Feasibility of the Audio-Visual Assisted Therapeutic Ambience in Radiotherapy (AVATAR) System for Anesthesia Avoidance in Pediatric Patients: A Multicenter Trial

Paulina M. Gutkin, Lawrie Skinner, Alice Jiang, Sarah S. Donaldson, Billy W. Loo, Justin Oh, Yi Peng Wang, Rie von Eyben, John Snyder, Jeremy S. Bredfeldt, John C. Breneman, Louis S. Constine, Austin M. Faught, Daphne Haas-Kogan, Jordan A. Holmes, Matthew Krasin, Charlene Larkin, Karen J. Marcus, Peter G. Maxim, Shearwood McClellandBlair Murphy, Joshua D. Palmer, Stephanie M. Perkins, Colette J. Shen, Stephanie Terezakis, Karl Bush, Susan M. Hiniker

Research output: Contribution to journalArticlepeer-review

4 Scopus citations


Purpose: The Audio-Visual Assisted Therapeutic Ambience in Radiotherapy (AVATAR) system was the first published radiation therapy (RT)–compatible system to reduce the need for pediatric anesthesia through video-based distraction. We evaluated the feasibility of AVATAR implementation and effects on anesthesia use, quality of life, and anxiety in a multicenter pediatric trial. Methods and Materials: Pediatric patients 3 to 10 years of age preparing to undergo RT at 10 institutions were prospectively enrolled. Children able to undergo at least 1 fraction of RT using AVATAR without anesthesia were considered successful (S). Patients requiring anesthesia for their entire treatment course were nonsuccessful (NS). The PedsQL3.0 Cancer Module (PedsQL) survey assessed quality of life and was administered to the patient and guardian at RT simulation, midway through RT, and at final treatment. The modified Yale Preoperative Anxiety Scale (mYPAS) assessed anxiety and was performed at the same 3 time points. Success was evaluated using the χ2 test. PedsQL and mYPAS scores were assessed using mixed effects models with time points evaluated as fixed effects and a random intercept on the subject. Results: Eighty-one children were included; median age was 7 years. AVATAR was successful at all 10 institutions and with photon and proton RT. There were 63 (78%) S patients; anesthesia was avoided for a median of 20 fractions per patient. Success differed by age (P = .04) and private versus public insurance (P < .001). Both patient (P = .008) and parent (P = .006) PedsQL scores significantly improved over the course of RT for patients aged 5 to 7. Anxiety in the treatment room decreased for both S and NS patients over RT course (P < .001), by age (P < .001), and by S versus NS patients (P < .001). Conclusions: In this 10-center prospective trial, anesthesia avoidance with AVATAR was 78% in children aged 3 to 10 years, higher than among age-matched historical controls (49%; P < .001). AVATAR implementation is feasible across multiple institutions and should be further studied and made available to patients who may benefit from video-based distraction.

Original languageEnglish (US)
Pages (from-to)96-104
Number of pages9
JournalInternational Journal of Radiation Oncology Biology Physics
Issue number1
StatePublished - Sep 1 2023

Bibliographical note

Publisher Copyright:
© 2023 The Author(s)

PubMed: MeSH publication types

  • Multicenter Study
  • Journal Article
  • Research Support, Non-U.S. Gov't


Dive into the research topics of 'Feasibility of the Audio-Visual Assisted Therapeutic Ambience in Radiotherapy (AVATAR) System for Anesthesia Avoidance in Pediatric Patients: A Multicenter Trial'. Together they form a unique fingerprint.

Cite this