Look of Life 2.0. Virtual Reality for Cancer Patients in Home Palliative Care

Background Many cancer patients experience severe levels of psychological distress, with a percentage varying from 10-15% to 20-40% (Mitchell et al., 2011; Shim et al., 2018). The average prevalence of mood disorders ranges from 29% in palliative care settings to 38% in cancer and hematological contexts (Jacobsen et al., 2005). In addition to the emotional distress, the advanced stages of the disease often imply a progressive loss of functional autonomy (Dong et al., 2016). This put the patient in a status of deprivation and forced isolation from relational and social aspects that were hitherto in their lives. This psychological distress naturally adds to the burden of the physical symptoms caused by the disease and/or invasive therapies, above all pain.

In the last years, technological innovation has allowed new solutions to meet old and emerging needs in the healthcare field. One of these is represented by Virtual Reality (VR), a non-invasive simulation technology that allows the user to be immersed in a multisensory experience. VR technologies can emotionally involve the patients, inducing a positive mood and allowing them to feel like a part of the virtual environment (Malloy and Milling, 2010; Pourmand et al., 2018; Ahmadpour et al., 2019). The distraction effect is recognized to be the primary principle underlying the effectiveness of VR (Schneider et al., 2004; Malloy and Milling, 2010; Wiederhold et al., 2014; Bani Mohammad and Ahmad, 2019), as it is capable of diverting patient's attention from his or her current clinical condition. Natural contents have been shown to induce relaxation and restore work productivity, based on the Attention Restoration Theory (Kaplan, 1995; Berto, 2005; Anderson et al., 2017). Moreover, water scenes with views and sound seem to be more appreciated than scenes without water (White et al., 2010; Anderson et al., 2017). Additionally, interactive contents could be even more effective in their distraction-based effect than contents that only require passive observation (Wiederhold and Wiederhold, 2007; Shahrbanian et al., 2012; Wender et al., 2019). VR-based interventions are a convenient solution, as they do not require complicated training to be used and can be employed in case of low mobility conditions.

VR has been used as an adjuvant treatment in various clinical conditions to relieve pain, anxiety, and depression (Dascal et al., 2017; Fodor et al., 2018), during invasive procedures (Hoffman et al., 2011; Shetty et al., 2019; Brown and Foronda, 2020), for chronic pain management (Wiederhold et al., 2014; Pekyavas and Ergun, 2017) and in rehabilitation settings (Shahrbanian et al., 2012; Lee et al., 2015). It has been extensively employed in promoting cancer patients' psychological well-being (Chirico et al., 2016; Zeng et al., 2019; Ioannou et al., 2020). Previous studies assessed the effects of VR in relieving cancer-related symptomatology mainly in clinical settings (Li et al., 2011; Baños et al., 2013; Mosadeghi et al., 2016; Bani Mohammad and Ahmad, 2019), alleviating anxiety and improving mood states. Studies in palliative care (PC) have proven the acceptability of VR interventions (Oyama, 1997; Brungardt et al., 2020; Weingarten et al., 2020) and their effect in reducing short-term symptoms (i.e., pain, drowsiness, lack of appetite, shortness of breath, depression, anxiety, and well-being) (Niki et al., 2019; Johnson et al., 2020).

The evidence about the use of VR in a home PC program is still insufficient. To fill this gap, the National Tumor Assistance Foundation (ANT), a non-profit organization working in Italy in the field of home PC and pain management, conducted a pilot study to test the feasibility of VR interventions for cancer patients assisted at home (Varani et al., 2018). This was the first attempt to introduce VR interventions in home-PC settings, obtaining promising results: most participants (73%) declared that they would be willing to keep a VR headset at home; patients showed a 20% decrease in anxiety and depression and a significant reduction of perceived pain and fatigue symptoms. As a further outcome, ANT collected patients' preferences as the output of a focus group and semi-structured interviews: all patients declared to prefer natural and relaxing scenarios, 36% expressed a preference for interactive videos, while 33% wanted to see videos as simple observers (Sichi et al., 2019).

After these encouraging results, ANT introduced the VR headset with interactive and non-interactive contents in its home-care practice.