Pain (P), fatigue (F), and insomnia (I) are among the most prevalent, distressing, and undermanaged symptoms experienced by cancer patients. Research has demonstrated that PFI co-occur; what remain unclear are the patterns and stability of PFI and the patient, disease, and treatment characteristics that predict PFI patterns over time. This secondary analysis used a data set composed of 867 elders (46% women) who were newly diagnosed with breast, colorectal, lung, or prostate cancer and followed at 4 points during the year after diagnosis. The university's institutional review board approved this study. Descriptive statistics and multistate transition models using multinomial logistic regression were used. The typical participant was 72.6 years old, who reported 7.9 symptoms and 2.7 comorbidities. Previous PFI pattern was consistently associated with significantly increased risks of subsequent PFI pattern. At observations 1 to 3, lung cancer, treatment, higher comorbidity with breast cancer, and late-stage colorectal cancer were significantly associated with increased risks of PFI patterns. Advancing age was not significantly associated with increased risks of PFI patterns. Pain, fatigue, and insomnia co-occurrence declined over time but was associated with significantly increased risks of death or loss to follow-up and increased reports of other symptoms. Pain, fatigue, and insomnia co-occurrence is associated with adverse outcomes and should be proactively targeted for intervention.