Results

Participant characteristics** **

Fifty patients consented to participate and were randomized to either SOC or immersive education. One patient was lost to follow-up for reasons unrelated to the intervention, resulting in 49 evaluable patients (24 SOC, 25 intervention). Baseline demographic characteristics were similar between groups. The mean patient age was 63 years, and the majority of patients underwent DIBH radiation therapy or general EBRT. Of the 25 intervention-arm participants, eight (32%) received headset-based immersive VR education, and 17 (68%) selected flattened 360-degree video delivery. No participants were assigned to flattened delivery because of cybersickness screening results; all participants receiving flattened video selected that modality based on preference. Patient demographics are summarized in Table 1, and the CONSORT (Consolidated Standards of Reporting Trials) diagram is presented in Figure 2.

Figure 2: CONSORT flow diagramCONSORT: Consolidated Standards of Reporting Trials; SOC: standard of care; VR: virtual reality

Characteristic | Overall (N = 49) | SOC (n = 24) | Enhanced education (n = 25; VR = 8, flat = 17)
Age, years, mean ± SD | 63 ± 10.8 | 65 ± 10.5 | 61 ± 9.5
Female, n (%) | 33 (67.3) | 14 (58.3) | 19 (76)
Race, White, n (%) | 41 (83.7) | 21 (87.5) | 20 (80)
Race, Black or African American, n (%) | 8 (16.3) | 3 (12.5) | 5 (20)
Ethnicity, Hispanic, n (%) | 1 (2) | 0 (-) | 1 (4)
Public insurance, n (%) | 26 (53.1) | 13 (54.2) | 13 (52)
Private insurance, n (%) | 23 (46.9) | 11 (45.8) | 12 (48)
DIBH, n (%) | 21 (42.9) | 9 (37.5) | 12 (48)
Prostate, n (%) | 5 (10.2) | 3 (12.5) | 2 (8)
General, n (%) | 18 (36.7) | 9 (37.5) | 9 (36)
SRS, n (%) | 5 (10.2) | 3 (12.5) | 2 (8)

The educational intervention was implemented within routine clinical workflows across multiple treatment pathways without requiring modifications to standard treatment delivery processes, supporting the feasibility of integrating IPEP into routine clinical practice.

Patient-reported outcomes

A summary of all patient-reported outcomes is presented in Table 2. Each area is further assessed in the following sections.

Outcome | Baseline median (IQR), SOC | Baseline median (IQR), intervention | End-of-treatment median (IQR), SOC | End-of-treatment median (IQR), intervention | Median Δ, SOC | Median Δ, intervention | P-value | W
Treatment-related anxiety | 4 (0) | 4 (2) | 4 (2) | 2 (1) | -0.5 | -1.5 | 0.10 | 121.5
Cancer-related anxiety | 4 (1) | 4 (2) | 4 (0.75) | 3 (1.75) | 0 | -1 | 0.22 | 146
Care plan-related anxiety | 3 (2) | 3.5 (1.25) | 3 (2) | 3 (2) | 0 | -1 | 0.01 | 61.5
Understanding of radiation therapy | 3 (1) | 3 (1) | 5 (5) | 5 (5) | 1 | 2 | 0.03 | 190.5
Satisfaction with educational materials | 4 (1) | 4 (1) | 5 (1) | 5 (1) | 0.5 | 1 | 0.36 | 97.5

Patient-Reported Anxiety

The intervention group demonstrated greater reductions in treatment-related, cancer-related, and care plan-related anxiety throughout the treatment course compared with SOC. Treatment-related anxiety decreased in both groups following consultation, with larger early reductions observed in the intervention arm. Although anxiety increased before treatment in both groups, lower treatment-related anxiety scores were observed in the intervention group at mid-treatment and end-of-treatment assessments. The median reduction in treatment-related anxiety from pre-consult to the end of treatment was greater in the intervention group compared with SOC (−1.5 vs. −0.5), though this difference was not statistically significant (W = 121.5, p = 0.10).

Cancer-related anxiety also decreased after consultation in both groups. At the end-of-treatment assessment, the intervention arm had lower mean and median cancer-related anxiety scores than the SOC arm. Median change from pre-consult to end of treatment favored the intervention arm (∆−1 vs. ∆0), though this difference was not statistically significant (W = 146, p = 0.22). The largest between-group difference was observed for care plan-related anxiety. The intervention arm began with higher baseline care plan-related anxiety than the SOC arm but demonstrated a larger reduction over time. Median reduction from pre-consult to end of treatment was significantly greater in the intervention arm than in the SOC arm (∆−1 vs. ∆0; W = 61.5, p = 0.01), as shown in Figure 3.

Figure 3: Care plan-related anxiety: change in median delta for care plan anxiety for each arm over timeIQR: interquartile range

Patient Understanding ** **

Patient-reported understanding of how radiation would be used to treat their cancer or condition increased in both groups following consultation. The intervention arm demonstrated a larger median improvement from pre-consult to end of treatment compared with the SOC arm (∆+2 vs. ∆+1), and this difference was statistically significant (W = 190.5, p = 0.03), as shown in Figure 4.

Figure 4: Patient understanding: change in median delta for understanding for each arm over timeIQR: interquartile range

Patient Satisfaction ** **

Patient satisfaction improved in both groups throughout treatment. Both arms demonstrated increased satisfaction following consultation and generally favorable satisfaction scores throughout treatment. Median change in satisfaction from pre-consult to end of treatment was greater in the intervention arm than in the SOC arm (∆+1 vs. ∆+0.5), but this difference was not statistically significant (W= 97.5, p = 0.36). Additional modality-specific questions administered to intervention-arm participants demonstrated favorable perceptions of both immersive and flattened video-based educational materials. All responding intervention participants rated their educational modality favorably. A substantial proportion of intervention patients selected flattened video viewing rather than full immersive VR, supporting the importance of flexible educational delivery options during clinical implementation.

Qualitative Feedback ** **

Limited qualitative feedback was collected. Responses from both study arms reflected positive perceptions of the educational experience. Participants receiving immersive education described the intervention as helpful and informative.

Clinical workflow metrics** **

Clinical workflow metrics were evaluated descriptively as exploratory outcomes, and the results are presented in Table 3.

Metric | % Negative slope, SOC | % Negative slope, intervention | ≥ 20% Reduction, SOC | ≥ 20% Reduction, intervention
Treatment duration | 68.2% | 91.7% | 75.0% | 76.0%
Number of setup images | 72.7% | 79.2% | 75.0% | 80.0%
Number of setup shifts | 40.9% | 62.5% | 54.2% | 60.0%
Translational shift magnitude | 59.1% | 41.7% | N/A | N/A
Rotational shift magnitude | 40.9% | 54.2% | N/A | N/A

A greater proportion of intervention-arm patients demonstrated decreasing treatment duration over time compared with SOC patients, based on descriptive patient-level slope analysis (91.7% vs. 68.2%). No statistical comparison was performed for these exploratory workflow metrics. Similar directional trends favored the intervention arm for number of images and number of setup shifts. The proportion of patients achieving at least a 20% reduction in treatment duration was similar between groups. Results for composite translational and rotational shift magnitude were mixed, with the SOC arm showing a greater proportion of patients with decreasing translational shift magnitude and the intervention arm showing a greater proportion with decreasing rotational shift magnitude. Overall, workflow metrics suggested possible treatment-efficiency trends favoring the intervention arm for selected measures; however, these findings should be interpreted as exploratory and hypothesis-generating.