The Effect of Using Engaging Distraction via Virtual Reality on Stress and Anxiety among Patients with Cancer Undergoing Chemotherapy in Palestine: A Randomized Controlled Trial

Abstract

Background

Virtual reality (VR) is increasingly recognized as a valuable adjunct in cancer supportive care, but evidence for its efficacy in reducing psychological distress during chemotherapy in Middle Eastern settings remains limited.

Objectives

To evaluate the effectiveness of immersive virtual reality as an engaging distraction on stress and anxiety among cancer patients during chemotherapy in Palestine.

Methods

Between June and September 2023, 150 cancer patients were randomly assigned to an intervention group (n = 75) receiving VR during chemotherapy or a control group (n = 75) receiving standard care. Outcomes were measured using the Generalized Anxiety Disorder scale (GAD-7) and Perceived Stress Scale (PSS-10) before and after intervention.

Results

Postintervention analysis revealed potential benefits with significantly lower stress levels in the experimental group (M = 17.7 ± 2.8) compared to controls (M = 19.2 ± 2.5; mean difference: 1.5 points, 95% CI 0.6, 2.4, p < .05, Cohen's d = 0.58, 95% CI 0.25, 0.91). Mean GAD-7 scores were significantly lower in the VR group (M = 6.2 ± 3.1) versus controls (M = 10.8 ± 4.2; mean difference: 4.6 points, 95% CI 3.3, 5.9, p < .001). 54.7% of VR participants (n = 41) achieved minimal anxiety compared to 26.7% of controls (n = 20) (Risk Ratio=2.05, 95% CI 1.35, 3.12). Effect sizes were moderate to large for both outcomes. The observed stress reduction of 1.5 points exceeds the established minimal clinically important difference (MCID) of approximately 1.0–1.5 points for the PSS-10, while the anxiety reduction of 4.6 points meets the MCID threshold of 4 points for the GAD-7.

Conclusion

Engaging distraction via virtual reality demonstrates potential benefit in reducing stress and anxiety among cancer patients during chemotherapy. However, this study design cannot isolate VR-specific immersive effects from general distraction. Future research with active control conditions is needed to establish VR's unique value proposition.

Keywords

anxiety cancer chemotherapy stress virtual reality supportive care Palestine

Introduction

Cancer represents one of the most significant global health challenges, with projections indicating it will become the leading cause of mortality worldwide by the end of the twenty-first century (Bray et al., 2021). According to GLOBOCAN 2020 data, there were an estimated 19.3 million new cancer cases worldwide, with projections suggesting this number could increase by 47% to 28.4 million cases by 2040 (Sung et al., 2021). In the West Bank, Palestine, cancer constitutes a major public health burden, with particularly high rates of lung, breast, and colon cancers (Salem, 2023). Among Palestinian men, lung cancer accounts for 22.8% of cancer-related deaths, while breast cancer represents 21.5% of cancer mortality in women (Abu-Rmeileh et al., 2016).

The cancer experience profoundly impacts patients’ psychological well-being, with many experiencing elevated stress, anxiety, and diminished quality of life (Rhoten et al., 2013; Taghian et al., 2014). The physical and emotional distress associated with cancer diagnosis and treatment can significantly impair patient outcomes and overall functioning (Lewandowska et al., 2020; Linden et al., 2012). Cancer patients commonly report multiple stressors throughout their disease trajectory, with chronic stress potentially impeding healing processes and contributing to poor prognostic outcomes (Antoni et al., 2023; Da Costa et al., 2023). Anxiety, prevalent among oncology populations, has been directly linked to increased mortality risk and reduced treatment adherence (Alagizy et al., 2020).

Review of Literature and Objectives

Chemotherapy administration presents particular challenges for psychological well-being. The clinical environment, combined with treatment-related side effects and uncertainty about outcomes, frequently exacerbates anxiety and stress responses (Gustafson, 2017; Mausbach et al., 2020). These psychological symptoms can negatively impact patients’ ability to cope with treatment and may compromise therapeutic outcomes (Lee et al., 2021).

In response to these challenges, healthcare providers are increasingly incorporating nonpharmacological interventions to address psychological distress in cancer care (Chirico et al., 2020; Tian et al., 2020). Virtual reality (VR) technology has emerged as a promising therapeutic tool, offering immersive, interactive experiences that can provide distraction and relaxation during medical procedures (Kim & Kim, 2020; Pensieri & Pennacchini, 2016). Recent systematic reviews demonstrate VR's efficacy in reducing pain, anxiety, and distress across various medical populations (Roche et al., n.d.; Scates et al., 2020).

Several high-quality studies have specifically examined VR interventions in adult cancer populations. A randomized controlled trial by Chirico et al. (2020) demonstrated significant reductions in anxiety and mood disturbances among breast cancer patients receiving chemotherapy. Similarly, Zeng et al.'s (2019) meta-analysis of VR interventions in cancer care showed consistent benefits for psychological outcomes, with effect sizes ranging from d = 0.3 to d = 0.8 across different outcome measures, though the analysis noted considerable heterogeneity (I² = 68%, p < .01). More recently, Reynolds et al. (2022) reported that immersive VR experiences significantly reduced chemotherapy-related distress and improved treatment satisfaction among adult cancer patients. A recent comprehensive systematic review by Fereidooni et al. (2024) synthesized evidence from multiple RCTs examining VR in cancer supportive care, documenting pooled effect sizes of d = 0.45–0.75 for anxiety reduction across various cancer populations and treatment contexts.

While this existing literature establishes VR's general efficacy, it originates predominantly from Western, high-income healthcare settings. The present study advances this evidence base by examining VR efficacy within the unique socio-cultural and healthcare context of Palestine, a Middle Eastern setting where such interventions have not been previously studied. The current investigation provides novel evidence on several fronts: (a) feasibility and acceptability of VR implementation within the Palestinian healthcare system, characterized by distinct challenges including limited mental health infrastructure, resource constraints, and restricted access to specialized psychological support services; (b) cultural considerations regarding technology acceptance in a traditional Middle Eastern context where digital health interventions remain uncommon; (c) implementation insights specific to resource-limited settings, including equipment durability, hygiene protocols, training requirements, and infrastructure needs; and (d) replication of VR's psychological benefits in a previously unstudied geographic and cultural context, strengthening the external validity of the broader VR literature. The healthcare challenges in Palestine, including resource constraints and limited access to specialized psychological support services, make potentially scalable, low-resource interventions particularly valuable (Massad et al., 2016). Furthermore, the COVID-19 pandemic has underscored the value of digital health interventions, including VR and telemedicine, in maintaining continuity of supportive care when in-person psychological services are disrupted or unavailable (Joudeh et al., 2020).

This randomized controlled trial aimed to evaluate the effectiveness of immersive virtual reality as an engaging distraction intervention on stress and anxiety levels among cancer patients undergoing chemotherapy in West Bank hospitals. It was hypothesized that patients receiving VR intervention would demonstrate significantly lower post-treatment stress and anxiety scores compared to those receiving standard care alone. However, due to the absence of an active control group, this study cannot definitively isolate whether observed effects are attributable to VR's specific immersive properties or to general distraction and attention effects inherent in receiving any engaging intervention.

Methods

Study Design

This study employed a randomized controlled trial design with pretest–posttest assessments. The protocol was registered with ClinicalTrials.gov (Trial ID: NCT07152938) prior to participant enrollment.

Protocol Adherence

This study was conducted based on a protocol approved by an Institutional Review Board (IRB No. 2023/A/99/N) (see S1 Protocol). The following modifications were made to the original protocol during trial implementation:

Outcome Measures: The primary outcomes were refined from the originally planned four (pain, stress, anxiety, and self-efficacy) to two: stress and anxiety. These modifications were made prior to participant enrollment and received IRB approval on May 15, 2023. In the original protocol, pain and self-efficacy were listed as co-primary outcomes alongside stress and anxiety. This decision was made to streamline data collection and focus the analysis on the most prominent psychological challenges faced by patients during chemotherapy sessions. Consequently, data on pain and self-efficacy were not collected.

Measurement Tool for Anxiety: The anxiety measure was changed from the State-Trait Anxiety Inventory (STAI) to the Generalized Anxiety Disorder scale (GAD-7). This modification was also implemented prior to participant enrollment and approved by the IRB. The GAD-7 was selected for its brevity, strong validation in medical populations, and specific focus on the symptoms of generalized anxiety disorder, which were deemed highly relevant to the chemotherapy context. While this change limits direct comparability with some previous VR studies in oncology that utilized the STAI (e.g., Chirico et al., 2020), the GAD-7 offers improved clinical utility for rapid screening in oncology settings and has demonstrated excellent psychometric properties in cancer populations.

All other procedures were carried out as per the approved protocol.

Setting and Participants

The study was conducted across three major governmental oncology centers in northern Palestine between June and September 2023. These referral hospitals serve the northern West Bank district and maintain specialized “daycare clinics” with dedicated oncology teams and pharmacies separate from main hospital services. Chemotherapy sessions in these facilities typically last 60–180 min and include venous cannulation, pre-medication administration, drug infusion, and line flushing procedures.

Sample Size Calculation

Sample size was calculated using G*Power 3.1.9.2 software, with power set at 0.80, alpha at .05, and medium effect size of 0.5. Based on independent t-test parameters, the required sample was 128 participants. To account for potential attrition, 150 participants were recruited (75 per group).

A total of 167 cancer patients were initially assessed for eligibility. Of these, 17 were excluded: 12 did not meet inclusion criteria and five declined to participate. The remaining 150 participants were randomized equally into two groups of 75 each. All participants in the intervention group received the allocated VR intervention, while all control group participants received standard care as allocated. No participants were lost to follow-up, discontinued their assigned intervention, or were excluded from analysis. Complete data were available for all 150 participants (75 interventions, 75 controls) for the final analysis (see Figure S1).

Inclusion and Exclusion Criteria

Inclusion criteria: Adult cancer patients (≥18 years) scheduled for chemotherapy who could provide informed consent in Arabic.

Exclusion criteria: History of VR-induced motion sickness, physical limitations preventing headset use, severe visual/auditory/vestibular impairments, uncontrolled medical conditions (severe nausea, vomiting, respiratory depression), cognitive impairments, or diagnosed psychiatric disorders requiring active treatment.

Randomization and Blinding

Participants were randomized using computer-generated randomization sequences with 1:1 allocation. The allocation sequence was implemented by a research nurse who was blinded to the study's hypotheses and group assignments. Due to the nature of the VR intervention, participants and the researchers administering the intervention could not be blinded. However, to minimize detection bias, research assistants responsible for collecting outcome data were trained using standardized scripts for questionnaire administration. All questionnaires were self-administered by participants, with research assistants available only to clarify questions without influencing responses.

Virtual Reality Intervention

Hardware Specifications

The intervention utilized Meta Quest 2 headsets (Model: KW49CM, 128 GB version), selected for their clinical suitability. Each device featured a resolution of 1,832 × 1,920 pixels per eye, a refresh rate of 90 Hz, and a field of view of approximately 90°. With a weight of 503 g, the headsets were lightweight enough to ensure comfort during use. In addition, their wireless operation allowed unrestricted movement, making them particularly suitable for patients undergoing chemotherapy.

Software and Content

VR experiences were delivered through selected applications from the Meta Quest store. The specific applications used were: Nature Treks VR (Version 1.5.2), which offered interactive natural environments such as forests, mountains, and beaches; Guided Meditation VR (version 2.1.0), providing 360° meditation experiences in tranquil settings with voiceover guidance in English (translated by research staff for Arabic-speaking participants); and Ocean Rift (Version 3.0.4), enabling underwater exploration with marine life encounters. These applications were selected based on: (a) evidence from previous studies showing nature-based and meditative content effectively reduces anxiety (Scates et al., 2020); (b) minimal cognitive load requirements suitable for patients during treatment; and (c) compatibility with wireless VR delivery in clinical settings. The content primarily consisted of 360° immersive videos and photospheres that allowed free head movement and basic hand controller interactions. To minimize cognitive load during treatment, no gamification elements or complex tasks were included.

Intervention Protocol

Each VR session lasted for the entire chemotherapy infusion period, with an average duration of 90 ± 25 min (range: 60–180 min). The intervention began immediately after intravenous cannula insertion and pre-medication administration and continued until chemotherapy completion. All participants received a standardized 5-min training session that covered headset adjustment and comfort optimization, controller use for menu navigation, available content selection, and safety procedures, including methods for communicating with staff. The training protocol was standardized across all participants and delivered by trained research nurses using a structured checklist to ensure consistency. Patients were then able to select their preferred environments from the available VR applications and could switch between experiences during treatment. While initial content selection was tracked, detailed usage patterns (e.g., frequency of environment switches, time spent in each environment) were not systematically recorded, which represents a limitation for understanding optimal content preferences. To ensure safety and hygiene, disposable VR face mask covers were provided for each session and replaced between patients, while headset surfaces were disinfected with 70% isopropyl alcohol wipes in accordance with institutional infection control protocols. Throughout the study period, no adverse events related to VR use were reported, including no instances of motion sickness, disorientation, visual discomfort, or other VR-related side effects. All participants tolerated the intervention well and completed their assigned VR sessions without complications.

Control Group Protocol

Control group participants received standard oncology care during chemotherapy sessions without VR intervention. Standard care included: (a) vital signs monitoring every 30 min; (b) access to nursing staff for symptom management and comfort measures; (c) provision of basic comfort amenities (pillows, blankets, adjustable chairs); and (d) routine pre-medication protocols as per institutional guidelines. Importantly, no structured psychological interventions, entertainment media (television, tablets), or active distraction techniques were provided during infusion to maintain a true standard care comparison. This design represents a critical limitation affecting internal validity, as it does not control for the attention and novelty effects inherent in receiving any engaging intervention (Hawthorne effect). The experimental group received a novel, immersive VR experience, while the control group received no comparable engaging activity. Therefore, it is possible that the observed effects are partly or entirely attributable to the provision of any engaging distraction rather than the specific immersive properties of VR. A more rigorous design would have employed an active control group (e.g., participants watching relaxing 2D videos on a tablet or listening to guided audio) to isolate VR's unique contributions. This fundamental limitation should be considered when interpreting all results.

Outcome Measures

Demographic and Clinical Data

A structured questionnaire collected age, gender, residence area, marital status, education level, employment status, cancer type, treatment stage, and number of previous chemotherapy sessions (see S2 File for complete questionnaire).

Perceived Stress Scale (PSS-10)

The PSS-10 assesses perceived stress over the previous month using 10 items rated on a 5-point Likert scale (0 = never to 4 = very often) (Cohen et al., 1983). Total scores range from 0 to 40, with higher scores indicating greater perceived stress. The Arabic version of the PSS-10 was used in this study (translated and validated by Chaaya et al., 2010) and demonstrates strong psychometric properties with Cronbach's alpha of .87 in cancer populations (Soria-Reyes et al., 2023). In the current study, the PSS-10 demonstrated excellent internal consistency (Cronbach's α = .89 at baseline). The Arabic PSS-10 has been previously validated in Middle Eastern populations, including cancer patients, showing good construct validity and test-retest reliability (r = .84) (Chaaya et al., 2010; see S3 File for the complete PSS-10 questionnaire).

Generalized Anxiety Disorder Scale (GAD-7)

The GAD-7 measures anxiety symptoms over the past two weeks using seven items rated from 0 to 3 (Kroenke et al., 2007). Total scores of 5, 10, and 15 represent cut-points for mild, moderate, and severe anxiety, respectively. The scale shows excellent reliability (Cronbach's α = .92) in oncology settings (Akkus et al., 2022). The Arabic version of the GAD-7 was used in this study (validated by AlHadi et al., 2017) and demonstrated excellent internal consistency in the current sample (Cronbach's α = .91 at baseline). The Arabic GAD-7 has been validated in clinical populations in the Middle East, showing strong convergent validity with other anxiety measures (r = .72 with Hospital Anxiety and Depression Scale) and good sensitivity (89%) and specificity (82%) for detecting anxiety disorders (AlHadi et al., 2017). The scale has been specifically validated for use with Palestinian populations in previous studies (see S4 File for the complete GAD-7 questionnaire).

Data Collection Procedure

Data collection occurred in two phases to prevent cross-contamination:

Phase 1 (Control Group): Participants completed baseline assessments before standard chemotherapy sessions, with post-treatment assessments immediately following treatment completion.

Phase 2 (Intervention Group): Following the same assessment schedule, participants received VR intervention throughout their chemotherapy sessions.

All questionnaires were administered by trained research assistants in private areas within the chemotherapy units. Participants received no financial compensation for participation, and the VR intervention was provided at no cost to participants or the healthcare facilities.

Statistical Analysis

Data analysis was performed using SPSS version 23.0. Statistical significance was set at p ≤ .05. Descriptive statistics (frequencies, percentages, means, standard deviations) summarized participant characteristics. Data normality was assessed using Shapiro-Wilk tests and visual inspection of histograms.

For continuous outcomes, Analysis of Covariance (ANCOVA) was conducted to compare postintervention stress and anxiety scores between groups, adjusting for baseline scores and demographic variables showing imbalance at baseline (marital status, residence). The ANCOVA models included postintervention outcome scores as the dependent variable, group assignment (VR vs. control) as the fixed factor, and baseline outcome scores, marital status, and residence as covariates. Model assumptions including homogeneity of variance and normality of residuals were verified prior to analysis. Independent samples t-tests were also performed for unadjusted comparisons. Mean differences with 95% confidence intervals (CIs) were calculated for all continuous outcomes. Chi-square tests examined categorical anxiety level distributions between groups. Risk ratios (RR) with 95% CIs were calculated for achieving minimal anxiety status.

Effect sizes were calculated using Cohen's d for continuous variables (with 95% CIs calculated using the noncentral t-distribution method) and Cramer's V for categorical comparisons (with 95% CIs estimated using bootstrap methods with 1,000 iterations). Number needed to treat (NNT) with 95% CIs was calculated for the outcome of achieving minimal anxiety.

Ethical Considerations

The study received ethical approval from an Institutional Review Board (IRB No. 2023/A/99/N). All procedures followed Declaration of Helsinki principles. Written informed consent was obtained from all participants, with emphasis on voluntary participation and right to withdraw without affecting care. Participant confidentiality was maintained through unique identification numbers, with data stored securely and accessible only to research team members.

Results

Participant Characteristics

The final sample comprised 150 participants (75 per group) with similar baseline demographic characteristics. The majority were female (intervention: 76.0%; control: 72.0%) and aged 40–60 years (intervention: 68.0%; control: 64.0%). Most participants had high school education or less (54.7% intervention, 68.0% control) and were married (56.0% intervention, 74.7% control). Baseline characteristics were well-balanced between groups, with marital status showing a trend toward difference (χ² = 7.492) and residence showing marginal imbalance (χ² = 7.596) that did not reach statistical significance. These variables were included as covariates in ANCOVA analyses (Table 1).

Table 1.

Baseline Demographic Characteristics of Participants (N = 150).

Variable	Category	Control group, n (%)	Intervention group, n (%)	χ²
Gender	Male	18 (24.0)	21 (28.0)	0.312
Gender	Female	57 (76.0)	54 (72.0)
Age	<40 years	14 (18.7)	15 (20.0)	0.307
	40–60 years	51 (68.0)	48 (64.0)
	>60 years	10 (13.3)	12 (16.0)
Education	High school or less	41 (54.7)	51 (68.0)	2.948
	Diploma/bachelor	27 (36.0)	20 (26.7)
	Postgraduate	7 (9.3)	4 (5.3)
Marital status	Married	42 (56.0)	56 (74.7)	7.492
	Single	20 (26.7)	15 (20.0)
	Divorced	6 (8.0)	2 (2.7)
	Widowed	7 (9.3)	2 (2.7)
Residence	City	21 (28.0)	22 (29.3)	7.596
	Village	32 (42.7)	36 (48.0)
	Camp	13 (17.3)	3 (4.0)
	Town	9 (12.0)	14 (18.7)
Employment	Employed	21 (28.0)	22 (29.3)	0.033
Employment	Unemployed	54 (72.0)	53 (70.7)

Note. Following CONSORT 2010 guidelines, p-values for baseline comparisons are not reported as any differences are by definition due to chance in a properly randomized trial. The focus is on the magnitude of imbalances rather than statistical significance. Variables showing notable imbalance (marital status and residence) were included as covariates in adjusted analyses (ANCOVA).

Clinical Characteristics

Breast cancer was the predominant diagnosis in both groups (70.7% intervention, 76.0% control), followed by colon cancer (29.3% intervention, 24.0% control). Most participants were receiving their first or second chemotherapy cycle, with no significant between-group differences in cancer type, treatment stage, or session number (Table 2).

Table 2.

Clinical Characteristics of Participants (N = 150).

Variable	Category	Control group, n (%)	Intervention group, n (%)	χ²
Cancer type	Colon	18 (24.0)	22 (29.3)	0.545
Cancer type	Breast	57 (76.0)	53 (70.7)
Chemotherapy session	Session 1	32 (42.7)	32 (42.7)	0.156
	Session 2	39 (52.0)	40 (53.3)
	Session 3	4 (5.3)	3 (4.0)
Chronic disease	Yes	24 (32.0)	33 (44.0)	2.292
Chronic disease	No	51 (68.0)	42 (56.0)
Cancer stage	First	42 (56.0)	32 (42.7)	2.794
	Second	32 (42.7)	41 (54.7)
	Third	1 (1.3)	2 (2.7)

Baseline Outcome Measures

Pre-intervention assessments showed no significant differences between groups for stress levels (PSS-10: intervention M = 19.6 ± 3.9, control M = 19.9 ± 4.2; mean difference: −0.3 points, 95% CI −1.8, 1.2, t = 0.443, p = .659) or anxiety distributions (χ² = 0.040, p = .998), confirming successful randomization (Table 3).

Table 3.

Baseline Outcome Measures (N = 150).

Outcome	Control group	Intervention group	Test statistic	95% CI	p-value
PSS-10 Score, M (SD)	19.9 (4.2)	19.6 (3.9)	t = 0.443	[−1.8, 1.2]	.659
GAD-7 Score, M (SD)	11.2 (4.5)	11.0 (4.3)	t = 0.274	[−1.6, 1.2]	.785
GAD-7 categories, n (%)			χ² = 0.040		.998
Minimal anxiety	14 (18.7)	14 (18.7)
Mild anxiety	24 (32.0)	25 (33.3)
Moderate anxiety	26 (34.7)	25 (33.3)
Severe anxiety	11 (14.7)	11 (14.7)

Primary Outcomes

Stress Reduction

Postintervention analysis revealed significantly lower stress scores in the VR group (M = 17.7 ± 2.8) compared to controls (M = 19.2 ± 2.5; mean difference: 1.5 points, 95% CI 0.6, 2.4, t = 3.371, p = .001, Cohen's d = 0.58, 95% CI 0.25, 0.91). After adjusting for baseline PSS-10 scores, marital status, and residence using ANCOVA, the group difference remained significant, F(1, 146) = 15.2, p < .001, partial η² = 0.094, with adjusted mean difference of 1.4 points (95% CI 0.5, 2.3) and adjusted means of 17.8 (SE = 0.3) for the VR group versus 19.2 (SE = 0.3) for the control group. This represents a moderate to large effect size, with the intervention group showing a mean reduction of 1.9 points from baseline compared to 0.7 points in the control group. The mean reduction of 1.5 points on the PSS-10 (scale 0–40) represents a clinically meaningful improvement. The observed change exceeds the established Minimal Clinically Important Difference (MCID) of approximately 1.0–1.5 points for the PSS-10 in cancer populations (Soria-Reyes et al., 2023), confirming that the statistical significance translates to clinically meaningful benefits for patients.

Anxiety Improvement

Mean GAD-7 scores were significantly lower in the VR group (M = 6.2 ± 3.1) compared to controls (M = 10.8 ± 4.2; mean difference: 4.6 points, 95% CI 3.3, 5.9, t = 7.85, p < .001, Cohen's d = 1.28, 95% CI 0.92, 1.64). After adjusting for baseline GAD-7 scores, marital status, and residence using ANCOVA, the group difference remained highly significant, F(1, 146) = 42.8, p < .001, partial η² = 0.226, with adjusted mean difference of 4.4 points (95% CI 3.2, 5.6) and adjusted means of 6.4 (SE = 0.4) for the VR group versus 10.8 (SE = 0.4) for the control group. This represents a large effect size and exceeds the established MCID of approximately 4 points for the GAD-7 in medical populations (Toussaint et al., 2020), indicating that the observed reductions represent clinically meaningful improvements in patient-reported anxiety symptoms.

Significant between-group differences were observed in post-treatment anxiety level distributions (χ² = 36.3, p = .001, Cramer's V = 0.49, 95% CI 0.35, 0.60). In the intervention group, 54.7% (n = 41) achieved minimal anxiety levels compared to 26.7% (n = 20) in the control group. Patients in the VR group were twice as likely to achieve minimal anxiety compared to controls (RR = 2.05, 95% CI 1.35, 3.12, p < .001). Conversely, severe anxiety was present in only 2.7% (n = 2) of VR participants versus 18.7% (n = 14) of controls (Table 4).

Table 4.

Postintervention Outcomes Comparison (N = 150).

Outcome	Control group	Intervention group	Test statistic	95% CI	p-value
PSS-10 Score M (SD)	19.2 (2.5)	17.7 (2.8)	t = 3.371	[0.6, 2.4]	.001**
Cohen's d			0.58	[0.25, 0.91]
GAD-7 Score M (SD)	10.8 (4.2)	6.2 (3.1)	t = 7.85	[3.3, 5.9]	<.001*
Cohen's d			1.28	[0.92, 1.64]
GAD-7 categories n (%)			χ² = 36.3		.001**
Minimal anxiety	20 (26.7)	41 (54.7)	RR = 2.05	[1.35, 3.12]
Mild anxiety	15 (20.0)	28 (37.3)
Moderate anxiety	26 (34.7)	4 (5.3)
Severe anxiety	14 (18.7)	2 (2.7)
Cramer's V			0.49	[0.35, 0.60]

*p < .01; *p ≤ .05.

Secondary Analyses

Effect size calculations demonstrated clinically meaningful improvements in both primary outcomes. The number needed to treat (NNT) for achieving minimal anxiety was four patients (95% CI 2.5, 7.1), indicating that for every four patients receiving VR intervention, one additional patient would achieve minimal anxiety compared to standard care alone.

Discussion

Principal Findings

This randomized controlled trial demonstrates that engaging distraction delivered via immersive virtual reality shows potential benefit in significantly reducing stress and anxiety among cancer patients during chemotherapy sessions. The intervention produced moderate to large effect sizes for both primary outcomes, with over half of VR participants achieving minimal anxiety levels compared to approximately one-quarter of control participants. The observed effects remained significant after controlling for baseline imbalances and represent clinically meaningful improvements that exceed established thresholds for minimal clinically important differences. However, the absence of an active control group means these findings demonstrate the benefits of providing engaging distraction during chemotherapy rather than establishing VR-specific effects attributable to immersion or presence.

Comparison with Existing Literature

The findings align with recent high-quality evidence supporting VR interventions in cancer care. The stress reduction observed (Cohen's d = 0.58, 95% CI 0.25, 0.91) is consistent with Chirico et al.'s (2020) findings among breast cancer patients (d = 0.61, 95% CI 0.40, 0.82), with the present study's effect size falling within their reported confidence interval, suggesting replicability across different settings. The observed anxiety improvements (d = 1.28) fall within the range reported in Zeng et al.'s (2019) meta-analysis of VR oncology interventions (effect sizes ranging from d = 0.3 to d = 0.8 across different outcome measures), with the present findings (d = 1.28) exceeding the median estimate, likely due to the use of GAD-7 which may be more sensitive to anxiety changes during acute treatment contexts compared to broader measures used in other studies. Similarly, a recent systematic review by Yazdani et al. (2022) found comparable effect sizes for VR-mediated anxiety reduction during medical procedures. The recent comprehensive systematic review by Fereidooni et al. (2024) synthesized evidence from multiple RCTs examining VR in cancer supportive care, documenting pooled effect sizes of d = 0.45–0.75 for anxiety reduction across various cancer populations and treatment contexts. The observed effect (d = 1.28) exceeds these pooled estimates, which may reflect differences in outcome measures (GAD-7 versus broader anxiety instruments), intervention duration (continuous use throughout chemotherapy sessions versus shorter exposures), or population characteristics. This alignment with established literature strengthens confidence in VR's potential as a distraction-based intervention while the larger effect size suggests potential advantages of prolonged, patient-controlled VR experiences during extended treatment sessions.

The magnitude of the observed effects compares favorably with other nonpharmacological interventions. Music therapy interventions in cancer care typically produce small to moderate effect sizes (d = 0.3–0.4) (Bradt et al., 2021), while the present VR intervention achieved larger effects with minimal training requirements and no ongoing therapist involvement.

Contextualizing VR Within Digital Health and Telemedicine

To better situate the role of VR during global health crises, it is important to consider it within the broader spectrum of digital health interventions (Fereidooni et al., 2024), particularly in relation to telemedicine for chronic disease management. The COVID-19 pandemic accelerated the adoption of digital tools to maintain continuity of care, highlighting their value when in-person services are disrupted (Joudeh et al., 2020). While telemedicine platforms have proven effective for remote consultation and monitoring in chronic conditions like cardiovascular disease (Asadi et al., 2024) and cancer (Toni & Ayatollahi, 2024), they primarily facilitate clinician–patient communication and data exchange. VR, as explored in this study, represents a distinct, patient-facing modality within this digital ecosystem. It functions not as a communication channel, but as a direct, immersive therapeutic intervention deployed at the point of care to manage procedure-related distress. This distinction is crucial: telemedicine expands access to supportive care, while VR can enhance the experience and tolerability of the care itself. In resource-limited or crisis settings like Palestine, where access to specialist psychological support is constrained, VR offers a scalable way to deliver immediate, nonpharmacological symptom relief during treatments like chemotherapy, complementing broader telemedicine strategies for holistic chronic disease management. Future integration could see VR prescribed remotely via telemedicine platforms and its use monitored digitally, creating a synergistic model for comprehensive supportive cancer care.

Regional and Clinical Significance

These findings carry particular importance for healthcare systems in the Middle East and similar resource-conscious settings. Palestine's healthcare challenges, including limited mental health resources and economic constraints, make potentially scalable interventions especially valuable (Massad et al., 2016). VR technology offers several advantages in this context: one-time equipment costs, minimal staff training requirements, and independence from specialized psychological services. However, it is important to note that this study did not include formal economic evaluation or cost-effectiveness analysis. Claims regarding cost-effectiveness require rigorous health economic evaluation comparing VR implementation costs (including equipment acquisition, staff training, maintenance, hygiene supplies, internet infrastructure, and device replacement cycles) against both clinical benefits and alternative interventions. Without such formal cost-effectiveness analyses, definitive statements about economic value cannot be made. Future research should include comprehensive economic evaluations using established frameworks to inform evidence-based implementation decisions.

Considerations for Clinical Implementation

The authors’ experience provides practical insights for hospitals considering VR program implementation. The wireless capability of modern VR headsets proved essential for integration with chemotherapy protocols, allowing unrestricted patient movement during treatment. High-resolution displays and immersive audio enhanced the distraction effect, likely contributing to the observed psychological benefits.

Several factors were identified as critical for successful implementation. Equipment durability: Consumer-grade Meta Quest 2 headsets demonstrated sufficient reliability for clinical use, with no device failures during the study period. However, long-term sustainability requires planning for device replacement on an estimated 3–5 year cycle. Hygiene protocols: The combination of disposable face covers and alcohol-based surface disinfection proved effective and efficient, adding approximately 2–3 min per patient setup time. Infection control compliance was maintained at 100% throughout the study. Staff training: A single 2-h training session enabled oncology nurses to competently manage the VR program, including device setup, patient instruction, troubleshooting, and hygiene protocols. No additional specialized IT support was required during routine operations. Patient selection: Simple screening questions effectively identified appropriate candidates, with exclusion rates under 10% of initially assessed patients. Infrastructure requirements: Stable broadband internet connectivity (minimum 5 Mbps) was necessary for content streaming, though offline content libraries are increasingly available and could reduce this barrier in settings with limited connectivity. Cost considerations: Initial equipment investment was approximately $400 per headset, with ongoing costs including replacement face covers ($0.50 per session), disinfection supplies ($0.25 per session), and potential software licensing fees ($5–15 per month for premium content). Based on the authors’ experience, a moderate-sized chemotherapy unit treating 20–30 patients daily would require 3–4 headsets to ensure availability while allowing for hygiene procedures and device charging between sessions, representing a total initial investment of approximately $1,600–2,000. However, comprehensive cost-effectiveness analysis requires evaluation of these implementation costs against clinical benefits, potential reductions in anxiolytic medication use, improved treatment adherence, and patient-reported quality of life improvements, analyses that were beyond the scope of the current study but are essential for informed implementation decisions.

Mechanisms of Action

The observed benefits likely result from multiple complementary mechanisms. However, it is important to emphasize that the current study design does not allow the authors to isolate the specific mechanisms responsible for the observed effects. The improvements may result from VR's immersive properties, or they may simply reflect the benefits of providing any engaging, distracting activity during treatment (attention/novelty effect). Without an active control group (e.g., 2D video or audio relaxation), the authors cannot definitively attribute the effects to VR's unique immersive qualities rather than general distraction or the Hawthorne effect of receiving special attention. Therefore, while previous literature suggests potential mechanisms such as attention redirection, sense of presence, and restoration of perceived control, this study cannot confirm these as the active components of the intervention.

Strengths and Limitations

This study's strengths include its randomized controlled design, adequate sample size based on formal power calculations, validated outcome measures with confirmed psychometric properties in the target population, and novel examination of VR efficacy in an under-researched region. The use of ANCOVA to control for baseline imbalances strengthens the validity of the findings, and the reporting of confidence intervals for all effect estimates enhances precision and comparability with other studies. The use of standardized protocols and training procedures enhances reproducibility. The absence of adverse events or participant withdrawals demonstrates the intervention's safety and acceptability in this clinical population.

Several limitations must be acknowledged. The most significant methodological limitation is the absence of an active control group. The experimental group received a novel, engaging VR experience, while the control group received standard care with no comparable engaging activity. This design does not control for the Hawthorne effect (attention bias), whereby the act of receiving any intervention, rather than the intervention's specific properties, may produce effects. Without an active control condition (e.g., watching relaxing 2D videos on a tablet, listening to guided audio, or reading materials), it is impossible to conclude definitively that the observed effects are attributable to VR's immersive properties rather than simply providing patients with distraction and engagement. This represents a critical limitation that affects the internal validity of the study, and future research should employ active control conditions to isolate VR's unique contributions.

The sequential data collection approach (control group in Phase 1: June-July, intervention group in Phase 2: August-September) was implemented to prevent cross-contamination between groups. However, this introduces potential for temporal confounding if patient characteristics, staffing patterns, or external factors (e.g., seasonal variations in hospital operations, staff experience levels, external political/security events) differed systematically between the two time periods. Although baseline demographic and clinical characteristics were balanced between groups, unmeasured temporal factors could have influenced results. Baseline demographic balance does not rule out unmeasured temporal factors. Future multi-center RCTs should employ concurrent enrollment with individual-level randomization to eliminate this potential source of bias.

Both primary outcome measures (GAD-7, PSS-10) rely on self-report, which is subject to social desirability bias (participants may report lower anxiety/stress to meet perceived expectations) and recall bias. VR participants may have been more likely to report improvements due to novelty effects or gratitude for receiving special attention. The lack of blinding of outcome assessors, while partially mitigated by standardized administration scripts and self-completed questionnaires, may have inadvertently influenced participant responses. Future studies should include objective physiological measures (e.g., salivary cortisol, heart rate variability, blood pressure) alongside self-report instruments to strengthen validity and reduce potential bias. Recent systematic reviews examining VR interventions in oncology have similarly emphasized the importance of integrating objective physiological measures alongside patient-reported outcomes to strengthen validity and reduce measurement bias.

The study was conducted in a single geographic region, potentially limiting generalizability to other cultural contexts. The sample was predominantly female (74%), included only breast and colon cancer patients (100%), and consisted primarily of patients in their first two chemotherapy cycles (95%). These characteristics limit generalizability to male patients, other cancer types (e.g., hematological malignancies, lung cancer), and patients in later treatment stages who may have different baseline psychological states or treatment tolerances. Future research should examine VR efficacy across diverse cancer types, treatment phases, and demographic subgroups.

While patients could choose VR content and switch between experiences during treatment, detailed data on actual usage patterns (e.g., time spent in each environment, frequency of switches, which content types were preferred) were not systematically collected. This limits the authors’ understanding of which specific VR content characteristics are most effective for anxiety and stress reduction. Logging interaction data in future studies would inform content optimization and enable more personalized VR interventions tailored to individual preferences.

The requirement for stable internet connectivity (5G/broadband) for content streaming may limit scalability in resource-limited settings, though offline content options are increasingly available. Follow-up assessments were conducted immediately post-treatment, precluding evaluation of longer-term effects and whether the psychological benefits persist beyond the immediate treatment session or accumulate over multiple chemotherapy cycles. Furthermore, a specific recommendation for future research should examine: (1) sustained benefits through longitudinal follow-up assessments across multiple chemotherapy cycles to determine whether VR's psychological benefits persist or accumulate over time; (2) optimal VR content types for different patient populations and treatment protocols, using systematic tracking of user preferences and interaction patterns; (3) cumulative effects across multiple chemotherapy sessions; (4) comparison with active control conditions (e.g., 2D relaxation videos, audio-guided meditation) to isolate VR-specific mechanisms from general distraction effects; (5) rigorous economic evaluations including formal cost-effectiveness and cost-utility analyses comparing VR with alternative supportive care interventions using established health economics frameworks; (6) implementation science studies addressing barriers and facilitators in resource-limited settings, including infrastructure requirements, training needs, and policy considerations; (7) personalization approaches using patient preference data and usage analytics to tailor VR experiences to individual characteristics; and (8) integration of objective physiological outcome measures (cortisol, heart rate variability) alongside self-report instruments to provide convergent validity for psychological benefits.

Implications and Future Directions

These findings suggest potential benefits for integrating VR technology into routine oncology supportive care protocols. The intervention's promising clinical outcomes and relatively modest initial equipment investment suggest potential value, though comprehensive economic evaluation including formal cost-effectiveness analysis is essential before recommending widespread adoption. Without rigorous health economic evaluation, claims about cost-effectiveness remain speculative.

Future research should investigate the optimal types of VR content suited to different patient populations and treatment protocols, as well as the long-term psychological and clinical outcomes associated with VR interventions. Economic evaluations, including formal cost-effectiveness analyses comparing VR implementation costs against clinical benefits and alternative interventions, are essential before recommending widespread adoption. In addition, further work should examine implementation strategies that address the challenges of resource-limited healthcare settings including policy and reimbursement frameworks, and explore personalization approaches that tailor VR experiences to individual patient preferences and characteristics. Future studies should also include active control conditions, objective physiological measures, and address the limitations of temporal confounding through concurrent enrollment designs.

Implications for Nursing Practice

This study has direct implications for oncology nursing practice. Nurses, as frontline providers during chemotherapy administration, are ideally positioned to implement and oversee VR distraction interventions. The findings suggest that with minimal training (a single 2-h session in this study), nurses can effectively manage VR setup, patient instruction, and safety protocols, integrating this tool into existing workflow. This empowers nurses to provide an immediate, nonpharmacological intervention for anxiety and stress, expanding their role in holistic patient care. Furthermore, by reducing visible patient distress, VR may decrease nursing time spent on reassurance and managing anxiety-related symptoms, potentially improving efficiency. Nurses can also play a key role in patient screening for suitability and in monitoring for comfort during VR use. Implementing such a nurse-led VR program could enhance patient satisfaction, contribute to a more positive treatment environment, and provide nurses with an effective, evidence-based tool to improve the psychological experience of chemotherapy.

Conclusion

This randomized controlled trial provides suggestive evidence that engaging distraction via virtual reality may offer potential benefit in reducing stress and anxiety among cancer patients during chemotherapy sessions. The intervention demonstrated moderate to large effect sizes that exceed established minimal clinically important differences with minimal implementation requirements, supporting its potential as a promising supportive care intervention that warrants further investigation with more rigorous control conditions and economic evaluation.

For healthcare providers, these findings suggest that VR technology may meaningfully enhance patient experience during cancer treatment with relatively modest initial investments in equipment and training, though comprehensive cost-effectiveness analyses are needed to establish true economic value relative to alternative interventions. For patients, VR offers a nonpharmacological approach to managing treatment-related distress that complements existing care protocols without interfering with medical procedures.

The success of this intervention in Palestine's healthcare context demonstrates VR's potential for global implementation, particularly in settings where traditional psychological support services may be limited. However, the lack of an active control group limits the authors’ ability to definitively attribute effects to VR's specific immersive properties versus general distraction or attention effects. Future studies employing active control conditions and comprehensive economic evaluations are needed to establish VR's unique value proposition and cost-effectiveness relative to alternative interventions. As VR technology continues advancing and costs decrease, its integration into routine cancer care represents a potentially viable strategy that requires economic evaluation for improving patient psychological well-being and quality of life throughout the treatment journey.

Supplemental Material

sj-docx-1-son-10.1177_23779608261418588 - Supplemental material for The Effect of Using Engaging Distraction via Virtual Reality on Stress and Anxiety among Patients with Cancer Undergoing Chemotherapy in Palestine: A Randomized Controlled Trial

Supplemental material, sj-docx-1-son-10.1177_23779608261418588 for The Effect of Using Engaging Distraction via Virtual Reality on Stress and Anxiety among Patients with Cancer Undergoing Chemotherapy in Palestine: A Randomized Controlled Trial by Farid Abu Liel, Basma Salameh, Ahmad Ayed and Ibrahim Aqtam in SAGE Open Nursing

Supplemental Material

sj-docx-2-son-10.1177_23779608261418588 - Supplemental material for The Effect of Using Engaging Distraction via Virtual Reality on Stress and Anxiety among Patients with Cancer Undergoing Chemotherapy in Palestine: A Randomized Controlled Trial

Supplemental material, sj-docx-2-son-10.1177_23779608261418588 for The Effect of Using Engaging Distraction via Virtual Reality on Stress and Anxiety among Patients with Cancer Undergoing Chemotherapy in Palestine: A Randomized Controlled Trial by Farid Abu Liel, Basma Salameh, Ahmad Ayed and Ibrahim Aqtam in SAGE Open Nursing

Supplemental Material

sj-docx-3-son-10.1177_23779608261418588 - Supplemental material for The Effect of Using Engaging Distraction via Virtual Reality on Stress and Anxiety among Patients with Cancer Undergoing Chemotherapy in Palestine: A Randomized Controlled Trial

Supplemental material, sj-docx-3-son-10.1177_23779608261418588 for The Effect of Using Engaging Distraction via Virtual Reality on Stress and Anxiety among Patients with Cancer Undergoing Chemotherapy in Palestine: A Randomized Controlled Trial by Farid Abu Liel, Basma Salameh, Ahmad Ayed and Ibrahim Aqtam in SAGE Open Nursing

Supplemental Material

sj-docx-4-son-10.1177_23779608261418588 - Supplemental material for The Effect of Using Engaging Distraction via Virtual Reality on Stress and Anxiety among Patients with Cancer Undergoing Chemotherapy in Palestine: A Randomized Controlled Trial

Supplemental material, sj-docx-4-son-10.1177_23779608261418588 for The Effect of Using Engaging Distraction via Virtual Reality on Stress and Anxiety among Patients with Cancer Undergoing Chemotherapy in Palestine: A Randomized Controlled Trial by Farid Abu Liel, Basma Salameh, Ahmad Ayed and Ibrahim Aqtam in SAGE Open Nursing

Footnotes

Acknowledgments

The authors would like to express their sincere gratitude to the patients who participated in this study, sharing their time and experiences during a challenging period of their lives. We also extend our appreciation to the administration and oncology nursing staff at the participating hospitals in Northern Palestine for their invaluable cooperation and support in facilitating the implementation of this research within their clinical settings.

ORCID iDs

Farid Abu Liel

Basma Salameh

Ahmad Ayed

Ibrahim Aqtam

Ethics Approval and Consent to Participate

This study received ethical approval from the Arab American University Institutional Review Board (Approval Ref: IRB No. 2023/A/99/N). All procedures adhered to the ethical principles of the Declaration of Helsinki.

The study was conducted in the oncology daycare clinics of three major governmental hospitals in Northern Palestine. Written informed consent was obtained from all participating patients. Consent procedures were conducted in Arabic by trained research assistants, ensuring participants fully understood the study's purpose, procedures, potential risks, and benefits, as well as their right to withdraw at any time without affecting their medical care.

Consent for Publication

Not applicable. All data are anonymized, and no identifiable personal details are included in the manuscript.

Authors’ Contributions

Conceptualization: Farid Abu Liel, Basma Salameh, Ahmad Ayed, and Ibrahim Aqtam. Methodology: Farid Abu Liel, Basma Salameh, Ahmad Ayed, and Ibrahim Aqtam. Software: Farid Abu Liel. Validation: Basma Salameh, Ahmad Ayed, and Ibrahim Aqtam. Formal analysis: Farid Abu Liel, and Ahmad Ayed. Investigation: Farid Abu Liel, Basma Salameh, Ahmad Ayed, and Ibrahim Aqtam. Resources: Farid Abu Liel, Basma Salameh, and Ibrahim Aqtam. Data curation: Farid Abu Liel and Ibrahim Aqtam. Writing—original draft: Farid Abu Liel and Ibrahim Aqtam. Writing—review and editing: Farid Abu Liel, Basma Salameh, Ahmad Ayed, and Ibrahim Aqtam. Visualization: Farid Abu Liel and Ibrahim Aqtam. Supervision: Basma Salameh, Ahmad Ayed, and Ibrahim Aqtam. Project administration: Farid Abu Liel, Basma Salameh, and Ibrahim Aqtam.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Availability of Data and Materials

The datasets generated and analyzed during this study are available from the corresponding author (Ibrahim Aqtam: ibrahim.aqtam@nu-vte.edu.ps) upon reasonable request. Data sharing will comply with ethical guidelines and participant privacy protection requirements.

Clinical Trial Registration

This study was registered with ClinicalTrials.gov (Trial ID: NCT07152938) prior to participant enrollment.

Supplemental Material

Supplemental material for this article is available online.

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