Transforming Reality: Using Virtual Reality to Treat Patients with Cancer

Given the choice of being on a beach or in an oncology ward, most people would choose the beach. So, if there was a technology that allowed you to take a mini-vacation while you waited for your appointment or received your treatment, you’d want to use it, right?

There is, and you can. Heather Bucalos of upstate New York learned the value of virtual reality in January 2020 when she resided in a hospital room at Roswell Park Cancer Institute in Buffalo for four weeks after a stem cell transplant to treat her recurrence of Hodgkin lymphoma.

“I felt closed in, kind of like a zoo animal,” Bucalos says. “My room was small and only had one window and the only interesting thing I could see was a multicolored house between the buildings in the distance. When I felt well enough, I used the headset and chose an application that is like going to a beach. I could see the sunshine and it was like being outside.”

With virtual reality, users look into a headset that includes a computer providing real-time animation which, in some cases, moves or changes based on the position of the head. Cynthia Waddington, a nurse navigator and clinical director of the cancer program at ChristianaCare — which serves all of Delaware and parts of Pennsylvania, Maryland and New Jersey — defines it as “a visual and auditory immersion into an environment that looks and feels real.”

Kim Vernick of Philadelphia describes her virtual reality experience at the Roberts Proton Therapy Center at Penn Medicine, in Philadelphia, as “Zen.” Vernick, who received a diagnosis of pancreatic cancer in 2010 and esophageal cancer in 2019, says that it transported her to “a happy place where I was sitting in an Adirondack chair by the lake watching the sunrise with geese flying over.”

Other patients have benefited from the technology, too. An aggregate analysis of studies that examined virtual reality use for symptom management in cancer care found statistically significant effects on reducing anxiety, depression and pain.

Virtual reality’s value isn’t limited to acute patient care. It can help with education — showing patients where their tumor is located and how treatment will work, as well as training medical practitioners how to treat certain condi- tions and operate equipment.

IMPROVING PATIENT COMFORT

Sitting in a waiting room and counting the long minutes until an appointment can be stressful enough for people with cancer and their families.

“Add on TV, chatter and overhead announcements and it can become even more stressful,” says Dr. William Levin, an associate professor of clinical radiation oncology at Penn Medicine in Philadelphia. “Utilizing this kind of immersive experience can take you out of that reality and give you time to regroup. It can make you feel better than you did when you walked in.”

Over the years, Levin has taught many patients about mindfulness meditation and seen it help slow their minds and calm their breathing. Still, some have trouble getting their brains to stop racing. He says technology can help patients over that hurdle, which is why Penn now offers a virtual reality mindfulness experience in its radiation oncology waiting area.

“The goal of using virtual reality is to combine deep breathing and being in the moment with an immersive experience,” Levin says. “Rather than closing your eyes and telling someone to think of nothing, we created a placid lake scene at sunrise. And we have the voice of a mindful- ness practitioner pointing out some of the salient features of the scene.”

Matthew Stoudt, the CEO and cofounder of AppliedVR, a Los Angeles company that develops therapeutic virtual reality content, agrees that some people find it hard to meditate. “A lot of people say, ‘Yeah, I understand the benefits of meditation, but I can’t do it.’ But you put them in a virtual reality headset that blocks everything else out and they can’t help but do it.”

Waddington, who oversees ChristianaCare’s cancer center and infusion sites, says those facilities offer six videos that provide a “positive distraction” without taxing the patient’s energy. A pilot study of the program found that all the partici- pants enjoyed the experience and would do it again — with 98% saying it was relaxing and 64% saying it reduced their anxiety and boredom.

“Every patient comes in highly anxious because they just don’t know what to expect,” Waddington says. “When we’re anxious, it’s hard to focus and it’s hard to retain information.”

Pain is just as serious a problem for many patients with cancer, and virtual reality may be able to help with that, too, not only by making patients more comfortable but also by reducing their reliance on opioids at a time when use of those drugs has reached epidemic proportions in the United States.

Ten years ago, Diane Jooris saw the technology’s potential while working at The University of Texas MD Anderson Cancer Center in Houston. Back then, Jooris sat with patients during breast cancer surgeries and provided clinical hypnosis, a psychological intervention that took the place of IV sedation.

These procedures were successful, but Jooris was limited by the number of therapists and the languages they spoke. She decided to start a company, Oncomfort, which would use virtual reality to make clinical hypnosis more acces- sible. Now, patients can choose from three sessions that last from two to 60 minutes and are offered in 12 languages. The aim is to reduce both anxiety and pain.

“Through these sessions, we bring the patient to a dissociated state,” Jooris says. “We have some patients who are snoring on the table during surgery. They’re in a state of modified consciousness, which allows them to be more comfortable while less aware of what is happening in the room and with their body. Often, they are so relaxed they don’t even feel when the doctor injects the local anesthesia.”

It’s proven to work. One 2019 study found that breast cancer patients randomized to receive a virtual reality experience in addition to morphine reported significant reduction in pain and anxiety compared with those who got morphine alone.

Additional studies have shown that virtual reality technology can help with other side effects of therapy.

Some treatments leave patients with low vision, an impairment that can’t be corrected medically, surgically or with conventional glasses, and virtual reality may be a way for them to see more clearly. In a study conducted at Johns Hopkins University and published in February 2019 in Translational Vision Science Technology, virtual reality devices improved vision in patients with macular degeneration, boosting it, on average, from 20/400 to 20/30 while the headsets were in use. Virtual reality is already in use at more than 100 U.S. ophthalmology and optometry centers, according to a 2019 article in the ASCO Post.

There is also evidence that virtual reality can help improve the symptoms of fatigue, another common side effect of cancer treatment.

PROVIDING VIRTUAL EDUCATION

Once Penn Medicine started working with virtual reality, Levin said, leaders there realized the technology could help solve another problem — communicating complicated information.

Stressed-out patients have a hard time understanding and remembering material that is conveyed verbally, so Levin’s team created an application to explain particular disease processes and treatments.

“For instance, if I’m speaking to someone with lung cancer,” Levin says, “they’ll be able to visualize the lungs and the location of the tumor and how it impacts normal functioning. The other thing we’ll be able to do is provide a visual of how the radiation treats that tumor and the potential side effects from the treatment itself.”

The team at ChristianaCare saw the opportunity for patient education about a different part of the treatment process. Waddington says team members decided to address a common question: “Why do I have to wait so long?”

“We filmed what happens in the pharmacy,” Waddington says. “It showed how the pharmacists are gowned and gloved and how they take orders, double check what we’ve already double checked, and make the medication in a sterile environment.”

Education via virtual reality is available to children, too. Oncomfort offers four applications for youngsters, including an interactive game that allows players to shoot and destroy cancer cells. It helps doctors explain what chemotherapy does in words that don’t create scary images or more fears.

“We use metaphors, specific verbiage and narrative to teach the kids about their treatment,” Jooris says. “It gives them the feeling they play an active part in their therapy while using techniques that completely dissociate them from the perception of the body so the nurse can connect the port and get chemotherapy running.”

At Penn Medicine, Fern Nibauer-Cohen, director of patient engagement in the department of radiation oncology, says that virtual reality technology is part of the facility’s global training and education program for radia- tion oncologists, therapists and medical physicists. When Penn decided to build a proton therapy center,

its radiation therapists, oncologists, physicists and dosimetrists came for two- to four-week in-person training programs. The curriculum was supplemented with virtual reality modules covering everything from how to position a patient on the table through delivery of treatment.

Levin points out that this technology also helps students understand human anatomy. “It’s important for trainees to learn three-dimensional thinking,” Levin says. “This can take a decade or more to develop, and we think that we can reduce the learning curve.”

VIRTUAL REALITY IN PRACTICE

Since her treatment, Bucalos has become an advocate for virtual reality and often tells her doctors about it. She hopes more patients will be able to realize the benefits soon.

Vernick is just as enthusiastic and now volunteers at Penn Medicine, where she offers a headset to anyone in the waiting room. “It should really be offered to all patients and caregivers,” she says, “because it takes away anxiety and angst and really puts you at ease.”

Levin envisions virtual reality headsets being used all over the medical center. “In the exam or consult room, it could be set up by anyone from a nurse to a volunteer to a nurse navigator or a student or a resident. It shouldn’t be labor- intensive or complicated,” he says.

But virtual reality isn’t right for everyone. Waddington says it isn’t recommended for patients who struggle with vertigo, dizziness or motion sickness.

Jooris says it isn’t appropriate for people who suffer from acute psychiatric disorders such as schizophrenia or have a fragmented vision of reality. It’s also not good for people who are very anxious and want to know everything that’s happening at all times, which Jooris says applies to about 2% to 3% of patients.

Levin says the devices themselves do not emit radiation, and that the only worry is that the headsets may be damaged by scattered radiation in certain treatment rooms. “The nice thing is that there are no irreversible side effects or significant toxicities,” Levin says. “If someone says they aren’t comfortable, it’s easy to just take off the headset.”

So how can the health care system get more virtual reality headsets to patients?

Stoudt says that his company’s systems are used in over 100 medical and hospital systems, including Northwestern Medicine in Chicago, Cedars Sinai in Los Angeles and Boston Children’s Hospital, as well as in people’s homes. Right now, the hospitals are focused on conducting studies that demonstrate the technology’s value — not only to drive adoption but also to validate requests for FDA approval for certain therapeutic uses.

In most cases, the hospitals pay for the headsets, which cost between $500 and $2,000 apiece, Stoudt says. A 2018 survey of hospitals showed that those that invested in the technology saved $5.39 per patient across their entire treatment population due to factors including shorter stays and less opioid use. That broke down to a savings of $98.49 per patient eligible and willing to use virtual reality therapy (20%) and a loss of $16.90 for every patient not eligible or not willing to try it (80%).

LOOKING AHEAD

Stoudt would like to see clinical standards of care change to include virtual reality headsets as a part of routine treatment for patients with cancer. To help build a body of evidence, AppliedVR has partnered with the National Cancer Institute to launch a feasibility study to investigate the efficacy of using virtual reality to treat anxiety patients with cancer.

About 2,000 patients are enrolled in various clinical trials testing virtual reality around the world, according to Jooris.

She describes one study: “One group had prostate resection surgery under intravenous sedation plus local anesthesia. The other had digital sedation, which is clinical hypnosis with virtual reality, and spinal-block anesthesia. Digital sedation was superior to IV sedation.” Both the patients and the anesthesiologists rated virtual reality higher than IV sedation because it avoided the respiratory side effects of the drug midazolam.

Stoudt believes the future of virtual reality ultimately will involve reaching America’s 50 million individuals with chronic pain. He envisions the technology being covered by public and private health insurers and the headsets being found in every home, allowing physicians to prescribe a variety of therapies delivered through the devices.

“Then it’s not simply a one-off intervention patients use in a moment of crisis or pain, but a tool to help them learn to live with their pain on a daily basis,” Stoudt says. “It’s about improving the quality of patients’ lives by addressing the pain, but also by teaching them coping skills so they can apply those skills in their daily lives outside of the headset.”

Stoudt is also excited about the possibility of using biofeedback to deliver more precise virtual reality content. AppliedVR has developed a system that can capture the patient’s breath and use that information to drive the virtual reality experience.

As wearable biofeedback devices that monitor factors such as heart rate variability and alpha and beta brain waves get smaller, they can be incorporated into the headsets to create all-in-one devices.

“As you get this data back, you can see the impact the content is making on the patient,” Stoudt says. “Then the challenge becomes how we optimize the content on the fly. How do we deliver the right piece of content to the right patient at the right time? Then you can adjust content in real time, and that gets super exciting.”