Palliative Care and Metastatic Breast Cancer: Practical Guidance from a Referring Oncologist

Deciding when to refer a patient with metastatic breast cancer to palliative care can feel like walking a tightrope. Refer too early, and the patient may feel overwhelmed; refer too late, and opportunities to provide meaningful support may be missed. This blog is for both oncologists and palliative care teams, aiming to clarify each other’s perspectives and offer practical guidance on timing referrals.

I often think back to my first surgery rotation as a medical student—assisting in the OR and constantly cutting the suture “too short” or “too long.” In many ways, for me as an oncologist the decision to refer patients to palliative care feels the same, whether “too early” or “too late”. There isn’t a one-size-fits-all approach; every patient is different, and uncertainty is part of the work. The goal is to meet each patient where they are, understand their disease, and provide support that fits their individual needs.

This is where the “art of oncology” comes in. My relationships with patients and families are often the most meaningful part of my work. If I were to meet three new patients with metastatic breast cancer who were the same age and had similar medical histories, one may live for two months, another for two years, and a third for two decades. Navigating that uncertainty is a challenge.

Metastatic breast cancer is not a single disease—it's at least three different diseases, and the people living with it contribute wonderfully to the complexity of trying to predict the future.

Prognosis and treatment vary significantly depending on subtype and patient factors. Triple negative breast cancer, for example, generally has a poor prognosis—often 1–2 years after metastasis, with fewer than half of patients able to receive second-line therapy. But even in this group, exceptions exist. I have a patient with androgen receptor–positive triple negative breast cancer who has lived over ten years with metastatic disease.

For patients with estrogen receptor–positive (ER+) or HER2-positive disease, outcomes are typically more favorable. With the right treatment, many live well for years—even decades. Of course, some cases progress rapidly despite targeted therapy, so we always have to individualize our expectations.

Earlier integration of palliative care improves outcomes, but timing still depends on context. For patients newly diagnosed with metastatic disease, especially if their prognosis could reasonably span decades, I don’t typically refer to palliative care immediately. They are already coping with a flood of information under stress, and the “big picture” might not look alarming yet. I need more time to understand how their disease will behave—and what they need—before broaching the topic with them.

I often describe metastatic breast cancer as a chronic disease like diabetes or heart disease—one that requires ongoing care but doesn’t always disrupt daily life. When I do refer to palliative care early, it’s usually to support patients coping with a chronic, life-altering diagnosis. If someone is coping well with their diagnosis, I usually wait to refer until there’s evidence of emotional or spiritual struggle.

My recommendation: approach every patient with a new diagnosis of metastatic breast cancer with a blank slate. Use their own history to start painting the picture of their life since diagnosis, be informed about the latest treatments, and talk to their oncologist. This may give you the clearest idea of the future.

When I meet a patient with metastatic breast cancer, I ask myself a set of questions to help guide my thinking about a referral to palliative care.

• Is this a new diagnosis (de novo metastatic) or a recurrence?
• If it’s a recurrence, how much time has passed between their early-stage diagnosis and the development of Stage IV disease?
• Has the metastatic site been confirmed with a biopsy?
• Is it a distant metastasis or a local/regional recurrence?

These questions matter because patients are sometimes referred to palliative care before their case is fully worked up by oncology, like the case below.

I once saw a woman who was referred to me for a second opinion after being told she had metastatic ER+ breast cancer by her first oncologist, based on a chest wall biopsy and some tiny lung nodules. She was started on standard endocrine therapy with CDK 4/6 inhibition (anastrozole + ribociclib), and she was understandably overwhelmed by the news that her cancer was now incurable.

But I wasn’t convinced. The lung nodules were nonspecific and too small to biopsy. If they were benign, and the chest wall recurrence was resectable, she might actually be curable according to the CALOR trial. I brought the case to our surgeons, who agreed to proceed with the resection. A follow-up scan showed the lung nodules had resolved. She went on to surgery and radiation and is currently doing well.

Had this patient only seen a palliative care team before an oncologist, an attentive clinician might have asked these same questions and changed the course of her care. In that case, they would have recognized that what may look like metastatic breast cancer on the surface is actually still curable and refer back to oncology for a second opinion. It was a reminder that in complex cases, all of us play a role in making sure the diagnosis and plan are solid.

One of the strongest prognostic indicators in metastatic breast cancer is how long a patient remains on first-line therapy. If they’ve been stable for years, that suggests indolent disease and a longer life expectancy. In the past, we expected each line of therapy to be less effective than the one before—but newer targeted agents and antibody-drug conjugates are challenging that assumption.

Unfortunately, this also means patients may experience a roller coaster of hope and disappointment. Next-generation sequencing is now common, but we still don’t know the best order in which to give all these new drugs. This uncertainty creates an emotional and cognitive burden for patients, and is another place where palliative care teams can make a major impact.

There are times when chemotherapy is appropriate, even for a patient in very poor condition.

Take the example of a woman who was healthy until a rapidly worsening cough landed her in the ICU, needing to be put on a ventilator. A biopsy revealed extensive-stage small cell lung cancer. Her performance status was terrible, but the disease was highly sensitive to treatment. A short course of chemotherapy allowed her to be extubated, talk to her family, and participate in decisions. This was a reminder that even if the prognosis is poor, the chance for closure and communication with a team including palliative care and oncology may make the risks of treatment worthwhile.

In these situations, chemotherapy isn’t just about survival. It’s about making space. And sometimes, ironically, treatment can give a patient and family members the time they need to come to terms with what’s happening.

In my opinion, there are three clear moments when an oncologist should involve palliative care in the care of patients with metastatic breast cancer:

If the patient is interested in extra support, refer right away.

If the first few years of treatment went well, but you anticipate rockier terrain ahead, that’s the right time.

The struggle could be physical, emotional, spiritual, or existential. You’ll know it when you see it.

Every patient with metastatic breast cancer deserves a thoughtful, individualized approach. We should all start with a blank slate and an open mind, learn about their disease and response to treatment, and keep an open line with each other. When in doubt, reach out. Ultimately, we’re all in this together.

Edited by Melissa Baron. Clinical review by Andrew Esch, MD, MBA.