How Virtual Reality Can Help Tackle ‘Scanxiety’ Among Cancer Patients

The cancer patient journey is fraught with challenges — physical, financial, and emotional. Managing the emotional toll of cancer care is especially hard as, more often than not, it is not immediately clear if therapy has worked and the tumor has been eliminated. To mitigate the anxiety inherent in the cancer patient experience, healthcare providers are turning to advanced technologies, like virtual reality (VR).

Multiple studies have shown that anxiety symptoms are common in cancer patients. Research published in 2009 shows that 12.4 percent of cancer patients displayed mixed anxiety/depression symptoms, with 18.3 percent displaying overall depression symptoms and 24 percent overall anxiety symptoms.

Anxiety is even more prevalent among primary brain tumor patients. These patients “experience distress throughout their disease trajectory,” according to a 2016 study.

This is largely due to the uncertain nature of the disease and treatment efficacy, with anxiety spiking around the time patients have to get their scans done, said Amanda King, PhD, nurse scientist and research fellow at the National Cancer Institute (NCI) of the National Institutes of Health (NIH).

“Patients always describe it the same way where they're just living scan to scan, and that period leading up to this scan is really scary for them, and there's really no interventions available apart from ‘here's an SSRI or some sort of medication,’” she said.

The lack of non-pharmacologic options led NCI to examine whether VR could help primary brain tumor patients better manage their anxiety. The institute partnered with healthcare VR provider AppliedVR to conduct a phase 2 clinical trial focused on the feasibility and efficacy of using VR to manage primary brain tumor patients’ ‘scanxiety.’

The interim analysis of the phase 2 study — which is part of an ongoing collaboration agreement between AppliedVR and the NCI — included 20 primary brain tumor patients with prior reports of distress and upcoming imaging scans. They were recruited between March 2021 and March 2022.

The patients were provided with an AppliedVR headset, which came pre-loaded with 50 scenarios divided into three categories.

The first category, Instant Escape, enables users to view places or have immersive experiences. For example, users could swim with dolphins or travel to different places.

“But, in those scenarios, there's no talking, there's really no teaching of anything,” King said. “It's just kind of an escape to somewhere nice so they can feel better than they did before they put the headset on.

The second category includes scenarios that guide users through slow diaphragmatic breathing to help bring down their heart rate and cortisol levels. The headset includes a breath shield that can detect the breathing pattern of the patient.

The third category is more meditative and includes scenarios that help users identify and address unhelpful thought patterns through positive thinking and coping mechanisms.

“I think what's cool about VR versus just giving an educational pamphlet or something like that is it's really immersive,” King said. “It helps take them somewhere else to a place that has nothing to do with their cancer so they can get in a better mind space and learn these helpful tools.”

In the study, the patients could begin using the VR headsets about two weeks before their following scan. They could use the headset as often as they wanted over the next month. Researchers collected patient-reported outcomes (PROs) before and immediately after the VR intervention and at one- and four weeks post-intervention.

The study was entirely remote, with researchers collecting PROs through electronic questionnaires.

The NCI published results from its interim analysis in the Journal for Neuro-Oncology earlier this year.

“For feasibility, really, we were interested in whether patients were interested in the study [and] once they were [enrolled], did they stay in study? Did they follow the use of VR? Did they complete all of their electronic questionnaires? And we've had really, really good results so far,” King said.

All patients completed the VR sessions, PRO questionnaires, check-ins, and qualitative interviews. A majority (90 percent) reported frequent VR use and high satisfaction. The research team recorded only seven adverse events, including headache, dizziness, nausea, and neck pain.

In general, patient feedback has been overwhelmingly positive.

“They’ve been so grateful just to have something to address these psychological symptoms that often are just not the focus — which, in a sense, rightfully so because [clinicians are] more concerned about the tumor and something that doesn't have a cure,” King said. “But they've been very, very thankful to be able to participate in this.”

As the NCI research team looks ahead to completing phase 2 of the study and moving on to phase 3, some factors could complicate the clinical trial process.

One of the critical challenges is the relatively conservative eligibility criteria, King noted.

“Patients can't be too close to surgery,” she said. “They can't have had any recent seizures. They can't have any significant nausea or motion sickness going into the trial just because those are potential side effects of using virtual reality. A lot of our patients can be quite sick. So, some of the patients that we feel would benefit the most just haven't been able to qualify just based on those exclusion criteria.”

However, conducting the clinical trial remotely — a decision initially made due to the COVID-19 pandemic — has proven beneficial in recruiting patients. King said that a remote clinical trial provides flexibility and convenience, allowing patients to remain in the comfort of their own homes while participating in the trial.

The next step in the study will involve examining the efficacy of the VR intervention in reducing ‘scanxiety’ among primary brain tumor patients and then expanding the scope of the study to other patients with solid tumors. The researchers are also considering expanding the study to other centers to diversify the study population.

As clinical evidence supporting VR use in healthcare grows, King believes the healthcare industry should lean more on these advanced technologies and move away from pharmacology where possible.

“This is what patients are asking for — things that they can do at home that they can do on their own without having to talk to a doctor every time they need an intervention…So, I think VR really has a lot of potential in this area,” she said. “And, it doesn't have to be in cancer. A lot of patients who have chronic conditions have spikes in their anxiety based on certain aspects of their illness trajectory. So, I think there's a lot of potential here…I think the sky's the limit.”