This nationwide retrospective cohort study demonstrates significant associations between the timing of SPC initiation and healthcare utilization among patients with breast cancer in Finland during the EOL period. Our findings show that initiating SPC more than 30 days before death was associated with significantly lower use of acute hospital services during the final month of life, including fewer emergency department visits and hospitalizations. Early SPC involvement also correlated with increased use of hospital-at-home services and a greater likelihood of dying in a dedicated SPC ward.

The optimal timing for initiating SPC remains debated and varies considerably across existing studies [5,6,7,8]. However, our choice to use a 30-day threshold was guided by established EOL quality indicators [13,14,15] and recent evidence highlighting that healthcare utilization typically intensifies during the last month of life [16], a finding consistent across different patient groups, including both malignant and non-malignant diseases [20].

Consistent with existing literature [22], we found that SPC remains underutilized, with only 35% of patients having any documented SPC contact and a median interval from first SPC contact to death of 89 days. This aligns with international reports suggesting persistent delays in palliative care referrals across cancer types [11, 23]. For example, Lucchi et al. [11] demonstrated that only a minority of patients with metastatic breast cancer received timely palliative care referrals, resulting in a high proportion of hospital deaths. Similarly, Hausner et al. [23] highlighted improvements in earlier SPC referrals following clear evidence supporting early integration, though delays remain common. These previous studies, along with others [5,6,7], have consistently shown that early SPC contact improves symptom control, enhances QOL, and reduces intensive healthcare utilization at the EOL. However, to our knowledge, our study is the first nationwide analysis specifically demonstrating the impact of SPC timing on healthcare utilization and place of death among patients with breast cancer.

Healthcare utilization in our cohort remained high, reflecting the significant symptom burden and disease progression typical of advanced breast cancer [11, 12]. However, patients in Group I had markedly fewer emergency department contacts and hospitalizations during their final month of life. These results suggest that earlier SPC involvement facilitates proactive care planning and symptom control, thereby minimizing unnecessary acute care needs [8, 10, 24]. Importantly, even after adjusting for age and municipality type, earlier SPC contact remained an independent and clinically meaningful factor associated with reduced intensity of end-of-life care.

Hospital-at-home services were used much more frequently among patients with breast cancer who were in Group I compared to those in Group II. In addition, those who received hospital-at-home service tended to have fewer hospital admissions, were more likely to receive concurrent home care, and more commonly spent their final days outside the hospital – either at home or in an SPC ward. These observations are consistent with earlier research demonstrating that hospital-at-home models can reduce hospital utilization, improve satisfaction, and increase the likelihood of dying at home [25,26,27].

Many patients with advanced cancer express a wish to spend their final days at home; however, their actual place of death often does not align with these preferences [28, 29]. In a nationwide multicenter study conducted in France by Lucchi et al. [11], only 16.7% of patients with metastatic breast cancer died at home, while 63.3% died in the hospital and 20% in a palliative care unit—highlighting the gap between patient desires and real-world outcomes. In our cohort, 74% of patients died in the hospital, closely mirroring the high rate of hospital deaths observed in Lucchi et al. [11]. Nevertheless, patients in Group I were significantly more likely to die in an SPC ward (15% vs. 3%), suggesting that timely referral can help ensure access to expert symptom management and holistic support in a dedicated palliative setting.

The study’s strengths include its nationwide coverage, capturing all breast cancer deaths in Finland during 2019, ensuring high external validity within the Finnish healthcare system. Nevertheless, certain limitations must be acknowledged. Due to its retrospective design, causality cannot be conclusively determined. Although age and municipality type were adjusted for in multivariable logistic regression models, potential unmeasured confounders such as disease severity, socioeconomic status, and comorbidities might still have influenced the findings. Additionally, our study did not include patient-reported outcomes or caregiver experiences, essential components of comprehensive palliative care evaluations. Finally, the generalizability of our results outside Finland may be limited due to differences in healthcare infrastructure, palliative care accessibility, and cultural factors that influence care preferences. Despite these limitations, our findings provide critical real-world evidence supporting the timely integration of SPC into standard oncological practice.