Decision Aids for Cancer Screening and Treatment

Project Summary Title and Description

Title
Decision Aids for Cancer Screening and Treatment
Description
Background: Many health decisions about screening and treatment for cancers involve uncertainty or tradeoffs between the expected benefits and harms. Patient decision aids have been developed to help health care consumers and their providers identify the available alternatives and choose the one that aligns with their values. It is unclear whether the effectiveness of decision aids for decisions related to cancers differs by people’s average risk of cancer or by the content and format of the decision aid.; Objectives: We sought to appraise and synthesize the evidence assessing the effectiveness of decision aids targeting health care consumers who face decisions about cancer screening or prevention, or early cancer treatment (Key Question 1), particularly with regard to decision aid or patient characteristics that might function as effect modifiers. We also reviewed interventions targeting providers for promotion of shared decision making using decision aids (Key Question 2).; Data sources: We searched MEDLINE®, Embase®, the Cochrane Central Register of Controlled Trials (CENTRAL), PsycINFO®, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL®) from inception to the end of June 2014.; Review methods: For Key Question 1, we included randomized controlled trials comparing decision aid interventions among themselves or with a control. We included trials of previously developed decision aids that were delivered at the point of the actual decision. We predefined three population groups of interest based on risk or presence of cancer (average cancer risk, high cancer risk, early cancer). The assessed outcomes pertained to measurements of decisional quality and cognition (e.g., knowledge scores), attributes of the decision-making process (e.g., Decisional Conflict Scale), emotion and quality of life (e.g., decisional regret), and process and system-level attributes. We assessed for effect modification by population group, by the delivery format or content of the decision aid or other attributes, or by methodological characteristics of the studies. For Key Question 2, we included studies of any intervention to promote patient decision aid use, regardless of study design and outcomes assessed.; Results: Of the 16,669 screened citations, 87 publications were eligible, corresponding to 83 (68 trials; 25,337 participants) and 5 reports for Key Questions 1 and 2, respectively. Regarding the evolution of the decision aid format and content over time, more recent trials increasingly studied decision aids that were more practical to deliver (e.g., over the Internet or without human mediation) and more often clarified preferences explicitly. Overall, participants using decision aids had higher knowledge scores compared with those not using decision aids (standardized mean difference, 0.23; 95% credible interval [CrI], 0.09 to 0.35; 42 comparison strata with 12,484 participants). Compared with not using decision aids, using decision aids resulted in slightly lower decisional conflict scores (weighted mean difference of -5.3 units [CrI, -8.9 to - 1.8] on the 0-100 Decisional Conflict Scale; 28 comparison strata; 7,923 participants). There was no difference in State-Trait Anxiety Inventory scores (weighted mean difference = 0.1; 95% CrI, -1.0 to 0.7 on a 20-80 scale; 16 comparison strata; 2,958 participants). Qualitative synthesis suggested that patients using decision aids are more likely to make informed decisions and have accurate risk perceptions; further, they may make choices that best agree with their values and may be less likely to remain undecided. Because there was insufficient, sparse, or no information about effects of decision aids on patient-provider communication, patient satisfaction with decision-making process, resource use, consultation length, costs, or litigation rates, a quantitative synthesis was not done. There was no evidence for effect modification by population group, by the delivery format or content of the decision aid or other attributes, or by methodological characteristics of the studies. Data on Key Question 2 were very limited.; Conclusions: Cancer-related decision aids have evolved over time, and there is considerable diversity in both format and available evidence. We found strong evidence that cancer-related decision aids increase knowledge without adverse impact on decisional conflict or anxiety. We found moderate- or low-strength evidence that patients using decision aids are more likely to make informed decisions, have accurate risk perceptions, make choices that best agree with their values, and not remain undecided. This review adds to the literature that the effectiveness of cancer-related decision aids does not appear to be modified by specific attributes of decision aid delivery format, content, or other characteristics of their development and implementation. Very limited information was available on other outcomes or on the effectiveness of interventions that target providers to promote shared decision making by means of decision aids.
Attribution
N/A
Authors of Report
N/A
Methodology description
Eligible Studies for Key Question 1: We included randomized controlled trials comparing use of patient decision aids with other patient decision aids or with no decision aid intervention. We included trials of mature patient decision aids delivered at the point of the actual decision. We excluded trials about hypothetical treatment decisions. For example, we excluded hypothetical questions about early cancer treatment in people not yet diagnosed with cancer, or trials about cancer screening among people who would not be typical screening candidates. We predefined three populations of interest, based on risk or presence of cancer. The first population included people without cancer who are at average risk and face decisions about cancer screening (whether or how to be screened). The second population included people without cancer but with high risk of cancer, e.g., because they are suspected or known to have a hereditary cancer-related condition, such as the Lynch or von Hippel-Lindau syndromes, or are carriers of deleterious BRCA gene mutations. This group may face decisions about further diagnostic workup or about undergoing preventive interventions. The third population included patients diagnosed with early cancer, defined as being at a stage with favorable prognosis (typically local disease only) and where interventions have curative intent (e.g., stage IIa or lower for prostate cancer). We accepted the individual study claims for the definition of early cancer. When a study used an alternative cancer staging, we adjudicated an early cancer stage using information for the National Cancer Institute site. We included only studies in people who were legally able to make decisions for themselves or an underage minor. We followed the IPDAS collaboration and previous systematic reviews in defining decision aid-based interventions as, at a minimum, (1) informing about available options and the expected associated benefits and harms, and (2) incorporating at least implicit clarification of the decisionmaker’s values.3,4 ; Eligible Studies for Key Question 2: For the second Key Question, we included comparative studies informing on the effectiveness of interventions for promoting shared decision making to providers caring for the populations discussed for the first Key Question, specifically provider-targeted interventions to increase shared decision making with the use or increased use of a decision aid. Because so few studies have been done on this topic, eligible designs included randomized and cluster- randomized trials, nonrandomized studies with concurrent comparators, before-after studies, and interrupted time series studies.
PROSPERO
N/A
DOI
10.7301/Z0W66HPN
Notes
*** The systematic review data of this published project was prospectively imported into SRDR by the Brown EPC on behalf of the Agency for Healthcare Research and Quality (AHRQ). For access to the full report available on the AHRQ website, follow this link: http://www.effectivehealthcare.ahrq.gov/ehc/products/529/2029/cancer-decision-support-tools-report-141223.pdf ***
Funding Source
AHRQ

Key Questions

1. For health care consumers facing screening or treatment decisions on premalignant or early stage malignant conditions, how does use of a decision support tool (DST)-based intervention compare with no use, usual care, or use of another DST with respect to (1) measurements of decision quality, (2) characteristics of the decisionmaking process, (3) choices and adherence to choices, (4) health outcomes, and (5) health care–system outcomes?
2. For health care providers who care for consumers facing screening or treatment decisions on premalignant or early stage malignant conditions, how do interventions for promoting shared decisionmaking compare with usual care or with other interventions for promoting shared decisionmaking (or with each other) with respect to (1) likelihood of engaging in shared decisionmaking and also to (2) measurements of decision quality, (3) characteristics of the decisionmaking process, (4) choices and adherence to choices, (5) health outcomes, and (6) health care–system outcomes?

Associated Extraction Forms

Associated Studies (each link opens a new tab)

TitleAuthorsYear
Empowerment of men newly diagnosed with prostate cancer.1997
Helping women make choices about mammography screening: an online randomized trial of a decision aid for 40-year-old women.2010
Videotape-based decision aid for colon cancer screening. A randomized, controlled trial.2000
Preference-based electronic decision aid to promote colorectal cancer screening: results of a randomized controlled trial.2007
Randomized trial examining the effect of two prostate cancer screening educational interventions on patient knowledge, preferences, and behaviors.2004
Preparing African-American men in community primary care practices to decide whether or not to have prostate cancer screening.2005
Pilot trial of a computerized decision aid for breast cancer prevention.-- Not Found --
Increasing patient involvement in choosing treatment for early breast cancer.1995
Randomized controlled trial of a patient decision aid for colorectal cancer screening.2002
Randomized trial of a patient decision aid for choice of surgical treatment for breast cancer.2001
A community-based randomised controlled trial of three different educational resources for men about prostate cancer screening.2005
Does evidence-based information about screening for prostate cancer enhance consumer decision-making? A randomised controlled trial.2003
A randomized controlled trial comparing internet and video to facilitate patient education for men considering the prostate specific antigen test.2003
A randomized trial of choice of treatment in prostate cancer: the effect of intervention on the treatment chosen.
Internet patient decision support: a randomized controlled trial comparing alternative approaches for men considering prostate cancer screening.2008
Randomized trial of a self-administered decision aid for colorectal cancer screening.2008
A randomized controlled trial of shared decision making for prostate cancer screening.2003
Psychosocial outcomes of three triage methods for the management of borderline abnormal cervical smears: an open randomised trial.2010
Acceptability and preliminary feasibility of an internet/CD-ROM-based education and decision program for early-stage prostate cancer patients: randomized pilot study.
Controlled trial of pretest education approaches to enhance informed decision-making for BRCA1 gene testing.1997
An interactive computer program can effectively educate patients about genetic testing for breast cancer susceptibility.2001
Effect of a computer-based decision aid on knowledge, perceptions, and intentions about genetic testing for breast cancer susceptibility: a randomized controlled trial.
Facilitating informed decision making about breast cancer risk and genetic counseling among women calling the NCI's Cancer Information Service.2005
Informed choice in mammography screening: a randomized trial of a decision aid for 70-year-old women.2007
Randomized trial of a shared decision-making intervention consisting of trade-offs and individualized treatment information for BRCA1/2 mutation carriers.2004
Informed decision making about prostate cancer testing in predominantly immigrant black men: a randomized controlled trial.2012
Reducing treatment decision conflict difficulties in breast cancer surgery: a randomized controlled trial.2013
The effect of offering different numbers of colorectal cancer screening test options in a decision aid: a pilot randomized trial.2008
Effect of a decision aid on knowledge and treatment decision making for breast cancer surgery: a randomized trial.2004
Decreased use of adjuvant breast cancer therapy in a randomized controlled trial of a decision aid with individualized risk information.2005
A randomized controlled trial of a decision aid for women considering genetic testing for breast and ovarian cancer risk.2008
A randomized trial of a breast/ovarian cancer genetic testing decision aid used as a communication aid during genetic counseling.2008
Randomized trial of a decision aid for individuals considering genetic testing for hereditary nonpolyposis colorectal cancer risk.2008
Entertainment education for prostate cancer screening: a randomized trial among primary care patients with low health literacy.2008
Does 'peer coaching' increase GP capacity to promote informed decision making about PSA screening? A cluster randomised trial.2005
Helping patients make informed choices: a randomized trial of a decision aid for adjuvant chemotherapy in lymph node-negative breast cancer.2003
Influence of a patient decision aid on decisional conflict related to PSA testing: a structural equation model.2008
Entertainment education for breast cancer surgery decisions: a randomized trial among patients with low health literacy.2011
Contextual factors in shared decision making: a randomised controlled trial in women with a strong suspicion of breast cancer.2009
Informing men about prostate cancer screening: a randomized controlled trial of patient education materials.2008
Mediated decision support in prostate cancer screening: a randomized controlled trial of decision counseling.2011
Supporting informed decision making for prostate specific antigen (PSA) testing on the web: an online randomized controlled trial.2010
Informed decision making and prostate specific antigen (PSA) testing for prostate cancer: a randomised controlled trial exploring the impact of a brief patient decision aid on men's knowledge, attitudes and intention to be tested.2006
A randomized trial of a computer-tailored decision aid to improve prostate cancer screening decisions: results from the take the wheel trial.2010
Managing uncertainty about treatment decision making in early stage prostate cancer: a randomized clinical trial.2009
A community-based intervention to promote informed decision making for prostate cancer screening among Hispanic American men changed knowledge and role preferences: a cluster RCT.
The Personal Patient Profile-Prostate decision support for men with localized prostate cancer: a multi-center randomized trial.2013
A decision aid to support informed choices about bowel cancer screening among adults with low education: randomised controlled trial.2010
Longitudinal changes in patient distress following interactive decision aid use among BRCA1/2 carriers: a randomized trial.2011
A randomized controlled trial of a decision aid for women at increased risk of ovarian cancer.2006
Fostering informed decisions: a randomized controlled trial assessing the impact of a decision aid among men registered to undergo mass screening for prostate cancer.2013
Pairing physician education with patient activation to improve shared decisions in prostate cancer screening: a cluster randomized controlled trial.
Effectiveness of a web-based colorectal cancer screening patient decision aid: a randomized controlled trial in a mixed-literacy population.
Decision Making in Prostate Cancer Screening Using Decision Aids vs Usual Care: A Randomized Clinical Trial.
Shared decision making for prostate cancer screening: the results of a combined analysis of two practice-based randomized controlled trials.2012
The role of personalized choice: A randomized controlled trial of an online decision aid for prostate cancer screening.2013
The impact of a novel computer-based decision aid on shared decision making for colorectal cancer screening: a randomized trial.2010
Comparing a generic and individualized information decision support intervention for men newly diagnosed with localized prostate cancer.2007
A comparison of a spiritually based and non-spiritually based educational intervention for informed decision making for prostate cancer screening among church-attending African-American men.2009
Women's interest in taking tamoxifen and raloxifene for breast cancer prevention: response to a tailored decision aid.2011
Shared decision-making using an interactive video disk system for women with early breast cancer... including commentary by Beaver K 1998
Testing the feasibility, acceptability and effectiveness of a 'decision navigation' intervention for early stage prostate cancer patients in Scotland--a randomised controlled trial.2013
Randomized trial of a decision aid for BRCA1/BRCA2 mutation carriers: impact on measures of decision making and satisfaction.2009
The impact of explicit values clarification exercises in a patient decision aid emerges after the decision is actually made: evidence from a randomized controlled trial.2012
Choice between prostatectomy and radiotherapy when men are eligible for both: a randomized controlled trial of usual care vs decision aid.2013
Randomized controlled trial of a computerized decision aid on adjuvant radioactive iodine treatment for patients with early-stage papillary thyroid cancer.2012
Effects of a pre-visit educational website on information recall and needs fulfilment in breast cancer genetic counselling, a randomized controlled trial.2012
Facilitating informed decisions regarding microsatellite instability testing among high-risk individuals diagnosed with colorectal cancer.2010
Physician communication regarding prostate cancer screening: analysis of unannounced standardized patient visits.2013
An effort to spread decision aids in five California primary care practices yielded low distribution, highlighting hurdles.
Barriers and facilitators to routine distribution of patient decision support interventions: a preliminary study in community-based primary care settings.2014
EDUCATION IN DELIVERING PATIENT-CENTERED CARE: PROVIDER COMFORT LEVEL IN COUNSELING WOMEN AGES 40-49 REGARDING BREAST CANCER SCREENING OPTIONS2013
Online Prostate Cancer Screening Decision Aid for At-Risk Men: A Randomized Trial.2013
An effort to spread decision aids in five California primary care practices yielded low distribution, highlighting hurdles.2013

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