Daily Symptom Shifts Linked to Quality of Life in Metastatic Breast Cancer

Patients with metastatic breast cancer (MBC) reported lower quality of life (QoL) at moments when their depression, anxiety, fatigue, appetite loss, or decreased libido was worse than their own usual levels. QoL was higher when they felt more socially connected, peaceful, or joyful than usual. These findings come from an observational study published in Cancer Medicine that used smartphone-based ecological momentary assessment (EMA).

Across the cohort, patients who reported more nausea had worse QoL than their peers, and those who reported more joy had better QoL. QoL was not associated with how long patients had been living with MBC.

The investigators concluded that both within-person and between-person variations in symptom severity and positive affect are associated with QoL. These results, they wrote, highlight "the need for adaptive, targeted intervention strategies to optimize QoL for all patients."

How was the study designed?

Investigators recruited patients with MBC from 5 Mid-Atlantic sites in Washington, DC; Baltimore, Maryland; and Hackensack, New Jersey, between January 2023 and April 2024. Eligible participants were assigned female at birth, were aged 18 years or older, spoke English or Spanish, had a life expectancy longer than 6 months, and had a phone with text messaging and internet access.

EMA asks participants to report how they feel in the moment, which reduces the recall bias of traditional questionnaires. Participants received text prompts 3 times a day (morning, afternoon, and evening) on 1 randomly assigned day per week for 4 weeks, for up to 12 assessments. Each assessment took about 2 minutes and 47 seconds on average.

At each prompt, participants rated the following on 0-to-100 visual analog scales:

• Global QoL
• Symptom severity: depression, anxiety, pain, fatigue, slowed cognition, appetite loss, nausea, gastrointestinal (GI) distress, and decreased libido
• Positive affect: social connection, peace, and joy

Patient advocates living with MBC helped design the study and review the assessment items.

Who participated in the study?

The analytic sample included 108 patients, who contributed 1,101 observations in total. Participants had a mean age of 57.8 years and had been diagnosed with MBC a mean of 4.4 years earlier (median, 2.5 years; range, 0.06-20.65 years).

In all, 44.4% identified as non-Hispanic White, 35.2% as non-Hispanic Black, and 9.3% as Hispanic or Latino/a. Hormone receptor (HR)–positive disease was present in 74.1% of participants, and 25.0% had HER2-positive disease. The most common current treatments were targeted therapy (59.3%) and hormone therapy (56.5%).

Which symptoms were most severe for patients with MBC?

The mean QoL rating across all assessments was 71.1 out of 100. The most severe symptoms on average were decreased libido (59.5) and fatigue (35.8), followed by anxiety (30.9) and depression (25.7). Appetite loss (21.2) and nausea (10.7) were the least severe.

Most of the variation in QoL (72.2%) came from differences between individuals rather than day-to-day fluctuations within the same person. Every symptom and positive affect score correlated with QoL at P < .001.

How did day-to-day changes in symptoms affect quality of life?

The investigators modeled within-person effects (moments when a patient felt better or worse than their own average) separately from between-person effects (patients who, on average, felt better or worse than the rest of the sample).

QoL was statistically significantly lower at times when patients had more of the following than usual:

• Depression (β = −0.177; P < .001)
• Anxiety (β = −0.049; P = .023)
• Fatigue (β = −0.052; P = .009)
• Appetite loss (β = −0.053; P = .028)
• Decreased libido (β = −0.058; P = .036)

QoL was higher at times when patients reported more social connection (β = 0.091; P = .001), joy (β = 0.055; P = .047), and peace (β = 0.107; P < .001) than usual.

Between patients, worse QoL was associated with more nausea (β = −0.109; P = .035), and better QoL was associated with more joy (β = 0.593; P < .001).

Did quality of life change with time since an MBC diagnosis?

QoL was not statistically significantly associated with years since MBC diagnosis (P = .956). Patients who were older (β = 0.482; P = .013) and partnered (β = 13.356; P = .005) were projected to have higher QoL at diagnosis. Patients who were employed at baseline had a projected 2.5-point increase in QoL per year since diagnosis (P < .001). Patients with HR-positive disease had a projected 1.3-point decrease per year (P = .001).

The authors cautioned that these time-related trends were statistical projections from a single point in each patient's disease course, not changes observed directly. They noted that reverse causation and survival bias could explain the findings and that longitudinal cohort studies are needed to confirm them.

How does this fit with nurse-led psychosocial care in breast cancer?

The authors noted that existing interventions in MBC mostly focus on reducing negative affect rather than building positive affect. Only 1 positive psychological intervention has been tested in this population, nearly 10 years ago.

Oncology Nursing News has reported on a trial of 70 women receiving long-term hormonal therapy for HR-positive breast cancer. In that trial, a structured nurse-led program addressing physical, psychological, spiritual, and sexual health lowered death anxiety scores compared with routine care. An oncology nurse living with stage 4 breast cancer has also described the value of listening to patients as part of their care.

What are the key takeaways for oncology nurses?

• Ask how today compares with usual: QoL dipped when depression, anxiety, fatigue, appetite loss, or decreased libido was worse than a patient's own baseline. Questions that compare today with a typical day may identify moments when a patient needs more support.
• Screen for depression at every visit: Depression had the largest within-person association with lower QoL in the study.
• Raise sexual health directly: Decreased libido was the most severe symptom on average. The authors pointed to sexual health–focused interventions as one supportive care option.
• Address nausea and appetite: Patients with more nausea had lower QoL than their peers, and day-to-day appetite loss also tracked with lower QoL. The authors listed nutrition consults among the options to consider.
• Build in connection, peace, and joy: Social connection, peace, and joy were each associated with better QoL. Referrals to social support and mental health resources may help address these areas.

References

1. Mossman B, Small BJ, Addington EL, et al. Quality of life in adults with metastatic breast cancer: the impact of between- and within-person changes in symptoms and positive affect. Cancer Med. 2026;15(10):e72338. doi:10.1002/cam4.72338
2. Nurse-led support reduces death anxiety in breast cancer care. Oncology Nursing News. September 28, 2026. Accessed October 5, 2026. https://www.oncnursingnews.com/view/nurse-led-support-reduces-death-anxiety-in-breast-cancer-care
3. Biese A. Oncology nurse shares insights from her stage 4 breast cancer journey. Oncology Nursing News. September 26, 2026. Accessed October 5, 2026. https://www.oncnursingnews.com/view/oncology-nurse-shares-insights-from-her-stage-4-breast-cancer-journey