Stein Kaasa

St. Olavs Hospital, Nidaros, Sør-Trøndelag, Norway

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Publications (417)1673.19 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Recently, the concept of integrating oncology and palliative care has gained wide professional and scientific support; however, a global consensus on what constitutes integration is unavailable. We conducted a Delphi Survey to develop a consensus list of indicators of integration of specialty palliative care and oncology programs for advanced cancer patients in hospitals with ≥100 beds. International experts on integration rated a list of indicators on integration over 3 iterative rounds under 5 categories: clinical structure, processes, outcomes, education and research. Consensus was defined a priori by an agreement of ≥70%. Major criteria (i.e. most relevant and important indicators) were subsequently identified. Among 47 experts surveyed, 46 (98%), 45 (96%) and 45 (96%) responded over the 3 rounds. 19 (40%) were female, 24 (51%) were from North America and 14 (30%) were from Europe. 16 (34%), 7 (15%) and 25 (53%) practiced palliative care, oncology and both specialties, respectively. After 3 rounds of deliberation, the panelists reached consensus on 13 major and 30 minor indicators. Major indicators included 2 related to structure (consensus 95-98%), 4 on processes (88-98%), 3 on outcomes (88-91%) and 4 on education (93-100%). The major indicators were considered to be clearly stated (9.8/10), objective (9.4/10), amenable to accurate coding (9.5/10) and applicable to their own countries (9.4/10). Our international experts reached broad consensus on a list of indicators of integration, which may be used to identify centers with a high level of integration, and facilitate benchmarking, quality improvement and research. © The Author 2015. Published by Oxford University Press on behalf of the European Society for Medical Oncology. All rights reserved. For permissions, please email: journals.permissions@oup.com.
    Annals of Oncology 06/2015; DOI:10.1093/annonc/mdv269 · 6.58 Impact Factor
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    ABSTRACT: Opioids modulate the perception of breathlessness with a considerable variation in response, with poor correlation between the required opioid dose and symptom severity. The objective of this hypothesis-generating, secondary analysis was to identify candidate single nucleotide polymorphisms (SNP) from those associated with opioid receptors, signalling or pain modulation to identify any related to intensity of breathlessness while on opioids. This can help to inform prospective studies and potentially lead to better tailoring of opioid therapy for refractory breathlessness. 17 hospice/palliative care services (tertiary services) in 11 European countries. 2294 people over 18 years of age on regular opioids for pain related to cancer or its treatment. The relationship between morphine dose, breathlessness intensity (European Organisation for Research and Treatment of Cancer Core Quality of Life Questionnaire; EORTCQLQC30 question 8) and 112 candidate SNPs from 25 genes (n=588). The same measures for people on oxycodone (n=402) or fentanyl (n=429). SNPs not in Hardy-Weinberg equilibrium or with allele frequencies (<5%) were removed. Univariate associations between each SNP and breathlessness intensity were determined with Benjamini-Hochberg false discovery rate set at 20%. Multivariable ordinal logistic regression, clustering over country and adjusting for available confounders, was conducted with remaining SNPs. For univariate morphine associations, 1 variant on the 5-hydroxytryptamine type 3B (HTR3B) gene, and 4 on the β-2-arrestin gene (ARRB2) were associated with more intense breathlessness. 1 SNP remained significant in the multivariable model: people with rs7103572 SNP (HTR3B gene; present in 8.4% of the population) were three times more likely to have more intense breathlessness (OR 2.86; 95% CIs 1.46 to 5.62; p=0.002). No associations were seen with fentanyl nor with oxycodone. This large, exploratory study identified 1 biologically plausible SNP that warrants further study in the response of breathlessness to morphine therapy. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
    BMJ Open 05/2015; 5(5):e006818. DOI:10.1136/bmjopen-2014-006818 · 2.06 Impact Factor
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    ABSTRACT: Background Renal impairment and the risk of toxicity caused by accumulation of opioids and/or active metabolites is an under-investigated issue. This study aimed at analysing if symptoms/adverse effects in opioid-treated patients with cancer were associated with renal function.Methods Cross-sectional multicentre study (European Pharmacogenetic Opioid Study, 2005–2008), in which 1147 adult patients treated exclusively with only one of the most frequently reported opioids (morphine/oxycodone/fentanyl) for at least 3 days were analysed. Fatigue, nausea/vomiting, pain, loss of appetite, constipation and cognitive dysfunction were assessed (EORTC QLQ-C30). Glomerular filtration rate (GFR) was estimated using Cockcroft–Gault (CG), Modification of Diet in Renal Disease (MDRD), and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI Creatinine) equations.ResultsMild to severe low GFR was observed among 40–54% of patients. CG equation showed that patients with mild and moderate/severe low GFR on morphine treatment had higher odds of having severe constipation (P < 0.01) than patients with normal GFR. In addition, patients with moderate/severe low GFR on morphine treatment were more likely to have loss of appetite (P = 0.04). No other significant associations were found.Conclusion Only severe constipation and loss of appetite were associated with low GFR in patients treated with morphine. Oxycodone and fentanyl, in relation to the symptoms studied, seem to be safe as used and titrated in routine cancer pain care.
    Acta Anaesthesiologica Scandinavica 05/2015; DOI:10.1111/aas.12521 · 2.31 Impact Factor
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    Pain 03/2015; DOI:10.1097/j.pain.0000000000000160 · 5.84 Impact Factor
  • Journal of Clinical Oncology 03/2015; 33(13). DOI:10.1200/JCO.2014.60.6475 · 17.88 Impact Factor
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    Supportive and Palliative Care 02/2015; DOI:10.1136/bmjspcare-2014-000722.
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    ABSTRACT: Depressive symptoms are common in patients with cancer and tend to increase as death approaches. The study aims were to examine the prevalence of depressive symptoms in patients with cancer in their final 24 h, and their association with other symptoms, sociodemographic and care characteristics. A stratified sample of deaths was drawn by Statistics Netherlands. Questionnaires on patient and care characteristics were sent to the physicians (N=6860) who signed the death certificates (response rate 77.8%). Adult patients with cancer with non-sudden death were included (n=1363). Symptoms during the final 24 h of life were assessed on a 1-5 scale and categorised as 1=no, 2-3=mild/moderate and 4-5=severe/very severe. Depressive symptoms were registered in 37.6% of the patients. Patients aged 80 years or more had a reduced risk of having mild/moderate depressive symptoms compared with those aged 17-65 years (OR 0.70; 95% CI 0.50 to 0.99). Elderly care physicians were more likely to assess patients with severe/very severe depressive symptoms than patients with no depressive symptoms (OR 4.18; 95% CI 1.48 to 11.76). Involvement of pain specialists/palliative care consultants and psychiatrists/psychologists was associated with more ratings of severe/very severe depressive symptoms. Fatigue and confusion were significantly associated with mild/moderate depressive symptoms and anxiety with severe/very severe symptoms. More than one-third of the patients were categorised with depressive symptoms during the last 24 h of life. We recommend greater awareness of depression earlier in the disease trajectory to improve care. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
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    Critical Reviews in Oncology/Hematology 02/2015; 94(1). DOI:10.1016/j.critrevonc.2014.12.010 · 4.05 Impact Factor
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    ABSTRACT: The aims of this study were to explore the efficacy of intranasal fentanyl spray* (INFS) 400 μg to evaluate 12-week tolerability of the nasal mucosa and to explore safety data for all dose strengths of INFS in patients with cancer-related breakthrough pain (BTP). Patients received a test dose of INFS 50 μg, followed by a titration phase. Those patients with doses titrated to 200 or 400 μg entered a randomized, double-blind, cross-over efficacy phase, in which 8 episodes of BTP were randomly treated with INFS 400 μg (6 episodes) and placebo (2 episodes), followed by a tolerability phase. Patients with doses titrated to 50 or 100 μg entered the tolerability phase directly. Primary outcome was measured by pain intensity difference at 10 minutes, analyzed using ANCOVA, and presented as least square mean difference. Examination of the nasal cavity was conducted at inclusion and after 12 weeks of treatment by an otorhinolaryngologist. Forty-six patients were included. Thirty-eight patients' doses were titrated to an effective dose of INFS; 50 μg (n = 8), 100 μg (n = 9), 200 μg (n = 9), and 400 μg (n = 12); 15 patients entered the efficacy phase and 31 entered the tolerability phase. In the efficacy phase, 88 and 29 episodes of BTP were treated with INFS 400 μg and placebo, respectively. Pain intensity difference at 10 minutes least square mean for INFS 400 μg was 2.5 (95% CI, 1.42-3.49) (P < 0.001) and least square mean difference between INFS 400 μg and placebo was 1.1 (95% CI, 0.41-1.79) (P = 0.002). Runny nose (10%) and change in color of the mucosa (9%) were the most frequent findings of nasal examination, and nausea and dizziness were the most frequent treatment-related adverse events. One serious adverse event (ie, respiratory depression) was considered related to INFS. INFS 400 μg is effective and nasal tolerability and overall safety profile is acceptable during 12 weeks of use. ClinicalTrials.gov identifier: NCT01429051. Copyright © 2015 Elsevier HS Journals, Inc. All rights reserved.
    Clinical Therapeutics 01/2015; 37(3). DOI:10.1016/j.clinthera.2014.12.010 · 2.59 Impact Factor
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    ABSTRACT: To examine whether the inter-individual variation in constipation among patients receiving opioids for cancer pain is associated with genetic or non-genetic factors. Cancer patients receiving opioids were included from 17 centers in 11 European countries. Intensity of constipation was reported by 1,568 patients on a four-point categorical scale. Non-genetic factors were included as covariates in stratified regression analyses on the association between constipation and 75 single-nucleotide polymorphisms (SNPs) within 15 candidate genes related to opioid- or constipation-signaling pathways (HTR3E, HTR4, HTR2A, TPH1, ADRA2A, CHRM3, TACR1, CCKAR, KIT, ARRB2, GHRL, ABCB1, COMT, OPRM1, and OPRD1). The non-genetic factors significantly associated with constipation were type of laxative, mobility and place of care among patients receiving laxatives (N=806), in addition to Karnofsky performance status and presence of metastases among patients not receiving laxatives (N=762) (P<0.01). Age, gender, body mass index, cancer diagnosis, time on opioids, opioid dose, and type of opioid did not contribute to the inter-individual differences in constipation. Five SNPs, rs1800532 in TPH1, rs1799971 in OPRM1, rs4437575 in ABCB1, rs10802789 in CHRM3, and rs2020917 in COMT were associated with constipation (P<0.01). Only rs2020917 in COMT passed the Benjamini-Hochberg criterion for a 10% false discovery rate. Type of laxative, mobility, hospitalization, Karnofsky performance status, presence of metastases, and five SNPs within TPH1, OPRM1, ABCB1, CHRM3, and COMT may contribute to the variability in constipation among cancer patients treated with opioids. Knowledge of these factors may help to develop new therapies and to identify patients needing a more individualized approach to treatment.
    01/2015; 6:e90. DOI:10.1038/ctg.2015.19
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    ABSTRACT: Both the American Society of Clinical Oncology and the European Society for Medical Oncology strongly endorse integrating oncology and palliative care (PC); however, a global consensus on what constitutes integration is currently lacking. To better understand what integration entails, we conducted a systematic review to identify articles addressing the clinical, educational, research, and administrative indicators of integration. We searched Ovid MEDLINE and Ovid EMBase between 1948 and 2013. Two researchers independently reviewed each citation for inclusion and extracted the indicators related to integration. The inter-rater agreement was high (κ = 0.96, p < .001). Of the 431 publications in our initial search, 101 were included. A majority were review articles (58%) published in oncology journals (59%) and in or after 2010 (64%, p < .001). A total of 55 articles (54%), 33 articles (32%), 24 articles (24%), and 14 articles (14%) discussed the role of outpatient clinics, community-based care, PC units, and inpatient consultation teams in integration, respectively. Process indicators of integration include interdisciplinary PC teams (n = 72), simultaneous care approach (n = 71), routine symptom screening (n = 25), PC guidelines (n = 33), care pathways (n = 11), and combined tumor boards (n = 10). A total of 66 articles (65%) mentioned early involvement of PC, 18 (18%) provided a specific timing, and 28 (28%) discussed referral criteria. A total of 45 articles (45%), 20 articles (20%), and 66 articles (65%) discussed 8, 4, and 9 indicators related to the educational, research, and administrative aspects of integration, respectively. Integration was a heterogeneously defined concept. Our systematic review highlighted 38 clinical, educational, research, and administrative indicators. With further refinement, these indicators may facilitate assessment of the level of integration of oncology and PC. ©AlphaMed Press.
    The Oncologist 12/2014; 20(1). DOI:10.1634/theoncologist.2014-0312 · 4.54 Impact Factor
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    ABSTRACT: Evidence-based treatment guidelines embedded in computer-based clinical decision support systems (CCDSS) may improve patient-reported outcomes (PRO). We systematically reviewed the literature for content and application of CCDSS, and their effects on PRO. A systematic review in MEDLINE and EMBASE was conducted according to PRISMA standards. Searches were limited to the publication period 1996-May 2014 and the English language. The search terms covered "computerized clinical decision systems" and "patient-reported outcomes". Screening and extraction was done independently by two reviewers according to predefined inclusion (computer and guideline) and exclusion criteria (no trial, no PRO). Study and CCDSS quality was rated according to predefined criteria. The database searches identified 1,331 references. Eighty-seven full-text articles were analyzed. The main reason for exclusion was no PRO as a study outcome measure. Fifteen studies met the inclusion criteria, representing 13,480 patients. Nine studies used a computerized device to fill in data; in four studies, this was used by the patients themselves. Most of the studies presented the data to the clinician at point of care and incorporated international guidelines. Three studies showed a positive effect on PRO, but only on symptoms. Overall, no negative effects were reported. There was no association with study quality or year of study publication. There are marginal positive effects of CCDSS on specific PRO. Factors that facilitate the use and effect are identified. Easy to use systems with difficult to ignore evidence-based advice need to be developed and tested.
    The patient 11/2014; DOI:10.1007/s40271-014-0100-1 · 1.96 Impact Factor
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    ABSTRACT: Patients with advanced cancer commonly experience multiple somatic symptoms and declining functioning. Some highly prevalent symptoms also overlap with diagnostic symptom-criteria of depression. Thus, assessing depression in these patients can be challenging. We therefore investigated 1) the effect of different scoring-methods of depressive symptoms on detecting depression, and 2) the relationship between disease load and depression amongst patients with advanced cancer. The sample included 969 patients in the European Palliative Care Research Collaborative-Computer Symptom Assessment Study (EPCRC-CSA). Inclusion criteria were: incurable metastatic/locally advanced cancer and ≥18 years. Biomarkers and length of survival were registered from patient-records. Depression was assessed using the Patient Health Questionnaire (PHQ-9) and applying three scoring-methods: inclusive (algorithm scoring including the somatic symptom-criteria), exclusive (algorithm scoring excluding the somatic symptom-criteria) and sum-score (sum of all symptoms with a cut-off ≥8). Depression prevalence rates varied according to scoring-method: inclusive 13.7%, exclusive 14.9% and sum-score 45.3%. Agreement between the algorithm scoring-methods was excellent (Kappa=0.81), but low between the inclusive and sum scoring-methods (Kappa=0.32). Depression was significantly associated with more pain (OR-range: 1.09-1.19, p<0.001-0.04) and lower performance status (KPS-score, OR-range=0.68-0.72, p<0.001) irrespective of scoring-method. Depression was assessed using self-report, not clinical interviews. The scoring-method, not excluding somatic symptoms, had the greatest effect on assessment outcomes. Increasing pain and poorer than expected physical condition should alert clinicians to possible co-morbid depression. The large discrepancy in prevalence rates between scoring-methods reinforces the need for consensus and validation of depression definitions and assessment in populations with high disease load. Copyright © 2014 Elsevier B.V. All rights reserved.
    Journal of Affective Disorders 11/2014; 173C:176-184. DOI:10.1016/j.jad.2014.11.006 · 3.71 Impact Factor
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    ABSTRACT: The study objective was to evaluate whether there are clinical or genetic differences between patients with cancer-induced bone pain (CIBP) and patients with non-CIBP, and, in the CIBP group, in those with good versus poor opioid response.
    The Oncologist 10/2014; 19(12). DOI:10.1634/theoncologist.2014-0174 · 4.54 Impact Factor
  • Sunil Xavier Raj, Stein Kaasa
    Supportive Care Cancer 10/2014; 22(12). DOI:10.1007/s00520-014-2464-0 · 2.50 Impact Factor
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    ABSTRACT: Neuropathic pain (NP) in cancer patients lacks standards for diagnosis. This study is aimed at reaching consensus on the application of the NeuPSIG criteria to the diagnosis of NP in cancer patients and on the relevance of patient reported outcome (PRO) descriptors for the screening of NP in this population. An international group of 42 experts was invited to participate in a consensus process through a modified two-round internet-based Delphi survey. Relevant topics investigated were: peculiarities of NP in patients with cancer, IASP NeuPSIG diagnostic criteria adaptation and assessment, standardized PRO assessment for NP screening. Median consensus scores (MED) and inter-quartile ranges (IQR), were calculated to measure expert consensus after both rounds. 29 experts answered and good agreement was found on the statement "the pathophysiology of NP due to cancer can be different from non-cancer NP" (MED=9, IQR=2). Satisfactory consensus was reached for the first three NeuPSIG criteria (pain distribution, history and sensory findings) (MEDs>=8, IQRs<=3), but not for the fourth one (diagnostic test/imaging) (MED=6, IQR=3). Agreement was also reached on clinical examination by soft brush or pin stimulation (MEDs>=7 and IQRs<=3) and on the use of PRO descriptors for NP screening (MED=8, IQR=3). Based on the study results a clinical algorithm for NP diagnostic criteria in cancer patients with pain was proposed. Clinical research on PRO in the screening phase and on the application of the algorithm will be needed to examine their effectiveness in classifying NP in cancer patients.
    Pain 10/2014; 155(12). DOI:10.1016/j.pain.2014.09.038 · 5.84 Impact Factor
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    ABSTRACT: Depression is common in patients with advanced cancer; however, it is not often recognized and therefore not treated. The aims of this study were to examine the prevalence of the use of antidepressants (ADs) in an international cross-sectional study sample and to identify sociodemographic and medical variables associated with their use. The study was conducted in patients with advanced cancer from 17 centres across eight countries. Healthcare professionals registered patient and disease-related characteristics. A dichotomous score (no/yes) was used to assess the use of ADs other than as adjuvant for pain. Self-report questionnaires from patients were used for the assessment of functioning and symptom intensity. Of 1051 patient records with complete data on ADs, 1048 were included (M:540/F:508, mean age 62 years, standard deviation [SD] 12). The majority were inpatients, and 85% had metastatic disease. The prevalence of AD use was 14%. Multivariate logistic regression analyses showed that younger age (odds ratio [OR] 2.46; confidence interval [CI] 1.32-4.55), female gender (OR 1.59; CI 1.09-2.33), current medication for pain (OR 2.68; CI 1.65-4.33) and presence of three or more co-morbidities (OR 4.74; CI 2.27-9.91) were associated with AD use for reasons other than pain. Disease-related variables (diagnoses, stage, Karnofsky Performance Status and survival) were not associated with the use of ADs. Female gender, younger age, analgesic use and multiple co-morbidities were associated with the use of ADs. However, information is still limited on which variables guide physicians in prescribing AD medication. Further longitudinal studies including details on psychiatric and medication history are needed to improve the identification of patients in need of ADs. Copyright © 2014 John Wiley & Sons, Ltd.
    Psycho-Oncology 10/2014; 23(10). DOI:10.1002/pon.3541 · 4.04 Impact Factor
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    ABSTRACT: Background. Sarcopenia is a defining feature of cancer cachexia associated with physical decline, poor quality of life and poor prognosis. Thus, maintaining muscle mass is an important aim of cachexia treatment. Many patients at risk for developing cachexia or with cachexia experience side effects of chemotherapy that might aggravate the development of cachexia. However, achieving tumor control might reverse the catabolic processes causing cachexia. There is limited knowledge about muscle mass changes during chemotherapy or whether changes in muscle mass are associated with response to chemotherapy. Patients and methods. In this pilot study, patients with advanced non-small cell lung cancer (NSCLC) receiving three courses of palliative chemotherapy were analyzed. Muscle mass was measured as skeletal muscle cross sectional area (SMCA) at the level of the third lumbar vertebrae using CT images taken before and after chemotherapy. Results. In total 35 patients, 48% women, mean age 67 years (range 56–86), participated; 83% had stage IV disease and 71% were sarcopenic at baseline. Mean reduction in SMCA from pre- to post-chemotherapy was 4.6 cm2 (CI 95% −7.3–−1.9; p < 0.002), corresponding to a 1.4 kg loss of whole body muscle mass. Sixteen patients remained stable or gained SMCA. Of these, 14 (56%) responded to chemotherapy, while two progressed (p = 0.071). Maintaining or gaining SMCA resulted in longer median overall survival (loss: 5.8 months, stable/gain: 10.7 months; p = 0.073). Stage of disease (p = 0.003), treatment regimen (p = 0.023), response to chemotherapy (p = 0.007) and SMCA change (p = 0.040), but not sarcopenia at baseline, were significant prognostic factors in the multivariate survival analyses. Conclusion. Almost half of the patients had stable or increased muscle mass during chemotherapy without receiving any cachexia treatment. Nearly all of these patients responded to the chemotherapy. Increase in muscle mass, but not sarcopenia at baseline, was a significant prognostic factor.
    Acta Oncologica 09/2014; 54(3). DOI:10.3109/0284186X.2014.953259 · 3.71 Impact Factor
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    ABSTRACT: Background. Many cancer patients receive chemotherapy and radiotherapy their last 30 days [end of life (EOL)]. The benefit is questionable and side effects are common. The aim of this study was to investigate what characterized the patients who received chemo- and radiotherapy during EOL, knowledge that might be used to improve practice. Methods. Patients dead from cancer in 2005 and 2009 were analyzed. Data were collected from hospital medical records. When performance status (PS) was not stated, PS was estimated from other information in the records. A Glasgow Prognostic Score (GPS) of 0, 1 or 2 was assessed from blood values (CRP and albumin). A higher score is associated with a shorter prognosis. Results. In total 616 patients died in 2005; 599 in 2009. Among the 723 analyzed, median age was 71; 42% had metastases at diagnosis (synchronous metastases); 53% had PS 2 and 16% PS 3-4 at the start of last cancer therapy. GPS at the start of last cancer therapy was assessable in 70%; of these, 26% had GPS 1 and 35% GPS 2. Overall, 10% received chemotherapy and 8% radiotherapy during EOL. The proportions varied significantly between the different types of cancer. Multivariate analyses revealed that those at age < 70 years, GPS 2, no contact with our Palliative Care Unit and synchronous metastases received most chemotherapy the last 30 days. PS 3-4, GPS 2 and synchronous metastases were strongest associated with radiotherapy the last 30 days. Conclusion. Ten percent received chemotherapy and 8% radiotherapy the last 30 days of life. GPS 2 and synchronous metastases were most significantly associated with cancer therapy the last 30 days of life, indicating that in general, patients with the shortest survival time after diagnosis of cancer received more chemo- and radiotherapy during EOL than other patients.
    Acta oncologica (Stockholm, Sweden) 08/2014; 54(3):1-8. DOI:10.3109/0284186X.2014.948061 · 3.71 Impact Factor
  • 08/2014; 5(4):1-13. DOI:10.1080/23294515.2014.938199

Publication Stats

17k Citations
1,673.19 Total Impact Points

Institutions

  • 2002–2015
    • St. Olavs Hospital
      Nidaros, Sør-Trøndelag, Norway
    • Royal Alexandra Hospital
      Edmonton, Alberta, Canada
    • Fondazione IRCCS Istituto Nazionale dei Tumori di Milano
      Milano, Lombardy, Italy
  • 1999–2015
    • Norwegian University of Science and Technology
      • • European Palliative Care Research Centre
      • • Department of Cancer Research and Molecular Medicine
      • • Department of Circulation and Medical Imaging
      • • Unit for Applied Clinical Research
      • • Faculty of Medicine
      Nidaros, Sør-Trøndelag, Norway
  • 2012
    • Turku University Hospital
      Turku, Province of Western Finland, Finland
  • 2001–2012
    • NTNU Samfunnsforskning
      Nidaros, Sør-Trøndelag, Norway
    • The Norwegian Medical Association
      Kristiania (historical), Oslo County, Norway
  • 1997–2011
    • University of Oslo
      • Department of Behavioural Sciences in Medicine
      Kristiania (historical), Oslo, Norway
    • Sahlgrenska University Hospital
      • Department of Cardiology
      Goeteborg, Västra Götaland, Sweden
  • 1995–2011
    • University Hospital of North Norway
      • Department of Oncology
      Tromsø, Troms, Norway
  • 2009
    • Sør-Trøndelag University College
      • Faculty of Technology
      Trondheim, Sor-Trondelag Fylke, Norway
    • Oslo University Hospital
      • Department of Oncology
      Oslo, Oslo, Norway
  • 2003–2007
    • Haukeland University Hospital
      Bergen, Hordaland, Norway
  • 2002–2007
    • University of Aberdeen
      • Institute of Applied Health Sciences
      Aberdeen, SCT, United Kingdom
  • 1999–2006
    • Norwegian University of Technology and Science
      Nidaros, Sør-Trøndelag, Norway
  • 2005
    • Harvard University
      Cambridge, Massachusetts, United States
  • 1988–1999
    • Norwegian Cancer Society
      Kristiania (historical), Oslo County, Norway
    • Institutt for samfunnsforskning, Oslo
      Kristiania (historical), Oslo County, Norway
  • 1998
    • University Medical Center Hamburg - Eppendorf
      Hamburg, Hamburg, Germany
  • 1995–1997
    • Universitetet i Tromsø
      • Department of Community Medicine
      Tromsø, Troms Fylke, Norway
  • 1992
    • University of Helsinki
      • Department of Radiotherapy and Oncology
      Helsinki, Southern Finland Province, Finland
  • 1991
    • Det Norske Veritas
      Kristiania (historical), Oslo County, Norway