This is the first study that investigated palliative care interventions in advanced head and neck patients in an ESMO certified in integrated oncology and palliative care.
There was a non-statistically significant reduction in aggressive treatment in the last month of life in the PC group and the majority of feeding tubes and/or tracheostomies (86%) were placed before palliative care referral in this group. This is a clinically important result according to an interesting analysis of a self-administered survey in head and neck cancer patients that demonstrated that the presence of a feeding tube and/or tracheotomy and chemotherapy were significant clinical predictors of worse quality of life. 
The ESMO clinical practice guideline about patient care at the end of life does not recommend the use of nutritional interventions in the last weeks of life because they do not improve quality of life or survival.  Moreover, even if a feeding tube is a physically accepted technique, both patients and caregivers can experience significant psychosocial distress as a result. [3, 11] Despite this evidence, a systematic literature review reported that artificial nutrition is a frequent intervention in the last week of a cancer patient’s life, being recorded in up to 50% of patients.  This contradiction may be related to communication and cultural issues and overestimation of prognosis on the part of clinicians, and is particularly seen in head and neck patients, for which artificial nutrition is used more often than for other cancers.  PC advises oncologists, patients and their families not to use enteral nutrition in the last few weeks of life, as demonstrated by Wiegert et al. 
Many head and neck cancer patients treated with a curative intent require a tracheostomy, and therefore guidelines for indication and management are available. On the contrary, data about the role of tracheostomy in the last month of life is lacking. There is evidence that tracheostomy has a profoundly negative impact on quality of life and requires specific training on its management.  On the other hand, acute dyspnoea could be an ethical challenge for both clinicians and caregiver, and therefore advance care planning and end-of-life issues may be addressed by engaging PC early in the disease trajectory. 
Choi et al. found that cancer care near the end of life became more aggressive when compared to the previous decade with respect to chemotherapy. They found that 42.7% of the study population received chemotherapy in the last month of life, whereas in our study only 12.8% received this treatment (12.7% in PC group vs 13% in non-PC group, p=0.088). This aspect could be optimized with the early introduction of PC, leading to less aggressive end-of-life care including reduced chemotherapy.  The start and/or prosecution of aggressive care (in particular chemotherapy) close to death is widely deemed as nonbeneficial due to a limited effect on overall survival, symptom deterioration, and the high burden of toxicity, leading to impairments (or the absence of improvement) in quality of life. Earle et al. described how difficult it is to both achieve patient satisfaction and avoid futile care, giving the responsibility to the physician to counsel patients and their families when it is time to stop anticancer treatments and focus on an end-of-life approach. 
Another innovative result of our study is that pain was the most common symptom in the evaluated population, at its peak affecting 95.3% of patients. This prevalence was higher than the 70% reported in a systematic review for head and neck cancer patients, but both figures show that pain is the most significant symptom for this type of cancer in all stages.  An interventional study, involving patients with chronic disease of whom 30% had cancer, showed that only 8% of patients received adequate pain treatment with opioids from the primary care provider. This is an important aspect because uncertainties about treatment outcome are known barriers for integrating PC within routine oncological care. [17, 22] However, the correct use of opioids is mandatory for pain relief, especially for head and neck cancer patients who have a significantly greater odds of opioid prescription compared with use among patients with lung or colon cancer. 
Our retrospective study did not demonstrate a statistically significant overall survival benefit of adding palliative interventions to oncological standard of care. In fact, the PC-group had a worse survival rate, reflecting the difficult nature of this disease. This is in line with a recent published phase III trial in which patients were randomized to either systemic therapy with or without the addition of early palliative interventions, which did not improve overall survival.  This is not difficult to understand because relapsed and metastatic head and neck cancer has a bad prognosis with little OS benefit even with the recent combination of chemotherapy and immunotherapy approved in the first-line setting. The bad prognosis, with a median OS of 5.9 months in our study, is similar to the 5.6–13 months mentioned in previous studies. [2, 28] This could explain the absence of a survival benefit from the addition of PC in our series. Furthermore, it could also explain the negativity of the only phase III study in head and neck cancers as opposed to other types of diseases such as lung cancer. 
We found no differences in the incidence of home deaths and in both groups the majority of patients died in a hospital setting. This is in contrast to other types of cancer, where early palliative care referral in end-of-life care was associated with fewer hospital deaths.  This remains an unresolved clinical need for head and neck patients.
Our results reflect the recommendations of oncology societies, which emphasize the importance of quality of life over survival. A key recommendation of the American Society of Clinical Oncology (ASCO) is to offer concurrent palliative provisions for patients with advanced cancer early in their disease course.  ASCO evaluated different randomized trials and publications about the role of PC and demonstrated only few examples of a statistically significant improvement in outcomes. Nevertheless, the data showed better management of different issues such as correct opioid use and end-of-life care. Therefore, ASCO guidelines give importance to PC not for classical oncological outcomes such as relapse free and overall survival (OS), but for patients’ and caregivers’ well-being, especially symptom management and the decision-making process. 
In a position paper about key patient-centred care interventions for the multiple needs of patients, the European Society of Medical Oncology (ESMO) mentions the importance of the integration of a multidisciplinary team to improve collaboration with the aim of educating the patient and the caregivers.  Our study suggests that oncologists tend to prioritize technical interventions in these patients. To enrich this approach a shared decision-making approach and early involvement of specialized PC to optimize cancer care, patient experience and caregiver education should be fostered.  In curative settings, retrospective analysis demonstrated the positive role of multidisciplinary teams (MDT) for better diagnosis and treatment. Therefore, MDT should also include supportive professionals in palliative care to improve outcome. In the palliative setting, this approach is particularly important because it is challenging for oncologists to identify and support both psychosocial and physical symptoms. A descriptive analysis of a cohort of palliative head and neck cancer patients, based on the clear multilevel needs of these patients, found that more than two-thirds of patients were referred to PC, as in our series. 
It is important to highlight that the evaluation of the impact of PC provision in high complexity patients, such as head and neck cancer patients, is difficult and studies may not capture the full extent of the benefit of PC provision.