Ruud Houben

Health care providers' orientations towards common low back pain predict perceived harmfulness of physical activities and recommendations regarding return to normal activity.

The Pain Attitudes and Beliefs Scale for Physiotherapists (PABS‐PT) differentiates between a biomedical versus a biopsychosocial treatment orientation with regard to common low back pain. This study re‐examined the factor structure and psychometric properties of the PABS‐PT, along with the relationship between PABS‐PT scores and the perceived harmfulness of physical activities and treatment recommendations for common low back pain. Two hundred and ninety‐seven paramedical therapists completed the PABS‐PT and questionnaires measuring related concepts, rated the perceived harmfulness of 41 daily physical activities depicted in photographs and gave recommendations for return to normal activity for three patients with low back pain. Analysis revealed two factors labelled ‘biomedical’ and ‘biopsychosocial treatment orientation’. Furthermore, scores on both factors of the PABS‐PT were related to measures of related concepts (statistically significant Pearson correlation coefficients between 0.30 and 0.65) such as the HC‐PAIRS and a therapist version of the TSK. Regression analyses revealed that both factors were consistent predictors of judgements of the harmfulness of physical activities (PHODA) and of recommendations for return to work and normal activity.

Identification of residual metabolic-active areas within individual NSCLC tumours using a pre-radiotherapy 18Fluorodeoxyglucose-PET-CT scan

BACKGROUND AND PURPOSE Non-small cell lung cancer (NSCLC) tumours are mostly heterogeneous. We hypothesized that areas within the tumour with a high pre-radiation (18)F-deoxyglucose (FDG) uptake, could identify residual metabolic-active areas, ultimately enabling selective-boosting of tumour sub-volumes. MATERIAL AND METHODS Fifty-five patients with inoperable stage I-III NSCLC treated with chemo-radiation or with radiotherapy alone were included. For each patient one pre-radiotherapy and one post-radiotherapy FDG-PET-CT scans were available. Twenty-two patients showing persistent FDG uptake in the primary tumour after radiotherapy were analyzed. Overlap fractions (OFs) were calculated between standardized uptake value (SUV) threshold-based auto-delineations on the pre- and post-radiotherapy scan. RESULTS Patients with residual metabolic-active areas within the tumour had a significantly worse survival compared to individuals with a complete metabolic response (p=0.002). The residual metabolic-active areas within the tumour largely corresponded (OF>70%) with the 50%SUV high FDG uptake area of the pre-radiotherapy scan. The hotspot within the residual area (90%SUV) was completely within the GTV (OF=100%), and had a high overlap with the pre-radiotherapy 50%SUV threshold (OF>84%). CONCLUSIONS The location of residual metabolic-active areas within the primary tumour after therapy corresponded with the original high FDG uptake areas pre-radiotherapy. Therefore, a single pre-treatment FDG-PET-CT scan allows for the identification of residual metabolic-active areas.

Radical Treatment of Non-Small-Cell Lung Cancer Patients with Synchronous Oligometastases Long-Term Results of a Prospective Phase II Trial (Nct01282450)

Background: Stage IV non–small-cell lung cancer (NSCLC) patients with oligometastases (< 5 metastatic lesions) may experience long-term survival when all macroscopic tumor sites are treated radically, but no prospective data on NSCLCs with synchronous oligometastases are available. Methods: A prospective single-arm phase II trial was conducted. The main inclusion criteria were pathologically proven NSCLC stage IV with less than five metastases at primary diagnosis, amendable for radical local treatment (surgery or radiotherapy). The study is listed in clinicaltrials.gov, number NCT01282450. Results: Forty patients were enrolled, 39 of whom were evaluable (18 men, 21 women); mean age was 62.1 ± 9.2 years (range, 44–81). Twenty-nine (74%) had local stage III; 17 (44%) brain, seven (18%) bone, and four (10%) adrenal gland metastases. Thirty-five (87%) had a single metastatic lesion. Thirty-seven (95%) of the patients received chemotherapy as part of their primary treatment. Median overall survival (OS) was 13.5 months (95% confidence interval 7.6–19.4); 1-, 2-, and 3-year OS was 56.4%, 23.3%, and 17.5%, respectively. Median progression-free survival (PFS) was 12.1 months (95% confidence interval 9.6–14.3); 1-year PFS was 51.3%, and both 2- and 3-year PFS was 13.6%. Only two patients (5%) had a local recurrence. No patient or tumor parameter, including volume and 18F-deoxyglucose uptake was significantly correlated with OS or PFS. The treatment was well tolerated. Conclusion: In this phase II study, long-term PFS was found in a subgroup of NSCLC patients with synchronous oligometastases when treated radically. Identification of this favorable subgroup before therapy is needed.

Is high-dose stereotactic body radiotherapy (SBRT) for stage I non-small cell lung cancer (NSCLC) overkill? A systematic review

BACKGROUND AND PURPOSE For stereotactic body radiotherapy (SBRT), typically a scheme of 60 Gy in 3-8 fractions is applied, producing local tumour control rates around 90%. The dose specification is in one point only and ignores possible underdosages at the edge of the planning target volume (PTV). We investigated the doses at the edge of the PTV and correlated this with local tumour control with the aim to shed light on the radiation dose needed to eradicate stage I NSCLC. MATERIALS AND METHODS Published data on the freedom from local progression (FFLP) data from SBRT and accelerated high-dose conventional radiotherapy series for stage I NSCLC with a follow up of at least 30 months were included. The EQD(2,T) was calculated from the dose at the periphery of the PTV. RESULTS Fifteen studies for SBRT (1076 patients) showed a median FFLP of 88.0±10.4% with a median EQD(2,T) of 76.9±17.4 Gy. The median FFLP was 87.6±6.0% for the accelerated schedules with an EQD(2,T) of 86.9±39.1 Gy, respectively. No significant relation was found between FFLP and the EQD(2,T) (p=0.23). CONCLUSIONS Several fractionated and accelerated schedules with equal biological doses achieve the same tumour control rates as SBRT. Lower, but more uniform doses to the whole PTV may be sufficient to achieve similar control rates, with the possibility to deliver SBRT in adapted schedules, beneficial to centrally located tumours in the vicinity of critical structures like the oesophagus and great vessels.

Do health care providers' attitudes towards back pain predict their treatment recommendations? Differential predictive validity of implicit and explicit attitude measures

&NA; The current study aimed to measure the differential predictive value of implicit and explicit attitude measures on treatment behaviour of health care providers. Thirty‐six physiotherapy students completed a measure of explicit treatment attitude (Pain Attitudes And Beliefs Scale For Physiotherapists—PABS‐PT) and a measure of implicit treatment attitude (Extrinsic Affective Simon Task—EAST). Furthermore, they gave treatment recommendations for a patient simulating back pain on three video scenes. The implicit and explicit measures of attitudes were only weakly related to each other. However, both were differentially related to treatment recommendations. The implications of the differential predictive value of implicit and explicit attitude measures for treatment behaviour are discussed.

The effects of failure feedback and pain-related fear on pain report, pain tolerance, and pain avoidance in chronic low back pain patients.

&NA; The aim of this study was to investigate the influence of non‐pain‐related failure experiences and pain‐related fear on pain report, pain tolerance and pain avoidance in chronic low back pain (CLBP) patients. Moreover, the mediating and moderating role of negative affectivity (trait‐NA) in the relationship between failure experiences and pain was examined. Seventy‐six patients were divided into high and low pain‐related fear groups and within each group they were randomly assigned to the failure or success feedback condition. In the first part of the study patients completed a ‘social empathy test’ and experimenter 1 subsequently delivered false failure or success feedback. A second experimenter, who was blind for the condition, subsequently administered two lifting tasks in order to obtain measures of pain report, tolerance and avoidance. Failure feedback did have an effect on pain avoidance but unexpectedly, and not as hypothesized, pain avoidance was reduced instead of enhanced. With regard to pain report and pain tolerance similar patterns were found, but these were not statistically significant. The effect of failure feedback on pain avoidance was moderated by trait‐NA. Only in the subgroup of patients who scored low on trait‐NA did failure feedback decrease pain avoidance. State‐NA did not mediate the effects of feedback. In line with previous findings, pain‐related fear resulted in lower pain tolerance. Moreover, this study was the first to show that pain‐related fear predicted higher pain report in CLBP patients. Pain‐related fear did not predict pain avoidance when pre‐lifting pain and gender were controlled for. Finally, pre‐lifting pain turned out to be the strongest predictor with regard to all pain measures. The role of pain‐related fear and unexpected findings with regard to feedback are discussed as well as some clinical implications.

18FDG-PET based radiation planning of mediastinal lymph nodes in limited disease small cell lung cancer changes radiotherapy fields: A planning study

BACKGROUND AND PURPOSE To investigate the influence of selective irradiation of 18FDG-PET positive mediastinal nodes on radiation fields and normal tissue exposure in limited disease small cell lung cancer (LD-SCLC). MATERIAL AND METHODS Twenty-one patients with LD-SCLC, of whom both CT and PET images were available, were studied. For each patient, two three-dimensional conformal treatment plans were made with selective irradiation of involved lymph nodes, based on CT and on PET, respectively. Changes in treatment plans as well as dosimetric factors associated with lung and esophageal toxicity were analyzed and compared. RESULTS FDG-PET information changed the treatment field in 5 patients (24%). In 3 patients, this was due to a decrease and in 2 patients to an increase in the number of involved nodal areas. However, there were no significant differences in gross tumor volume (GTV), lung, and esophageal parameters between CT- and PET-based plans. CONCLUSIONS Incorporating FDG-PET information in radiotherapy planning for patients with LD-SCLC changed the treatment plan in 24% of patients compared to CT. Both increases and decreases of the GTV were observed, theoretically leading to the avoidance of geographical miss or a decrease of radiation exposure of normal tissues, respectively. Based on these findings, a phase II trial, evaluating PET-scan based selective nodal irradiation, is ongoing in our department.

Patient satisfaction with nurse-led telephone follow-up after curative treatment for breast cancer

BackgroundCurrent frequent follow-up after treatment for breast cancer does not meet its intended aims, but does depend on expensive and scarce specialized knowledge for routine history taking and physical examinations. The study described in this paper compared patient satisfaction with a reduced follow-up strategy, i.e. nurse-led telephone follow-up, to satisfaction with traditional hospital follow-up.MethodsPatient satisfaction was assessed among patients (n = 299) who were participants of a randomized controlled trial investigating the cost-effectiveness of several follow-up strategies in the first year after treatment for breast cancer. Data on patient satisfaction were collected at baseline, three, six and 12 months after treatment, using the Dutch version of Wares Patient Satisfaction Questionnaire III (PSQ III). In addition to general satisfaction, the PSQ III reports on satisfaction scores for technical competence, interpersonal aspects, and access of care. Regression analysis was used to predict satisfaction scores from whether or not nurse-led telephone follow-up was received.ResultsNurse-led telephone follow-up had no statistically significant influence on general patient satisfaction (p = 0.379), satisfaction with technical competence (p = 0.249), and satisfaction with interpersonal aspects (p = 0.662). Regarding access of care, patient satisfaction scores were significantly higher for patients receiving telephone follow-up (p = 0.015). However, a mean difference at 12 months of 3.1 points was judged to be not clinically relevant.ConclusionsNo meaningful differences were found in satisfaction scores between nurse-led telephone and hospital follow-up in the first year after breast cancer treatment. With high satisfaction scores and the potential to substantially reduce clinic visits, nurse-led telephone follow-up may be an acceptable alternative to traditional hospital follow-up.Trial registration numberISRCTN 74071417.

In Vivo Quantification of Hypoxic and Metabolic Status of NSCLC Tumors Using [18F]HX4 and [18F]FDG-PET/CT Imaging

Purpose: Increased tumor metabolism and hypoxia are related to poor prognosis in solid tumors, including non–small cell lung cancer (NSCLC). PET imaging is a noninvasive technique that is frequently used to visualize and quantify tumor metabolism and hypoxia. The aim of this study was to perform an extensive comparison of tumor metabolism using 2[18F]fluoro-2-deoxy-d-glucose (FDG)-PET and hypoxia using HX4-PET imaging. Experimental Design: FDG- and HX4-PET/CT images of 25 patients with NSCLC were coregistered. At a global tumor level, HX4 and FDG parameters were extracted from the gross tumor volume (GTV). The HX4 high-fraction (HX4-HF) and HX4 high-volume (HX4-HV) were defined using a tumor-to-blood ratio > 1.4. For FDG high-fraction (FDG-HF) and FDG high-volume (FDG-HV), a standardized uptake value (SUV) > 50% of SUVmax was used. We evaluated the spatial correlation between HX4 and FDG uptake within the tumor, to quantify the (mis)match between volumes with a high FDG and high HX4 uptake. Results: At a tumor level, significant correlations were observed between FDG and HX4 parameters. For the primary GTV, the HX4-HF was three times smaller compared with the FDG-HF. In 53% of the primary lesions, less than 1 cm3 of the HX4-HV was outside the FDG–HV; for 37%, this volume was 1.9 to 12 cm3. Remarkably, a distinct uptake pattern was observed in 11%, with large hypoxic volumes localized outside the FDG-HV. Conclusion: Hypoxic tumor volumes are smaller than metabolic active volumes. Approximately half of the lesions showed a good spatial correlation between the PET tracers. In the other cases, a (partial) mismatch was observed. The addition of HX4-PET imaging has the potential to individualize patient treatment. Clin Cancer Res; 20(24); 6389–97. ©2014 AACR.

Metabolic control probability in tumour subvolumes or how to guide tumour dose redistribution in non-small cell lung cancer (NSCLC): An exploratory clinical study

PURPOSE To characterize the relationship between pre-radiotherapy (18)Fluorodeoxyglucose (FDG) uptake in a tumour voxel, radiation dose and the probability to achieve metabolic control in the tumour voxel after radiotherapy. MATERIALS AND METHODS Thirty-nine patients with inoperable stage I-III non-small cell lung cancer, treated with radiotherapy (RT) alone or sequential chemo radiation were analysed retrospectively. Twenty-two showed metabolic active areas in the tumour 3 months post-radiotherapy, which is known to be a surrogate for persistent local tumour failure and worse survival. Pre- and post-RT FDG-PET-CT scans were registered and the metabolic active zones within the tumour after RT were projected on the pre-RT scan. Multi-level logistic regression was performed to determine the relation between the FDG uptake if a voxel pre-RT and its metabolic state after RT. RESULTS The probability that a voxel is metabolically controlled (mVCP), decreased significantly with increasing FDG uptake in a voxel (SUV) (OR=0.72), increasing tumour volume (20 cm(3)) (OR=0.89) and increasing dose (Gy) (OR=0.99). Inter-patient differences in mVCP were substantial. CONCLUSION A methodology was presented to derive relationships between FDG uptake, dose and metabolic control. Although no strong dose effect relation was demonstrated, mVCP decreased with increasing FDG uptake and tumour volume.