Video distraction minimizes anesthesia for children undergoing radiotherapy
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Pediatric patients undergoing treatment with radiation therapy often have difficulty tolerating the process of daily treatment.
“It can be very challenging and scary for some children undergoing radiotherapy because they have to be very still for up to an hour and are alone in the treatment room during much of the procedure,” Susan Hiniker, MD, pediatric radiation oncologist at Stanford Medicine Children’s Health and associate professor of radiation oncology at Stanford School of Medicine, told Healio.
“That is why many young patients need daily general anesthesia when undergoing radiotherapy to help keep them still to ensure treatment accuracy,” she added. “However, there are associated medical risks and potential long-term neurodevelopmental effects, as well as logistical issues associated with daily anesthesia.”
To help reduce the potential risks, time and costs associated with daily anesthesia, Hiniker and a team of researchers at Stanford Medicine developed a video immersion system designed to calm and distract children undergoing radiation, thus avoiding the need for anesthesia. They evaluated the audio-visual assisted therapeutic ambience in radiotherapy (AVATAR) in a study of 81 children aged 3 to 10 years being treated for cancer at 10 U.S. pediatric hospitals. Hiniker spoke with Healio about the study, which is published in International Journal of Radiation Oncology, Biology and Physics.
Healio: Why is it important to minimize the use of anesthesia in the setting of pediatric radiotherapy?
Hiniker: Daily anesthesia is an invasive procedure associated with short-term medical risks. In addition, recent medical studies have shown potential long-term neurocognitive risks in children from undergoing repeated doses of general anesthesia. Additionally, it’s much more costly to the patient, family and health care system, and the use of anesthesia requires children and families to spend much more time at the hospital each day.
At Stanford Medicine, we started to notice that kids could be very still, calm, transfixed and cooperative, as long as they were distracted, watching a tablet. We wanted to explore if there was a way we could use video immersion during radiation therapy to help them remain calm and cooperative during treatment.
Healio: How did you develop the AVATAR system, and how does it work?
Hiniker: The AVATAR system includes a wireless projector and speaker, and a custom-designed radiolucent screen and attachments. While the child is distracted by a video of the patient’s choosing, radiation therapy can be administered, and the radiation beam passes directly through the screen without affecting the radiation dose that the child is receiving.
Healio: How did you evaluate the AVATAR system?
Hiniker: After we developed the system and assessed its safety, we performed measurements of dose delivered with and without the AVATAR system in place to ensure that the AVATAR system was not affecting the radiation beam or treatment received. We started using AVATAR routinely at Stanford Medicine several years ago, and we performed an analysis of patients who were given the opportunity to use AVATAR vs. patients who were treated before we had incorporated AVATAR into our department.
We found there was a significantly lower need for anesthesia among patients who had the opportunity to use AVATAR. Once we presented and published these results, our colleagues and friends at other institutions contacted us and were interested in finding a way to use AVATAR with their own patients.
So, we developed the concept of a collaborative multicenter trial testing the feasibility of implementing the AVATAR system at other institutions and prospectively assessing anesthesia use rates, anxiety, and patient and family quality of life. We opened this multicenter study as a prospective trial enrolling children preparing to undergo radiation therapy. Patients were given the opportunity to use AVATAR instead of anesthesia, and we measured the rates of children able to avoid anesthesia while using AVATAR. We then prospectively performed serial quality-of-life and anxiety assessments using standardized metrics.
Healio: What did you find?
Hiniker: Of the 81 children involved from all 10 centers across the country, we found that 78% were successful in avoiding anesthesia while using AVATAR. We didn’t have a control arm, but we compared this rate of anesthesia avoidance to the best data we have from the literature. Among age-matched historical controls, about 49% of children aged 3 to 10 years in the literature were reported to receive radiation without anesthesia.
Also exciting to us is the fact that all 10 centers were successful in using AVATAR. We defined institutional success as at least 50% of patients being able to avoid anesthesia during radiotherapy while using AVATAR. This was very positive, because it showed us that this relatively simple technique could be implemented at a variety of centers with many different practices, varying treatment techniques and patient populations.
Healio: What are your hopes for the future of the AVATAR system?
Hiniker: We are working on incorporating AVATAR into global health and radiation oncology in other countries, some of them with fewer resources. We have ongoing collaborations with centers in Tanzania, India and Romania, and we are working on incorporating AVATAR there.
Some of these countries and centers don’t have access to anesthesia. If a child at those centers can’t do radiation therapy awake, then they will not receive the treatment they need. By using AVATAR, we hope we can increase the success rates of treatment and also make it a more enjoyable experience for younger patients.
Healio: Do kids seem to enjoy it?
Hinkier: We have noticed that kids everywhere seem to really enjoy watching streaming video.
In pediatric oncology, we’re dealing with smaller patient numbers, but each situation is very critical and important, and it matters to us a great deal what the children’s treatment experiences are like. Hearing about specific children and how helpful AVATAR was to them has been very meaningful to us. One of our collaborating institutions at The Ohio State University was able to use the system on a 2-year-old. This patient wasn’t old enough to be in our trial, but the Ohio State center wanted to see if the patient could do radiation without anesthesia, and he was successful. It’s exciting to see people really embrace this technology and use it in amazing ways.
Healio: Is there anything else you’d like to mention?
Hiniker: We are fortunate to have a lot of support for our work here. It was initially funded through the Stanford Medicine Clinical Innovation Fund, which supports creative ideas that have the potential to improve patient care. Lawrie Skinner, PhD, has been leading this project with me from the physics side, and Bill Loo, MD, PhD, and Sarah Donaldson, MD, really pioneered the concept.
Having been involved in research for a while, I’d say this has been one of the most gratifying projects I’ve done — to be involved in a research product and very directly see how much it is positively impacting patients. Just being able to work with our collaborators on this trial has been a wonderful experience.
Reference:
Gutkin PM, et al. Int J Radiation Oncol Biol Physics. 2023;doi:10.1016/j.ijrobp.2023.03.063.
For more information:
Susan Hiniker, MD, can be reached at email: shiniker@stanford.edu.
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