The Effect of Virtual Reality on Pediatric Oncology Patients: A Systematic Review and Meta-analysis
Mohammed Alhakami *1,2,3, Douaa Albukhari 1,2,3, Yasir Alghamdi 1,4,
Mohammed Hadidi 1,4, Abdullah Alsharif 1,4, Ghufran Aljawi 1,2,3,4
*Correspondence to: Mohammed Alhakami, College of medicine, King Saud bin Abdulaziz University for Health and Sciences, Jeddah, Saudi Arabia.
Copyright.
© 2026 Mohammed Alhakami, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 16 October 2026
Published: 01 November 2026
DOI: https://doi.org/10.5281/zenodo.23911460
Abstract
Context: Pediatric cancer patients undergoing treatment frequently experience anxiety and pain, which can negatively impact their overall treatment experience. Virtual reality (VR) is one of several potential interventions to alleviate these symptoms.
Objectives: This systematic review and meta-analysis aimed to evaluate the effectiveness of VR in reducing anxiety and pain in pediatric oncology patients receiving cancer therapy.
Methodology: A computerized search was conducted in the MEDLINE, Web of Science, and CENTRAL databases for randomized controlled trials (RCTs) comparing VR interventions to control groups in pediatric oncology patients undergoing cancer treatment. The primary endpoints were self-reported and parent-reported anxiety and pain scores before and after the intervention. A secondary endpoint included pulse rate (PR) measurements between both groups. The meta-analysis was performed using a random-effects model in RevMan (Review Manager) version 5.3 (Cochrane Collaboration).
Results: Five RCTs were included in the meta-analysis. VR interventions significantly reduced self-reported anxiety (Mean Difference = -2.68, 95% CI [-3.61, -1.76], p <0.00001) and self-reported pain (Mean Difference = -1.61, 95% CI [-2.85, -0.37], p =33 0.01) after the intervention compared to control groups. Parent-reported pain scores also showed a significant reduction in favor of the VR intervention (Mean Difference = -2.07, 95% CI [-3.50, -0.63], p = 0.005). No significant differences were observed in self-reported anxiety and pain before the intervention or in PR between the VR and control groups.
Conclusion: This meta-analysis demonstrates that VR interventions are effective in reducing anxiety and pain in pediatric oncology patients undergoing cancer therapy. The results suggest that VR can be a valuable tool to improve the treatment experience for this patient population. Further research is needed to determine the optimal VR protocols and to explore other effects of VR interventions in pediatric oncology care.
Key words: Pain, anxiety, Virtual reality, Pediatric cancer, therapy, chemotherapy, radiation therapy.
Key Massage: This is a systematic review and meta-analysis that discusses the pain and anxiety pediatric cancer patients go through during their treatment. The study assessed whether the use of virtual reality as a tool to distract patients, thereby lowering pain and anxiety levels.
Introduction
Cancer stands as a prominent cause of mortality among children on a global scale, with the incidence of pediatric cancer steadily increasing over time [1]. Additionally, cancer patients face multiple management options and alternatives. Each of them has different outcomes and side effects [2]. Children receiving cancer therapy have greater rates of physical symptoms like pain, and psychological effects. These findings indicate how significantly a patient's quality of life (QoL) gets affected [3].
Various distraction techniques, including music playback, balloon inflation, and distraction cards, have been proposed in recent studies, demonstrating efficacy in alleviating both physical and psychological symptoms [4-5]. Studies have demonstrated that virtual reality (VR) is considered a promising distraction modality for pediatric and cancer patients [6-7]. Furthermore, collaborative efforts between physicians, programmers, and researchers are important to utilize VR as a distracting technique in diverse clinical settings, aimed at enhancing QoL of pediatric cancer patients [7]. To the best of our knowledge, there were other systematic reviews that addressed this subject. However, these reviews were limited by their qualitative nature [8-10].
Therefore, this systematic review and meta-analysis was conducted to evaluate the effectiveness of VR on children with cancer undergoing cancer therapy in terms of physical symptoms such as pain and psychological symptoms such as anxiety.
Methods
This systematic review and meta-analysis were reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) checklist [11]. This review was based on a pre-specified protocol registered in PROSPERO (CRD42024520220). Our review was exempted from IRB review by King Abdullah International Medical Research Center (KAIMRC).
Information Sources and Search Strategy
A computerized search was performed in the following databases: MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, and Google Scholar. Additionally, the scanning of reference lists was performed. The complete search strategy is provided in the supplementary material. The last systemic
search was on March 10, 2024, with no restrictions on the date.
Eligibility criteria
Pediatric cancer patients aged 19 or below who underwent cancer therapy were eligible for inclusion.
We included studies in which participants used VR as a distraction for their cancer management compared to either placebo or non-VR intervention.
Eligible trials must have at least one of the following pre-specified outcomes: pain, anxiety, or pulse rate (PR).
We included Randomized Controlled Trials (RCTs) and pilot RCTs. Studies written in languages other than English were excluded.
Study selection
Independent and duplicate eligibility screening was carried out by two reviewers. Firstly, the reviewers carefully screened the titles and abstracts. Eligible abstracts were then assessed by reviewing the full text. Disagreements were settled through discussion or a third reviewer.
Data extraction
Two reviewers independently extracted the data in duplicate using a pre-defined data collection model. We gathered data on participants’ demographics, diagnosis of cancer, the VR equipment, cancer management, pain, anxiety, PR, duration of follow-up, and scales used for each outcome.
Risk of Bias Assessment
Risk of bias assessment was conducted independently and in duplicate by two reviewers using the revised Cochrane Risk of Bias Tool 2 [12]. Any disagreement was settled by discussion or the opinion of a third reviewer.
Effect measures
The continuous outcomes were represented as standardized mean difference (SMD) whereas the dichotomous outcomes were represented as risk ratios (RRs).
Meta-analysis
The meta-analysis was performed using the random-effects model in RevMan (Review Manager) version 5.3 (Cochrane Collaboration). The confidence level was set at 95%, with a threshold of P < 0.05. We used I2 and the P-value of Chi2 to assess the statistical heterogeneity. All outcomes were pooled by the inverse variance
weighting methods.
Certainty of evidence
The Grading of Recommendation Assessment, Development, and Evaluation (GRADE) was used to evaluate the certainty of evidence of each outcome in our study.
Results
Figure 1 demonstrates the flowchart of the included RCTs. The computerized and manual search yielded 580 studies. These 580 records were screened, and we ended up with 36 records that were eligible for full-text assessment. Eventually, five articles were deemed eligible.
1. Trial characteristics
This systematic review and meta-analysis included 351 participants, with 191 (54.4%) in the VR group and 160 (45.6%) in the control group. The mean age of the children in the included studies ranged from 10.2 to 12.6 years. The gender distribution comprised 189 males (53.8%) and 162 females (46.2%). Three RCTs compared VR to standard care, which entails no intervention, while the other two compared VR to a non-VR distraction (i.e., iPad) [13-17]. Further details on study characteristics are shown in Table 1.
2. Risk of Bias Assessment
Among the five trials, one was assessed as having a high risk of bias, four were identified as having some concerns regarding bias, and one was found to have a low risk of bias. Figures 2 and 3 provide detailed information on the risk of bias across different domains.
Pain was assessed based on the timing, either before or after the cancer therapy session, and was reported through either self-reports by the children or reports by their parents. This outcome was documented in all five RCTs [13-17]. Additionally, pain was measured using various scales across the studies, such as the Child-report Visual Analogue Scale (VAS), the 11-point Numeric Rating Scale, and the Wong-Baker Faces Pain Rating Scale.
Three trials involving 238 participants were included in the meta-analysis to compare the VR and control groups on self-reported pain before the therapy session. [13-15]. The pooled results showed no significant difference between the groups (Mean Difference = -0.03, 95% CI [-0.71, 0.64], P = 0.93, I2=50%, Moderate certainty of evidence), suggesting that the experimental and control groups had similar levels of self-reported pain before the intervention. Further details in Figure 4.
The meta-analysis included five studies (n=351) [13-17]. These studies compared the experimental and control groups on self-reported pain after the therapy sessions. The pooled results showed a significant difference in favor of the VR group (Mean Difference = -1.61, 95% CI [-2.85, -0.37], P = 0.01, I2=88%, Low certainty of
evidence, Figure 5), indicating that the experimental intervention was effective in reducing self-reported pain compared to the control group.
Three RCTs documented this outcome with a total of 153 participants. The meta- analysis included three studies (Gerçeker et al., 2020; Hundert, 2022; Semerci et al.,2020) comparing the experimental and control groups on parent-reported pain after the cancer therapy session. The pooled results showed a significant difference favoring the VR group (Mean Difference = -2.07, 95% CI [-3.50, -0.63], P = 0.005, I=75%, Low certainty of evidence, Figure 6), showing that the VR intervention was more effective in lowering pain