Redefining the timing of palliative care initiation in advanced and metastatic cancer: from prognostic thresholds to needs-based concurrent integration along the therapeutic trajectory

Introduction. In contemporary oncology, palliative care is increasingly conceptualized as an integrated lon­gi­tu­di­nal intervention rather than an exclusively ter­mi­nal stage. This shift is supported by the consensus-based re­de­fi­ni­tion of palliative care and by updates to on­co­lo­gic guidelines recommending its integration into stan­dard care. The “early integrated palliative care” mo­del involves the concurrent introduction of palliative care alongside active antineoplastic therapies, with the ob­jec­tive of systematically monitoring symptomatology and to­xi­ci­ties, preserving functional status and supporting pa­tient-centered therapeutic decision-making. Aim. This narrative review critically synthesizes the 2020-2025 li­te­ra­ture regarding the optimal timing of palliative care initiation in patients with advanced locoregional or metastatic cancer, examining the relationship bet­ween timing and symptom burden, functional status, to­le­ra­bi­lity of oncologic treatments and continuity of care. Metho­do­logy. A narrative analysis was conducted of in­ter­na­tio­nal guidelines, randomized and observational stu­dies and real-world practice reports published between 2020 and 2025. The selection targeted papers relevant to the temporality of initiation and to clinically meaningful out­comes: symptomatology, functional status, stages of on­co­lo­gic treatment, healthcare utilization and treatment to­le­ra­bi­lity. Results. Convergent evidence indicates that the benefits of palliative care are dependent on the timing of initiation. Concurrent integration with active treatment fa­ci­li­tates early identification of symptoms and toxicities, re­duces clinical instability, and supports the preservation of func­tio­nal autonomy. In contrast, delayed initiation in the con­text of advanced functional decline limits intervention to reactive symptom control and reduces its influence on the therapeutic trajectory. Recent literature identifies func­tio­nal status, recurrent toxicities, repeated treatment ad­just­ments and transitions between therapeutic lines as useful ope­ra­tio­nal benchmarks for early initiation. Conclusions. Post-2020 publications support the transition from rigid prog­nos­tic criteria toward models guided by clinical needs and key therapeutic moments. Early and concurrent in­te­gra­tion represents a modifiable determinant of the clinical tra­jec­tory, with potential to optimize treatment tolerability and continuity of oncologic care.