of life between adults with terminal noncancer illness or cancer. JAMA Network Open, 2021;4:e210677. europepmc.org/article/PMC/PMC7933993
  16. Mondor L, Wodchis WP, Tanuseputro P. Persistent socioeconomic inequalities in location of death and receipt of palliative care: a population-based cohort study. Palliative Medicine, 2020;34:1393-1401. europepmc.org/article/MED/32772809
  17. Iqbal J, Moineddin R, Fowler RA, et al. Socioeconomic status, palliative care, and death at home among patients with cancer before and during COVID-19. JAMA Network Open, 2024;7:e240503. europepmc.org/article/PMC/PMC10900963
  18. Davies JM, Maddocks M, Chua KC, Demakakos P, Sleeman KE, Murtagh FEM. Socioeconomic position and use of hospital-based care towards the end of life: a mediation analysis using the English Longitudinal Study of Ageing. Lancet Public Health, 2021;6(3):e155-e163. europepmc.org/article/PMC/PMC7910274
  19. French M, Keegan T, Anestis E, Preston N. Exploring socioeconomic inequities in access to palliative and end-of-life care in the UK: a narrative synthesis. BMC Palliative Care, 2021;20:179. europepmc.org/article/PMC/PMC8606060
  20. Cole AP, Nguyen DD, Meirkhanov A, et al. Association of care at minority-serving vs non-minority-serving hospitals with use of palliative care among racial/ethnic minorities with metastatic cancer in the United States. JAMA Network Open, 2019;2:e187633. europepmc.org/article/PMC/PMC6484582
  21. Enzinger AC, Ghosh K, Keating NL, et al. Racial and ethnic disparities in opioid access and urine drug screening among older patients with poor-prognosis cancer near the end of life. Journal of Clinical Oncology, 2023;41(14):2511-2522. europepmc.org/article/PMC/PMC10414726
  22. Sharpe KH, Cezard G, Bansal N, Bhopal RS, Brewster DH. Policy for home or hospice as the preferred place of death from cancer: Scottish Health and Ethnicity Linkage Study population cohort shows challenges across all ethnic groups in Scotland. BMJ Supportive & Palliative Care, 2015;5(4):443-451. europepmc.org/article/MED/24644191
  23. Conlon MS, Caswell JM, Santi SA, et al. Access to palliative care for cancer patients living in a northern and rural environment in Ontario, Canada. Clinical Medicine Insights: Oncology, 2019;13. europepmc.org/article/PMC/PMC6378418
  24. Peeler A, Afolabi OA, Sleeman KE, et al. Confronting global inequities in palliative care. BMJ Global Health, 2025;10(5):e017624. europepmc.org/article/PMC/PMC12086877
  25. World Health Organization. Palliative care (fact sheet), 5 August 2020. WHO, 2020. who.int/news-room/fact-sheets/detail/palliative-care
  26. Knaul FM, Arreola-Ornelas H, Kwete XJ, et al. The evolution of serious health-related suffering from 1990 to 2021: an update to The Lancet Commission on global access to palliative care and pain relief. Lancet Global Health, 2025;13(3):e422-e436. europepmc.org/article/PMC/PMC11868779
  27. Sleeman KE, de Brito M, Etkind S, et al. The escalating global burden of serious health-related suffering: projections to 2060 by world regions, age groups, and health conditions. Lancet Global Health, 2019;7(7):e883-e892. europepmc.org/article/PMC/PMC6560023
Cancer · research library

More from this library

See all Cancer research