Pain Management in Cancer Patients: The Effectiveness of Digital Game-based Interventions: A Rapid Literature Review

Behrouz Alizadeh Savareh; Zahra Karandish; Fardis Farhoudi; Azadeh Bashiri

doi:10.4258/hir.2024.30.4.297

Healthc Inform Res > Volume 30(4); 2024 > Article

Savareh, Karandish, Farhoudi, and Bashiri: Pain Management in Cancer Patients: The Effectiveness of Digital Game-based Interventions: A Rapid Literature Review

Review Article

Healthcare Informatics Research 2024;30(4):297-311.

Published online: October 31, 2024

DOI: https://doi.org/10.4258/hir.2024.30.4.297

Pain Management in Cancer Patients: The Effectiveness of Digital Game-based Interventions: A Rapid Literature Review

Behrouz Alizadeh Savareh¹

, Zahra Karandish^2,³

, Fardis Farhoudi^2,³

, Azadeh Bashiri^2,⁴

¹Department of Artificial Intelligence, Naaptech Company, Tehran, Iran

²Department of Health Information Management, School of Health Management and Information Sciences, Shiraz University of Medical Sciences, Shiraz, Iran

³Student Research Committee, Health Human Resources Research Center, Shiraz University of Medical Sciences, Shiraz, Iran

⁴Health Human Resources Research Center and Clinical Education Research Center, Shiraz University of Medical Sciences, Shiraz, Iran

Corresponding Author: Azadeh Bashiri, Department of Health Information Management, School of Health Management and Information Sciences, Health Human Resources Research Center and Clinical Education Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
Tel: +989175014231, E-mail: Bashiri.azadeh@gmail.com (https://orcid.org/0000-0001-9446-8453)

Received March 6, 2024 Revised August 1, 2024 Revised September 26, 2024 Accepted September 27, 2024

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Objectives

Pain is a common side effect of cancer that negatively impacts biopsychosocial well-being and quality of life. There has been increasing interest in using digital game interventions for managing pain in cancer patients. The present study aimed to consolidate and summarize knowledge regarding the role of games in reducing pain among cancer patients and enhancing their overall quality of life.

Methods

We reviewed studies published between 2000 and April 8, 2023, from databases such as PubMed, Scopus, and Web of Science. The focus was on determining the impact of health games on pain management in cancer patients.

Results

An initial search identified 2,544 studies, which were narrowed down to 10 relevant articles after removing duplicates and assessing quality. These studies examined the use of mobile and computer games across various types of cancer, including both pediatric and adult cases. The findings indicate that digital games, particularly those utilizing virtual reality technologies, can diminish pain and anxiety while enhancing treatment outcomes. Overall, the application of these technologies has the potential to improve cancer treatment.

Conclusions

Digital game interventions empower cancer patients by fostering effective communication and patient-centered approaches, which enhance perceptions, outcomes, and overall well-being. These games provide real-time feedback and facilitate interaction with healthcare professionals, which promotes self-management and boosts patient motivation and adherence to treatment protocols. As personalized educational platforms, they increase engagement through educational resources and symptom tracking, while also encouraging physical activity. Furthermore, they act as distraction tools during painful procedures, presenting new research opportunities in pain management and enhancing overall quality of life.

Keywords: Pain Management, Neoplasms, Digital Technology, Video Games, Gamification

I. Introduction

Pain is a common side effect of cancer that adversely affects biopsychosocial well-being and quality of life [1]. Psychological factors such as stress, anxiety, and depression can intensify the perception of pain. For example, a higher level of emotional distress is strongly associated with increased pain intensity and duration in cancer patients. Additionally, social isolation often exacerbates both emotional distress and the experience of pain in these patients [2,3]. Cancer pain is complex and arises from interactions among tumor cells, the nervous system, and the immune system. Tumors may induce nociceptive pain, while treatments can lead to neuropathic pain and influence pain perception through inflammatory responses [4,5].

Cancer patients often experience pain associated with their disease or its treatment, and conventional pain management strategies, such as medications, may not always provide relief or could lead to undesirable side effects [6]. Personalized and targeted interventions have significantly advanced cancer treatment, resulting in marked improvements in survival rates [7]. Nevertheless, effectively managing pain continues to be a significant challenge for these patients, as they cope with the painful side effects of both the disease and its treatments [6].

As the population ages and advanced cancer therapies are developed, the current World Health Organization pain management guidelines remain overly broad and fail to address the diverse mechanisms of pain experienced by cancer patients. Consequently, many of these patients seek emergency care and do not receive adequate pain relief [4]. Reports indicate that approximately 32% of individuals experiencing cancer-related pain did not receive adequate treatment [8]. Patients often report their pain as being more severe than their physicians perceive it to be, although they generally believe that pain medications are effective [9]. However, prolonged use of potent opioids in patients who respond well to them can lead to various adverse effects, including constipation, tolerance, and addiction [8]. Several studies have highlighted the positive impact of technology on symptom management. Technologies such as digital games, virtual reality, and mobile applications have shown promise in improving the management of symptoms [10–15].

Digital games may incorporate various technologies, such as artificial intelligence, animation, graphics, and game engine software, to enhance user experience and gameplay [16]. Digital game interventions for healthcare have gained prominence in recent years [17]. These interventions have proven valuable for various purposes, including Health Education (games educate users about health topics), Rehabilitation (games assist in physical therapy and motor skill improvement), Cognitive Stimulation (games enhance memory and attention), Pain Management (distraction-based games reduce pain), and Behavioral Change (gamification motivates healthy habits) [18–20].

Digital games promote mild to moderate physical activity and offer psychological benefits, enhancing movement, mood, and overall well-being in cancer patients [21]. These games are particularly effective when cancer patients actively participate and engage in behavior rehearsal [18,22]. Their ability to captivate users has made them increasingly popular among children and adolescents. Research consistently demonstrates a strong correlation between playing video games and reduced pain intensity in various patient groups, including those with chronic pain and burn patients. Additionally, these games improve patients’ adaptability during medical procedures that may cause discomfort [23,24].

In the context of digital games, serious games are defined as any form of interactive computer-based software designed for one or multiple players, usable on any digital platform, and developed with the intention of serving purposes such as learning, training, or treatment beyond mere entertainment [25,26]. The process of integrating serious games into non-game contexts is known as gamification [27]. Applying gamification in pain management for cancer patients has the potential to be a highly effective strategy for actively involving patients in their treatment and ensuring they are well-informed about their therapies. For optimal results, this approach should be based on established and tested theories to ensure its effectiveness and be meticulously designed to effectively influence behavioral change [28].

Recently, a wide variety of digital games have emerged, spanning computer-based, mobile, and web-based platforms. These games incorporate advanced technologies such as artificial intelligence to create adaptive gameplay, virtual and augmented reality for immersive experiences, and cloud gaming to improve accessibility across multiple devices [29–31]. Innovations such as blockchain technology are used to secure transactions and establish digital ownership, while advances in graphics rendering increase visual realism. Furthermore, game engines and mobile optimization are essential in crafting engaging and interactive gaming experiences [30,32,33]. These technologies have been thoroughly explored for their potential in physical rehabilitation, pain management, and surgical training [30]. Immersive gaming experiences have proven effective in reducing perceived pain levels and anxiety during medical procedures, especially among cancer patients [30,34–37].

These engaging tools hold considerable promise in supporting cancer patients, particularly children and adolescents. They offer educational resources and facilitate communication with healthcare professionals, optimizing cancer pain management. However, it is essential to design these games with a thorough understanding of the unique challenges that patients face [18,38].

This study assesses the effectiveness of digital games in managing pain among cancer patients, contributing to evidence-based guidelines and enhancing quality of life.

II. Methods

This rapid review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) method [39] to highlight the impacts of digital game interventions on pain management in cancer patients.

This review addresses the increasing burden of cancer and explores the role of digital game interventions in managing pain. It seeks to identify effective game types for various cancers, emphasizing successful interventions and user-friendly options. Additionally, it assesses associated outcomes and offers a rapid review to support timely health policy and decision-making [40]. This study was conducted as a rapid review to provide valuable insights for decision-makers in the cancer domain, underscoring the benefits of using digital games as a supplementary approach to medication therapy for pain management in patients.

The present review utilized the PICO framework to identify and search for appropriate sources and evidence, which helped in formulating research questions and facilitating the literature search [41]. The components of the PICO framework in this study were as follows: population (cancer patients), intervention (digital games), comparator (not restricted) and outcome (the effect of digital games on pain management).

1. Searching Literature

We utilized three databases—PubMed, Web of Science, and Scopus—to address our research question: What is the effectiveness of digital game-based interventions in pain management for cancer patients? Additionally, we established search restrictions based on our inclusion and exclusion criteria. To ensure comprehensive research across these databases, specific search strings were employed. Table 1 displays the search strings and the fields to which they were applied during the database searches.

2. Inclusion and Exclusion Criteria

To ensure quality, we included original articles written in English and published between 2000 and April 8, 2023 that focused on health games, serious games, and gamification. We excluded articles published before 2000 due to the emergence of digital health games. Additionally, non-English articles, books, letters to the editor, and reviews were excluded to maintain rigor and relevance.

3. Quality Assessment of the Studies

The quality of all included articles was assessed by two independent researchers (A.B. and B.A.), using the Joanna Briggs Institute (JBI) critical appraisal checklists. These checklists are designed to evaluate the risk of bias in both observational and interventional studies, specifically in analytical cross-sectional studies and randomized clinical trials (RCTs) [42]. The checklists include eight questions for cross-sectional studies and 13 questions for RCTs, with each question scored as 1 (yes), 0 (no), or unclear/not applicable. The overall score for each article is presented as a percentage. Based on this scoring, articles are categorized into three levels of bias risk: high risk (20%–50% of items scored yes), moderate risk (50%–80% of items scored yes), and low risk (80%–100% of items scored yes), as per the JBI guidelines. The application of the JBI checklist resulted in the exclusion of two additional studies. Any disagreements were resolved through discussion meetings, ultimately leading to the inclusion of 10 relevant studies in our analysis.

4. Screening and Extraction of Literature Characteristics

In the final stage, reviewers (A.B., Z.K., F.F., and B.A.) extracted necessary data from the papers. This data included information about the authors and publication year, the aim of the study, the type of cancer, the study design, the characteristics of the participants, the pain measurement tool used, and the study results, all based on a predefined extraction form. After extracting the data, researchers (A.B. and B.A.) verified its accuracy. In the event of discrepancies, the researchers reached an agreement by discussing and comparing their findings to resolve any disagreements.

III. Results

The present study was conducted to explore the effects of digital games on pain management in cancer patients. The study focused on three main questions:

RQ1: Which types of cancer were most frequently mentioned?
RQ2: Which types of games (computer games or mobile games) were more commonly used?
RQ3: How can games assist cancer patients in managing pain?

1. Summary of the Paper Selection Process

After reviewing numerous studies on the impact of gaming on cancer patients, we initially considered 2,544 studies. However, following a detailed selection process, we narrowed our focus to 10 studies that specifically addressed pain management through digital games. We excluded 1,414 studies based on title and abstract screening, and an additional 863 studies were excluded for reasons including lack of originality, non-English language, or irrelevance to our research aim.

2. Quality Assessment Results

In this phase, two studies were excluded based on the appraisal using the JBI Checklist. Tables 1 and 2 present the risk of bias results according to the JBI checklist for observational and interventional studies, respectively [43–54]. Figure 1 illustrates the search and screening process for this study.

3. Summary of Included Studies

Table 3 categorizes the reviewed articles based on various criteria, including aim, cancer type, type of digital game, study type, participant characteristics, study methodology, pain measurement tool, and results.

4. Answers to the Study Questions

RQ1: Which types of cancer were most frequently mentioned?

Out of the 10 articles examined, seven focused on various forms of pediatric cancers, including acute lymphoblastic leukemia, brain tumors, Hodgkin lymphoma, non-Hodgkin lymphoma, and osteosarcoma. Among adult cancers, two articles specifically addressed breast cancer in women, while the remaining article did not specify the type of cancer under investigation.

Based on the information provided, it can be inferred that digital games, including mobile games, computerized games, and those utilizing virtual reality technologies, can serve as distraction interventions. These interventions have the potential to reduce pain and anxiety levels while enhancing the effectiveness of treatment.

RQ2: Which types of games (computer games or mobile games) were more commonly used?

Out of the 10 reviewed articles, three focused on mobile games, while another three discussed computer games, including one that was based on virtual reality. Additionally, two studies centered around virtual reality, and two others were based on web-based games, without specifying whether they were computer games or mobile games.

RQ3: How can games assist cancer patients in managing pain?

According to studies, digital games can positively impact cancer-related pain by enhancing physical activity and satisfaction [21], and reducing depression and stress [11]. They also improve patients’ understanding, coping skills, and cognitive functioning, serving as effective distractions and supportive care for pediatric cancer patients. These tools are informative, beneficial, and contribute to enhancing cancer treatment for adolescents, thereby improving treatment efficacy. For instance, included studies [43–45], have highlighted the utility of video games and other interactive virtual experiences in enhancing cognitive functioning over time and reducing pain during certain cancer treatment procedures. It is important to note that these games, used in pain research, are not designed to educate patients about cancer or to change their attitudes toward the disease or its treatment. Instead, they are commercially available games intended solely for entertainment purposes, without any cancer-related content. Another included study [46] has demonstrated that virtual reality has been utilized in medical settings to manage pain associated with cancer and medical procedures. The virtual reality simulation, often presented as a game, effectively diverts patients’ attention from their physical pain, resulting in a reduction in both perceived pain and associated anxiety levels [46].

To address the challenges faced by chronically ill children, Gerling et al. [47] have highlighted the development of STARBRIGHT World, a web-based community. This platform is distinct from others as it does not concentrate on any specific medical condition. Instead, it features various mini-games that do not explicitly reference any particular disease. The aim of this community is to offer support and benefits to these children, drawing on research that indicates engagement in online platforms can enhance treatment compliance, alleviate pain, and improve coping strategies.

Nilsson et al. [46] concluded that experiencing pain during examinations and treatments is a common physical issue among pediatric cancer patients. A potential alternative approach to managing this pain involves using distraction techniques to lessen the distress caused by these medical procedures.

One study included in the review suggested that using ePRO and serious games can enhance pediatric cancer care by actively engaging patients. Additionally, Bernier Carney et al. [48] stated that school-age children with cancer can share their pain experiences through mobile apps that incorporate gaming elements. This aids healthcare professionals in comprehensively assessing and managing pain in this group [49].

According to the study by Feyzioglu et al. [50], Kinect-based virtual reality therapy can be effectively utilized in clinical settings for patients experiencing significant fear of movement or intense pain following breast cancer surgery.

Carrion-Plaza et al. [51] emphasized the need for further research in technology to enhance pediatric cancer interventions within the HabitApp project. They highlighted the importance of integrating caregivers into play therapy for a comprehensive approach to treatment. Another included study [52] emphasized that hospital architectural design, computer games, and nurse behavior can positively influence treatment efficacy for adolescent cancer patients.

IV. Discussion

Cancer pain is a common symptom among patients with cancer, and effective pain assessment and management are essential for improving their quality of life and overall health outcomes. However, despite the availability of various treatments, there remains significant room for improvement in the management of cancer pain [55].

Digital games are an emerging technological approach being explored to enhance pain management in cancer patients by providing distraction and improving emotional well-being [56,57]. This category includes a wide range of games played on digital platforms, from personal computers to game consoles, and on devices such as tablets and mobile phones [58]. While digital games serve various purposes, those used beyond entertainment—for education and therapeutic interventions—are commonly known as serious games [59].

Serious games effectively educate cancer patients about medication adherence, disease prevention, self-management, and pain relief, actively engaging them in their health outcomes [60].

A study [61] demonstrated that incorporating gamification into pain management applications could effectively motivate patients and enhance their treatment experience. The Pain-Mentor app, designed to assist teenage cancer patients with pain management, was highly rated by 13 healthcare experts using the Mobile Application Rating Scale. The experts praised the app for its engaging content and gamification features, which encourage patient involvement in their care [61]. Consistent with this research, the majority of the studies reviewed underscore the effectiveness of gamification in improving pain management, especially for pediatric cancer patients, through the successful implementation of both mobile and computer games. For instance, a study [48], evaluated the Color Me Healthy app, which enables school-age children with cancer to self-report symptoms and pain experiences using gamified elements. With data analyzed from 19 participants, the study showed that the app significantly improved symptom communication and patient engagement [48].

Recognizing that each cancer patient’s experience of pain is unique and influenced by a variety of biopsychosocial factors, researchers are increasingly advocating for a multidisciplinary approach. They are also utilizing mobile and digital platforms, virtual reality, and machine learning to tailor and optimize treatment interventions [60,62].

Mobile video games and virtual reality are increasingly being utilized for pain management in cancer patients. These tools have proven effective in reducing pain and anxiety, while also enhancing patient engagement and improving the overall care experience [20,48,55,61].

In a study conducted by Schneider et al. [65] involving 20 women with breast cancer undergoing chemotherapy, it was found that virtual reality effectively reduced symptoms such as distress, fatigue, and anxiety compared to those receiving chemotherapy without any distraction therapy. Additionally, mobile-based games have been shown to improve drug compliance and reduce side effects in cancer patients by enhancing education, engagement, and symptom management, while also providing a distraction [66]. The present study encompasses research that highlights the positive effects of mobile games on pain management, particularly for pediatric cancer patients, as well as the benefits of virtual reality-based games for adults with breast cancer.

Incorporating serious games into pain management for cancer patients can be beneficial. These games can assist patients in setting goals and solving problems related to their pain management, thereby encouraging active participation [67]. They can also serve as educational tools, teaching patients about various pain management strategies, including relaxation techniques, distraction methods, and medication management [68]. Serious games also have the potential to motivate patients to actively engage in managing their pain, ultimately improving their quality of life [69]. Furthermore, these games can be customized to meet the specific needs and preferences of individual cancer patients [70].

Hospitalization and painful medical procedures can induce emotional distress in cancer patients, leading to common responses such as worry, fear, and uncertainty [22,71]. Digital games can help alleviate anxiety and pain in cancer patients, although side effects from medications may limit participation. It is crucial to develop user-friendly, accessible games specifically tailored to their needs, allowing healthcare professionals to improve patient outcomes and quality of life [47,72,73]. This review advocates for the customization of digital games to meet the individual needs of cancer patients, their early implementation in treatment, and the involvement of caregivers. Effectively integrating these games into clinical settings can significantly alleviate pain and anxiety. Healthcare providers should select age-appropriate games, incorporate them into treatment plans, train staff, and involve patients in the selection process to enhance outcomes and quality of life.

The present study highlights the limitations of study quality, publication bias, and language bias in research on digital game-based interventions for cancer patients. Despite these challenges, it provides valuable insights and sets the stage for future studies that will systematically categorize outcomes and enhance understanding of the effectiveness of these interventions in pain management.

Effective communication between patients and healthcare providers is crucial for improving perceptions and outcomes. Serious games can empower patients by teaching pain management strategies, promoting physical activity, and personalizing care. The potential of serious games and virtual reality in cancer pain management presents exciting opportunities for further research and development.

Notes

Conflict of Interest

No potential conflict of interest relevant to this article was reported.

Figure 1

Preferred Reporting Items for Systematic Reviews and Meta-Analyses diagram showing the screening process used for the selected papers. WOS: Web of Science, AI: artificial intelligence, JBI: Joanna Briggs Institute.

Table 1

Risk of bias according to the Joanna Briggs Institute (JBI) Checklist for observational studies

Study	Risk of bias according to JBI Checklist
Study	1	2	3	4	5	6	7	8	Overall	Weight
Kato et al. [45]	1	1	1	1	0	0	1	1	75%	−
Meyerhiem et al. [49]	1	1	1	1	1	1	1	1	100%	+
Tong et al. [44]	1	1	1	1	0	0	1	1	75%	−
Zheng et al. [52]	1	0	1	1	0	0	1	1	62.5%	−
Bernier Carney et al. [48]	1	1	1	1	0	0	1	1	75%	−

“+” indicates low risk and “−” moderate risk.

Table 2

Risk of bias according to the Joanna Briggs Institute (JBI) Checklist for interventional studies

Study	Risk of bias according to JBI Checklist
Study	1	2	3	4	5	6	7	8	9	10	11	12	13	Overall	Weight
Feyzioglu et al. [50]	1	1	1	0	0	1	1	1	1	1	1	1	1	84.6%	+
Bellens et al. [43]	1	0	1	0	0	1	0	1	1	0	1	1	1	61.5%	−
Carrion-Plaza et al. [51]	0	1	1	0	0	0	0	1	1	0	1	1	1	53.8%	−
Gerling et al. [47]	0	0	1	0	0	1	0	1	1	0	1	1	1	53.8%	−
Ng et al. [72]	0	1	0	0	0	0	0	1	1	0	0	1	0	30.7%	x
Nilsson et al. [46]	0	1	1	0	0	1	0	1	1	0	1	1	1	53.8%	−
Chai et al. [73]	0	1	0	0	0	0	0	0	1	1	0	1	0	30.7%	x

“+” indicates low risk, “−” moderate risk, and “x” high risk.

Table 3

Summary of studies on digital game-based interventions for pain management in cancer patients

Study, year	Study aim	Cancer type	Digital game type	Study type	Participants characteristics	Study methodology	Pain measurement tool	Results
Gerling et al. [47], 2011	To explore casual game design, focusing on the integration of serious game elements that promote health and well-being.	Pediatric cancer (unspecified childhood cancer type)	Web-based digital game	Interventional study (questionnaire and qualitative interviews)	n = 23 (17 M, 6 F) Age: 7–19 yr	Subjects were introduced to the Cytarius game and completed a questionnaire on its usability and their gaming experience. Qualitative interviews were also conducted to gather insights from players, parents, and medical staff regarding their perceptions of the game.	N/A	Digital games can help young patients improve their pain management skills.
Kato et al. [45], 2006	To investigate the acceptability of an action video game about cancer as a learning tool for adolescent and young adult cancer patients regarding cancer and self-care during treatment.	Pediatric and adult cancers (acute lymphoblastic leukemia, Hodgkin’s lymphoma, acute myelocytic leukemia, brain tumor, non-Hodgkin’s lymphoma, osteosarcoma and other types of cancer)	Computer-based video game	Observational study (interview)	n = 43 (26 M, 17 F) Age: 13–25 yr	Interviews were conducted with subjects regarding a proposed video game animation, and they also completed questionnaires assessing their personality and adaptive style.	N/A	Enhancing the comprehension and self-management skills of adolescent and young adult with cancer patients to control pain.
Nilsson et al. [46], 2009	To assess the effects of non-immersive VR on pain and distress in children and adolescents during needle-related procedures in a pediatric oncology unit, along with their feedback on the VR experience.	Pediatric cancer (hematological diseases, leukemia, lymphoma, CNS tumor and another solid tumor)	VR-based game	Interventional study	n = 42 (24 M, 17 F) Age: 5–18 yr	The study involved 21 children and adolescents using non-immersive VR in an intervention group and 21 in a control group undergoing venous procedures. Data on pain, distress, heart rate, and observational scores were collected at various stages, along with qualitative interviews after the intervention.	FLACC scale	Reduction in the levels of pain and distress.
Meyerhiem et al. [49], 2021	To assess the feasibility of the MyPal ePRO-based digital system for early palliative care in pediatric oncology patients, focusing on enhancing symptom reporting and improving quality of life in children with cancer.	Pediatric cancer (leukemia or solid cancer)	Mobile-based game	Observational prospective clinical feasibility study	n = 100 Age: 6–17 yr	Participants utilized mobile applications from a digital health platform for 6 months to complete monthly ePROs on quality of life, care satisfaction, and the impact of illness on families. The platform also features a serious game designed for children that facilitates priority-based symptom reporting.	EQ-5D-3L version	Enhancing patients’ ability to cope mobility, self-care, usual activities, pain/discomfort and anxiety/depression.
Feyzioglu et al. [50], 2020	To investigate the potential effects of early postoperative VR therapy on pain, ROM, muscle strength, functionality, and fear of movement.	Adult cancers (breast cancer)	VR-based game	Interventional study (clinical trial)	n = 40 (40 F) Average age: 50 yr	The subjects were randomly divided into two groups: one receiving Kinect-based VR rehabilitation and the other receiving standardized physical therapy. Assessments were conducted at baseline and after 6 weeks, measuring pain, grip strength, functionality, muscle strength, ROM, and fear of movement.	VAS	Decreased the pain in patient with breast cancer.
Bellens et al. [43], 2020	To evaluate the effectiveness of a web-based cognitive training video game in improving cognitive decline among breast cancer patients when used alongside standard rehabilitation care.	Adult cancers (breast cancer)	Web-based video game	Interventional study (prospective randomized pilot trial)	n = 23 (23 F) Age: 18–71 yr	Patients used a web-based video game and online cognitive assessments, with the early intervention group (n = 23) engaging in a 6-month training program alongside standard rehabilitation. The delayed intervention group (n = 23) received standard care for three months before starting the same training, and outcomes were measured using MyCQ scores, ADL, mood, and cognitive status.	RAND 36	Enhancing cognitive functioning over a period of time and pain reduction.
Bernier Carney et al. [48], 2021	To assess the self-reported pain experiences of schoolage children with cancer involved in a feasibility trial of a game-based symptom assessment app.	Pediatric cancers (acute lymphoblastic leukemia, brain tumor, Hodgkin’s lymphoma, non-Hodgkin’s lymphoma, and osteosarcoma)	Mobile-based game	Observational study	n = 19 (12 M, 7 F) Age: 6–12 yr	Participants tracked their symptoms for 5 days between clinical visits using a game-based symptom assessment app. Children could report general pain and localize it on an avatar, as well as describe symptoms through free-text responses or a diary feature within the app.	Color Me Healthy app	Assisting healthcare professionals in employing various methods to obtain a comprehensive and clinically significant assessment of pain in cancer patients.
Zheng et al. [52], 2020	To propose a model for evaluating the effects of hospital architecture, computer games, and nurses’ behavior on the treatment effectiveness.	Pediatric cancer (unspecified type of cancer)	Computer-based game	Observational study	n = 70 (32 M, 35 F) Age: N/A	The study uses a mixed-methods approach, combining quantitative measures of self-reported pain and distress with qualitative interviews to assess patient experiences. Data will be gathered from both intervention and control groups to evaluate the impact of these factors on treatment effectiveness.	N/A	Improve the efficacy of the treatment procedure among cancer patients and help to reduce their pain and discomfort.
Carrion-Plaza et al. [51], 2020	To evaluate the impact of HabitApp on the psychosocial well-being of patients and caregivers, with the goal of enhancing the hospitalization experience in the short term.	Pediatric cancer (unspecified type of cancer)	Mobile-based game	Observational study	n = 39 (25 M, 14 F) Age: 1–16 yr	The subjects utilized the HabitApp tool, and an ad hoc observational assessment was performed.	Somatic Complaints List (SCL)	Improving the involvement of caregivers in play therapy for pediatric oncology patients and pain assessment.
Tong et al. [44], 2018	To assess the effectiveness of home-use VR for managing chronic pain in cancer survivors over 6 weeks.	Adult cancers (unspecified type of cancer)	Computerized virtual reality-based game	Observational study (mixed method approach)	n = 7 (7 F) Age: ≥19 yr	Participants engaged in VR games for at least 30 minutes a day, 3 days a week, using curated content for chronic pain management. The study evaluates patients’ experiences with these VR games compared to non-VR conditions to determine optimal gaming experiences for pain relief.	N/A	The positive impact of digital game on pain distraction and management.

VR: virtual reality, ROM: range of motion, ePROs: electronic patient-reported outcomes, ADL: activities of daily living, FLACC: Face, Legs, Activity, Cry, and Consolability scale, EQ-5D-3L: European Quality of Life 5 Dimensions 3 Level, VAS: visual analogue scale, M: male, F: female.

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