Profesjonsgrenser i norsk bildediagnostikk : Tid for en ny arbeidsdeling?

Sykehus er komplekse institusjoner der grenser mellom samhandlende helseprofesjoner stadig utfordres. Denne oppgaven tar for seg forholdet innen fagfeltet medisinsk bildediagnostikk der radiologer som legespesialister, jobber tett sammen med radiografer, en yrkesgruppe med treårig bachelorutdannelse. Etter eksempel fra utlandet ønsker norske radiografer nå utvidede roller der de ikke bare fremskaffer bildemateriale, men også selvstendig bidrar i tyding og rapportering av undersøkelsene. Med dette ekspanderer de inn på radiologenes tradisjonelle enemerker. En slik jobbglidning vil kreve videreutdanning og opplæring der radiologene må gi fra seg praktisk og teoretisk kunnskap til sine tradisjonelle medhjelpere, radiografene. Radiografenes profesjonsbevissthet øker, samtidig som deres utdanningsinstitusjoner gjennomgår en akademisering. Jobbglidning kan åpne nye karriereveier og passer derfor godt inn i dette bildet. Det er i Norge som i mange andre land, økende etterspørsel etter bildediagnostiske tjenester. Radiologene opplever stort arbeidspress og ser seg selv som en mangelfull ressurs. Jeg som forsker er selv radiolog. Med denne oppgaven ønsker jeg å belyse fenomenet jobbglidning sett fra radiologenes synsvinkel. Hva avgjør radiologenes holdninger til dette, og i hvilken grad uttrykker de en pågående profesjonskonflikt? For å utvide egen horisont har jeg skaffet meg et teorigrunnlag fra profesjonssosiologien der særlig Andrew Abbotts refleksjoner rundt samhandling mellom profesjoner står sentralt. Jeg ser også nærmere på prosesser og arbeidsdeling mellom radiologer og radiografer i andre land, særlig Storbritannia Empiri er hentet fra debatt i norske radiologiske fagfora og fra to fokusgruppeintervjuer med til sammen ni leger fra radiologiske sykehusavdelinger. Legene er svært splittet i sin argumentasjon. De framstiller en presset hverdag preget av vanskelige prioriteringer og følelse av utilstrekkelighet. De ønsker avlastning men har likevel store betenkeligheter med å slippe til sine tidligere medhjelpere radiografer på det diagnostiske området. I et klima der opplæring av nye legespesialister ofte må nedprioriteres i forhold til ren produksjon, ønsker de å prioritere sine egne framfor en annen yrkesgruppe. De mener også de som leger, har et spesielt ansvar og uttrykker bekymring for kvalitet og pasientsikkerhet hvis ikke-leger slipper til. Det avtegner seg et bilde av en klassisk profesjonskonflikt der svært mange av de mekanismer Abbott beskriver er til stede. Legene ønsker prinsipielt å holde på sin jurisdiksjon til hele det diagnostiske området. De understreker viktigheten av egen akademisk kunnskap og setter seg selv i en særstilling blant helsepersonell. De har likevel respekt for radiografene som ansvarsfulle medarbeidere som utfører viktige oppgaver, men ser altså helst at de holder seg innenfor sine tradisjonelle enemerker. Radiologene er imidlertid ikke helt avvisende til enhver form for jobbglidning. Gitt klare begrensninger og tilstrekkelig medisinsk kontroll, kan flere av legene se for seg utvalgte radiografer i begrensede diagnostiske roller. Det er likevel ingen stor entusiasme å spore blant radiologkollegene

Early performance measures following regular versus irregular screening attendance in the population-based screening program for breast cancer in Norway

Irregular attendance in breast cancer screening has been associated with higher breast cancer mortality compared to regular attendance. Early performance measures of a screening program following regular versus irregular screening attendance have been less studied. We aimed to investigate early performance measures following regular versus irregular screening attendance. Methods We used information from 3,302,396 screening examinations from the Cancer Registry of Norway. Examinations were classified as regular or irregular. Regular was defined as an examination 2 years ± 6 months after the prior examination, and irregular examination >2 years and 6 months after prior examination. Performance measures included recall, biopsy, screen-detected and interval cancer, positive predictive values, and histopathological tumor characteristics. Results Recall rate was 2.4% (72,429/3,070,068) for regular and 3.5% (8217/232,328) for irregular examinations. The biopsy rate was 1.0% (29,197/3,070,068) for regular and 1.7% (3825/232,328) for irregular examinations, while the rate of screen-detected cancers 0.51% (15,664/3,070,068) versus 0.86% (2003/232,328), respectively. The adjusted odds ratio was 1.53 (95% CI: 1.49–1.56) for recall, 1.73 (95% CI: 1.68–1.80) for biopsy, and 1.68 (95% CI: 1.60–1.76) for screen-detected cancer after irregular examinations compared to regular examinations. The proportion of lymph node-positive tumors was 20.1% (2553/12,719) for regular and 25.6% (426/1662) for irregular examinations. Conclusion Irregular attendance was linked to higher rates of recall, needle biopsies, and cancer detection. Cancers detected after irregular examinations had less favorable histopathological tumor characteristics compared to cancers detected after regular examinations. Women should be encouraged to attend screening when invited to avoid delays in diagnosis

Participation and cancer detection after reminders versus ordinary invitations in BreastScreen Norway

Objectives - To compare attendance, recall and cancer detection as well as histopathological tumor characteristics among women attending BreastScreen Norway after a reminder versus an ordinary invitation. Setting - This study was conducted on data from a population-based screening program inviting women aged 50–69 to biennial two-view mammography. Methods - We used de-identified data from 883,020 women invited to BreastScreen Norway, 2004–2020, to analyze invitations, participation, recalls, biopsies, cancer detection, and histopathological tumor characteristics. All results were stratified by reminders and ordinary invitations. Early screening outcomes after reminders versus ordinary invitations were compared using bivariate tests and multivariable logistic regression. Results - Reminders increased overall participation rate by 5.0%. The recall rate was 4.3% for reminded women and 3.3% for the ordinary invited. For reminded women, the rate of screen-detected cancer was 7.3 per 1000 screening examinations compared to 5.8 per 1000 for ordinary attenders. The interval cancer rates were 1.9 and 1.7 per 1000 for reminded and ordinary invited women, respectively. Median tumor diameter was 14 mm (interquartile range (IQR): 10–16) for screen-detected cancers (SDC) among reminded women and 13 mm (IQR: 10–16) for ordinary invited. A higher percentage of histological grade III cancers was observed among the reminded: 25.2% versus 21.7% for the ordinary invited. We also found a higher proportion of lymph node positive cases in those reminded: 23.6% versus 20.9%. Conclusions - Postponing screening examinations affects early screening outcomes, including cancer detection and histopathological tumor characteristics. Women should be encouraged to attend screening at regularly intervals to avoid delays in diagnosis

Breast cancer stromal elastosis is associated with mammography screening detection, low Ki67 expression and favourable prognosis in a population-based study

Background: Mammography screen-detected breast cancers have a better prognosis than predicted from established prognostic markers. A search for additional features that are characteristic for these tumours and their prognosis is needed to reduce overtreatment, a recognized challenge in breast cancer patient management today. Here, we have investigated the occurrence and importance of tumour elastosis. Methods: We performed a population based retrospective study of breast cancers detected in the Norwegian Breast Cancer Screening Programme in Vestfold County during 2004–2009. In total, 197 invasive screen-detected cancers and 75 interval cancers in patients aged 50–69 years were compared with regard to standard clinico-pathological parameters and tumour shape, as well as ER, PR, HER2 and Ki67 expression. In particular, the presence of elastotic material in tumours was graded on a 4-tiered scale (score 0–3). Results: Screen-detected cancers had a significantly higher content of stromal elastosis than interval cancers (p < 0.001). High content of elastosis (score 3) correlated strongly with stellate tumour shape, low histological grade, and ER+/HER2- status. Further, high elastosis score was significantly associated with lower Ki67 expression. In survival analyses, cases with high elastosis demonstrated increased recurrence free (p = 0.03) and disease-specific survival (p = 0.11) compared to cases with low elastosis. Conclusion: There is a strong correlation between the presence of tumour elastosis, stellate tumour shape and mammography detection of breast cancers. To our knowledge, this is the first time elastosis has been studied in relation to breast cancer detection method. Presence of elastosis is associated with low tumour cell proliferation (Ki67) and a good prognosis

sj-docx-1-msc-10.1177_09691413231199583 - Supplemental material for Early performance measures following regular versus irregular screening attendance in the population-based screening program for breast cancer in Norway

Supplemental material, sj-docx-1-msc-10.1177_09691413231199583 for Early performance measures following regular versus irregular screening attendance in the population-based screening program for breast cancer in Norway by Jonas E. Thy, Marthe Larsen, Einar Vigeland, Henrik Koch, Tone Hovda and Solveig Hofvind in Journal of Medical Screening</p

Digital Breast Tomosynthesis and Synthetic 2D Mammography versus Digital Mammography: Evaluation in a Population-based Screening Program

Purpose: To compare the performance of digital breast tomosynthesis (DBT) and two-dimensional synthetic mammography (SM) with that of digital mammography (DM) in a population-based mammographic screening program. Materials and Methods: In this prospective cohort study, data from 37 185 women screened with DBT and SM and from 61 742 women screened with DM as part of a population-based screening program in 2014 and 2015 were included. Early performance measures, including recall rate due to abnormal mammographic findings, rate of screen-detected breast cancer, positive predictive value of recall, positive predictive value of needle biopsy, histopathologic type, tumor size, tumor grade, lymph node involvement, hormonal status, Ki-67 level, and human epidermal growth factor receptor 2 status were compared in women who underwent DBT and SM screening and in those who underwent DM screening by using x2 tests, two-sample unpaired t tests, and tests of proportions. Results: Recall rates were 3.4% for DBT and SM screening and 3.3% for DM screening (P = .563). DBT and SM screening showed a significantly higher rate of screen-detected cancer compared with DM screening (9.4 vs 6.1 cancers per 1000 patients screened, respectively; P , .001). The rate of detection of tumors 10 mm or smaller was 3.2 per 1000 patients screened with DBT and SM and 1.8 per 1000 patients screened with DM (P , .001), and the rate of grade 1 tumors was 3.3 per 1000 patients screened with DBT and SM versus 1.4 per 1000 patients screened with DM (P , .001). On the basis of immunohistochemical analyses, rates of lymph node involvement and tumor subtypes did not differ between women who underwent DBT and SM screening and those who underwent DM screening. Conclusion: DBT and SM screening increased the detection rate of histologically favorable tumors compared with that attained with DM screening

Efficacy of antibiotic treatment in patients with chronic low back pain and Modic changes (the AIM study): double blind, randomised, placebo controlled, multicentre trial

Objective - To assess the efficacy of three months of antibiotic treatment compared with placebo in patients with chronic low back pain, previous disc herniation, and vertebral endplate changes (Modic changes). Design - Double blind, parallel group, placebo controlled, multicentre trial. Setting - Hospital outpatient clinics at six hospitals in Norway. Participants - 180 patients with chronic low back pain, previous disc herniation, and type 1 (n=118) or type 2 (n=62) Modic changes enrolled from June 2015 to September 2017. Interventions - Patients were randomised to three months of oral treatment with either 750 mg amoxicillin or placebo three times daily. The allocation sequence was concealed by using a computer generated number on the prescription. Main outcome measures - The primary outcome was the Roland-Morris Disability Questionnaire (RMDQ) score (range 0-24) at one year follow-up in the intention to treat population. The minimal clinically important between group difference in mean RMDQ score was predefined as 4. Results - In the primary analysis of the total cohort at one year, the difference in the mean RMDQ score between the amoxicillin group and the placebo group was −1.6 (95% confidence interval −3.1 to 0.0, P=0.04). In the secondary analysis, the difference in the mean RMDQ score between the groups was −2.3 (−4.2 to−0.4, P=0.02) for patients with type 1 Modic changes and −0.1 (−2.7 to 2.6, P=0.95) for patients with type 2 Modic changes. Fifty patients (56%) in the amoxicillin group experienced at least one drug related adverse event compared with 31 (34%) in the placebo group. Conclusions - In this study on patients with chronic low back pain and Modic changes at the level of a previous disc herniation, three months of treatment with amoxicillin did not provide a clinically important benefit compared with placebo. Secondary analyses and sensitivity analyses supported this finding. Therefore, our results do not support the use of antibiotic treatment for chronic low back pain and Modic changes

Efficacy of antibiotic treatment in patients with chronic low back pain and Modic changes (the AIM study): double blind, randomised, placebo controlled, multicentre trial

Objective To assess the efficacy of three months of antibiotic treatment compared with placebo in patients with chronic low back pain, previous disc herniation, and vertebral endplate changes (Modic changes). Design Double blind, parallel group, placebo controlled, multicentre trial. Setting Hospital outpatient clinics at six hospitals in Norway. Participants 180 patients with chronic low back pain, previous disc herniation, and type 1 (n=118) or type 2 (n=62) Modic changes enrolled from June 2015 to September 2017. Interventions Patients were randomised to three months of oral treatment with either 750 mg amoxicillin or placebo three times daily. The allocation sequence was concealed by using a computer generated number on the prescription. Main outcome measures The primary outcome was the Roland-Morris Disability Questionnaire (RMDQ) score (range 0-24) at one year follow-up in the intention to treat population. The minimal clinically important between group difference in mean RMDQ score was predefined as 4. Results In the primary analysis of the total cohort at one year, the difference in the mean RMDQ score between the amoxicillin group and the placebo group was −1.6 (95% confidence interval −3.1 to 0.0, P=0.04). In the secondary analysis, the difference in the mean RMDQ score between the groups was −2.3 (−4.2 to−0.4, P=0.02) for patients with type 1 Modic changes and −0.1 (−2.7 to 2.6, P=0.95) for patients with type 2 Modic changes. Fifty patients (56%) in the amoxicillin group experienced at least one drug related adverse event compared with 31 (34%) in the placebo group. Conclusions In this study on patients with chronic low back pain and Modic changes at the level of a previous disc herniation, three months of treatment with amoxicillin did not provide a clinically important benefit compared with placebo. Secondary analyses and sensitivity analyses supported this finding. Therefore, our results do not support the use of antibiotic treatment for chronic low back pain and Modic changes

Efficacy of antibiotic treatment in patients with chronic low back pain and Modic changes (the AIM study): double blind, randomised, placebo controlled, multicentre trial

Objective: To assess the efficacy of three months of antibiotic treatment compared with placebo in patients with chronic low back pain, previous disc herniation, and vertebral endplate changes (Modic changes). Design: Double blind, parallel group, placebo controlled, multicentre trial. Setting: Hospital outpatient clinics at six hospitals in Norway. Participants: 180 patients with chronic low back pain, previous disc herniation, and type 1 (n=118) or type 2 (n=62) Modic changes enrolled from June 2015 to September 2017. Interventions: Patients were randomised to three months of oral treatment with either 750 mg amoxicillin or placebo three times daily. The allocation sequence was concealed by using a computer generated number on the prescription. Main outcome measures: The primary outcome was the Roland-Morris Disability Questionnaire (RMDQ) score (range 0-24) at one year follow-up in the intention to treat population. The minimal clinically important between group difference in mean RMDQ score was predefined as 4. Results: In the primary analysis of the total cohort at one year, the difference in the mean RMDQ score between the amoxicillin group and the placebo group was −1.6 (95% confidence interval −3.1 to 0.0, P=0.04). In the secondary analysis, the difference in the mean RMDQ score between the groups was −2.3 (−4.2 to−0.4, P=0.02) for patients with type 1 Modic changes and −0.1 (−2.7 to 2.6, P=0.95) for patients with type 2 Modic changes. Fifty patients (56%) in the amoxicillin group experienced at least one drug related adverse event compared with 31 (34%) in the placebo group. Conclusions: In this study on patients with chronic low back pain and Modic changes at the level of a previous disc herniation, three months of treatment with amoxicillin did not provide a clinically important benefit compared with placebo. Secondary analyses and sensitivity analyses supported this finding. Therefore, our results do not support the use of antibiotic treatment for chronic low back pain and Modic changes