Analyzing the Efficacy and Design Considerations of VR Environments to Manage Anxiety & Depression in AYA Cancer Patients
Authors: Cull Elizabeth H. , Saha Aniket , Stanley Laura Michelle , Prabhu Vishnunarayan , Biro Joshua 
Published: November 2019

Prior studies have reported that adolescent and young adult (AYA) patients are specifically vulnerable to distress because of the intersection of disease and age. Compared to older cancer patients, AYA cancer patients indicate a more negative psychosocial outcome. Recent studies have focused on improving the quality of life of AYA patients by providing adjunctive non-pharmacological interventions. Popular methods adopted include cognitive behavioral therapy, hypnosis, video games and virtual reality (VR) exposure. Although VR has been tested among other cancer populations, to our knowledge, no studies have focused on the efficacy of VR for mitigating mental distress in the AYA population. Additionally, no studies have focused on what specific virtual-based experiences are efficacious without causing cybersickness in cancer patients. Research has found that up to 25% of healthy patients exposed to VR experience some form of cybersickness.
This longitudinal study analyzed the efficacy of VR in the AYA population and sought to understand their preferences in virtual environments. The study included eight AYA cancer patients admitted to our institution receiving inpatient chemotherapy. Seven patients had acute leukemia and the 8th patient had medulloblastoma. Patients were offered the VR intervention every other day during the hospital stay. On average, patients were enlisted in the study for 19 days, and were provided with 27 different virtual environments to choose from. Subject scores were collected using validated survey instruments, including the Numeric Rating Scale (NRS) for pain, State Trait Anxiety Inventory (STAI) for anxiety, and Hospital Anxiety and Depression Scale (HADS-D) for depression. Objective measures were also collected including heart rate and electrodermal response. Additional qualitative data were collected via patient interviews to better understand the patient's attitudes and behaviors regarding their virtual reality experience.
Responses collected from patients using HADS-D, STAI showed that, on average, there was a 15% decrease in depression and 13% decrease in general anxiety after receiving the VR intervention. Additionally, the response from the NRS showed that their perception of pain decreased by 18%. Moreover, these results were supported by the objective measures, where the frequency domain metric of heart rate variability, LF/HF (Low frequency to High Frequency power) ratio decreased by 42% displaying a high parasympathetic nervous system activity during the intervention and decrease in the number of bursts in skin conductance response by 7%. It was also observed from the survey that AYA patients preferred environments with more interaction and presence rather than simply exploring. Although no participants reported significant cybersickness, it was observed that 50% of the population reported fatigue at least once during the period of study. Hence, the design consideration of the VR environment is a crucial factor, especially while providing intervention for cancer patients.
This proof of concept study affirms the capability of VR to be used as an adjunct therapy to help manage pain, anxiety and depression in AYA patients and provides design consideration for VR environments to be used in AYAs. Future work includes the development and testing of adaptive environments using affective computing techniques where the virtual environment changes according to the patient's mood.

Disclosures
Cull: Celgene: Speakers Bureau; ADC Therapeutics: Research Funding.