Background: The Engagement of Patients with Advanced Cancer (EPAC) randomized Veterans with newly diagnosed stage 3 or 4 cancer or recurrent disease to usual care (control) or usual care with 6-month community health worker (CHW) support (intervention) to engage Veterans in end-of-life (EOL) goals of care discussions. At 6- and 15-months follow-up, the intervention tripled goals of care documentation (primary), doubled hospice (secondary), and reduced end-of-life (EOL) acute care use (secondary) and total costs (secondary). This post-hoc analysis after 10 years from study initiation evaluates effects on overall survival (OS) and EOL healthcare use and costs. Methods: We abstracted dates of death, emergency department (ED), hospitalization, palliative care (PC), hospice use, and costs within and outside Veterans Affairs (VA) using electronic health record and claims before data cut-off on February 1, 2023 for all EPAC participants. We compared OS using Kaplan Meier and log-rank, risk of death using Cox-proportional hazard models, ED, hospitalization, PC, hospice use and costs in the last 30 days of life using Logistic Regression, and incidence rate ratios of ED and hospitalizations using Poisson regression. Results: Among 213 participants, there were no imbalances in demographic or clinical characteristics. 165 (77.4%) were White, 211 (99%) males, 80 (37.6%) had lung cancer, and 118 (55.3%) had stage 4 disease. Median follow-up was 298 days (range 12-3438). Intervention group participants had greater OS (log rank p=0.03), 25% reduction in risk of death, lower acute care use, greater PC and hospice, and lower total costs (p<0.001) than control group participants. Conclusions: The CHW-led intervention significantly improved OS and maintained robust effects on EOL healthcare use and costs. Results support integration of CHWs into care to improve clinical outcomes. Clinical trial information: NCT02966509.