Dear Editor,

We read with great interest the exploratory study by Andreis et al. (Reference Andreis, Deori and Meriggi2026) evaluating dignity therapy (DT) during active chemotherapy for advanced gastric and pancreatic cancer. Among 30 completers, emotional and dignity-related distress decreased after the 3-session intervention and remained lower at 1-month follow-up, while quality of life was stable. The study importantly relocates dignity work from the final days of life to a period in which patients remain engaged in disease-directed treatment.

This relocation requires more than delivering the same protocol earlier. DT is a brief psychotherapy developed to address psychosocial and existential distress (Chochinov et al. Reference Chochinov, Hack and Hassard2005). Its legacy-oriented questions may provide continuity and meaning, yet during chemotherapy they may also imply premature closure. Indeed, newly diagnosed patients receiving DT emphasized living with illness, identity, and relationships, not solely preparation for death (Dose and Rhudy Reference Dose and Rhudy2018). We therefore suggest reframing early DT as culturally responsive narrative-existential counseling: a collaborative conversation that follows the patient’s present temporal horizon rather than assuming readiness for a final account.

A practical adaptation could offer 3 patient-chosen narrative pathways. A legacy pathway would retain the generativity document; identity continuity would explore valued roles and aspects of self-threatened by illness; and living forward would identify near-term hopes, relationships, and attainable sources of agency. Patients could move between pathways as treatment, prognosis, and preferences change. This approach is compatible with evidence that individual meaning-centered psychotherapy improves spiritual well-being and reduces existential distress in advanced cancer (Breitbart et al. Reference Breitbart, Pessin and Rosenfeld2018) while retaining DT’s distinctive focus on dignity.

Cultural responsiveness should be elicited, not inferred from ethnicity. A counselor might ask who should participate, which experiences may be recorded, how hope and suffering are understood, and whether family involvement is supportive or burdensome. In family-oriented settings, local values such as mutual obligation, collective deliberation, spiritual surrender, and intergenerational continuity may strengthen meaning; they may also constrain disclosure or individual choice. Such values should therefore become invitations for exploration, not prescribed content. The benefits reported with Chinese culture-adapted DT during chemotherapy support adaptation beyond linguistic translation (Lin et al. Reference Lin, Guo and Xi2023), but local versions should be co-designed with patients, families, clinicians, and community or spiritual representatives.

Finally, 23 of 53 recruited participants (43%) did not complete the intervention. Deterioration and death are expected in advanced cancer, but withdrawal may also indicate burden, unsuitable timing, or psychological unreadiness. Future studies should distinguish reasons for non-completion, reassess consent and readiness before each session, monitor immediate post-session distress, and include non-completer perspectives where feasible. Attrition can systematically limit the generalizability of meaning-centered intervention research (Applebaum et al. Reference Applebaum, Lichtenthal and Pessin2012). Early DT should thus be judged not only by symptom change among completers but by whether it remains voluntary, culturally congruent, emotionally safe, and responsive to how patients wish to live now.