Immersive Virtual Reality (VR) at the Time of Clinical Evaluation to Improve Psychological Distress and Anxiety in Primary Brain Tumor (PBT) Patients

A Phase II Feasibility Trial Using Immersive Virtual Reality (VR) at the Time of Clinical Evaluation to Improve Psychological Distress and Anxiety in Primary Brain Tumor (PBT) Patients

Background:

Distress, anxiety, and other psychological disorders may be more common in people with primary brain tumors (PBTs). PBTs can affect their symptoms, quality of life, and their tolerance of cancer treatments. Researchers want to learn if virtual reality (VR) technology can help reduce stress and improve mood. VR uses computer technology to make fake experiences and environments that look real. This allows people to escape from their lives and experience more positive thoughts and emotions.

Objective:

To learn if it is feasible to use a VR relaxation intervention in people with PBTs.

Eligibility:

Adults 18 and older who have a brain tumor and have recently reported psychological distress during their participation in the Natural History Study (NHS), protocol #16C0151

Design:

The VR intervention and all patient-reported outcome measures (PROs) will be done remotely using telehealth.

Participants will be mailed a VR headset. This headset looks like a thick pair of goggles that is worn over the eyes. Participants will view computer-generated environments on this VR headset.

Participants will fill out symptom questionnaires at 4 different times points during participation in this study, including questionnaires for the NHS as well as 4 questionnaires unique to this study. There are also optional saliva samples that are collected at 2 of the timepoints. The 4 timepoints are:

• Baseline (before the VR intervention)
• Immediate post-VR (right after the VR intervention)
• 1 week later
• 4 weeks later

Participants will also have a phone interview 4 weeks after the initial VR intervention, which will last 10 to 15 minutes.

Participation lasts 4 to 6 weeks.

Background

• Psychological distress is a common concern for patients across the cancer trajectory, which has been associated with worse clinical outcomes in terms of quality of life, adherence to treatment regimens, satisfaction with care, and poorer survival in past research.
• Virtual reality (VR) has the potential to alleviate some of the negative aspects of illness by allowing individuals to escape from their lives and experience more positive thoughts and emotions, which can be accomplished using mindfulness, breathing techniques and distraction (all of which can improve psychological symptoms).
• Past VR research has shown promising improvements in anxiety, pain, distress and distraction through use of immersive VR interventions, though there is scant evidence in primary brain tumors (PBTs) population, particularly in the time period surrounding their neuroimaging and clinical appointments when distress and anxiety can be highest.
• Recent evidence has demonstrated that the coronavirus disease 2019 (COVID-19) pandemic and associated mitigation procedures introduce additional stress for cancer patients, with higher levels of anxiety, depression, loneliness, and financial toxicity being reported during this time.
• The purpose of this phase II clinical trial is to determine the feasibility of implementing an immersive VR relaxation intervention in a PBT population and to assess the efficacy of the intervention to improve psychological distress and anxiety at the time of clinical evaluation. VR is an innovative delivery approach to teach our patients validated breathing and mindfulness techniques that can improve their psychological symptoms and their ability to self-manage these symptoms.

Objectives

-To describe the feasibility of implementing a VR intervention in a PBT population, including eligibility, accrual, compliance, device-related adverse effects, study completion, and participant satisfaction with the intervention

Eligibility

• PBT patients enrolled on the Natural History Study (NHS) trial in the Neuro-Oncology Branch (NOB) (all tumor types and grades eligible)
• Patients can be newly diagnosed, receiving active treatment, or on surveillance
• Adults (greater than or equal to 18 years of age) who are English-speaking and able to self-report symptoms
• Active corticosteroid therapy is permissible
• Participants have reported greater than or equal to 1 on distress item from MD Anderson Symptom Inventory (MDASI) Brain Tumor (MDASI-BT) prior to past clinic appointment
• Exclude patients without tissue diagnosis, recent cranial surgery (less than or equal to 2 weeks), scalp wound healing issues, or seizures within the last 6 weeks
• Exclude patients who have a hypersensitivity to motion, severe nausea, or significant visual field deficits that might interfere with VR experience (including hemianopsia, diplopia, and agnosia)
• Exclude patients with a current diagnosis of generalized anxiety disorder (GAD), post-traumatic stress disorder (PTSD), claustrophobia, or panic disorder

Design

• This is a phase II feasibility clinical trial with a single arm experimental design. The VR intervention and all patient-reported outcome measures (PROs) will be done remotely using telehealth.
• Study will include collection of self-reported PROs for distress, anxiety, mood disturbance, symptom burden/interference, quality of life, cognitive function, loneliness, and financial toxicity, as well as optional salivary stress biomarkers. These measures will be collected at baseline and immediately after a brief VR relaxation intervention to determine acute effects on distress, anxiety, and biological stress measures. Repeat post-intervention assessments will be done approximately 1 week and 1 month following the initial intervention to determine sub-acute effects on distress and anxiety, as well as impact on other symptoms. A semi-structured qualitative interview will also be conducted 1 month after the initial intervention to assess participant satisfaction with the intervention and how the pandemic has affected their psychological symptoms.
• Descriptive statistics, T-tests, Wilcoxon rank sum tests, and multiple logistic regression models will be used to evaluate the feasibility of the VR intervention. Linear mixed models and effect size calculations will be used to evaluate the acute and sub-acute effects of the VR intervention on self- reported PRO's. Pearson or Spearman correlations will be used to evaluate the relationship between the biological stress measures and self-reported PRO's.
• A total of 120 PBT patients will participate in this study.

• INCLUSION CRITERIA:
• Primary brain tumor (PBT) patients enrolled on the Natural History Study (NHS) trial (16C0151) in the Neuro-Oncology Branch (NOB) who have an upcoming scan and clinical appointment
• Participants can be newly diagnosed, receiving active treatment, or on surveillance
• Concurrent enrollment in other NOB trials is permissible
• Adults (greater than or equal to 18 years of age) who are English-speaking
• Participants must be able to reliably self-report symptoms, based on clinician assessment
• Participants report greater than or equal to 1 on distress item from MD Anderson Symptom Inventory (MDASI) Brain Tumor (MDASI-BT) prior to clinic appointment
• Active corticosteroid therapy is permissible
• Ability of subject to understand and the willingness to sign a written informed consent document

EXCLUSION CRITERIA:

• Participants who do not have a tissue diagnosis (no past surgery or biopsy to confirm diagnosis)
• Cranial surgery less than or equal to 2 weeks prior to initiation of study intervention
• Scalp wound healing issues that might interfere with comfortable virtual reality (VR) headset use
• Those who have epilepsy or have had a seizure in the last 6 weeks
• Participants with a current diagnosis of generalized anxiety disorder (GAD), post-traumatic stress disorder (PTSD), claustrophobia, or panic disorder
• Participants who have a hypersensitivity to motion or severe nausea, which could make the VR experience uncomfortable
• Those with visual deficits that might interfere with the VR experience, including hemianopsia, diplopia, and agnosia based on their most recent clinical assessment