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Purpose Cybersecurity vulnerabilities are often due to human users acting according to their own ethical priorities. With the goal of providing tailored training to cybersecurity professionals, the authors conducted a study to uncover profiles of human factors that influence which ethical principles are valued highest following exposure to ethical dilemmas presented in a cybersecurity game.Design/methodology/approach The authors’ game first sensitises players (cybersecurity trainees) to five cybersecurity ethical principles (beneficence, non-maleficence, justice, autonomy and explicability) and then allows the player to explore their application in multiple cybersecurity scenarios. After playing the game, players rank the five ethical principles in terms of importance. A total of 250 first-year cybersecurity students played the game. To develop profiles, the authors collected players' demographics, knowledge about ethics, personality, moral stance and values.Findings The authors built models to predict the importance of each of the five ethical principles. The analyses show that, generally, the main driver influencing the priority given to specific ethical principles is cultural background, followed by the personality traits of extraversion and conscientiousness. The importance of the ingroup was also a prominent factor.Originality/value Cybersecurity professionals need to understand the impact of users' ethical choices. To provide ethics training, the profiles uncovered will be used to build artificially intelligent (AI) non-player characters (NPCs) to expose the player to multiple viewpoints. The NPCs will adapt their training according to the predicted players’ viewpoint.

Introduction The efficacy of immune checkpoint inhibitors (ICIs) is low among EGFR-mutated non–small-cell lung cancer (NSCLC), although prolonged responses have occasionally been reported. We investigated the association between mutation subtypes and ICI outcomes among HER2- and EGFR-mutated NSCLC. Patients and Methods This retrospective single-center study analyzed patients with EGFR- and HER2-mutated advanced NSCLC who received at least 1 cycle of ICI between 2013 and 2019. Patient characteristics, mutation subtype, and ICI outcomes. Results Among 48 patients with advanced NSCLC, 14 (29%) had HER2 mutations and 34 (71%) had EGFR mutations. EGFR mutations included 16 (47%) exon 19 deletion, 7 (21%) L858R, 5 (15%) uncommon, and 6 (18%) exon 20 insertion. Compared to EGFR-sensitizing mutations (ESMs), HER2 and EGFR exon 20 mutations were associated with a trend toward better response (respectively, ESM, HER2, and EGFR exon 20: 11%, 29%, and 50%; P = .07) and significantly better disease control rates (respectively, 18%, 57%, and 67%; P = .008). Compared to ESM, HER2 mutations (adjusted hazard ratio, 0.35; P = .02) and EGFR exon 20 mutations (adjusted hazard ratio, 0.37; P = .10 trend) were also associated with improved PFS. Programmed death ligand 1 (PD-L1) expression remained an independent predictor of PFS (adjusted hazard ratio, 0.42; 95% confidence interval, 0.23-0.76; P = .004). The 6-month PFS rates were 29% (HER2), 33% (EGFR exon 20), and 4% (ESM). ICIs were generally well tolerated in this population. Importantly, no immune-related toxicity was observed in 10 patients who received a tyrosine kinase inhibitor (TKI) as the immediate next line treatment after ICI. Conclusion HER2 and EGFR exon 20 mutations derive greater benefit from ICIs with comparable PFS to wild-type historical second/third-line unselected cohorts. ICIs remain a treatment option for this genomic subgroup, given the absence of approved targeted therapies for these rare mutations.

Morals are an important part of many stories, and central to why storytelling developed in the first place as a means of communication. They have the potential to provide a framework for developing story structure, which could be utilised by modern storytelling systems. To achieve this we need a general representation for morals. We propose patterns of character emotion as a suitable foundation. In this paper, we categorise Aesop’s fables based on the morals they convey, and use them as a source of emotion data corresponding to those morals. We use inductive logic programming to identify relationships between particular patterns of emotion and the morals of the stories in which they arise.

Narrative AI needs to model more than just action. In this paper, we investigate the Belief-Desire-Intention (BDI) agent architecture to allow plots to be modelled in terms of character motivation. This allows authors to focus on elements of the character model which are highly relevant to plot. We describe an extended implementation of the ConGolog agent programming language which includes BDI syntax and semantics. Using this language, we provide an example of how plot could be advantageously modelled in terms of character motivation.

Morality meters are a commonly used mechanic in many ethically notable video games. However, there have been several theoretical critiques of such meters, including that people can find them alienating, they can instrumentalise morality, and they reduce morality to a binary of good and evil with no room for complexity. While there has been much theoretical discussion of these issues, there has been far less empirical investigation. We address this gap through a qualitative study that involved participants playing a custom-built visual novel game ( The Great Fire) with different intuitive and counter-intuitive morality meter settings. Overall, we found that players’ attitudes towards the morality meter in this game was complex, context sensitive and variable throughout gameplay and that the intuitiveness of the meter encouraged participants to treat the meter more ‘as a moral guide’ that prompts reflection and less ‘as a score’ to be engaged with reactively.

As robots and Artificial Intelligences become more enmeshed in rich social contexts, it seems inevitable that we will have to make them into moral machines equipped with moral skills. Apart from the technical difficulties of how we could achieve this goal, we can also ask the ethical question of whether we should seek to create such Artificial Moral Agents (AMAs). Recently, several papers have argued that we have strong reasons not to develop AMAs. In response, we develop a comprehensive analysis of the relevant arguments for and against creating AMAs, and we argue that all things considered we have strong reasons to continue to responsibly develop AMAs. The key contributions of this paper are threefold. First, to provide the first comprehensive response to the important arguments made against AMAs by Wynsberghe and Robbins (in “Critiquing the Reasons for Making Artificial Moral Agents”, Science and Engineering Ethics 25, 2019) and to introduce several novel lines of argument in the process. Second, to collate and thematise for the first time the key arguments for and against AMAs in a single paper. Third, to recast the debate away from blanket arguments for or against AMAs in general, to a more nuanced discussion about the use of what sort of AMAs, in what sort of contexts, and for what sort of purposes is morally appropriate.

BACKGROUND Convergence insufficiency may be treated by visual exercises designed to increase convergence while maintaining single, clear, binocular vision. However, compliance with treatment is problematic, as patients often cease treatment when symptoms start to improve and before treatment is complete. The purpose of the present study was to assess the feasibility of using gamification of vision training to: (a) treat convergence insufficiency; and (b) improve compliance to treatment in comparison to a conventional treatment over a six-week treatment period. METHODS Two interventions, anaglyphs and a virtual reality game of Snakes, were evaluated for their effectiveness in treating adults with convergence insufficiency. The prescribed training regimen was 20 minutes, three times per week for six weeks. Vision was assessed before and after the treatment period. Participants also filled in the Core Elements of the Gaming Experience Questionnaire to gauge impact of game design on compliance. RESULTS Eighteen participants (mean age 20.8 ± 1.8 years) met the inclusion criteria for convergence insufficiency and nine participants were randomly assigned to each intervention. Repeated measures analysis of variance showed a significant effect of visit for near point of convergence (F1,16 = 38.32, p

Introduction: The addition of durvalumab after chemoradiation therapy (CRT) in unresectable stage III NSCLC significantly improves survival. The benefit of this approach in elderly patients is controversial given the toxicity associated with CRT and, thus, may be underutilized. We sought to investigate the outcomes of elderly patients treated with CRT without or without durvalumab at our center. Methods: We reviewed all stage III patients with NSCLC treated with CRT between 2018 and 2020. Patients were analyzed on the basis of age: less than 70 years and 70 years and older. The end points evaluated were treatment patterns, toxicity, progression-free survival, and overall survival. Results: The baseline characteristics including Eastern Cooperative Oncology Group performance status and comorbidities were similar among the 115 patients (44 elderly, 71 young). Completion rates of CRT (100%, 97%) and chemotherapy dose intensity (97%, 97%) were high in elderly and young patients, respectively. There was a trend toward increased hospitalizations in elderly patients because of infections (27% versus 13%, p = 0.08). Of those who did not have primary progression after CRT, 78% of eldery and 81% of young patients received durvalumab. The incidence of grade 3 or higher immune-related adverse events was 9% in elderly and 6% in young patients (p = 0.67). The median progression-free survival was similar (15.6 versus 10.5 mo, p = 0.10), even after adjusting for comorbidities (hazard ratio = 0.6, p = 0.09). The 12-month overall survival rates were 78% in the elderly and 76% in young patients (p = 0.98). Conclusions: Well-selected elderly patients can be treated safely with CRT followed by durvalumab with similar survival benefits compared with their younger counterparts. We would advocate for the referral of all elderly patients for oncologic assessment to avoid undertreatment.

When we make ethical decisions in everyday life, our choices are often influenced by what we see others doing around us. In psychology, this phenomenon is known as social proof. When we are uncertain about what to do, we are likely to follow the crowd, especially if we identify with them. In this study, we examine how this behaviour extends to video games, and how it is influenced by other design factors such as time-limited decisions. We present the results of a quantitative study of player behaviour in a visual-novel game The Great Fire. Before making a decision, players are presented with statistics showing what other players chose. We manipulated these figures to display different choices as popular, under timed and untimed conditions. We present preliminary work-in-progress results that suggest that players are indeed influenced to follow the crowd when facing an ambiguous moral decision, but can also show unexpected behaviour when faced with the non-moral choice of calling a coin flip.

INTRODUCTION Advances in novel treatment options may render renal cell cancer (RCC) patients susceptible to the financial toxicity (FT) of cancer treatment, and the factors associated with FT are unknown.Eligible patients were ≥ 18 years old and had a diagnosis of stage IV RCC for at least 3 months. Patients were recruited from Princess Margaret Cancer Centre and Sunnybrook Odette Cancer Centre (Toronto, Canada). FT was assessed using the validated Comprehensive Score for Financial Toxicity (COST) instrument, a 12-question survey scored from 0-44, with lower scores reflecting worse FT. Patient and treatment characteristics, out-of-pocket costs (OOP) and private insurance coverage (PIC) were collected. Factors associated with worse FT (COST score21) were determined.Sixty-five patients were approached and 80% agreed to participate (n = 52). The median age was 62 (44-88); 20% were female (n = 10); 43% were age ≥ 65 (n = 22); 63% were Caucasian (n = 31). Median COST score was 20.5 (3-44). Factors associated with worse FT were age65 (OR 9.5, p = 0.007), high OOP (OR 4.4, p = 0.04) and receiving treatment off clinical trial (in comparison to being on surveillance or on clinical trial) (OR 5.9, p = 0.03), when adjusting for other factors in multivariable logistic regression. However, there was no correlation between annual income or PIC and FT.Financial toxicity in the RCC population is more significant in younger patients and those on treatment outside of a clinical trial. Financial aid should be offered to these at-risk patients to optimize adherence to life prolonging RCC treatments.

According to cognitive psychologists, moral decision-making is a dual-process phenomenon involving two types of cognitive processes: explicit reasoning and implicit intuition. Moral development involves training and integrating both types of cognitive processes through a mix of instruction, practice, and reflection. Serious games are an ideal platform for this kind of moral training, as they provide safe spaces for exploring difficult moral problems and practicing the skills necessary to resolve them. In this article, we present Morality Play, a model for the design of serious games for ethical expertise development based on the Integrative Ethical Education framework from moral psychology and the Lens of the Toy model for serious game design.

Introduction: Durvalumab immunotherapy has rapidly emerged as standard treatment for stage 3 NSCLC patients following definitive chemoradiotherapy (CRT). Multiple novel immunotherapeutic strategies are in development to enhance the chance of cure in this setting as well. There exists a critical need to identify blood-based biomarkers capable of predicting clinical benefit from adjuvant immunotherapy as well selecting patients at high-risk of relapse for further drug development. Cell-free DNA (cfDNA)-based analysis of both minimal residual disease (MRD) and T-cell receptor (TCR) clonality have immense potential to predict and monitor response to adjuvant immunotherapy. In this study, we have combined innovative cfDNA measures of MRD (CAPPseq), TCR clonality (CapTCR-seq) and methylation (cfMeDIPseq) as potential predictive biomarkers of disease progression in stage 3 NSCLC patients treated with CRT and durvalumab. Methods: Stage 3 NSCLC patients undergoing CRT and durvalumab were recruited prospectively to undergo serial blood collections at baseline, pre- and post- durvalumab. CAPPseq and cfMeDIPseq were performed as measures of MRD. TCR repertoire analysis (CapTCR-seq) was performed on cfDNA using hybrid-capture TCR sequencing and TCR diversity/clonality was estimated using the Shannon's index. Correlations between MRD, TCR clonality, response and progression-free survival (PFS) were examined using logistic/cox regression. Results: 79 stage 3 NSCLC patients have been prospectively recruited and undergone serial blood collection. CAPPseq, cfMeDIPseq and capTCR-seq have been completed in 22 patients (5 primary progression on CRT, 17 received durvalumab). Tumor cfDNA was detectable by CAPPseq at baseline in 14 patients. High correlation between tumor cfDNA detected by CAPPseq and cfMeDIPseq was found (R=0.68, p Conclusions: Failure to clear MRD and decreasing TCR clonality as assessed by cfDNA was highly correlated with increased risk of recurrence and reduced PFS with consolidation durvalumab. This innovative approach has significant potential to define a new biomarker for the use and development of adjuvant immunotherapy. Citation Format: Sally CM Lau, Shirin Soleimani, Jinfeng Zou, Justin Burgener, Shelley Kuang, Stephanie WY Wong, Malcolm Ryan, Ben X. Wang, Stephanie Pedersen, Devalben Patel, Penelope A. Bradbury, Geoffrey Liu, Natasha Leighl, Ming S. Tsao, Pamela S. Ohashi, Scott V. Bratman, Trevor Pugh, Frances A. Shepherd, Adrian G. Sacher. cfDNA-based analysis of minimal residual disease and T-cell receptor clonality as predictors of relapse in stage 3 NSCLC treated with chemoradiotherapy and durvalumab [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 563.

8547 Background: Recently, it has been demonstrated that the addition of durvalumab after chemoradiation (CRT) in unresectable stage 3 non-small cell lung cancer (NSCLC) significantly improves overall survival (OS). The benefit of CRT in elderly patients is considered controversial given its increased toxicity. As such, CRT followed by durvalumab in elderly patients may be underutilized despite its demonstrated superiority. The practice pattern at our center is to offer curative treatment unless clearly contraindicated. We sought to investigate the outcomes of elderly patients treated with CRT +/- durvalumab at our center. Methods: We conducted a review of all stage 3 NSCLC patients treated with CRT between 2018 and 2020. Patients were analyzed based on age: < 70 years, ≥70 years. Endpoints evaluated were treatment patterns, toxicity, progression free survival (PFS) and overall survival (OS). Results: We identified 115 stage 3 patients: 44 patients ≥70 years (70-89) and 71 patients < 70 years (34-69). Patients were fit: ECOG 0-1 (98%/97%), mean Charlson comorbidity index (CCI) (1.1/0.9) in elderly vs young patients; p > 0.05. All other baseline characteristics including PD-L1 expression were similar. The chemotherapy regimens (platinum in combination with etoposide, paclitaxel or pemetrexed), dose intensity (97% vs 97%) and percentage of planned cycles received (91% vs 96%) were similar. There were 2 treatment related deaths from CRT among the younger cohort and none in the elderly patients. At the completion of CRT, 75% of elderly and 72% of young patients received durvalumab. Clinician/patient preference was the most common reason for not receiving consolidation durvalumab in older patients (55% vs 25%). The median time to starting durvalumab was 43 days in the elderly and 37 days in young patients (p = 0.19). Durvalumab was well tolerated in the elderly and incidence of grade ≥3 immune-related adverse events was 9% compared to 6% in young patients; p = 0.68. The durvalumab completion rates were 30% in elderly and 24% in young patients; p = 0.22. Median PFS was similar between elderly and young patients (17.9 vs 10.6 months respectively; p = 0.07), even after adjusting for the CCI (HR 0.60; p = 0.07). The 24- and OS rates are also similar (p = 0.93): 77% in elderly and 77% in young patients. Conclusions: Definitive CRT followed by durvalumab can be safely delivered in elderly patients ≥70 years with comparable outcomes. The non-significant trend towards better PFS in elderly patients suggests that only select fit patients are being referred for treatment. In conclusion, all patients should undergo comprehensive oncologic assessment to determine if curative intent treatment can be delivered to avoid undertreatment of elderly patients.

e21127 Background: KRAS alterations constitute the most common driver mutations in metastatic non-small cell lung cancers (mNSCLC) and occur in approximately 30% of patients. KRAS mutational subtype as well as the presence of co-mutations has been associated with altered activation of downstream signaling pathways in preclinical models. We hypothesize that different KRAS G12C mutational subsets will be associated with variable clinical outcome and response to therapy. To this end, we have performed a retrospective analysis of survival and treatment outcomes by KRAS mutation subtype (G12C vs non-G12C). Methods: A review of KRAS-mutated mNSCLC patients treated with immunotherapy between 2013 and 2020 was conducted. Patient demographics, smoking status, KRAS mutational subtype, co-mutations and PD-L1 status were collected. Overall response rate (ORR) and progression-free survival (PFS) were analyzed in each subgroup. Results: 98 KRAS mutant mNSCLC patients were treated with immune checkpoint inhibitors (ICI): 37% with a KRAS G12C mutation, 62% with a non-G12C mutation. Patients with a G12C mutation were more likely to be of Caucasian ancestry (86% vs 56%; p = 0.01) whereas all other characteristics were similar between the groups including smoking history, PD-L1 expression ≥50% (61% vs 40%) and the presence of a TP53 co-mutation (48% vs. 54%); all p > 0.05. Treatment patterns were similar between the groups, with PD-1 inhibitor monotherapy given in 86% vs 79% of KRAS G12C and non-G12C patients. Overall response rate was 51% vs 27% in G12C vs non-G12C (p = 0.03). PFS was superior in G12C mutants (19.6 months vs 4.0 months), even after adjusting for smoking history, TP53 co-mutation status and PD-L1 expression (adjusted HR 0.51; p = 0.02). In subgroup analyses, the superiority in PFS was driven by the G12C mutants with high PD-L1 expression (n = 19): 26.8 months in G12C, PD-L1 high vs 4.7 months in G12C, PD-L1 low vs. 4.7 months in KRAS transversion mutations, PD-L1 high vs 4.0 months in transversion mutations, PD-L1 low vs. 3.0 months in transition mutations; p < 0.001. Conclusions: The presence of a KRAS G12C mutation is associated with improved ORR and PFS after treatment with ICI compared to non-G12C mutations in mNSCLC. The greatest benefit in PFS was observed in the subgroup with G12C mutation and high PD-L1 expression. Differential activation of downstream signaling associated with specific KRAS codon 12 mutation variants may modulate the composition of the tumor immune microenvironment thereby contributing to the variable response to immunotherapy. Further understanding on these molecular mechanisms may direct the development of new treatment strategies in KRAS mutant lung cancers.

This special issue of Games and Culture focuses on the intersection between video games and ethics. This introduction briefly sets out the key research questions in the research field and identifies trends in the articles included in this special issue.

Tablet computer displays are amenable for the development of vision tests in a portable form. Assessing color vision using an easily accessible and portable test may help in the self-monitoring of vision-related changes in ocular/systemic conditions and assist in the early detection of disease processes. Tablet computer-based games were developed with different levels of gamification as a more portable option to assess chromatic contrast sensitivity. Game 1 was designed as a clinical version with no gaming elements. Game 2 was a gamified version of game 1 (added fun elements: feedback, scores, and sounds) and game 3 was a complete game with vision task nested within. The current study aimed to determine the normative values and evaluate repeatability of the tablet computer-based games in comparison with an established test, the Cambridge Colour Test (CCT) Trivector test. Normally sighted individuals [N = 100, median (range) age 19.0 years (18-56 years)] had their chromatic contrast sensitivity evaluated binocularly using the three games and the CCT. Games 1 and 2 and the CCT showed similar absolute thresholds and tolerance intervals, and game 3 had significantly lower values than games 1, 2, and the CCT, due to visual task differences. With the exception of game 3 for blue-yellow, the CCT and tablet computer-based games showed similar repeatability with comparable 95% limits of agreement. The custom-designed games are portable, rapid, and may find application in routine clinical practice, especially for testing younger populations.

This new edition encompasses a wide selection of our research outcomes and a detailed overview of our core programs: Architecture and Habitat, User Experience Design for Services, Future-Self and Design Living Lab, Smart Equipment Engineering and Wearable Technology Design and Advanced Product Design and Development.The CDI has grown significantly over the last two years, a product of our sustained success in conducting serious deep research that creates innovative outcomes in a range of different design fields. This report delves into the information pursuit of our team, exploring the way the CDI navigates the contextual factors that shape uptake and adaption, as well as the positive effect our catalogue of work has had on end-users both locally and internationally.

Background: Vergence eye movements are the disconjugate movements of the two eyes, needed to accurately ‘point’ the eyes at an object of interest. Convergence insufficiency is the reduced ability to elicit and maintain the eyes in the accurate convergence position, and it affects about 5% of the population, often leading to visual symptoms such as diplopia (double vision), eye strain and headaches, especially during near tasks. The ability to converge and diverge accurately can be trained with vision training, but vision training activities are not standardized and they are often not complied with. Methods: We developed a novel virtual reality (VR) snake game and compared it with conventional anaglyph treatments in a randomized controlled trial on typical adults. Compliance was assessed by the time spent doing the prescribed vision training over a period of three weeks. Results: There was a statistically significant improvement of convergence ability in both the VR snake and anaglyph treatment groups, and no difference in compliance between the two groups. Conclusion: Virtual reality headsets may be used to train vergences in adults. Further work is required to determine its utility in people with convergence insufficiency who require training for longer than 3 weeks.