Virtual reality for reducing pain, anxiety, and distress in children, adolescents, and young adults with cancer: a systematic review and meta-analysis of randomized controlled trials.

Background: Needle-related procedures are a significant source of pain, anxiety, and distress for children with cancer. This systematic review and meta-analysis aimed to evaluate the effectiveness of virtual reality (VR) as a distraction intervention for reducing these outcomes in pediatric oncology patients undergoing needle-related procedures. Methods: A systematic search of PubMed, Embase, Cochrane Central Register of Controlled Trials, PsycINFO, and CINAHL was conducted from database inception to March 23, 2026. We included randomized controlled trials (RCTs) evaluating the effect of VR (immersive or non-immersive) compared to standard care or active distraction in pediatric oncology patients (aged ≤21 years) undergoing needle-related procedures. The primary outcome was self-reported pain. Secondary outcomes included parent-reported pain, nurse-reported pain, self-reported fear, parent-reported fear, nurse-reported fear, self-reported anxiety, parent-reported anxiety, distress, procedure duration, and heart rate. Meta-analyses were performed using random-effects models. Risk of bias was assessed using the Cochrane RoB 2.0 tool. Results: Ten RCTs enrolling 536 participants were included. VR significantly reduced self-reported pain (Standardized Mean Difference [SMD] = -0.99, 95% Confidence Interval [CI]: -1.37 to -0.61, p = 0.001, I² = 71.7%), parent-reported pain (SMD = -1.10, 95% CI: -1.66 to -0.54, p < 0.001, I² = 83.6%), and nurse-reported pain (SMD = -1.00, 95% CI: -1.92 to -0.08, p = 0.025, I² = 80.0%). Significant reductions were also observed in self-reported fear (Weighted Mean Difference [WMD] = -1.10, 95% CI: -1.50 to -0.70, p < 0.001, I² = 58.0%), parent-reported fear (WMD = -1.31, 95% CI: -1.58 to -1.03, p < 0.001, I² = 7.1%), nurse-reported fear (WMD = -1.15, 95% CI: -1.55 to -0.75, p < 0.001, I² = 0.0%), self-reported anxiety (SMD = -1.06, 95% CI: -1.63 to -0.49, p = 0.002, I² = 79.9%), parent-reported anxiety (SMD = -1.59, 95% CI: -2.24 to -0.95, p < 0.001, I² = 51.5%), and distress (SMD = -0.35, 95% CI: -0.67 to -0.03, p = 0.032, I² = 19.6%). VR also significantly shortened procedure duration (WMD = -0.76 minutes, 95% CI: -1.34 to -0.19, p = 0.009, I² = 0.0%) but had no significant effect on heart rate (WMD = 1.57, 95% CI: -3.51 to 6.64, p = 0.544, I² = 80.3%). The overall risk of bias was low risk for five studies, some concerns for four studies, and high risk for one study. Conclusion: The available evidence suggests that VR may reduce pain, fear, anxiety, and distress and may shorten procedure duration in pediatric oncology patients undergoing needle-related procedures. These findings should be interpreted cautiously because several outcomes were based on few small trials and substantial heterogeneity was present. Larger multicenter RCTs are needed before routine implementation can be recommended. Systematic review registration: https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42026134853.