Materials and methods

Study design** **

This prospective pilot feasibility study enrolled eligible patients over a predefined six-month period. The enrollment period was determined by the project timeline and available resources rather than by a target sample size. As the primary objective was to evaluate the feasibility and preliminary impact of the IPEP, no a priori power calculation was performed. Patients were randomized to receive either SOC education or an immersive educational intervention integrated into routine clinical workflows. Patients were randomized using simple randomization based on a coin flip before enrollment. Study identification numbers were preassigned to either the SOC or intervention arm according to the randomization sequence, and enrolled patients were assigned the next available study identification number after obtaining consent.

This process ensured that treatment assignment was determined by a predetermined randomization sequence without investigator discretion at the time of enrollment. SOC education consisted primarily of physician-delivered education during the initial radiation oncology consultation. This discussion included information regarding the patient's diagnosis, recommended radiation treatment, anticipated treatment process, and potential side effects. No standardized supplemental educational materials were provided as part of SOC during the study period. As physicians did not know which arm a patient would be randomized to at the time of the consultation, all patients received the SOC education provided during the clinical consultation. Patients randomized to the intervention arm subsequently received the IPEP in addition to SOC education. Therefore, this study evaluated the incremental benefit of adding the IPEP to the existing patient education workflow.

Feasibility outcomes included successful integration into routine clinical workflow, patient completion of educational sessions, modality utilization patterns, tolerability of immersive content, and scalability of educational delivery across treatment pathways. Exploratory secondary outcomes included longitudinal patient-reported measures of anxiety, understanding, satisfaction, and treatment workflow metrics intended to support hypothesis generation for future studies. The study protocol was approved by the institutional review board (approval No. 24-2626). The project was supported through the Duke Endowment Grant (7039-SP).

Educational intervention** **

Educational content was developed and reviewed by a multidisciplinary radiation oncology team consisting of radiation oncologists, medical physicists, radiation therapists, nurses, dosimetrists, and research staff. Four treatment-specific educational pathways were created for deep inspiration breath-hold (DIBH) breast radiation therapy, prostate radiation therapy, stereotactic radiosurgery (SRS), and general external beam radiation therapy (EBRT). General was used for patients receiving EBRT for disease sites other than DIBH, prostate, or SRS, for which site-specific IPEPs had not been developed.

Educational materials reviewed key components of the radiation therapy process, including consultation, simulation, treatment planning, treatment delivery, and supportive resources. Materials were reviewed for clinical accuracy and patient-centered communication before implementation. Educational materials were available in both immersive VR and flattened 360-degree video formats to improve accessibility and accommodate patient preference or intolerance to headset-based immersive viewing modalities. The educational program averaged approximately 20 minutes of standard educational video content with an additional average of seven minutes of immersive or flattened educational content.

Study population** **

All adult patients receiving EBRT in the Department of Radiation Oncology during the six-month pilot period (May 2025 through October 2025) were eligible for enrollment unless they had a cognitive impairment or a benign diagnosis. Because the IPEP educational videos were only available in English during the study period, only English-speaking patients were included. Patients randomized to the IPEP arm completed cybersickness screening before immersive video viewing. Patients with a high probability of cybersickness were transitioned to the flattened 360-degree video format rather than excluded from the study. Patients were recruited following routine radiation oncology consultation appointments. Patients who enrolled were then randomized to either SOC (as defined in the study design above) or immersive educational intervention.

Patients assigned to the intervention arm completed a cybersickness screening before immersive content viewing (Appendices) [15]. Based on patient focus group feedback, patients who preferred not to participate in immersive VR viewing, or who screened positive for potential cybersickness concerns, were instead provided flattened video-based educational materials. Patients randomized to the IPEP arm received the educational pathway corresponding to their disease site. Disease-specific pathways were available for breast, prostate, and SRS. Patients with all other EBRT treatment sites received the general IPEP pathway, which was developed for disease sites without a dedicated site-specific module.

All educational materials were viewed in clinic to standardize exposure. The timeline shown in Figure 1 outlines the time point at which educational materials and survey materials were provided relative to the patient's care plan.

Figure 1: Timeline of survey administrationSurvey administration timeline illustrating administration of a multi-domain patient survey and physician-reported measures across key clinical milestones during radiation therapyVR: virtual reality

Patient-reported outcomes** **

Study-specific patient-reported survey instruments were developed by the research team based on concepts identified in prior literature related to patient education, treatment understanding, anxiety, and satisfaction. These instruments were not formally validated but were designed to capture preliminary patient-reported outcomes relevant to the feasibility evaluation of IPEP (Appendices).

Patient surveys were collected at four predefined time points: pre-consult, post-consult, midpoint of treatment, and end of treatment. The pre-consult survey was administered immediately before the initial radiation oncology consultation during the patient's first visit to the department. The post-consult survey was administered following the physician consultation and delivery of any assigned educational intervention. The midpoint survey was administered during an on-treatment visit (OTV) occurring approximately halfway through the patient's prescribed radiation treatment course. The end-of-treatment survey was administered during the final OTV at completion of the radiation treatment course.

Clinical workflow metrics** **

Clinical workflow metrics were extracted from the Varian ARIA oncology information system. Metrics included treatment duration, defined as the interval from Mode-Up Time to Plan Closure Time within ARIA, the number of setup images, the number of setup shifts, and composite translational and rotational shift magnitudes. These measures were evaluated longitudinally to assess trends in treatment efficiency and setup consistency.

Statistical analysis** **

Survey responses were summarized using descriptive statistics. Longitudinal changes were evaluated relative to pre-consult baseline values at predefined study time points. Between-group comparisons of change from baseline were performed using Wilcoxon rank-sum testing due to the ordinal nature of Likert-scale responses. Statistical significance was defined as p < 0.05. Workflow metrics were evaluated longitudinally using patient-level trend analyses to determine the proportion of patients demonstrating improvement over the treatment course. Given the pilot feasibility design, exploratory nature of the study, and limited sample size, statistical analyses were intended to identify preliminary trends and support hypothesis generation rather than provide definitive evaluation of clinical efficacy. Future studies with larger sample sizes will incorporate longitudinal statistical models that account for within-subject correlation across repeated measurements.