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J.K. Cataldo

Moderator of

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    O25 - Stigma and Nihilism (ID 139)

    • Event: WCLC 2013
    • Type: Oral Abstract Session
    • Track: Nurses
    • Presentations: 6
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      O25.01 - Reliability of and Correlates with a Measure of Lung Cancer Stigma in Norwegian Patients Who Underwent Lung Cancer Surgery (ID 2017)

      16:15 - 16:25  |  Author(s): T. Oksholm, T. Rustoen, C. Miaskowski, S. Paul, J. Cataldo, J. Kongerud

      • Abstract
      • Presentation
      • Slides

      Background
      In HIV, cancer, and other diseases, stigma is known to have a negative impact on patient outcomes. Regardless of smoking status, lung cancer patients feel stigmatized because their disease is strongly associated with smoking. In addition, higher levels of lung cancer stigma (LCS) are associated with higher levels of depression and poorer quality of life (QOL). Previous studies have measured LCS in heterogeneous samples of patients at various stages of their disease and treatment. The purpose of this study was to evaluate LCS levels in a homogenous sample of patients 5 months after lung cancer surgery and to identify correlates of LCS.

      Methods
      Patients were recruited from three university hospitals in Norway. They completed a number of self-report questionnaires and the Cataldo Lung Cancer Stigma Scale (CLCSS). The CLCSS is a 31-item scale with each item rated on a 4-point Likert scale (i.e., strongly disagree to strongly agree). Descriptive statistics were used to present demographic and clinical characteristics. Reliability of the CLCSS was assessed using Cronbach’s alpha. Multiple regression analysis was done to identify characteristics associated with higher levels of LCS.

      Results
      Findings from this study provide data on the first time use of the CLCSS in a Norwegian sample of patients with lung cancer. Cronbach's alpha for the total CLCSS score was 0.95. The sample consisted of 121 (57.1%) men and 91 (42.9%) women who had a mean age of 66.1 years (SD=8.3, range 30 to 87). The mean stigma score was 44.0 (SD=13.8) with a range of 31 to 109 (a higher score, indicates higher level of stigma). Bivariate analysis of demographic and clinical characteristics revealed that patients with a higher level of stigma were younger (r = -.18, p =.01), more likely to live in a small town compared to rural areas (p=.04), had smoked until the time of surgery (p=.008), and had higher levels of depression (r = .24, p˂.001). Marital status was included in the multivariate analysis, because it approached significance in the bivariate analysis (p=.07). In the multivariate analysis, marital status (p=.002) and depression (p=.006) remained significant. The final multivariate model explained 13.5% of the variance in stigma scores. Marital status and depression symptom scores uniquely explained 3.6% and 4.6% of the variance of stigma, respectively. Patients who were married and patients who reported higher depression scores reported higher stigma scores.

      Conclusion
      The CLCSS is a valid measure of stigma in Norwegian patients with lung cancer. The majority of the patients (97%) reported stigma scores below 75.7, the mean score obtained in a United States sample. However, 3% of the sample had a stigma score of >75.7. In a Norwegian sample of lung cancer patients, being married and having a higher mean score on the Center for Epidemiological Studies-Depression Scale (i.e., 27.3 (SD=13.4)) were associated with higher LCS.

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      O25.02 - The Social Stigma of Lung Cancer: Death Anxiety and Health Beliefs as Antecedent Variables (ID 2015)

      16:25 - 16:35  |  Author(s): T. Frew, V. Knott

      • Abstract
      • Presentation
      • Slides

      Background
      Lung cancer patients in Australia report a profound experience of stigma. Therapeutic nihilism, differences in chemotherapy treatment options compared to other cancers, and the onset controllability of the disease are some of the contributing factors to the stigma and its effects on the patient, such as poor psychosocial and quality of life outcomes. This is the first known study to investigate the constructs underlying the community’s views on lung cancer through the lens of a prominent social stigma model. This model explores three domains of stigma; enforcement of social norms, avoidance of disease and exploitation of the stigmatised group. Health Locus of Control Theory and Terror Management Theory explore the role of health beliefs and death anxiety as antecedent variables to the social stigma of lung cancer.

      Methods
      A total of 211 university students (males = 56, females = 155) (64% undertaking a health degree) completed an online survey containing the Cataldo Lung Cancer Stigma Scale (CLCSS), the Death Anxiety Inventory (DAI) and the Internal and Chance subscales of the Multidimensional Health Locus of Control scale (MHLC). Approximately 65% of participants were 18-25 years of age and “never smokers”. Approximately 40% had current or previous contact with a person suffering lung cancer.

      Results
      The underlying structure of the CLCSS was investigated using principal axis factoring with varimax rotation. Four factors accounted for 61% of variance in lung cancer stigma. To test the hypothesis that the fear of death and health beliefs respectively account for a portion of variance in lung cancer stigma, a hierarchical multiple regression analysis (MRA) was employed. On step 1, demographic variables, smoking status, family smoking history and contact with lung cancer accounted for a significant 10% of the variance in lung cancer stigma, R[2 ]=.10, F(7, 201) = 3.03, p =.005. Entering death anxiety and health beliefs respectively at step two explained an additional 4% variance in lung cancer stigma, ∆R[2 ]=.14, ∆F(3, 198) = 3.16, p =.001. A combined effect of this magnitude can be considered “medium” (f [2] = .16). Smoking status (sr[2] = .03) and fear of death (sr[2] = .03) were significant predictors of lung cancer stigma. Health beliefs were non-significant predictors.

      Conclusion
      A lung cancer patient is likely to evoke emotions associated with a fear of death for community members who are high on death anxiety. This result aligns with the social stigma model; empathy for the patient is replaced with avoidance of the diseased person. This has implications for media and research representations which focus on the high mortality rate and the “ugly” nature of the disease. The 60% variance in social stigma explained by the CLCSS conceptually aligns with domains of lung cancer stigma identified in the theoretical model. However, for the remaining variance, health beliefs were non-significant predictors of stigmatising norms against lung cancer patients. This suggests the moral dimensions underpinning the social stigma of lung cancer may warrant further investigation, particularly in relation to smoking behaviours.

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      O25.03 - The Unique Contribution of Lung Cancer Stigma to Patient Quality of Life (ID 2639)

      16:35 - 16:45  |  Author(s): C.G. Brown-Johnson, J. Brodsky, J.K. Cataldo

      • Abstract
      • Presentation
      • Slides

      Background
      Lung cancer is associated with greater levels of psychological distress than any other cancer. Anxiety and depression are associated with diminished QOL for lung cancer patients, but do not explain the total variance in QOL. Lung cancer stigma (LCS) may explain some of the additional variance in QOL. LCS is a perceived stigma resulting from negative perceptions about the relationship between smoking and lung cancer. This study’s theoretical framework is the Lung Cancer Stigma Model (LCSM), a patient-centered model that includes precursors, perception and responses to LCS. LCS, according to LCSM, is characterized by diagnosis and connections to tobacco exposure and smoking stigma; experiences of discrimination, isolation or shame; and responses ranging from increased symptom burden to Stigma Resistance (SR), defined as “opposition to the imposition of … stereotypes by others” (Thoits, 2011)and shown to positively correlate with self-esteem, empowerment and QOL. Study aims and hypotheses were to: 1) Investigate the relationship of LCS with anxiety, depression and QOL; 2) Explore whether LCS has a unique contribution to the explanation of QOL after controlling for significant covariates (i.e., sex, age); and 3) Compare whether study variables vary by smoking status.

      Methods
      This was a descriptive, cross-sectional study (N=149). An online survey of lung cancer patients recruited from cancer information and support websites included demographic questions, the Cataldo Lung Cancer Stigma Scale, the Spielberger State Anxiety Questionnaire, the CES-D, and the Quality of Life Inventory.

      Results
      Data from primarily Caucasian female participants with a history of smoking demonstrated strong negative associations among anxiety, depression, LCS and QOL, regardless of smoking status; this confirmed previous findings that LCS is positively correlated with anxiety and depression and negatively correlated with QOL. A final hierarchical multiple regression with revealed an overall model explaining 71.5% of the total variance of QOL (F~5,143~=71.61, p<.001). After controlling for significant covariates, anxiety, and depression, LCS provided a small but significant unique contribution to the explanation of variance in QOL (1.2%; p=.015). Furthermore, results substantiate previous findings of no difference in these relationships by smoking status. Both ever and never smokers’ experiences are similar with respect to anxiety, depression, LCS and QOL.

      Conclusion
      Because lung cancer is widely viewed as a smoker’s disease, patients who have never smoked often experience the same stigmatization as smokers, characterized by a feeling imparted from others that one’s disease was self-inflicted. This investigation explored this experience of LCS and validated previous findings linking QOL and LCS. LCS provides unique explanatory contribution to the understanding of QOL for lung cancer patients. Therefore, providers should consider not only typical psychosocial aspects of the diagnosis, but also patient experience of LCS. Related, LCS literature suggests a gap in the psychosocial care of lung cancer patients; no stigma reduction intervention is currently available. Providers might encourage their patients to engage in potential stigma reduction behaviors that may positively impact QOL: 1) self-educate about their diagnosis, 2) critically evaluate their treatment plans, 3) attend support groups, and 4) advocate against stigma.

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      O25.04 - Lung Cancer Stigma, Anxiety, Depression and Symptom Severity (ID 1690)

      16:45 - 16:55  |  Author(s): J.K. Cataldo

      • Abstract
      • Presentation
      • Slides

      Background
      Lung cancer survivors experience more physical and psychosocial problems for a longer period of time than survivors of other cancers. Whether they have ever smoked or not, lung cancer patients feel stigmatized because their disease is strongly associated with smoking. In our previous work, lung cancer stigma (LCS) was a significant predictor of increased depression and decreased quality of life (QOL). With an increased number of lung cancer survivors and a dearth of information on all perspectives of their health and QOL, additional research is needed to understand not only the associations among LCS and psychosocial factors, but also associations among LCS and physical symptom burden. This study was designed to investigate the relationship between LCS, anxiety, depression and physical symptom severity.

      Methods
      This study employed a cross-sectional, correlational design with recruitment of patients from online lung cancer websites. LCS, anxiety, depression and physical symptoms were measured by patient self-report using validated scales via the Internet. Hierarchical multiple regression was performed to investigate the individual contributions of LCS, anxiety, and depression to symptom severity.

      Results
      One hundred and forty-four participants ranged in age from 23 to 79 years (mean age=56.7 years); 93% were Caucasian, 79% were current or former smokers, and 74% were female. There were strong positive relationships between LCS and anxiety (r=0.413, p<.001); depression (r=0.559, p<.001); and total lung cancer symptom severity (r= 0.483, p<.001). Although small, LCS provided a unique and significant explanation of the variance in symptom severity beyond that of age, anxiety, and depression, by 1.3% (p<.05).

      Conclusion
      Because LCS is associated with both psychosocial and physical patient outcomes, research is needed to develop interventions to assist patients to manage LCS Some evidence suggests that LCS is a hindrance to help-seeking behavior and prevents early detection and treatment and may keep patients from reporting distressing symptoms. A significant number of smokers report feeling unworthy of treatment. Patients are frequently reluctant to report respiratory symptoms when they are smokers, a behavior clearly related to the feelings of shame and guilt. This reluctance is a consequence of general supposition that lung cancer is a self-inflicted disease. Because lung cancer is widely viewed as a smoker’s disease, those who have never smoked often experience the same stigmatization: a feeling that their disease was self-inflicted. Although the prognostic outlook for lung cancer patients is changing, clinicians know that lung cancer has one of the poorer prognoses of all human malignancies and that might unintentionally limit communication, treatment options, and symptom management. Future research is needed to elucidate the mechanisms that underlie lung cancer stigma; longitudinal investigations of LCS and patient outcomes are needed to understand causal relationships; and development of effective interventions to decrease both perceived and projected stigma are essential.

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      O25.05 - Stigma and nihilism in lung cancer: the perspective of Australian health professionals and consumers (ID 2653)

      16:55 - 17:05  |  Author(s): S. Sinclair, S. Chambers, D. O'Connell, P. Youl, S. Occhipinti, P. Baade, J. Aitken, G. Garvey, P. Valery, H. Zorbas, J. Dunn, E. King

      • Abstract
      • Presentation
      • Slides

      Background
      It has been proposed that stigma and nihilism surrounding lung cancer may influence lung cancer outcomes. A clear understanding of the impact of lung cancer related stigma and nihilism from the perspectives of health professionals and consumers will assist in informing best practice lung cancer care and health promotion messages in Australia. As part of a national lung cancer program, Cancer Australia commissioned Cancer Council Queensland, in partnership with Griffith University, to undertake a three-phase research project on stigma and nihilism about lung cancer in the Australian context.

      Methods
      Phase 1: A systematic literature review examined the evidence on the influence of stigma and nihilism on lung cancer patterns of care; patients' psychosocial and quality of life (QOL) outcomes; and how this may link to public health programs. Phase 2: The perspectives of health professionals on the impact of stigma and nihilism on diagnosis and disease management were investigated. Semi-structured interviews and a Delphi process with 31 key informants developed a consensus view, which was then tested with 323 health professionals in a national online survey. Phase 3: The perspectives of lung cancer patients and carers on the effects of stigma and nihilism on their cancer experience were investigated. Qualitative interviews were undertaken with 17 patients and 11 carers followed by a cross-sectional survey with 147 lung cancer patients in QLD and NSW.

      Results
      Systematic review: Stigma relating to lung cancer was reported by both patients and health professionals and was related to poorer QOL and higher psychological distress in patients. Empirical explorations of nihilism were not evident. Qualitative evidence from patients’ perspectives suggested that public health programs contribute to stigma about lung cancer. Health professionals’ perspectives: Health-related stigma and the need for positive messaging about lung cancer and smoking cessation were priorities. Geographical barriers to access and a lack of rural/regional services were described. Barriers for Aboriginal and Torres Strait Islander people included fear of dying away from community and poor cancer knowledge. Patient and carer perspectives: Qualitative data were consistently indicative of stigma amongst patients due to perceived personal responsibility in the smoking-lung cancer relationship and perceived links between lung cancer and negative outcomes. Quantitative data revealed high levels of psychological distress but low help seeking; health-related stigma was significantly related to poorer psychological and QOL outcomes.

      Conclusion
      Health-related stigma has negative impacts on people affected by lung cancer in Australia and may contribute to poorer psychological health and QOL outcomes. The research helps to build the evidence about factors influencing lung outcomes in Australia. It provides an important foundation for further research and the development of strategies to ameliorate the effects of stigma on patients and carers.

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      O25.06 - Electromagnetic Navigation Bronchoscopy directed pleural tattoo to aid surgical resection of Peripheral Pulmonary Lesion (ID 1738)

      17:05 - 17:15  |  Author(s): J.H. Tay, M. Larobina, P. Russell, L. Irving, D. Steinfort

      • Abstract
      • Presentation
      • Slides

      Background
      Limited (wedge) resection of pulmonary lesions is frequently performed as a diagnostic/therapeutic procedure. Some lesions may be difficult to locate thoracoscopically and conversion to open thoracotomy or incomplete resection are potential limitations to this approach. Multiple methods have been described to aid Video-assisted thoracoscopic surgical (VATS) wedge resection of pulmonary nodules including hookwire localization, percutaneous tattoo or intra-operative ultrasound. We report on our experience using Electromagnetic Navigational (EMN) bronchoscopic dye marking of small subpleural lesions to assist wedge resection.

      Methods
      Six patients planned for VATS resection of a peripheral pulmonary lesion underwent pre-operative bronchoscopy. Electromagnetic navigation was utilized to accurately guide a 25-gauge needle to within/adjacent to the lesion for resection and 1mL of methylene blue or indigo carmine was injected under fluoroscopic vision.

      Results
      Six patients underwent bronchoscopic marking of peripheral pulmonary lesions. Navigation to lesions was successful in all six patients. Surgery was performed within 24 hours of bronchoscopic marking. Pleural staining by dye was visible thoracoscopically in all six lesions either adjacent to or overlying the lesion. All lesions were fully excised with wedge resection. Pathologic examination confirmed accuracy of dye staining and established the diagnosis of malignancy.

      Conclusion
      EMN bronchoscopic dye marking of peripheral lesions is feasible, and is not compromised by complications associated with percutaneous marking procedures. Further experience is required but early findings suggest this method may have utility in aiding minimally invasive resection of small subpleural lesions.

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Author of

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    ITONF - International Thoracic Oncology Nursing Forum (ITONF) Workshop (ID 220)

    • Event: WCLC 2013
    • Type: Other Sessions
    • Track: Nurses
    • Presentations: 1
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      ITONF.03 - Out of the Shadows into the Clinic (ID 4034)

      13:35 - 14:05  |  Author(s): J.K. Cataldo

      • Abstract
      • Presentation
      • Slides

      Abstract not provided

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    O06 - Cancer Control and Epidemiology I (ID 135)

    • Event: WCLC 2013
    • Type: Oral Abstract Session
    • Track: Prevention & Epidemiology
    • Presentations: 1
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      O06.07 - DISCUSSANT (ID 4003)

      11:45 - 12:00  |  Author(s): J.K. Cataldo

      • Abstract
      • Presentation
      • Slides

      Abstract not provided

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    O25 - Stigma and Nihilism (ID 139)

    • Event: WCLC 2013
    • Type: Oral Abstract Session
    • Track: Nurses
    • Presentations: 2
    • +

      O25.03 - The Unique Contribution of Lung Cancer Stigma to Patient Quality of Life (ID 2639)

      16:35 - 16:45  |  Author(s): J.K. Cataldo

      • Abstract
      • Presentation
      • Slides

      Background
      Lung cancer is associated with greater levels of psychological distress than any other cancer. Anxiety and depression are associated with diminished QOL for lung cancer patients, but do not explain the total variance in QOL. Lung cancer stigma (LCS) may explain some of the additional variance in QOL. LCS is a perceived stigma resulting from negative perceptions about the relationship between smoking and lung cancer. This study’s theoretical framework is the Lung Cancer Stigma Model (LCSM), a patient-centered model that includes precursors, perception and responses to LCS. LCS, according to LCSM, is characterized by diagnosis and connections to tobacco exposure and smoking stigma; experiences of discrimination, isolation or shame; and responses ranging from increased symptom burden to Stigma Resistance (SR), defined as “opposition to the imposition of … stereotypes by others” (Thoits, 2011)and shown to positively correlate with self-esteem, empowerment and QOL. Study aims and hypotheses were to: 1) Investigate the relationship of LCS with anxiety, depression and QOL; 2) Explore whether LCS has a unique contribution to the explanation of QOL after controlling for significant covariates (i.e., sex, age); and 3) Compare whether study variables vary by smoking status.

      Methods
      This was a descriptive, cross-sectional study (N=149). An online survey of lung cancer patients recruited from cancer information and support websites included demographic questions, the Cataldo Lung Cancer Stigma Scale, the Spielberger State Anxiety Questionnaire, the CES-D, and the Quality of Life Inventory.

      Results
      Data from primarily Caucasian female participants with a history of smoking demonstrated strong negative associations among anxiety, depression, LCS and QOL, regardless of smoking status; this confirmed previous findings that LCS is positively correlated with anxiety and depression and negatively correlated with QOL. A final hierarchical multiple regression with revealed an overall model explaining 71.5% of the total variance of QOL (F~5,143~=71.61, p<.001). After controlling for significant covariates, anxiety, and depression, LCS provided a small but significant unique contribution to the explanation of variance in QOL (1.2%; p=.015). Furthermore, results substantiate previous findings of no difference in these relationships by smoking status. Both ever and never smokers’ experiences are similar with respect to anxiety, depression, LCS and QOL.

      Conclusion
      Because lung cancer is widely viewed as a smoker’s disease, patients who have never smoked often experience the same stigmatization as smokers, characterized by a feeling imparted from others that one’s disease was self-inflicted. This investigation explored this experience of LCS and validated previous findings linking QOL and LCS. LCS provides unique explanatory contribution to the understanding of QOL for lung cancer patients. Therefore, providers should consider not only typical psychosocial aspects of the diagnosis, but also patient experience of LCS. Related, LCS literature suggests a gap in the psychosocial care of lung cancer patients; no stigma reduction intervention is currently available. Providers might encourage their patients to engage in potential stigma reduction behaviors that may positively impact QOL: 1) self-educate about their diagnosis, 2) critically evaluate their treatment plans, 3) attend support groups, and 4) advocate against stigma.

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      O25.04 - Lung Cancer Stigma, Anxiety, Depression and Symptom Severity (ID 1690)

      16:45 - 16:55  |  Author(s): J.K. Cataldo

      • Abstract
      • Presentation
      • Slides

      Background
      Lung cancer survivors experience more physical and psychosocial problems for a longer period of time than survivors of other cancers. Whether they have ever smoked or not, lung cancer patients feel stigmatized because their disease is strongly associated with smoking. In our previous work, lung cancer stigma (LCS) was a significant predictor of increased depression and decreased quality of life (QOL). With an increased number of lung cancer survivors and a dearth of information on all perspectives of their health and QOL, additional research is needed to understand not only the associations among LCS and psychosocial factors, but also associations among LCS and physical symptom burden. This study was designed to investigate the relationship between LCS, anxiety, depression and physical symptom severity.

      Methods
      This study employed a cross-sectional, correlational design with recruitment of patients from online lung cancer websites. LCS, anxiety, depression and physical symptoms were measured by patient self-report using validated scales via the Internet. Hierarchical multiple regression was performed to investigate the individual contributions of LCS, anxiety, and depression to symptom severity.

      Results
      One hundred and forty-four participants ranged in age from 23 to 79 years (mean age=56.7 years); 93% were Caucasian, 79% were current or former smokers, and 74% were female. There were strong positive relationships between LCS and anxiety (r=0.413, p<.001); depression (r=0.559, p<.001); and total lung cancer symptom severity (r= 0.483, p<.001). Although small, LCS provided a unique and significant explanation of the variance in symptom severity beyond that of age, anxiety, and depression, by 1.3% (p<.05).

      Conclusion
      Because LCS is associated with both psychosocial and physical patient outcomes, research is needed to develop interventions to assist patients to manage LCS Some evidence suggests that LCS is a hindrance to help-seeking behavior and prevents early detection and treatment and may keep patients from reporting distressing symptoms. A significant number of smokers report feeling unworthy of treatment. Patients are frequently reluctant to report respiratory symptoms when they are smokers, a behavior clearly related to the feelings of shame and guilt. This reluctance is a consequence of general supposition that lung cancer is a self-inflicted disease. Because lung cancer is widely viewed as a smoker’s disease, those who have never smoked often experience the same stigmatization: a feeling that their disease was self-inflicted. Although the prognostic outlook for lung cancer patients is changing, clinicians know that lung cancer has one of the poorer prognoses of all human malignancies and that might unintentionally limit communication, treatment options, and symptom management. Future research is needed to elucidate the mechanisms that underlie lung cancer stigma; longitudinal investigations of LCS and patient outcomes are needed to understand causal relationships; and development of effective interventions to decrease both perceived and projected stigma are essential.

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    P1.24 - Poster Session 1 - Clinical Care (ID 146)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Supportive Care
    • Presentations: 1
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      P1.24-022 - mHealth Tool for Lung Cancer - Development and Demonstration (ID 1696)

      09:30 - 09:30  |  Author(s): J.K. Cataldo

      • Abstract

      Background
      With the rise of technology in health care, the use of electronic or virtual games provides new possibilities for cost effective and individually tailored health care interventions. The advantages of virtual games are the ability and opportunity to incorporate ethnic and cultural diversity and sensitivity, access hard to reach populations, provide motivation and positive feedback for behavior change, and provide information for personalized cancer symptom management. Lung cancer is the leading cause of cancer death in both men and women and is associated with greater levels of psychological distress than any other cancer. Stigma has been found to have a major role in the distress and health outcomes of lung cancer patients. Lung cancer stigma (LCS) is based on the belief that one caused their own cancer (ie, smoking) and negatively impacts patient outcomes. Lung cancer patients report inadequate communication with physicians about important topics such as: symptom experience, prognosis, treatment preferences, practical and financial worries, spiritual concerns, and hospice care. Stigma is a factor that contributes to poor patient-clinician communication and inappropriate referrals. Although palliative care consultation is recommended throughout the trajectory of lung cancer, it is underutilized. Understanding factors that influence communication and referral decisions, such as stigma, can improve integration of symptom assessment and support and palliative care into lung cancer management. Currently there are no interventions to decrease LCS and improve lung cancer patient-clinician communication. The goal of this project was to develop, the mHealth TLC an interactive, immersive 3-dimensional iPad health game that allows individuals to experience first person virtual visits with their clinicians and to conduct initial usability testing.

      Methods
      Because of the innovative nature of an immersive 3D game for lung cancer patients, iterative development/validation was used. Usability was assessed with participation satisfaction questionnaires and focus groups. Four areas were explored: believability and value; technical issues; transparency of goals; and game outcomes.

      Results
      Positive usability results for the mHealth TLC included believable game narrative, minimal game experience interference, participant generation of game and intervention goals, and indications that mHealth TLC will be able to influence lung cancer patient outcomes.

      Conclusion
      mHealth TLC can provide engagement and experiential learning by delivering important information about lung cancer and symptom management and by providing lung cancer patients the opportunity to practice a new communication strategy. Figure 1