Abstract
Background/Aim: In this study, we aimed to evaluate the effect of virtual reality (VR) therapy on pain, anxiety, and other outcomes in patients with cancer undergoing central venous (CV) port placement.
Patients and Methods: We conducted a single-center randomized controlled trial with 10 adults with cancer undergoing CV port placement. Participants were randomized into the VR group (n=5), which received VR therapy with the Therapeia VR system (xCura), or the control group (n=5), which underwent conventional procedures. The primary and secondary outcomes included intraoperative pain, intraoperative and postoperative anxiety, blood loss, operative time, sensation of obstruction, and patient and surgeon satisfaction.
Results: No significant differences were found between the VR and control groups regarding operative time, blood loss, preoperative anxiety, obstruction sensation, or surgeon satisfaction. However, compared with the control group, the VR group showed markedly lower intraoperative pain (p=0.03), intraoperative/postoperative anxiety (p=0.04), and higher patient satisfaction (p=0.03).
Conclusion: The use of immersive VR therapy during CV port placement significantly reduced intraoperative pain and anxiety and enhanced patient satisfaction. These findings indicated that VR therapy may be an effective nonpharmacological adjunct for improving patient experience during invasive procedures.
- Central venous port placement
- gastrointestinal cancer
- intraoperative pain
- nonpharmacological adjunct
- virtual reality
Introduction
Virtual reality (VR) allows users to experience an environment created with three-dimensional computer graphics through video displays, therefore providing real-time visual, auditory, and tactile experiences (1). Recently, the integration of VR with affordable head-mounted displays has accelerated its adoption in the medical field (2). The importance of VR in surgical simulations and rehabilitation has been reported (3, 4).
Cancer is one of the most common diseases and a leading cause of death globally, with a steadily increasing incidence (5). Pain and anxiety are common symptoms experienced by patients with cancer and their families (6). These symptoms are usually exacerbated by the side-effects of ongoing chemotherapy (7, 8). Chemotherapy regimens commonly used for various cancer types include long-term administration and combinations of multiple drugs. A totally implanted central venous access (CV) port is part of the standard treatment option to prevent complications of peripheral venous chemotherapy (9). Despite extensive studies on the complications and management of CV port placement [reviewed in (10)], there remains a lack of research focusing on strategies for alleviating pain and anxiety during the placement procedure.
The clinical application of VR during dental procedures and gastrointestinal endoscopy has shown potential in pain and anxiety reduction (11, 12). We hypothesized that combining VR therapy with CV port placement in patients with cancer undergoing chemotherapy would reduce procedural pain and anxiety. In this study, we aimed to evaluate the effect of VR therapy on pain, anxiety, and other outcomes in patients with cancer undergoing CV port placement.
Patients and Methods
This single-center randomized controlled trial was conducted at the Department of Surgery of the International University of Health and Welfare Hospital from July to October 2024. The inclusion criteria were as follows: requirement for CV port placement for adjuvant chemotherapy after curative resection of gastrointestinal cancer; or undergoing chemotherapy for unresectable gastrointestinal cancer. The exclusion criteria included visual impairment, alternative venous access approaches other than the internal jugular vein, history of psychiatric disorders, motion sickness susceptibility, and inability to provide informed consent (Figure 1). The primary endpoint was pain score by the intraoperative pain scale, while the secondary endpoints included blood loss, operative time, intraoperative and postoperative anxiety, intraoperative narrowness, and patient and surgeon satisfaction.
Enrollment and randomization.
This study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of the International University of Health and Welfare Hospital (approval number: 24-TK-003). Written informed consent was obtained from each patient. The trial was registered with the University Hospital Medical Information Network Clinical Trials Registry (registration number: UMIN000063471).
Procedure for totally implantable venous access port. The patient was placed supine and given local anesthesia (1% xylocaine, 20 ml for all cases). A prophylactic antibiotic (1 g cefazolin) was administered preoperatively. The procedure was carried out with a 6-Fr Orphis CV kit (Sumitomo Bakelite Company Limited, Tokyo, Japan). Subsequently, all procedures were performed by a single senior resident. The following steps were common to all cases.
For catheter insertion, under local anesthesia, the internal jugular vein was accessed under ultrasound guidance, and a guidewire was inserted and placed in the superior vena cava under fluoroscopy. A dilator and a sheath were placed along with the guidewire. The guidewire and dilator were removed, and a catheter was inserted into the remaining sheath in the vessel and positioned in the superior vena cava. The catheter tip position was confirmed by fluoroscopy.
To create a subcutaneous pocket, under local anesthesia, a 3-cm incision was made on the anterior chest wall on the same side to create a subcutaneous pocket for port insertion. To connect the catheter and port, the catheter was tunneled subcutaneously using a tunneler and connected to the port under local anesthesia. The port was inserted into the subcutaneous pocket and sutured to the pectoralis fascia using a 3-0 Vicryl at two points. The skin was closed with absorbable sutures, and Dermabond® (Ethicon; Johnson & Johnson, Tokyo, Japan) was applied. Postoperatively, a third party distributed patient and surgeon questionnaires, which were completed by the patient and surgeon.
Questionnaires. A questionnaire composed of various visual analog scales was sent to both patients and surgeons. The responses to the following items were recorded (Figure 2).
Scales for ratings used in this study.
Patient-reported items: A visual anxiety analog scale was used to evaluate preoperative anxiety, which was assessed on a scale of 0 (calm) to 10 (extreme anxiety) (13). A numerical rating scale was used to evaluate intraoperative pain, which was assessed on a scale of 0 (no pain) to 10 (worst possible pain) (14). A visual analog scale was used to evaluate the intraoperative narrowness, which was assessed using a scale from 0 (no narrowness) to 10 (strong narrowness).
A visual analog scale was used to evaluate the intraoperative and postoperative anxiety, which was assessed using a scale of 0 (calm) to 10 (extreme anxiety) (13).
A 10-point Likert scale was used to evaluate patient satisfaction, which was assessed on a scale of 0 (very dissatisfied) to 10 (very satisfied) (15).
Surgeon-reported items: A 10-point Likert scale was used to evaluate the operator’s satisfaction with the procedure (stress related to patient movement or behavior during surgery), which was assessed on a scale of 0 (very dissatisfied) to 10 (very satisfied) (15).
VR Intervention. The head-mounted display was a PICO G2 VR Headset (PICO, Beijing, PR China) (Figure 3). Therapeia VR software (xCura, Fukuoka, Japan) was used by the patient, which immersed them in an environment featuring space, forest, and ocean settings, guiding their breathing rhythm with voice and lyrics to promote relaxation (Figure 4).
Immersive virtual reality system equipped with a head-mounted display. (A) Front view; (B) Side view.
Example of Nature Treks virtual reality experience. (A) Ocean setting; (B) Forest setting.
Randomization. Ten patients who met the inclusion criteria were assigned by a third party into two groups using a simple randomization procedure (block replacement method): a VR group undergoing CV port placement with VR therapy (n=5) and a control group (n=5) undergoing conventional CV port placement.
Statistical analyses. For patient background and outcome analyses, univariate analysis was performed using chi-square tests for categorical variables and either the Mann-Whitney U-test or unpaired t-test for continuous variables. Statistical analyses were conducted using STATA/IC (version 16.0; Stata Corp, College Station, TX, USA), and significance was set at p<0.05.
Results
Comparison of patient characteristics. The results are summarized in Table I. Ten patients were included in this study: five men and five women. The median age was 63.1 years. The primary diagnoses were colorectal cancer in seven, gastric cancer in one, esophageal cancer in one, and pancreatic cancer in one patient. CV port placement was performed for adjuvant chemotherapy and chemotherapy for unresectable cancer in three and seven cases, respectively. There were no significant differences in patient backgrounds, including age, sex, primary disease, or purpose of CV port placement between the VR and control groups.
Comparison of the baseline characteristics and outcome of 10 patients who underwent totally implantable central venous access port placement between under virtual reality (VR) and control groups.
Comparison of outcomes. There were no complications in the VR or control group during or after surgery. No significant differences were observed between groups concerning operative time, blood loss, preoperative anxiety, narrowness, or surgeon satisfaction. However, the VR group demonstrated significantly better outcomes than the control group in terms of intraoperative and postoperative anxiety (p=0.04), intraoperative pain (p=0.03), and patient satisfaction (p=0.03) (Table I, Figure 5).
Comparison of questionnaire results shown in a radar chart.
Discussion
This study demonstrated that immersive VR use during CV port placement in adults with cancer undergoing chemotherapy significantly improved intraoperative pain, intraoperative/postoperative anxiety, and patient satisfaction. To our knowledge, this is the first study to demonstrate that immersive VR improves patient outcomes during CV port placement.
VR can be divided into non-immersive, which enables users to experience virtual spaces on a computer, and immersive VR, in which users wear a head-mounted display to engage multiple senses, including vision and hearing, in a virtual environment (16). Notably, immersive VR creates a strong sensation of “being physically present” in the constructed environment, thereby eliciting physiological responses similar to those experienced in a real location (16). This unique characteristic suggests that combining immersive VR with analgesics or anesthesia can further alleviate pain and anxiety during medical procedures (17).
Previous studies have reported the effectiveness of immersive VR in reducing pain and anxiety, primarily in pediatric cases. Gold et al. conducted a randomized controlled trial of 20 children using immersive VR during venipuncture. They discovered that the VR group experienced significantly less pain than the control group (18). Liu et al. conducted a randomized controlled trial with 53 children undergoing endoscopy. They reported significantly reduced pain, anxiety, and discomfort, with higher satisfaction in the immersive VR group than in the control group (19). However, these studies were limited to pediatric patients. To our knowledge, there have been no reports on the use of immersive VR for CV port placement in adults with cancer, who likely experience higher levels of anxiety and pain.
Humans may engage in “chest breathing” when experiencing fear, anger, or tension, which shortens inhalation and exhalation. In contrast, intentional “abdominal breathing” can lengthen exhalation relative to inhalation, substantially increasing alpha waves and inducing a relaxed state through activation of the parasympathetic nervous system (20). Therapeia VR, introduced in 2023, is an immersive VR technology designed to maximize relaxation effects by guiding breathing patterns in a virtual environment in combination with autogenic training and eye movement exercises. It was developed to alleviate pain and anxiety that cannot be addressed by anesthesia or analgesics.
In this study, the combination of Therapeia VR and local anesthesia during CV port placement substantially improved intraoperative pain, anxiety, and patient satisfaction, thereby contributing to better patient outcomes. In the control group, sensory input, such as vision and hearing, was restricted by the surgical drape placed to maintain a sterile field. The immersive VR system provided a multisensory experience in the virtual environment, guiding the patient’s breathing patterns and leading to a relaxed state. This likely contributed to favorable outcomes. Another advantage of using Therapeia VR intraoperatively under local anesthesia is that it facilitates communication among healthcare professionals. By immersing the patient’s visual and auditory senses in a virtual reality environment, Therapeia VR reduces the patient’s awareness of the surrounding environment. In this context, the use of Therapeia VR enables more fluid and uninhibited communication between medical staff, which has the potential to improve the overall quality of the surgery, particularly by enhancing the performance of healthcare professionals during stressful surgical procedures. Furthermore, the VR technology used in this study holds potential for application in other procedures performed under local anesthesia.
A consideration when using Therapeia VR during CV port placement is the alignment of the image axis during the initial setup. As the patient’s head was elevated on the right side for the internal jugular vein puncture, adjusting the image axis at the start of the VR use was important to prevent misalignment during the procedure.
The limitations of this study include its single-center design and small sample size. In addition, pain, anxiety, and satisfaction were assessed using subjective questionnaires. Therefore, further validation of VR’s true efficacy requires high-quality, large-scale studies.
In conclusion, this study demonstrated that combining immersive VR and local anesthesia during CV port placement significantly reduced intraoperative pain and intraoperative/postoperative anxiety, as well as improving patient satisfaction in adults undergoing chemotherapy.
Footnotes
Authors’ Contributions
Teppei Kamada: Writing – original draft, conceptualization, formal analysis. Hironori Ohdaira: Writing – review and editing. Ryosuke Nishie: methodology, conceptualization. Daisuke Yamagishi: Data curation. Takashi Aida: Data curation. Junji Takahashi: Data curation. Eisaku Ito: Data curation. Shunjin Ryu: Writing – review and editing. Satoshi Narihiro: Writing – review and editing. Reo Takizawa: Methodology, conceptualization. Taigo Hata: Data curation. Masashi Yoshida: Data curation. Ken Eto: Writing – review and editing, supervision. Makoto Sumi: Writing – review and editing, supervision. Yutaka Suzuki: Writing – review and editing, supervision.
Conflicts of Interest
Shunjin Ryu receives funds for a collaborative research project from Anaut, Inc.
- Received January 10, 2025.
- Revision received February 6, 2025.
- Accepted February 11, 2025.
- Copyright © 2025 The Author(s). Published by the International Institute of Anticancer Research.
This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY-NC-ND) 4.0 international license (https://creativecommons.org/licenses/by-nc-nd/4.0).
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