Exploring Oncologists’ Perspectives on the Early Integration of Specialty Palliative Care in Korea: Challenges, Needs, and Clinical Implications

Article information

Cancer Res Treat. 2026;58(1):339-348

Publication date (electronic) : 2025 April 10

doi : https://doi.org/10.4143/crt.2025.158

Shin Hye Yoo¹, Yu Jung Kim², Ye Sul Jeung¹, Jung Sun Kim³, Kwonoh Park⁴, Eun Mi Nam⁵, Si Won Lee⁶, Jun Ho Ji⁷, Jwa Hoon Kim⁸, Joon Young Hur⁹, Song Ee Park¹⁰, Jung Lim Lee¹¹, Su-Jin Koh^,12

¹Center for Palliative Care and Clinical Ethics, Seoul National University Hospital, Seoul, Korea

²Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea

³Division of Medical Oncology, Department of Internal Medicine, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea

⁴Division of Hematology-Oncology, Department of Internal Medicine, Hanyang University Seoul Hospital, Hanyang University College of Medicine, Seoul, Korea

⁵Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea

⁶Division of Medical Oncology, Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea

⁷Division of Hematology and Oncology, Department of Internal Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea

⁸Division of Medical Oncology, Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea

⁹Department of Hematology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea

¹⁰Department of Internal Medicine, Chung-Ang University Gwangmyeong Hospital, Chung-Ang University College of Medicine, Gwangmyeong, Korea

¹¹Division of Hematology and Medical Oncology, Department of Internal Medicine, Daegu Fatima Hospital Cancer Center, Daegu, Korea

¹²Department of Hematology and Oncology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea

Correspondence: Su-Jin Koh, Department of Hematology and Oncology, Ulsan University Hospital, University of Ulsan College of Medicine, 25 Daehakbyeongwon-ro, Dong-gu, Ulsan 44033, Korea Tel: 82-52-250-8978 E-mail: sujinkoh@uuh.ulsan.kr

Received 2025 February 11; Accepted 2025 April 9.

Abstract

Introduction

The provision of palliative care—a medical approach focused on enhancing the quality of life for patients with advanced cancer and their families [1]—is a cornerstone of high-quality cancer care. Historically rooted in hospice care provided during end-of-life (EOL) situations, palliative care has evolved into a broader, holistic approach that begins at the time of diagnosis of a serious illness [2]. This paradigm shift has positioned palliative care in cancer treatment as a patient-centered approach addressing needs throughout the disease trajectory [3]. Studies performed since the early 2000s have consistently shown improvements in quality of life, reductions in aggressive care during EOL scenarios, enhanced understanding of illness, and increased understanding and facilitation of advance care planning related to early palliative care, supporting its integration into standard oncology practice [4]. Reflecting these findings, the updated 2024 American Society of Clinical Oncology guidelines emphasize the importance of timely referral to specialty palliative care (SPC), beyond the primary support provided by oncology clinicians [5]. The guidelines recommend the early referral of patients with advanced cancers to interdisciplinary palliative care teams to address unresolved physical, psychosocial, or spiritual distress alongside ongoing cancer treatment. Additionally, caregivers are encouraged to access SPC services to ensure comprehensive support.

Despite existing guidelines advocating for the early integration of SPC, a significant gap persists between these recommendations and actual clinical practice. Numerous studies have reported that palliative care is often introduced late and in a fragmented manner, rather than being integrated early in the course of illness [6]. Various factors—including limited awareness of the scope of palliative care, insufficient resources, cultural resistance within healthcare settings, and reimbursement or policy constraints—have been identified as barriers that contribute to the gap between ideal practice guidelines and real-world implementation of early SPC [7]. Addressing these challenges and developing strategies for improvement are therefore of critical importance to the field. Establishing appropriate referral criteria has emerged as a key priority in ensuring the timely delivery of SPC [8].

Despite the availability of hospice care services specifically for patients with cancer in Korea since 2004 [9], referrals to SPC have neither been frequent nor initiated early [10]. Furthermore, hospice utilization has reached only about one-quarter of eligible patients [11]. This limited uptake may partially stem from the traditional restriction of SPC services to inpatient hospice settings. The legislative landscape changed in 2018 with the enactment of the Hospice-Palliative Care and Life-Sustaining Treatment Decision-Making Act, which expanded the scope of palliative care services to include inpatient hospice, home-based hospice, and consultative hospice services [12]. A recent study [13] demonstrated the positive impact of early palliative care interventions on outcomes such as improved symptom control, enhanced quality of life, and increased satisfaction with care, further strengthening the evidence for the benefits of early SPC integration in Korea.

Nevertheless, it remains unclear whether current clinical practices and healthcare provider readiness are sufficient to support the practical implementation of early SPC integration. This study aims to examine the perceptions of Korean oncologists regarding the early integration of SPC, including their referral patterns, perceived barriers, and clinical needs.

Materials and Methods

Results

Survey responses were received from 227 participants, yielding a response rate of 36.7%. The majority of respondents (70%) were in their 30s and 40s. Among all participants, 67.4% were employed at tertiary care hospitals, with 66.5% of these institutions located in metropolitan areas. Of the hospitals represented in the survey, 67.8% provided SPC services, and 42.3% of respondents reported having direct experience with SPC services (S1 Table).

1. Experiences and preferences regarding referrals to specialty palliative care

Among the respondents, 68.7% reported frequent direct experience with SPC referrals. Younger physicians, particularly those in their 30s and 40s, were significantly more likely to make frequent referrals compared to those in older age groups (p < 0.001). Frequent referrals were also associated with larger hospitals, with respondents who worked in institutions with ≥ 1,000 beds reporting the highest rates (p=0.008). Institutions with in-house SPC teams had substantially higher referral rates (77.9%) compared to those without such teams (49.3%, p < 0.001). Similarly, respondents who treated a greater proportion of patients with advanced cancer (≥ 90%) were more likely to report frequent referrals than those with fewer advanced cases (p=0.001) (Table 1).

Table 1.

Factors associated with the frequency of referral to SPC

Regarding referral preferences, 30.4% of the respondents preferred to refer their patients to an in-house SPC team, 26.4% favored co-management with internal SPC teams, and 43.2% opted for external referrals. The participants who worked in metropolitan hospitals predominantly chose in-house (37.1%) or external referrals (46.4%), whereas those in non-metropolitan ones generally preferred co-care (46.1%, p < 0.001). Respondents working in institutions with in-house SPC teams predominantly favored in-house management (37.7%), whereas those without such teams preferred external referrals (75.3%, p < 0.001). Physicians with SPC experience preferred co-care (39.6%), whereas those without SPC experience leaned heavily toward external referrals (53.4%, p < 0.001) (Table 2).

Table 2.

Factors associated with preferred methods of referral to SPC

3. Patterns and perceptions concerning referrals to specialty palliative care

Regarding actual referral practices to SPC, > 70% of our respondents indicated that they make referrals in cases of disease progression or poor prognosis, termination of chemotherapy, poor performance status, patient states that suggest imminent mortality, decision-making regarding life-sustaining treatment, patient or family requests, and uncontrolled symptoms. Conversely, 60% of the respondents reported not referring their patients to SPC at the moment of an incurable cancer diagnosis. Furthermore, the percentage of referrals made for socioeconomic or existential issues was relatively low, at 55% and 62%, respectively (Fig. 1).

Fig. 1.

Actual patterns of referral to specialty palliative care among the study respondents.

Regarding perceptions of time-based criteria for SPC referrals, our results indicated that 60% of respondents considered a prognosis of 6-12 months to represent an adequate timeframe for referral, followed by 50% for a prognosis of 3-6 months. By contrast, for prognoses of < 3 months, 80% of the respondents deemed referrals to be late or too late. For longer prognoses, such as 12-24 months, 40% of the respondents viewed the timing as too early, and this proportion increased to 60% for prognoses of ≥ 24 months. Referrals after disease progression despite palliative second-line treatment were considered adequate by 67.4%, whereas progression after first-line treatment was seen as early by 70% of the respondents (Fig. 2).

Fig. 2.

Attitudes toward time- and trajectory-based referral criteria among the study respondents.

When asked about need-based criteria for SPC referrals, > 70% of the respondents agreed on the following triggers: patient or family request (96.5%), psychological distress (89.9%), uncontrolled symptoms (83.3%), recurrent emergency department visits or hospitalizations (78.4%), inadequate familial support systems (76.2%), existential issues (74.9%), and the need to clarify goals of care (71.8%). By contrast, the criteria with the highest rates of disagreement included the need for critical care (31.3%), the need for invasive procedures or operations (29.1%), communication issues between healthcare professionals (15.4%), and inter-/intra-professional conflicts or ethical issues regarding care coordination (15.0%) (Fig. 3).

Fig. 3.

Attitudes toward need-based referral criteria among the study respondents.

4. Identified barriers to referrals to SPC and perceived priorities for implementation of early integration

The most frequently reported barrier to SPC referral was patient and/or family refusal (70.0%). This was followed by concerns that discussing palliative care might convey to patients and families that the physician is giving up on treatment (46.3%), or that the discussion might lead to disappointment (17.2%). Additionally, 34.4% of the respondents indicated that the absence of an available SPC team represented a substantial reason for not referring patients (Table 3).

Table 3.

Barriers to referring patients to specialty palliative care services

For the successful implementation of early integration of SPC, the highest priority identified was promoting and improving awareness of palliative care among patients and their families. The second most important factor was ensuring that hospitals are adequately staffed with SPC providers, followed by the establishment of reimbursement structures for early palliative care services (Table 4).

Table 4.

Priority areas for implementing early integration of specialty palliative care

Discussion

To the best of our knowledge, this is the first study to explore the practices and perceptions of oncologists in Korea regarding SPC referrals, providing critical insights into the current landscape of this practice in the country. Our findings highlight a strong recognition of the benefits of early SPC integration, while also revealing significant barriers—such as patient and family resistance and limited availability of SPC teams—that may complicate the introduction of palliative care. Referral preferences varied widely among our respondents, influenced by institutional characteristics and access to in-house SPC teams. These results underscore the need for targeted strategies to address these challenges, including educational initiatives to improve awareness among patients and families, expanding the availability of SPC services, and developing systematic frameworks to streamline referrals and support early integration.

Our study highlights positive attitudes toward the early integration of palliative care among Korean oncologists, consistent with findings from previous related studies [15,16]. Notably, these attitudes appear more favorable than those reported in a Swedish survey-based study, which included a more heterogeneous group of physicians not predominantly composed of oncologists [16]. Despite the differences in participant groups, the attitudes observed in our study are significantly more positive than those reported in a 2014 survey of 440 physicians in Korea regarding palliative care consultation teams [17]. These findings suggest that positive attitudes toward SPC referral have increased over the past decade, potentially reflecting improved awareness and knowledge of palliative care among healthcare providers [18].

Although hospice utilization in Korea remains < 25% as of 2023 [11], data on SPC referral rates is limited. Retrospective single-center studies report an increase in in-house palliative care consultation referrals, from 30% in the 2010s [10] to up to 50% in recent years [19]—though these findings may not fully represent overall practice patterns. Our study reveals that a substantial number of oncologists frequently refer patients to SPC, yet these referrals often do not lead to hospice service utilization. The observed delays in SPC referrals, which themselves often occur later than expected or recommended, align with findings from other studies that highlight a prevalent gap between ideal and actual referral timing [15,16]. These delays may partially explain the low level of hospice service utilization we observed, as earlier referrals tend to facilitate more appropriate EOL care. These findings reinforce the need to promote earlier integration of SPC to improve EOL care.

Importantly, we observed that Korean oncologists tend to refer patients later than recommended by international consensus. While global guidelines suggest initiating SPC within three months of diagnosing incurable cancer with a life expectancy of ≤ 1 year [14], our respondents most frequently selected a prognosis of 3-6 months as the optimal referral window. For trajectory-based criteria, there was a predominant preference for referral after the failure of second-line palliative chemotherapy, which aligns more closely with international recommendations [14]. This trend likely reflects practical constraints within the Korean healthcare system, such as inadequate palliative care staffing and the lack of reimbursement for palliative care services outside of hospice care [20]. These limitations make earlier referrals, such as those made at the onset of incurable cancer, challenging. While the timing favored by Korean oncologists may be later than international recommendations, it highlights the need to develop locally applicable guidelines that account for existing infrastructure and resources.

The referral patterns and attitudes toward needs-based criteria observed in this study highlight the significant value that many oncologists place on addressing the subjective suffering and care planning of patients and their families. This aligns with the international consensus [14], where severe symptoms and care planning issues form major criteria for early palliative care referrals. However, oncologists appear less attuned to identifying socioeconomic and spiritual needs, which corresponds to the lower reported demand for assistance in these areas [21]. Similarly, broader indications such as healthcare utilization and interprofessional conflicts are relatively undervalued in the country compared to what has previously been reported elsewhere [16], suggesting a gap in the perception of what comprehensive palliative care can offer. Addressing these overlooked needs through SPC is critical, as such situations often involve complex symptom management, decision-making challenges, and significant emotional distress for patients and their families. Effective SPC referrals can enhance quality of care, align treatment goals among healthcare teams, and provide essential support to patients and their families [3,22].

Patient and family resistance emerged as the most significant barrier to SPC referral, echoing prior studies in both Korean and international contexts [23,24]. The need for education and awareness campaigns targeting patients and families was deemed critical for implementation, reflecting common challenges in Korea—where the term “palliative care” is unfamiliar, and “hospice” is often associated with death. According to the 2023 Hospice Palliative Care Annual Report in Korea [11], a survey of Korean adults aged 20-80 years revealed that 72.9% viewed hospice positively and 91.7% acknowledged its necessity. However, 35.8% associated palliative care with care provided only at impending death, and 28.1% believed it is appropriate solely when death is imminent. Although public perceptions are gradually improving, a significant proportion still limits hospice to EOL care, posing challenges to the adoption of early palliative care. Similar barriers have been noted even in countries where palliative care is more widely recognized [21]. To address these issues, there is a pressing need to raise awareness and broaden understandings of palliative care among patients, families, and healthcare providers [15]. This may require redefining terminology and reframing the concept of palliative care to extend beyond EOL contexts. Oncologists should develop effective strategies to introduce palliative care to patients and families to overcome these barriers and facilitate early integration [23,24].

In addition to clinical and institutional efforts, national policy-level support is essential to ensure the sustainable and equitable integration of SPC in Korea. Our study identified key barriers—such as limited staffing, insufficient institutional incentives, and delayed referrals—that require multifaceted solutions. First, financial incentives, including expanded reimbursement for outpatient and consultative SPC services and the inclusion of early referral rates in hospital quality assessments [25], could encourage hospitals to establish and maintain in-house teams. This is particularly relevant given the relatively low accessibility to SPC in our study compared to previous reports [26], considering that consultative models offer a resource-efficient approach to cancer care [7]. In Korea, consultative hospice services are already reimbursed by national insurance, suggesting that scaling and expanding these services could support broader SPC implementation. Second, automatic referral systems embedded in electronic medical record platforms [27] may promote timely, needs-based referrals by reducing reliance on individual clinician discretion. This approach is supported by recent evidence that automated, criteria-driven referrals achieve outcomes comparable to universal early palliative care [28-30]. Strengthening institutional capacity for systematic needs assessment may further enhance these strategies. In parallel, targeted education for oncologists—particularly on systematic needs screening and referral processes—can help embed early SPC referral into routine clinical practice [29-31]. Notably, our findings indicate that oncologists who frequently refer to SPC are more likely to recognize its necessity, pointing to the complementary roles of clinical experience and education in fostering referral readiness. Finally, as SPC services remain concentrated in tertiary centers, expanding access to secondary and regional hospitals is critical. This will require government investment and national standards to monitor SPC team quality alongside existing hospice policies [7,9]. Ultimately, the success of early palliative care integration depends on aligning infrastructure, policy, and workforce development with real-world oncology practice.

This study has several key limitations worth noting. First, although we provided definitions of palliative care, SPC, and early palliative care within the survey, the respondents may still have had varying interpretations, potentially affecting the accuracy of their responses. Second, as the study relied on self-reported data from oncologists, there was a possibility of response bias, with respondents potentially overestimating or underestimating their actual referral practices and attitudes toward palliative care. Finally, the response rate was limited to a subset of eligible specialists, which may affect the generalizability of our findings. In particular, the response rate of 36.7% raises the possibility of nonresponse bias, as oncologists with more favorable views toward SPC may have been more likely to participate.

This study revealed that, although SPC referrals in Korea still predominantly occur at later stages, many oncologists express positive attitudes toward the early referral and integration of SPC. While the results should be interpreted with caution due to the self-reported nature of the data and the relatively low response rate, they underscore the need to establish practical guidelines and policy frameworks that account for Korea’s specific healthcare environment and resource limitations. Strengthening public awareness, expanding institutional capacity, and enhancing referral systems—including national-level support—are all critical to advancing the timely and equitable delivery of SPC services across the country.

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