Purpose <p>Prognostic understanding among patients with life-limiting diseases may help patient to make informed decisions about their care. The aim of our study was to assess the level of prognostic understanding among patients recently referred to an enhanced supportive care (ESC) service, to explore the factors associated with prognostic understanding and its association with patient-relevant outcomes.</p> Methods <p>Adult patients with metastatic cancer referred to the ESC service between November 13th, 2023, and August 31st, 2024, at the University College Hospital Macmillan Cancer Centre London were eligible and completed a structured online questionnaire. The primary endpoint was patients’ prognostic understanding assessed with the Prognosis and Treatment Perception Questionnaire. Secondary endpoints included symptoms of anxiety and depression, measured with the General Anxiety Disorder 2-item (GAD-2) and Patient Health Questionnaire-2 (PHQ-2), respectively.</p> Results <p>Out of 311 patients referred to the ESC, 91 were included in the study. Of these 91 patients, 34 (37.4%) were unaware of their incurable prognosis. In a regression model adjusted for age and gender, being in a relationship was significantly associated with good prognostic understanding (adjusted OR 2.75, 95% CI 1.11 to 6.8, <i>p</i> = 0.03). Patients who had a good prognostic understanding reported fewer symptoms of anxiety (16% vs. 36%; adjusted OR 0.32, 95% CI 0.12 to 0.88, <i>p</i> = 0.03) and depression (23% vs. 45%; adjusted OR 0.35, 95% CI 0.13 to 0.91, <i>p</i> = 0.03).</p> Conclusion <p>A significant proportion of patients with metastatic cancer were unaware that their cancer was not curable at referral to the ESC service. Improving prognostic understanding may help to reduce psychological distress and enhance emotional well-being, supporting better patient-centred ESC care.</p>