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Background: The PEARL study showed that palbociclib plus endocrine therapy (palbociclib/ET) was not superior to capecitabine in improving progression-free survival in postmenopausal patients with metastatic breast cancer resistant to aromatase inhibitors, but was better tolerated. This analysis compared patient-reported outcomes., Patients and Methods: The PEARL quality of life (QoL) population comprised 537 patients, 268 randomised to palbociclib/ET (exemestane or fulvestrant) and 269 to capecitabine. Patients completed the European Organisation for Research and Treatment of Cancer QLQ-C30 and QLQ-BR23 and EQ-5D-3L questionnaires. Changes from the baseline and time to deterioration (TTD) were analysed using linear mixed-effect and stratified Cox regression models, respectively., Results: Questionnaire completion rate was high and similar between treatment arms. Significant differences were observed in the mean change in global health status (GHS)/QoL scores from the baseline to cycle 3 (2.9 for palbociclib/ET vs. -2.1 for capecitabine (95% confidence interval [CI], 1.4-8.6; P = 0.007). The median TTD in GHS/QoL was 8.3 months for palbociclib/ET versus 5.3 months for capecitabine (adjusted hazard ratio, 0.70; 95% CI, 0.55-0.89; P = 0.003). Similar improvements for palbociclib/ET were also seen for other scales as physical, role, cognitive, social functioning, fatigue, nausea/vomiting and appetite loss. No differences were observed between the treatment arms in change from the baseline in any item of the EQ-5D-L3 questionnaire as per the overall index score and visual analogue scale., Conclusion: Patients receiving palbociclib/ET experienced a significant delay in deterioration of GHS/QoL and several functional and symptom scales compared with capecitabine, providing additional evidence that palbociclib/ET is better tolerated., Trial Registration Number: NCT02028507 (ClinTrials.gov)., Eudract Study Number: 2013-003170-27., Competing Interests: Conflict of interest statement Z.K. has participated in advisory boards of and received speaker fees or travel support from Pfizer, Roche, AstraZeneca and Novartis. M.G-G.- has received honoraria from Pfizer and Eisai and has participated in advisory boards of Genentech and Daiichi Sankyo. He has received travel support from Pfizer, Novartis, Daiichi Sankyo, Roche and Kern. M.R.B. has received speaker fees and advisory grants from Pfizer, Novartis and Lilly. E.Ca., who has a stock and other ownership interests from Lilly, has received travel and accommodation support from Roche, and her husband, who has participated in consulting and advisory board activities with Bristol Myers Squibb, Novartis, Celgene, Roche Pharma, Janssen, Amgen, Incyte, AbbVie and Pfizer, has received travel and accommodation support from Celgene, Novartis and Bristol Myers Squibb. His institution has received research funding from Celgene, Janssen, Bristol Myers Squibb, Novartis, Roche/Genentech, Amgen, Pfizer and AbbVie. GEICAM has received research funding from Roche/Genentech, Bristol Myers Squibb, Novartis, Pfizer, Celgene, AstraZeneca, Merck Sharp & Dohme, Pierre Fabre and Takeda. E.Ci. has received advisory board honoraria from Lilly, Novartis, MSD, AstraZeneca, Pfizer and Roche and speakers' honoraria from Roche, Lilly and Pfizer, and she has received travel and congress assistance support from Pfizer and Roche. M.Mu. has received travel and congress assistance support from Roche, Novartis, Pfizer and Eisai. B.B. has received advisory board honoraria from Roche, Novartis and MSD and speakers' honoraria from Roche, Novartis, MSD, Pfizer and Pierre Fabre, and she has received travel and congress assistance support from Pfizer. M.Marg. has received advisory board fees from Roche, Novartis, Pfizer and Eisai. Her institution, ICO-Badalona. B-ARGO (Badalona Applied Research Group in Oncology) Hospital Universitari Germans Trias i Pujol, Badalona, has received research funding from Roche, Pfizer, Novartis, Lilly, AstraZeneca, Eisai and Kern, and she has received travel and congress assistance support from Roche. A.A. has received advisory board fees from Bayer, Spain. E.A. has received advisory board fees from Roche, Novartis, Pfizer, Lilly, Bristol Myers Squibb, Genomic Health and Nanostring. He has received travel support from Celgene. His institution, Hospitales Regional y Virgen de la Victoria, Málaga, has received research funding from Roche, Pfizer, Sysmex, Merck Sharp & Dohme and Nanostring. J.d.l.H-R. has received speaker's honoraria from AstraZeneca, Pfizer, Novartis and Lilly. M.R. has received honoraria from Novartis, Roche and Pfizer. I.M.A-L. has received consulting or advisory board honoraria from AstraZeneca, Pfizer, Novartis, Palex and Roche; speakers' honoraria from AstraZeneca, Pfizer, Novartis, Roche and Eisai; travel and congress assistance support from AstraZeneca, Pfizer, Roche and Eisai and research funding from Pfizer, Novartis, AstraZeneca and Roche. E.G-Y. has received honoraria and travel support and has participated in advisory boards for Pfizer, Roche, Novartis and Eli Lilly. S.G-S. has received consulting or advisory board honoraria from Pfizer, MSD, GSK and Roche and speakers' honoraria from AstraZeneca, Pfizer and Novartis. C.A.R. has received consulting or advisory board honoraria from AstraZeneca, Pfizer, Novartis, SeaGen, DaiiChi Sankyo and Roche and speakers' honoraria from MSD, Pfizer, Novartis, Roche, Nanostring, Amgen and Eisai. S.S. has received consulting or advisory board or speakers' honoraria from Roche, Eisai, Daiichi Sankyo, AstraZeneca, MSD and Genomic Health. M.C. is employed by Pfizer and has the company's stock options. X.H. is employed by Pfizer and has the company's stock options. C.Z. has received consulting fees and speaker's honoraria from Roche, Novartis, Bristol Myers Squibb, Merck Sharp & Dohme, Imugene, Ariad, Pfizer, Merrimack, Merck KGaA, FibroGen, AstraZeneca, Tesaro, Gilead, Servier, Shire, Eli Lilly and Athenex. His institution, Central European Cancer Center, Wiener Privatklinik Hospital, has received fees from Bristol Myers Squibb, Merck Sharp & Dohme, Pfizer, AstraZeneca and Merck KGaA. M.Mart. has received consulting fees from AstraZeneca, Amgen, Taiho Oncology, Roche/Genentech, Novartis, PharmaMar, Eli Lilly, PUMA, Taiho Oncology and Pfizer; speakers' honoraria from AstraZeneca, Amgen, Roche/Genentech, Novartis, Daiichi Sankyo and Pfizer and contracted research fees from Roche, Novartis and PUMA. All remaining authors have declared no conflicts of interest. A complete list of the PEARL trial collaborators is provided in the Supplementary Appendix., (Copyright © 2021 The Author(s). Published by Elsevier Ltd.. All rights reserved.)