This thesis aims to improve the treatment of patients with stage III melanoma. The first part describes different aspects of treatment with Talimogene Laherparepvec (T-VEC), a genetically modified... Show moreThis thesis aims to improve the treatment of patients with stage III melanoma. The first part describes different aspects of treatment with Talimogene Laherparepvec (T-VEC), a genetically modified herpes virus, which is used as oncolytic immunotherapy for skin and lymph node metastases in melanoma patients. We show that patients with a low tumor burden have the best outcomes, suggesting T-VEC should be used earlier on in the course of the disease. We present a prediction model, allowing a more accurate selection of patients for T-VEC monotherapy. Two studies focused on the use of T-VEC in clinical practice and the results allowed us to make recommendations on the use of PET/CT and dermoscopy during T-VEC treatment. Part two focuses on the value of surveillance and screening imaging in high-risk melanoma patients. We show that FDG-PET/CT is a valuable imaging tool to detect recurrence after complete resection of stage III disease, even shortly after surgery (before starting adjuvant therapy). Finally, we conclude that nodal staging with US as adjunct to SLNB is useful in the work- up of stage IIB/C melanoma, as it can lead to alterations in treatment and prevent unnecessary surgery. Show less
For people with chronic kidney disease (CKD), adhering to a range of self-management tasks—such as healthy eating, frequent physical activity, and non-smoking—is crucial. However, changing health... Show moreFor people with chronic kidney disease (CKD), adhering to a range of self-management tasks—such as healthy eating, frequent physical activity, and non-smoking—is crucial. However, changing health behaviors is difficult. To support patients in doing so, an eHealth care pathway was developed and evaluated. The results provide different insights into patients' priorities and care needs. Many individuals with CKD experience problems in self-management, which can be hindered by many different barriers of which a common one is psychological distress. Therefore, personalized interventions are needed with screening and treatment of both psychological distress and suboptimal self-management, tailored to the specific barriers and needs of the individual patient. The E-GOAL eHealth care pathway is an example of such a personalized intervention, combining cognitive behavioral therapy with self-management support. Patients were enthusiastic about the eHealth care pathway. However, in a randomized study, the intervention was not effective in reducing psychological distress compared with regular care only. Patients did experience improvements in areas of functioning and self-management that they prioritized themselves. These mixed results show that interventions could be implemented that are person-tailored, with personalized outcomes that reflect individually meaningful treatment goals and improvements for every patient. Show less
