Stein Kaasa

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

Are you Stein Kaasa?

Claim your profile

Publications (451)1752.1 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Importance Differences in utilization and costs of end-of-life care among developed countries are of considerable policy interest.Objective To compare site of death, health care utilization, and hospital expenditures in 7 countries: Belgium, Canada, England, Germany, the Netherlands, Norway, and the United States.Design, Setting, and Participants Retrospective cohort study using administrative and registry data from 2010. Participants were decedents older than 65 years who died with cancer. Secondary analyses included decedents of any age, decedents older than 65 years with lung cancer, and decedents older than 65 years in the United States and Germany from 2012.Main Outcomes and Measures Deaths in acute care hospitals, 3 inpatient measures (hospitalizations in acute care hospitals, admissions to intensive care units, and emergency department visits), 1 outpatient measure (chemotherapy episodes), and hospital expenditures paid by insurers (commercial or governmental) during the 180-day and 30-day periods before death. Expenditures were derived from country-specific methods for costing inpatient services.Results The United States (cohort of decedents aged >65 years, N = 211 816) and the Netherlands (N = 7216) had the lowest proportion of decedents die in acute care hospitals (22.2.% and 29.4%, respectively). A higher proportion of decedents died in acute care hospitals in Belgium (N = 21 054; 51.2%), Canada (N = 20 818; 52.1%), England (N = 97 099; 41.7%), Germany (N = 24 434; 38.3%), and Norway (N = 6636; 44.7%). In the last 180 days of life, 40.3% of US decedents had an intensive care unit admission compared with less than 18% in other reporting nations. In the last 180 days of life, mean per capita hospital expenditures were higher in Canada (US $21 840), Norway (US $19 783), and the United States (US $18 500), intermediate in Germany (US $16 221) and Belgium (US $15 699), and lower in the Netherlands (US $10 936) and England (US $9342). Secondary analyses showed similar results.Conclusions and Relevance Among patients older than 65 years who died with cancer in 7 developed countries in 2010, end-of-life care was more hospital-centric in Belgium, Canada, England, Germany, and Norway than in the Netherlands or the United States. Hospital expenditures near the end of life were higher in the United States, Norway, and Canada, intermediate in Germany and Belgium, and lower in the Netherlands and England. However, intensive care unit admissions were more than twice as common in the United States as in other countries.
    No preview · Article · Jan 2016 · JAMA The Journal of the American Medical Association
  • [Show abstract] [Hide abstract]
    ABSTRACT: Chemotherapy is increasingly being used in advanced pancreatic cancer, but side-effects are common. The aim of this systematic review was to assess whether chemotherapy improves health-related quality of life (HRQoL), pain or cachexia. Thirty studies were reviewed. Four of 23 studies evaluating HRQoL, 7 of 24 studies evaluating pain and 0 of 8 studies evaluating cachexia found differences between treatment arms. Change in HRQoL from baseline was evaluated in 14 studies: five studies reported an improvement in at least one treatment arm; three a worsening and the remaining stable scores. Change in pain intensity from baseline was evaluated in eight studies, and improvement was observed in seven. Of the four studies reporting improved survival, three reported improved HRQoL or pain. In conclusion, chemotherapy can stabilize HRQoL and improve pain control. Effects on cachexia are hard to elucidate. Improved survival does not come at the expense of HRQoL or pain control.
    No preview · Article · Jan 2016 · Critical reviews in oncology/hematology
  • [Show abstract] [Hide abstract]
    ABSTRACT: Background: Depressive symptoms are prevalent in patients with advanced cancer, sometimes of a severity that fulfil the criteria for a major depressive episode. Aim: The aim of this study was to investigate how the item on depression in the Edmonton Symptom Assessment System with a 0-10 Numerical Rating Scale performed as a screener for major depressive episode. A possible improved performance by adding the Edmonton Symptom Assessment System-Anxiety item was also examined. Design: An international cross-sectional study including patients with incurable cancer was conducted. The Edmonton Symptom Assessment System score was compared against major depressive episode as assessed by the Patient Health Questionnaire-9. Screening performance was examined by sensitivity, specificity and the kappa coefficient. Setting: Patients with incurable cancer (n = 969), median age 63 years and from eight nationalities provided report. Median Karnofsky Performance Status was 70. Median survival was 229 days (205-255 days). Results: Patient Health Questionnaire-9 major depressive episode was present in 133 of 969 patients (13.7%). Edmonton Symptom Assessment System-Depression screening ability for Patient Health Questionnaire-9 major depressive episode was limited. Area under the receiver operating characteristic curve was 0.71 (0.66-0.76). Valid detection or exclusion of Patient Health Questionnaire-9 major depressive episode could not be concluded at any Edmonton Symptom Assessment System-Depression cut-off; by the cut-off Numerical Rating Scale ⩾ 2, sensitivity was 0.69 and specificity was 0.60. By the cut-off Numerical Rating Scale ⩾ 4, sensitivity was 0.51 and specificity was 0.82. Combined mean ratings by Edmonton Symptom Assessment System-Depression and Edmonton Symptom Assessment System-Anxiety revealed similar limited screening ability. Conclusion: The depression and anxiety items of the Edmonton Symptom Assessment System, a frequently used assessment tool in palliative care settings, seem to measure a construct other than major depressive episode as assessed by the Patient Health Questionnaire-9 instrument.
    No preview · Article · Jan 2016 · Palliative Medicine
  • [Show abstract] [Hide abstract]
    ABSTRACT: Purpose: Cancer pain (CP) management is challenging. In recent years, efforts were undertaken to achieve better CP management, e.g. clinical research, new treatment modalities, development of guidelines, education and focus on implementation. The aim of the present study was to compare the prevalence and characteristics of pain and breakthrough pain (BTP) between cross-sectional studies conducted in 2008 and 2014. It was hypothesized that an improvement in pain control would be observed the years in between. Methods: Two cross-sectional studies were conducted where adult cancer patients answered questions from Brief Pain Inventory and the Alberta Breakthrough Pain Assessment Tool for cancer patients. Physicians reported socio-demographic and medical data. Regression models were applied for analysis. Results: In total, 168 inpatients, 92 in 2008 and 76 in 2014, and 675 outpatients, 301 in 2008 and 374 in 2014, were included. The patient characteristics of the samples were comparable. Prevalence of CP among inpatients was 55 % in 2008 and 53 % in 2014, and among outpatients, 39 and 35 %, respectively. Inpatients reported average pain intensity (0-10 numerical rating scale, NRS) of 3.60 (standard deviation, SD 1.84) (2008) and 4.08 (SD 2.11) (2014); prevalence of BTP was 52 % (2008) and 41 % (2014). For outpatients, average pain intensity was 3.60 (SD 2.04) (2008) and 3.86 (SD 2.20) (2014); prevalence of BTP was 43 % (2008) and 37 % (2014). None of the differences were statistically significant. Conclusion: Unexpectedly, no improvement in pain control was observed. Efforts are still needed to improve cancer pain management.
    No preview · Article · Dec 2015 · Supportive Care Cancer
  • [Show abstract] [Hide abstract]
    ABSTRACT: Background: Patients with advanced, incurable cancer receiving anticancer treatment often experience multidimensional symptoms. We hypothesize that real-time monitoring of both symptoms and clinical syndromes will improve symptom management by oncologists and patient outcomes. Patients and methods: In this prospective multicenter cluster-randomized phase-III trial patients with incurable, symptomatic, solid tumors, who received new outpatient chemotherapy with palliative intention, were eligible. Immediately before the weekly oncologists' visit patients completed the palm-based E-MOSAIC assessment (Edmonton-Symptom-Assessment-Scale, ≤3 additional symptoms, estimated nutritional intake, body weight change, Karnofsky Performance Status, medications for pain, fatigue, nutrition). A cumulative, longitudinal monitoring sheet (LoMoS) was printed immediately. Eligible experienced oncologists were defined as one cluster each and randomized to receive the immediate print-out LoMoS (intervention) or not (control). Primary analysis limited to patients having uninterrupted (>4/6 visits with same oncologist) patient-oncologist sequences was a mixed model for the difference in patients global quality of life (G-QoL; items 29/30 of EORTC-QlQ-c30) between baseline (BL) and week 6. Intention-to-treat analysis included all eligible patients. Results: In 8 centers, 82 oncologists treated 264 patients (median 66y; overall survival intervention 6.3, control 5.4 mts) with various tumors. The between-arm difference in G-QoL of 102 uninterrupted patients (intervention: 55; control: 47) was 6.8 (p=0.11) in favour of the intervention, in a sensitivity analysis (oncologists treating ≥2 patients; 50, 39) it was 9.0 (p=0.07). Intention-to-treat analysis revealed improvement in symptoms (difference last study visit - BL: intervention -5.4 versus control 2.1, p= 0.003) and favoured the intervention for communication and coping. More patients with high symptom load received immediate symptom management (chart review, nurse-patient interview) by oncologists getting the LoMoS. Conclusion: Monitoring of patient symptoms, clinical syndromes and their management clearly reduced patients' symptoms, but not QoL. Our results encourage the implementation of real-time monitoring in the routine workflow of oncologist with a computer solution.
    No preview · Article · Dec 2015 · Annals of Oncology
  • Source
    Stein Kaasa

    Preview · Article · Dec 2015 · Journal of Clinical Oncology

  • No preview · Article · Nov 2015 · Annals of Oncology

  • No preview · Article · Oct 2015 · Quality of Life Research
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Common adverse symptoms of cancer and chemotherapy are a major health burden; chief among these is pain, with opioids including transdermal fentanyl the mainstay of treatment. Innate immune activation has been implicated generally in pain, opioid analgesia, cognitive dysfunction, and sickness type symptoms reported by cancer patients. We aimed to determine if genetic polymorphisms in neuroimmune activation pathways alter the serum fentanyl concentration-response relationships for pain control, cognitive dysfunction, and other adverse symptoms, in cancer pain patients. Cancer pain patients (468) receiving transdermal fentanyl were genotyped for 31 single nucleotide polymorphisms in 19 genes: CASP1, BDNF, CRP, LY96, IL6, IL1B, TGFB1, TNF, IL10, IL2, TLR2, TLR4, MYD88, IL6R, OPRM1, ARRB2, COMT, STAT6 and ABCB1. Lasso and backward stepwise generalised linear regression were used to identify non-genetic and genetic predictors, respectively, of pain control (average Brief Pain Inventory < 4), cognitive dysfunction (Mini-Mental State Examination ≤ 23), sickness response and opioid adverse event complaint. Serum fentanyl concentrations did not predict between-patient variability in these outcomes, nor did genetic factors predict pain control, sickness response or opioid adverse event complaint. Carriers of the MYD88 rs6853 variant were half as likely to have cognitive dysfunction (11/111) than wild-type patients (69/325), with a relative risk of 0.45 (95% CI: 0.27 to 0.76) when accounting for major non-genetic predictors (age, Karnofsky functional score). This supports the involvement of innate immune signalling in cognitive dysfunction, and identifies MyD88 signalling pathways as a potential focus for predicting and reducing the burden of cognitive dysfunction in cancer pain patients.
    Full-text · Article · Sep 2015 · PLoS ONE

  • No preview · Article · Sep 2015
  • [Show abstract] [Hide abstract]
    ABSTRACT: Patient-reported outcomes should ideally be adapted to the individual patient while maintaining comparability of scores across patients. This is achievable using computerized adaptive testing (CAT). The aim here was to develop an item bank for CAT measurement of the pain domain as measured by the EORTC QLQ-C30 questionnaire. The development process consisted of four steps: (1) literature search, (2) formulation of new items and expert evaluations, (3) pretesting and (4) field-testing and psychometric analyses for the final selection of items. In step 1, we identified 337 pain items from the literature. Twenty-nine new items fitting the QLQ-C30 item style were formulated in step 2 that were reduced to 26 items by expert evaluations. Based on interviews with 31 patients from Denmark, France and the UK, the list was further reduced to 21 items in step 3. In phase 4, responses were obtained from 1103 cancer patients from five countries. Psychometric evaluations showed that 16 items could be retained in a unidimensional item bank. Evaluations indicated that use of the CAT measure may reduce sample size requirements with 15-25 % compared to using the QLQ-C30 pain scale. We have established an item bank of 16 items suitable for CAT measurement of pain. While being backward compatible with the QLQ-C30, the new item bank will significantly improve measurement precision of pain. We recommend initiating CAT measurement by screening for pain using the two original QLQ-C30 pain items. The EORTC pain CAT is currently available for "experimental" purposes.
    No preview · Article · Aug 2015 · Quality of Life Research
  • [Show abstract] [Hide abstract]
    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.
    No preview · Article · Jun 2015 · Clinical and Translational Gastroenterology
  • [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.
    No preview · Article · Jun 2015 · Annals of Oncology
  • Source
    [Show abstract] [Hide abstract]
    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.
    Full-text · Article · May 2015 · BMJ Open
  • [Show abstract] [Hide abstract]
    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.
    No preview · Article · May 2015 · Acta Anaesthesiologica Scandinavica
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Purpose of review: This review considers the role of physical therapies in osteoarthritis management, highlighting key findings from systematic reviews and randomized controlled trials published in the last 2 years. Recent findings: Three new trials question the role of manual therapy for hip and knee osteoarthritis. No between-group differences in outcome were detected between a multimodal programme including manual therapy and home exercise, and placebo in one trial; a second trial found no benefit of adding manual therapy to an exercise programme, while a third trial reported marginal benefits over usual care that were of doubtful importance. Recent trials have also found no or uncertain clinical benefits of transcutaneous electrical nerve stimulation (TENS) or acupuncture, or of valgus braces or lateral wedge insoles for pain and function in knee osteoarthritis. Available evidence suggests a small to moderate effect of exercise in comparison with not exercising for hip or knee osteoarthritis, although optimum exercise prescription and dosage are unclear. One trial also observed a delay in joint replacement in people with hip osteoarthritis. Two trials have reported conflicting findings about the effects of exercise for hand osteoarthritis. Summary: Other than exercise, recent data suggest that the role of physical therapies in the treatment of osteoarthritis appears limited.
    Full-text · Article · Mar 2015 · Pain
  • Source
    Ørnulf Paulsen · Nina Aass · Pål Klepstad · Stein Kaasa

    Preview · Article · Mar 2015 · Journal of Clinical Oncology
  • Source

    Full-text · Article · Feb 2015 · Supportive and Palliative Care
  • Source
    [Show abstract] [Hide abstract]
    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.
    Full-text · Article · Feb 2015 · Supportive and Palliative Care
  • Source

    Full-text · Article · Feb 2015 · Critical Reviews in Oncology/Hematology

Publication Stats

21k Citations
1,752.10 Total Impact Points

Institutions

  • 2002-2016
    • St. Olavs Hospital
      Nidaros, Sør-Trøndelag, Norway
    • Royal Alexandra Hospital
      Edmonton, Alberta, Canada
  • 1998-2015
    • Norwegian University of Science and Technology
      • • Department of Cancer Research and Molecular Medicine
      • • European Palliative Care Research Centre
      • • Department of Circulation and Medical Imaging
      • • Unit for Applied Clinical Research
      • • Faculty of Medicine
      Nidaros, Sør-Trøndelag, Norway
  • 1995-2015
    • University Hospital of North Norway
      • Department of Oncology
      Tromsø, Troms, Norway
  • 2001-2014
    • NTNU Samfunnsforskning
      Nidaros, Sør-Trøndelag, Norway
    • The Norwegian Medical Association
      Kristiania (historical), Oslo County, Norway
    • Lund University
      • Department of Oncology
      Lund, Skåne, Sweden
    • Sahlgrenska University Hospital
      • Department of Cardiology
      Goeteborg, Västra Götaland, Sweden
  • 1999-2011
    • University of Oslo
      • Department of Behavioural Sciences in Medicine
      Kristiania (historical), Oslo, Norway
  • 2010
    • Bispebjerg Hospital, Copenhagen University
      • Department of Palliative Medicine
      København, Capital Region, Denmark
    • VU University Amsterdam
      • Department of Public and Occupational Health
      Amsterdamo, North Holland, Netherlands
  • 2009
    • Kantonsspital St. Gallen
      San Gallo, Saint Gallen, Switzerland
  • 1999-2006
    • Norwegian University of Technology and Science
      Nidaros, Sør-Trøndelag, Norway
  • 2002-2004
    • University of Aberdeen
      • Institute of Applied Health Sciences
      Aberdeen, Scotland, United Kingdom
  • 2003
    • Haukeland University Hospital
      Bergen, Hordaland, Norway
    • Calais Regional Hospital
      Калаис, Maine, United States
  • 1988-1999
    • Norwegian Cancer Society
      Kristiania (historical), Oslo County, Norway
    • Institutt for samfunnsforskning, Oslo
      Kristiania (historical), Oslo County, Norway
  • 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
  • 1991-1992
    • Det Norske Veritas
      Kristiania (historical), Oslo County, Norway
  • 1990
    • Cancer Research Institute
      New York, New York, United States