Are Decision Aids Useful for Men Choosing Prostate Cancer Screening?

A recent review compared the use of decision aids versus usual care in men choosing to undergo prostate cancer screening. The researchers found that there is no strong evidence favoring the use of decision aids in this population.

The choice of whether or not to undergo prostate cancer screening would ideally be made through shared decision-making, according to the researchers—although this is not always an option.

“Shared decision-making is challenging because of time constraints and the specific skills that it requires,” wrote the study authors, reporting in JAMA Internal Medicine. “Well-designed decision aids may, at least in part, address these challenges by summarizing the current best evidence and by supporting conversations that address the issues that matter most to patients.”

For the review, researchers queried MEDLINE, Embase, CINAHL, PsychINFO, and Cochrane Central Register of Controlled Trials for relevant randomized controlled trials (RCTs). Studies focused on men debating undergoing prostate cancer screening and compared decision aid interventions to usual care. Interventions were classified as decision aids “if the material helped men making individual choices and included information regarding the association of screening with the following patient-important outcomes: risk of dying, risk of urinary or bowel symptoms, and risk of erectile dysfunction.” An intervention was considered usual care if information was not presented in a structured format. The intervention was considered informative material if some formal information was provided but did not meet the criteria to be considered a decision aid. The following outcomes were assessed:

  • Knowledge of prostate cancer screening
  • Decisional conflict
  • Screening discussions
  • Actual screening decision
  • Screening decision satisfaction

Evidence Weakly Supports Decision Aids

The final analysis included 19 RCTs. Types of decision aids used in the studies included printed material (booklets and leaflets), education (group sessions and individual education), computer-based tools, and videos. Shared decision-making was used in one study.

In total, 12 decision aids were identified through reviewing original articles (n = 5), electronic searches (n = 4), and from the study authors (n = 3). Using a modified version of the International Patient Decision Aid Standards instrument (IPDASi), version 3 for screening, decision aids scored well (8-10 points, n = 3), less well (5-7 points, n = 4), or poorly (≤ 4 points, n = 5). The mean IPDASi score overall was 5.6. Decision aids were also evaluated based on what information they reported:

  • Screening aim (n = 12/12)
  • Association between screening and overall or prostate cancer-specific mortality (n = 11/12)
  • Harms of the increase in surgery and radiotherapy that accompanies the increased diagnosis of prostate cancer consequent to screening (erectile dysfunction, urinary incontinence, and bowel problems) (n = 10/12)
  • Probability information of receiving a true-negative result (n = 4/12)
  • Probability information of a false-negative result, or how to proceed if results are negative (n = 3/12)
  • Odds of detecting prostate cancer with and without screening (n = 2/12)

In a pooled analysis of six of the studies, a small association was observed between the decision aids and decisional conflict—while small, the researchers noted the correlation was “consistent and statistically significant.”

There was a significant gap in how often a screening discussion occurred between the clinician and patient in the usual care (8–97%) and decision aid (16–99%) groups. The study authors observed, “The pooled analysis from 6 studies failed to demonstrate an association with whether physicians and patients discussed prostate cancer screening (risk ratio, 1.12; 95% CI, 0.90-1.39; low-quality evidence; Table 2 and Figure 3B). In 4 studies, the decision aid was distributed 1 to 2 weeks before the visit or assessment; in 1 study, the decision aid was distributed 1 hour before the assessment; and in 1 study, the decision aid was distributed 8 months before the visit.”

Large gaps were also observed regarding the frequency of patients choosing to undergo prostate cancer screening, ranging from 5–94% and 5–90% in the usual care and decision aid groups, respectively. A pooled analysis of 13 studies found no between-group association in the men’s choice of whether or not they underwent screening.

The authors concluded, “The available evidence does not provide a compelling rationale for clinicians to use existing decision aids to facilitate shared decision-making in their discussions with men considering undergoing prostate cancer screening. Future decision aids should include provision for continuous updating and not only provide education to patients but also promote shared decision-making in the patient-physician encounter.”