Purpose <p>Advances in early cancer detection and treatment have significantly improved survival rates, resulting in over 18.1 million cancer survivors in the USA. Many of these survivors experience chronic pain, fatigue, and neuropathic symptoms related to cancer or its treatments. Emerging evidence suggests that autonomic nervous system dysfunction plays a crucial role in these symptoms. Heart rate variability (HRV), a measure of autonomic function, has shown potential in predicting the onset and progression of these cancer-related symptoms. This systematic review aimed to assess the association of HRV with pain, fatigue, and neuropathy in cancer patients and survivors.</p> Methods <p>A comprehensive search was conducted across multiple databases, yielding 23 studies that met inclusion criteria. These studies varied in cancer types, stages, and HRV measurement methods.</p> Results <p>Most studies focused on breast cancer and reported a predominant female population. Fatigue was the most studied symptom (<i>n</i> = 15), followed by pain (<i>n</i> = 7), and only one study assessed neuropathic symptoms. HRV measures included both time and frequency domain variables, with significant variability in measurement duration and control for confounding factors.</p> Conclusion <p>Findings suggest that decreased HRV is associated with increased fatigue and pain, providing potential support for a bidirectional relationship between autonomic dysfunction and these symptoms. However, the heterogeneity in HRV measurement methods and the high risk of bias in many studies highlight the need for high-quality prospective and interventional studies with standardized HRV protocols in cancer research.</p>