Discussion

This prospective pilot feasibility study suggests that implementation of an IPEP may improve patient-reported outcomes during radiation therapy. For this study, our IPEP included either headset-based immersive VR or flattened 360-degree first-person video. Patients receiving immersive educational intervention demonstrated greater reductions in anxiety and greater improvements in treatment understanding compared with SOC education. The most pronounced improvement was observed in care plan-related anxiety, where the intervention group demonstrated significantly greater reductions over the treatment course. These findings suggest that immersive educational interventions may improve patient preparedness and familiarity with radiation oncology workflows. Improved patient understanding observed in the intervention group may represent a potential mechanism underlying reductions in anxiety. Prior studies have demonstrated associations between improved treatment understanding and reduced anxiety among oncology patients [3-5,7,16-19]. Immersive educational approaches may enhance understanding by improving visualization of treatment environments and procedural expectations.

In addition to patient-reported outcomes, workflow metrics demonstrated exploratory trends toward improved treatment efficiency in the intervention arm. Greater proportions of intervention patients demonstrated reductions in treatment duration, imaging frequency, and setup shifts over time based on descriptive patient-level trend analyses. Although these findings were not statistically evaluated and should be interpreted cautiously, they suggest potential associations between immersive educational interventions and treatment workflow measures that warrant further investigation in larger, adequately powered studies. Our findings are consistent with prior studies evaluating immersive educational interventions in radiation oncology. Previous investigations have demonstrated improvements in patient understanding, engagement, and satisfaction following VR- and video-based educational interventions [3,5,10-13,18-19]. Unlike many prior studies, the present study prospectively evaluated an immersive educational intervention integrated into routine clinical workflow using a randomized design.

This study has several limitations. First, this was a single-institution pilot study with a limited sample size, which may reduce generalizability. The relatively small sample size and absence of an a priori power calculation limit the statistical power and generalizability of the findings. As this was a prospective pilot feasibility study conducted over a predefined six-month enrollment period, the primary objective was to evaluate the feasibility and preliminary impact of IPEP. Future studies with larger, adequately powered cohorts are needed to confirm these findings. Additionally, the use of simple randomization without formal allocation concealment may have led to group imbalances, particularly given the relatively small sample size. Future studies should consider more robust randomization approaches, such as block randomization or stratification based on relevant demographic and clinical characteristics, to minimize potential group imbalances and strengthen comparisons between study arms. Second, treatment pathways were not evenly distributed, with a large proportion of patients undergoing DIBH breast radiation therapy. Additionally, baseline care plan-related anxiety differed between study arms, which may have influenced the magnitude of observed longitudinal changes.

Third, the sample size did not permit direct comparison between immersive VR and flattened video participants within the intervention arm, limiting assessment of modality-specific effects. The proportion of patients selecting flattened video viewing also suggests that patient comfort and familiarity with immersive technologies may substantially influence implementation and scalability. Additionally, provider turnover during this study period may have introduced variability in patient experience, potentially influencing patient-reported outcomes. Similarly, this study included patients enrolled by six physicians and physician assistants, each with distinct consultation and education styles; therefore, education delivered within the SOC arm was not fully standardized. Fourth, patient-reported outcomes were assessed using study-specific Likert-scale survey items rather than previously validated domain-specific instruments. While these measures provided preliminary insights into patient perceptions of understanding, anxiety, and satisfaction, future studies should incorporate validated instruments to improve measurement consistency and comparability. Fifth, as with most patient education interventions, participants may have accessed additional educational resources outside of the study intervention. The amount and type of outside information reviewed before or during treatment were not controlled or quantified and may have influenced patient-reported outcomes. Finally, workflow metrics evaluated in this study represent surrogate indicators of treatment efficiency rather than direct measures of treatment compliance.

Despite these limitations, this study demonstrates the feasibility of implementing immersive educational interventions within routine radiation oncology workflows. Feasibility was assessed descriptively through successful patient enrollment and completion of the intervention, integration of the intervention into standard clinical workflows, development and deployment of treatment-specific educational content, accommodation of multiple educational delivery modalities, and expansion of the program to additional clinical sites within the organization.

Future studies should evaluate these interventions in larger and more heterogeneous patient populations while further assessing the relative impact of immersive versus standard video educational delivery. Additionally, formal evaluation of educational content quality using validated assessment tools, such as the Patient Education Materials Assessment Tool (PEMAT), to further characterize the understandability and actionability of IPEP educational materials should be performed. Implementation of IPEPs requires consideration of cost and scalability. The hardware used for this study, including VR headsets and supporting tablet devices, cost approximately $2,000 per educational station, excluding filming equipment and personnel time required for content development and workflow integration.

To improve scalability and accessibility, the intervention was intentionally designed to support both immersive VR and flattened video-based delivery modalities. A substantial proportion of patients selected flattened video viewing rather than full immersive VR, suggesting that flexible delivery approaches may improve implementation feasibility while reducing barriers related to patient comfort, familiarity with technology, and potential cybersickness concerns. The educational materials developed during this study have since been expanded for use across additional clinical sites within the organization. Future implementation efforts will focus on broader electronic distribution through patient portal platforms to improve accessibility for patients and caregivers outside the clinic setting.