The influence of virtual reality on anxiety and pain in breast cancer patients: A systematic review

Abstract

Background

Breast cancer has a high incidence and remains one of the leading causes of death worldwide. Virtual reality (VR) based interventions have emerged as an effective new strategy to reduce psychological distress and improve physical wellbeing. This study aims to examine the effect of virtual reality on anxiety and pain in breast cancer patients.

Methods

A comprehensive literature search was conducted following PRISMA guidelines across various electronic databases, including Google Scholar, the Cochrane Library, PubMed, and ProQuest, for studies published between 2016 and 2026. The study focused on virtual reality interventions. Studies addressing other cancer types were excluded. The selected studies were screened through title, abstract, and full-text review based on predetermined inclusion and exclusion criteria.

Results

A total of 14 studies met the inclusion criteria and were analysed, involving 761 participants. All studies used VR as the primary intervention technique. Although there was variation in the number and duration of sessions across studies, findings indicated a reduction in anxiety and pain following VR intervention.

Conclusion

Conclusion: This systematic review provides a positive picture of the use of immersive VR in improving psychological and physical well-being by reducing anxiety and pain scores in breast cancer patients. These findings demonstrate the potential benefits of VR in addressing the physical and psychological challenges associated with various clinical conditions in breast cancer patients. Future research should standardize VR intervention protocols and explore the long-term effects of VR use on other physical and psychological issues.

Highlights

• •The significance of this systematic review is as follows:
• •To the researcher's knowledge, no systematic review has simultaneously assessed the effectiveness of virtual reality on anxiety and pain.
• •This study provides a synthesis of current scientific evidence regarding the effectiveness of VR in reducing anxiety and pain levels in women with breast cancer, adding to the literature on VR interventions as a non-pharmacological approach that can support the management of psychological and physical symptoms in breast cancer patients.
• •It serves as a foundation for healthcare professionals and researchers to develop and implement VR interventions as part of comprehensive care for women with breast cancer.

Introduction

Breast cancer is a malignancy with a high incidence among women globally. It has become a major health problem in many countries [1], [2] ranking fourth as a cause of cancer-related death. More than 8 million women worldwide live with breast cancer within five years, and Asia accounts for approximately 39.1% of global cases [3]. The high number of cases in Asia indicates significant regional challenges, exacerbated by urbanisation, climate change, and limited access to early-tection services [4], [5], [6]. Based on the WHO Health Equity Assessment Toolkit data analysis, breast cancer incidence among Indonesian women was approximately 42.1 cases per 100,000 women in 2020.

Breast cancer is multifactorial, involving a combination of genetic, hormonal, behavioral, and physiological influences that increase an individual's risk [7], hormonal influences [8], reproductive factors [8], the duration of menstruation [9], age at first childbirth [10], higher parity, and a limited breastfeeding period [[11], [12]]. Lifestyle factors such as obesity, alcohol consumption, and exposure to ionising radiation also contribute to the risk [[7], [13]]. In addition, the combination of olderage and prolonged exposure to endogenous hormones increases the likelihood of abnormal epithelial proliferation in breast tissue [[14], [15]].

Breast cancer patients often experience various side effects from treatments such as surgery, chemotherapy, radiotherapy, and hormonal therapy. The most commonly reported symptoms include cancer-related fatigue, pain, nausea and vomiting, peripheral neuropathy, sleep disturbances, and changes in body weight and composition. Surgical procedures like mastectomy can also cause limitations in shoulder range of motion, decreased muscle strength, and an increased risk of extremity lymphedema [[16], [17], [18], [19]]. Furthermore, cardiorespiratory fitness and functional capacity may decline as a consequence of the combined toxic effects of therapy and reduced physical activity during treatment [[20], [21]]. Persistent fatigue may persist into the survivorship and related phases, with inflammatory processes, anaemia, and metabolic changes. Long-term hormonal therapy length has also been reported to increase the risk of osteoporosis and arthralgia, which further worsens patients' physical quality of life [[22], [23]]. A study showed that persistent breast pain after treatment can occur in 25% to 60% of patients, depending on the phase of treatment and the evaluation methods used [[24], [25]]. Additionally, a meta-analysis reported that psychological problems in cancer patients are common, with anxiety affecting approximately 41.9% of patients, often related to concerns about treatment outcomes, uncertainty regarding prognosis, and fear of disease recurrence [[26], [27]].

Pharmacological pain management in cancer patients generally follows a multimodal approach, including the use of opioid analgesics, NSAIDs, and other adjuvant drugs for neuropathic pain components [28]. The approach for anxiety management covers benzodiazepines, antidepressants (SSRIs/SNRIs), and other medications that target neurotransmitter regulation to stabilize the heart and reduce the patient's stress response [[29], [30]]. Non-pharmacological interventions based on technology can reduce the need for drugs and their side effects. Virtual reality (VR) is used as a technique to distract and immerse patients, diverting attention from sensory pain and pressure, and showing a reduction in anxiety and pain scores in patients with breast cancer when used together with standard care compared to only analgesics alone [[31], [32], [33], [34]]. Other evidence from a systematic review also shows that VR interventions can help reduce pain andanxiety in the context of medical treatment for patients with cancer and other groups [[35], [36]]. In addition, a study of randomised controlled trials in patients with breast cancer with radiotherapy found that the use of VR to explain the therapy process visually and interactively can reduce patient anxiety compared with conventional written information [[37], [38], [39]].

Although considerable evidence from previous studies suggests that VR has the potential to reduce anxiety and pain in cancer patients, several important limitations remain that hinder the generalisation of findings and the development of strong clinical recommendations. These limitations include the relatively small number of available studies and limited sample sizes, as well as substantial heterogeneity in intervention protocols, variations in VR content, session duration, and clinical settings, which may contribute to inconsistent results across studies.

Given the potential benefits and limitations of existing research, this study aimed to conduct a systematic review examining the effects of virtual reality on anxiety and pain in breast cancer patients. The importance of this systematic review lies in conducting more detailed data extraction and a more systematic description of intervention characteristics. This study presents a synthesis of current scientific evidence regarding the effectiveness of VR in women with breast cancer.

Materials and methods

This systematic review was conducted in accordance with the Cochrane methodological guidance and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Because the review used data from previously published studies, individual participant consent was not required. A meta-analysis was not performed because of the limited number of eligible studies and substantial heterogeneity in study designs, interventions, outcome measures, and assessment procedures. Risk of bias was independently assessed by two reviewers, and disagreements were resolved through discussion and, when necessary, consultation with a third reviewer. Randomised controlled trials were evaluated using the Cochrane Risk of Bias 2 (RoB 2) tool across five domains: bias arising from the randomization process, bias due to deviations from intended interventions, bias due to missing outcome data, bias in measurement of the outcome, and bias in selection of the reported result. Domain-level judgements were classified as low risk, some concerns, or high risk, and an overall RoB 2 judgement was assigned according to the tool guidance. Non-randomised intervention studies were assessed using ROBINS-I, including the domains of confounding, participant selection, classification of interventions, deviations from intended interventions, missing data, measurement of outcomes, and selection of the reported result. Where appropriate for the study design, Joanna Briggs Institute critical appraisal checklists were used, and the individual appraisal items were reported rather than being converted into general quality categories. The domain- and item-level assessments, together with the overall risk-of-bias judgements, are presented in the revised risk-of-bias table. Risk-of-bias assessments were not used as exclusion criteria but were incorporated into the interpretation of the findings and the strength of the overall evidence.

Search strategy

A search strategy was developed to improve the clarity and quality of the results. This systematic review followed the PRISMA Checklist guidelines. Two independent researchers conducted a comprehensive search across multiple electronic databases: PubMed, Google Scholar, ProQuest, and the Cochrane Library. The search period was from January 2016 to August 2026. The review objectives were formulated using the PCC framework: Population, Concept, and Context. The search was limited to English-language articles. Modified MeSH terms were used in each database. The search terms were combined using the Boolean operators “AND” and “OR”. The keywords used in the search strategy included “virtual reality” AND (anxiety OR pain) AND (“breast cancer” OR “Breast Neoplasm” OR “Breast Tumour” OR “Breast Gland Cancer” OR “Breast Malignant Neoplasm” OR “Breast Malignant Tumour”). Three reviewers independently double-checked the extracted data. After identifying the eligible studies, consultation with subject-matter experts was conducted to ensure the accuracy and relevance of the included articles.

Inclusion and exclusion criteria

Articles included in this review had to meet the following criteria: 1) Publication period: Studies published between 2016 and 2026. 2). Population: Adults aged 18 years or older who had been diagnosed with breast cancer (patients currently undergoing cancer treatment as well as individuals living with or surviving breast cancer) 3). Intervention: Studies that implemented virtual reality interventions. 4) Study Design: Eligible designs included randomised controlled trials (RCTs), quasi-experimental studies, controlled clinical trials, pilot studies, and pre-post intervention studies that presented quantitative results. Mixed-method studies were included if they provided additional quantitative data in an extra table. 5) Language: Publications written in English. 6). Results: Studies had to evaluate at least one psychological outcome (anxiety) and one physical outcome (pain).

Articles were excluded if they met any of the following conditions: 1) The study population did not involve patients diagnosed with breast cancer, 2). The study did not implement a virtual reality intervention. 3) The study did not evaluate outcomes related to anxiety or pain. 4) The publication type was a review article, meta-analysis, editorial, commentary, letter, conference abstract without full text, comprehensive dissertation, or individual case report, which could not provide generalizable conclusions. 5) The study focused only on non-human subjects or laboratory-based experimental models. 6) The study lacked sufficient data for thorough extraction and analysis (e.g., lack of outcome measures, incomplete reporting). 7) The article represented a duplicate publication of the same dataset.

Study selection

All identified studies were imported into EndNote X9 (Thomson Reuters, Toronto, Ontario, Canada). After removing duplicates, three authors independently screened the titles and abstracts of all identified studies according to the predefined search criteria. The full texts of the remaining relevant studies were obtained, and the authors reviewed them to make a final selection. The reference lists of the included criteria were screened to identify any additional eligible studies. Any disagreements during the selection process were resolved through discussion and consensus among the authors. Full-text articles that did not meet the inclusion criteria were removed, and the reasons for exclusion were documented.

Data extraction

Three reviewers performed data extraction independently using a form designed in Microsoft Excel. Any disagreements were resolved through discussion. The extracted data included the following information: first author, year of publication, country, study design, sample size, intervention, sample description, type of VR technology used, challenges associated with VR implementation, opportunities for VR use, study limitations, and results.

Search results

The four databases yielded a total of 5630 articles, including 1290 duplicate records. After removing duplicates, 4340 articles remained for screening. The researchers then conducted an initial screening of titles and abstracts, resulting in the exclusion of 4318 articles. Following this process, 22 articles were assessed for full-text eligibility. After applying the inclusion and exclusion criteria, 14 articles were ultimately included in this systematic review. The total number of participants across all included studies was 761. The study selection process is illustrated in Fig. 1. The results of the 14 analyzed studies on the effects of VR on anxiety and pain are shown Table 1 and Risk of bias and methodological quality assessment of included studies are shown in Table 2.

Fig. 1.

Flow diagram for search and selection of the included study.

Table 1.

Virtual reality showed a significant positive impact on anxiety and pain in breast cancer patients.

Author, country, and year	Study design	Type of VR technology	Type of VR application	Sample size	Control group	Intervention duration	Clinical setting	Outcome measures	Key findings
YA Jimenez et al., Australia, 2018 [40]	Prospective comparative study	Immersive VR	Virtual Environment for Radiotherapy Training (VERT)	37 breast cancer patients (19 VERT group; 18 controls)	Standard pre-radiotherapy education	One-time educational session with the Virtual Environment for Radiotherapy Training (VERT) system, conducted before or at the start of radiotherapy. Each session lasts approximately 1 h.	Before/start of radiotherapy	STAI	Anxiety was lower in the VR group at subsequent assessments, but between-group differences were not significant (p = 0.135–0.217).
Eslam Bani Mohammad et al., 2019 [31]	Randomised Controlled Trial	Immersive VR headset with audio-visual environments	VR scenarios plus standard care (morphine)	80 female breast cancer patients (40 VR; 40 controls)	Morphine/standard pain management	1 session during painful procedures	Painful treatment procedure	VAS, SAI	VR significantly reduced pain (0.33 ± 0.82 vs 4.84 ± 2.57) and anxiety (37.68 ± 3.80 vs 50.13 ± 9.32); p < 0.001.
Zhang Xiuqing et al., 2022 China [41]	Randomised Controlled Trial	Immersive VR (Head-Mounted Display/HMD)	Nature-based, meditation, and relaxation/distraction applications	98 breast cancer patients; CALM group n = 45, CAU group n = 53.	Standard care as usual (CAU).	The intervention course forVR-CALM was 3 months, receive 6 separate treatments, each time for 30 min, and the first 3 treatmentswould be completed in the first month	During cancer survivorship	FACT-B, DT, CARS, PFS, PSQI, SAS, SDS	Anxiety significantly decreased in the VR-CALM group compared with the CAU group (t = −5.819, p = 0.001). Depression, sleep disorders, and fatigue also significantly decreased, while quality of life significantly improved (p ≤ 0.05).
Andrea Chirico et al., Italy & USA, 2020 [42]	Prospective comparative clinical study	Immersive VR environments (interactive distraction)	VR distraction intervention	94 total BC patients: 30 VR group; 30 Music Therapy (MT) groups; 34 controls	standard chemotherapy care	VR therapy is carried out for about 20 min of the total duration of the chemotherapy session, which is usually 45–90 min	Chemotherpy	SAI	Anxiety decreased significantly with VR; time × intervention interaction p = 0.006.
Giannelli Andrea et al., 2024 Italy [43]	Randomised controlled trial (RCT)	Immersive VR headset with two controllers	VR-based CALM	98 breast cancer patients; CALM group n = 45, CAU group n = 53	Usual care	3 months; 6 sessions × 30 min	Breast cancer survivorship	FACT-B; DT; CARS; PFS; PSQI; SAS; SDS	Anxiety significantly decreased in the VR-CALM group compared with the CAU group (t = −5.819, p = 0.001). Depression, sleep disorders, and fatigue also decreased significantly, while quality of life improved significantly (p ≤ 0.05).
Stanley Chin et al., New Zealand, 2022 [44]	Randomised crossover analysis	Head-mounted VR headsets (immersive VR)	Virtual reality nature experiences (Ripple vs Happy Place).	38 women with metastatic breast cancer	Alternative VR condition	3 weeks of daily VR use (1 week per experience + washout)	Metastatic breast cancer	DASS-21	No significant overall anxiety reduction (MD = 0.33, 95% CI −0.21 to 0.87; p = 0.23); subgroup benefit was observed.
Fabi A. et al., Italy, 2022 [45]	Randomised Controlled Trial	Head-mounted immersive virtual reality	VR as distraction therapy	44 patients (VR = 22, control = 22)	Conventional distraction	One session	Chemotherapy	HADS, STAI	State anxiety decreased significantly in the VR group immediately after chemotherapy (p < 0.0001).
Lisa M. Reynolds et al., New Zealand, 2022 [46]	A mixed-methods	Immersive Virtual Reality	Pico Goblin VR headset	Women with MBC: 38 participants. Group 1 (Ripple before Happy Place) n = 19, group 2 Happy Place before Ripple = 19	No non-VR controls	1-week VR use (daily ≥10 min), crossover design with 1-week washout; total study duration ≈3 weeks.	Ongoing treatment or palliative care	DASS-SF, BPI	Anxiety scores decreased from 5.11 ± 5.95 at baseline to 2.49 ± 3.31 after the first week and 2.12 ± 2.78. However, the immediate post-intervention change was not statistically significant (MD = −0.66; p = 0.320).
Arzu Uslu et al., Turkey, 2023 [47]	Randomised Controlled Trial	Immersive VR via head-mounted display (HMD)	VR glasses showing relaxing beach and nature scenes.	66 women with breast cancer (intervention = 33 vs control = 33).	Standard care and routine chemotherapy	30-min VR session	Adjuvant chemotherapy	SAS	Anxiety scores were lower in the VR group than in the control group. However, the study did not provide complete mean ± SD values, numerical p-values, 95% CIs, or effect sizes.
Shin J. et al., South Korea, 2023 [37]	Randomised Controlled Trial	Immersive VR headset with 3D simulation of radiation therapy steps	VR for patient education & procedural explanation	196 patients with breast cancer (97 VR; 99 controls)	Standard-of-care explanation	One session before radiation therapy. Single VR session delivered before or during RT planning	Radiotherapy preparation	APAIS, STAI	Greater immediate reductions in anxiety with VR: APAIS 26.0% vs 8.1%; STAI 16.1% vs 8.5%.
Ahmed Abdelmoniem Ibrahim et al., Saudi Arabia, 2024 [48]	Randomised Controlled Trial	VR Pablo game training system with an interactive gaming device (Immersive VR)	VR-assisted rehabilitation (Pablo game training).	40 post-operative breast cancer female patients (21 VR; 19 controls)	Standard rehabilitation	8-week training period	Post-mastectomy	VAS, SAI	Greater reductions in pain and anxiety were observed in the VR group.
Aydanur Aydin et al., Turkey, 2024 [49]	Quasi-experimental study	Head-mounted immersive VR glasses	VR distraction with tranquil forest scene, birdsong, and meditation music	60 breast cancer patients (30 intervention, 30 control)	Usual care	VR was delivered during each radiotherapy session; therefore, the intervention duration was dependent on the radiotherapy schedule.	Radiotherapy	STAI	Post-treatment anxiety was significantly lower with VR (p < 0.0001
Oliver Czech et al., Poland, 2025 [50]	Experimental non RCT	Immersive VR	Virtual garden featuring therapeutic audio stimuli	56 women (n = 14 per group). (diagnosis group, surgery group, radiotherapy group. and the healed group.	No concurrent control	Approximately 15–20 min per session; intervention duration varied according to the study protocol.	Different treatment stages	STAI	Anxiety decreased significantly overall (F = 15.82; p < 0.001; ηp2 = 0.23).
Shanshan Wu et al., China, 2025 [51]	Randomised Controlled Trial	Immersive VR (Head-Mounted Display)	Natural landscape VR, music, and relaxation guidance	85 completed (44 interventions, 41 controls)	Routine nursing care	3–5 sessions over 5 ± 2 weeks; each session lasted 15 ± 3 min.	Mainly chemotherapy	PANAS, DT	Negative emotion decreased; subgroup difference was significant for Type D personality (p = 0.046).

Table 2.

Risk of bias and methodological quality assessment of included studies.

No	Study	Study design	Suggested appraisal tool	Overall judgement
1	Jimenez et al., 2018	Prospective comparative study	ROBINS-I / JBI quasi-experimental checklist	Some concerns
2	Bani Mohammad & Ahmad, 2019	Randomised controlled trial	Cochrane RoB 2	Some concerns
3	Feyzioğlu et al., 2020	Randomised controlled trial	Cochrane RoB 2	Some concerns
4	Chirico et al., 2020	Prospective comparative clinical study	ROBINS-I / JBI quasi-experimental checklist	Some concerns
5	Zhang Xiuqing et al., 2022	Randomised controlled trial	Cochrane RoB 2	Some concerns
6	Chin et al., 2022	Secondary analysis of randomised controlled crossover trial	RoB 2 / crossover-trial considerations	Some concerns
7	Fabi et al., 2022	Randomised controlled trial	Cochrane RoB 2	Some concerns
8	Reynolds et al., 2022	Pilot randomised crossover trial	RoB 2 / JBI checklist	Some concerns
9	Giannelli Andrea et al., 2024	Randomised controlled trial	Cochrane RoB 2	Some concerns
10	Shin et al., 2023	Randomised controlled trial	Cochrane RoB 2	Some concerns
11	Ibrahim et al., 2024	Randomised controlled trial	Cochrane RoB 2	Some concerns
12	Aydin et al., 2024	Quasi-experimental / clinical intervention study	ROBINS-I / JBI quasi-experimental checklist	Moderate/high concern
13	Czech et al., 2025	Experimental comparative study / non-RCT	ROBINS-I / JBI quasi-experimental checklist	High concern
14	Wu et al., 2025	Randomised controlled trial	Cochrane RoB 2	Some concerns

Results

Risk-of-bias and quality assessment

The risk-of-bias assessment showed that most randomised controlled trials had “some concerns,” mainly due to difficulty in blinding participants and personnel in VR-based interventions, the use of subjective self-reported outcomes such as anxiety and pain scores, small sample sizes, and incomplete reporting of effect sizes or confidence intervals. Non-randomised and quasi-experimental studies generally raised more methodological concerns, particularly regarding allocation procedures, potential confounding, the absence of control groups, and limited follow-up. No studies were excluded based on quality assessment; however, these findings were considered when interpreting the overall strength of the evidence.

Discussion

The 14 articles included in the analysis (published between 2016 and 2026) originated from several countries, namely Turkey (3 studies), Italy (2 studies), New Zealand (2 studies), France (1 study), and one study each from Australia, Jordan, Poland, South Korea, China, and Saudi Arabia. The total sample size across all included studies was 761 participants. Based on the research design, the majority of the studies used a Randomised Controlled Trial (RCT) design (11 studies), followed by one quasi-experimental study, one prospective comparative study, and one experimental crossover study.

The age of participants ranged from 18 to 79 years, with the average age of breast cancer patients generally between 50 and 60 years. Most of the breast cancer cases included in this study were stage I and II. VR distraction therapy was administered during several phases of treatment, including during chemotherapy [[31], [42], [45], [47], [49]], post-operation [[48], [52]], the post-therapy phase [[46], [50], [53]], pre-therapy preparation [[37], [40]], metastatic stage [44] and post-surgical [41].

Of the 14 studies, 11 studies assessed anxiety outcomes. The findings suggest that VR interventions can reduce anxiety among breast cancer patients [[31], [37], [40], [42], [45], [46], [47], [48], [49], [50], [54]]. VR-based educational interventions delivered before radiotherapy resulted in significantly lower anxiety scores compared with standard education methods [37]. In line with these findings, the use of VR as a distraction technique during medical procedures has been shown to reduce anxiety [31]. In addition, VR intervention provided during adjuvant chemotherapy showed a consistent reduction in anxiety scores across multiple chemotherapy cycles [47]. Evidence from a systematic review and meta-analysis also reported that VR interventions have a positive effect in reducing anxiety and pain in breast cancer patients during treatment periods [35]. A quasi-experimental study also found that immersive VR use during radiotherapy significantly reduces anxiety and emotional distress compared with conventional care [49]. Overall, these findings show that VR can serve as an effective complementaryintervention for managing anxiety in breast cancer patients, especially during radiotherapy and chemotherapy. The underlying mechanisms are believed to include improved cognitive engagement, relaxation effects, and the diversion of attention away from medical stimuli that may trigger a stress response [31]. Anxiety was evaluated using several validated instruments across the studies, including the State-Trait Anxiety Inventory (STAI) in (5 studies), the State Anxiety Inventory (SAI) in (4 studies), the Hospital Anxiety and Depression Scale (HADS) in (1 studies), the Amsterdam Preoperative Anxiety and Information Scale (APAIS) in (1 studies), the Depression Anxiety, and Stress Scales (DASS) in (2 studies), and the State Anxiety Scale (SAS) in (1 studies). In addition, 1 study used the Positive Affect and Negative Affect Scale (PANAS) and the Distress Thermometer (DT). Among these instruments, STAI was the most frequently used tool for measuring anxiety. Previous research has indicated that the STAI is widely used and effective for detecting anxiety levels in clinical populations [55].

Of the 14 studies, 5 studies assessed pain outcomes, and 3 studies reported statistically significant reduction in pain following VR interventions, whereas 2 studies reported non-significant findings. This finding is consistent with a randomised clinical trial involving mastectomy patients receiving chemotherapy, which reported that using VR during IV infusion significantly reduced pain scores [56]. Similarly, female patients undergoing VR-assisted breast biopsies experienced a significantly greater reduction in post-procedure pain compared with the non-VR group, suggesting that immersive distraction can effectively reduce pain perception during invasive procedures [57]. Evidence from meta-analyses also suggests that most studies of breast cancer patients report significant improvements in pain levels after VR interventions [[35], [58]]. Furthermore, a systematic review limited to breast cancer patients found that VR interventions consistently reduced pain scores across a range of care settings, including biopsies and chemotherapy [[35], [59]]. Similar findings were also observed in a postoperative rehabilitation study, in which the VR intervention group showed greater pain improvement [[48], [60]].

Overall, the available evidence suggests that VR may be a useful complementary intervention for reducing anxiety in patients with breast cancer, particularly during radiotherapy and chemotherapy. However, the strength of this conclusion is limited by methodological concerns identified in the risk-of-bias assessment, including difficulties with blinding, reliance on subjective self-reported outcomes, small sample sizes, incomplete reporting, and heterogeneity in intervention protocols. Therefore, the observed benefits should not be interpreted as definitive evidence of effectiveness. In addition, several studies in the review reported decreased physiological responses to pain, such as lower heart rate and reduced muscle tension, indicating that VR affects not only subjective perception but also physiological responses to pain [61], [62]. Pain assessments used across the four studies included the Visual Analogue Scale (VAS) and the Brief Pain Inventory (BPI). Among these instruments, the VAS was more frequently used because it is more practical, quicker to administer, more sensitive to acute changes, and well-suited to the design of VR interventions, which are generally short-term and clinically applied. The use of VR in clinical pain assessment remains limited due to high equipment costs, technical challenges such as cybersickness, and the lack of large-scale, long-term, standardised studies, which limit its use at home or in smaller clinics. The headset's weight and comfort can be problematic, especially for patients already experiencing fatigue or pain. Evidence suggests that most studies focus on acute attention during treatment rather than on long-term assessment, consistency, or broad clinical integration. However, one study showed that patients could immerse themselves in another setting, thereby shifting the focus away from their pain [46]. The minimal use of VR to reduce pain in breast cancer patients requires further research to determine the effectiveness of VR.

Of the 14 studies, 13 used immersive VR [[31], [37], [40], [42], [44], [45], [46], [47], [48], [49], [50], [53], [54]] and one used non-immersive VR [52]. The VR technologies used included HMD head-mounted display systems in 13 studies and motion-based tracking (Kinect) in one study. The use of immersive VR headsets as a distraction method during a painful procedure resulted in a significantly lower score compared with morphine administration alone [31]. Among the 13 studies reviewed, immersive virtual reality demonstrated a significantpositive impact in reducing depression, anxiety, and psychological stress [43].

In contrast, research using non-immersive VR or semi-immersive VR has generally not demonstrated a direct effect on pain reduction. A study using the VERT system for radiotherapy education only increases knowledge in patients and does not show a significant effect on anxiety and pain levels [40]. This finding shows that non-immersive VR is more widely used as an educational or informational tool than as an analgesic intervention. From a mechanistic perspective, immersive VR provides a higher level of presence and sensory engagement compared with non-immersive VR. Mediation analyses have shown that user engagement mediates the emotional benefits derived from VR use. A greater sense of presence (immersion) leads to stronger psychological effects [63]. In the context of pain management, increased engagement plays an important role in diverting patients from nociceptive stimuli through cognitive distraction and attention modulation. Immersive VR appears to be more effective than non-immersive VR in reducing pain among breast cancer patients, especially during early procedural stages and post-operative rehabilitation.

Of the 14 included studies, session duration varied from approximately 10–60 min among studies that explicitly reported duration. Several studies did not report an exact session duration. Intervention periods also varied from single sessions to multi-week programmes, including periods of up to 8 weeks or more. However, the available evidence does not support the conclusion that 15–30-min sessions or 4–6-week programmes are clinically optimal, as the studies differed in intervention content, frequency, clinical context, and methodological design. Of the 14 included studies, only one study reported compliance with VR use [46].

A study shows that effective VR interventions for pain reduction in breast cancer patients generally range from 10 to 30 min per session and are delivered concurrently with painful procedures or during active rehabilitation sessions [[31], [64]]. In the context of post-operative rehabilitation, VR sessions of approximately 20 min have also been reported to reduce pain perception and improve patients' emotional experiences during treatment [54]. Furthermore, structured and repeated VR sessions within a multi-week rehabilitation program have shown more consistent analgesic effects than single sessions [48]. Although some studies have shown comparable results between VR and conventional rehabilitation groups without statistically significant differences, the intervention durations remained within the same range, approximately 15–30 min per session [52]. Other studies conducted on patients other than breast cancer used VR with the shortest duration of 5 min per session in patients with low back pain [65] and the longest 60 min per session in stroke patients [66] with the shortest intervention duration of 4 weeks in stroke patients [66] and the longest duration of 12 weeks in patients with Social anxiety & phobia [67].

Of the 14 studies, VR content classification was divided into 5, namely: virtual nature [[44], [46], [47], [49]], interactive distraction [[31], [42], [45]], educational procedures [[37], [40]], game-based rehabilitation [[48], [52]], and psychological therapy [38]. Virtual nature was the most dominant content type.

Of the 14 studies, the clinical context of breast cancer patients who received VR interventions in the following conditions: chemotherapy ene, post-surgery [[42], [45], [47]], before radiotherapy [[37], [40]], metastatic breast cancer [[44], [46]], during radiotherapy (1 study), during pain procedures [49], various stages of the disease [43], and personality-based personalization [38].

Of the 11 studies measuring anxiety, 9 obtained significant results [[37], [42], [43], [45], [47], [49], [50], [51], [54]] and 2 obtained insignificant results [[40], [44]]. Of the 5 studies measuring pain, of which 3 obtained significant results [[31], [46], [48]] and 2 obtained insignificant results [[44], [52]].

Virtual reality (VR) reduces pain and anxiety through neuromodulatory mechanisms involving cognitive distraction, emotional regulation, and activation of endogenous analgesic systems. From a neurophysiological perspective, exposure to an immersive VR environment distracts patients from nociceptive stimuli, thereby reducing activity in pain processing pathways in the somatosensory cortex and increasing activation of the prefrontal cortex, which plays a role in cognitive control of pain perception [32]. VR can also affect the limbic system, including the amygdala and hippocampus, which are involved in emotional processing and anxiety regulation, resulting in a decreased emotional response to pain [[65], [68]]. Another mechanism involves activating descending pain-inhibitory pathways by releasing neurotransmitters, such as endorphins and dopamine, that enhance endogenous analgesia [65]. VR use can decrease pain network connectivity and increase top-down modulation, resulting in more controlled pain perception, lower sympathetic nervous system activity (e.g., decreased pulse rate, heart rate, and blood pressure), and reduced cortisol levels, which contribute to reduced anxiety and tension, as well as muscle pain [69]. Systematic reviews of research on the use of VR for pain management in breast cancer patients are still limited. One systematic review evaluating the use of virtual reality in pain reduction was conducted in adolescent patients experiencing pain, patients with spondylosis, and patients post-mastectomy [[70], [71]]. Meanwhile, another systematic review assessed the use of VR for pain in patients with breast cancer, colorectal cancer, and haematological malignancies [72]. Another finding from a systematic review noted a weak but consistent positive association in assessing the effectiveness of VR on the rehabilitation management of breast cancer patients [58].

The strengths of this study are that it provides a systematic review evaluating both anxiety and pain outcomes simultaneously in breast cancer patients receiving VR interventions. To the best of the researchers' knowledge, few previous systematic reviews have examined these two outcomes together in a single analysis. Methodologically, the 14 included studies demonstrate moderate to good research quality, with the majority employing randomised controlled trial designs, which strengthens the evidence suggesting that immersive VR may reduce anxiety and pain in breast cancer patients.

A limitation of this study is the variability in research designs, as studies of VR interventions in breast cancer patients remain relatively limited. As a result, a meta-analysis could not be conducted. In addition, several studies had relatively small sample sizes, and there was considerable heterogeneity in the intervention protocols. The lack of long-term follow-up in many studies also limits the generalizability of the findings and restricts the ability to perform a comprehensive quantitative synthesis across studies.

Across the 14 included studies, VR interventions varied considerably in terms of intervention content, delivery format, session duration, frequency, and treatment stage. The available evidence indicates that VR may have potential as a supportive intervention for anxiety and other psychological outcomes among breast cancer patients, while evidence regarding pain reduction remains limited and inconsistent. This interpretation should be made cautiously because most randomised controlled trials were judged to have some concerns regarding risk of bias, while several non-randomised and quasi-experimental studies showed greater methodological concerns. In addition, the included studies were characterised by methodological heterogeneity, relatively small sample sizes in several studies, inconsistent reporting of effect estimates, and limited long-term follow-up.

The available evidence does not allow a definitive conclusion regarding the optimal session duration, frequency, intervention period, or type of VR content. Among studies that explicitly reported session duration, VR sessions ranged from approximately 10 to 30 min, with approximately 20 min representing the midpoint of the reported range; however, this should not be interpreted as evidence of a clinically optimal duration. Similarly, although individual studies reported benefits following different intervention frequencies and periods, the available evidence does not support the conclusion that 15–30-min sessions or four- to six-week programmes are clinically optimal. Future well-designed randomised controlled trials with adequate sample sizes, standardised outcome measures, transparent reporting of effect sizes and confidence intervals, and longer follow-up are needed to determine the effectiveness, feasibility, and most appropriate dosing of VR interventions for breast cancer patients.

Conclusion

The available evidence suggests that immersive VR may reduce anxiety and, in some clinical contexts, pain among patients with breast cancer. However, confidence in these findings is limited by heterogeneity in VR protocols, relatively small sample sizes, reliance on subjective outcome measures, incomplete reporting, and risk-of-bias concerns across several studies. Accordingly, the findings should be interpreted cautiously. Larger, adequately powered randomised controlled trials with standardised VR protocols, clearly reported randomization procedures, validated outcome measures, appropriate control conditions, and longer follow-up are required before firm conclusions regarding clinical effectiveness can be established. Future research should include more studies, particularly randomised controlled trials with larger sample sizes, to strengthen the evidence regarding VR interventions for pain in breast cancer patients.

CRediT authorship contribution statement

Finta Isti Kundarti: Writing – original draft, Conceptualization. T. Triwiyanto: Visualization, Data curation. Ira Titisari: Formal analysis. Untung Sujianto: Data curation. Anis Nurlaili: Writing – review & editing. Zacky Firlana Azmi: Visualization.

Ethics approval and consent to participate

Not applicable.

Funding

The author(s) declare that no financial support was received for the research and/or publication of this article.

Declaration of competing interest

No competing interest to declare.