- Decision Aids for Cancer Screening and Treatment
- 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.
- Authors of Report
- 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.
- *** 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