In men without evidence of prostate cancer does a decision support intervention or decision aid compared with usual care improve knowledge, decisional satisfaction, decision-related distress and decisional uncertainty about PSA testing for early detection of prostate cancer? (PICOi question 2)
Guidelines developed in partnership with
Prostate Cancer Foundation of Australia and Cancer Council Australia PSA Testing Guidelines Expert Advisory Panel. Clinical practice guidelines PSA Testing and Early Management of Test-Detected Prostate Cancer. Sydney: Cancer Council Australia. [Version URL: http://wiki.cancer.org.au/australiawiki/index.php?oldid=122825, cited 2017 Nov 19]. Available from: http://wiki.cancer.org.au/australia/Guidelines:PSA_Testing/Decision_support_for_men_considering_PSA_testing.
National Health and Medical Research Council
In approving the guidelines (recommendations), NHMRC considers that they meet the NHMRC standard for clinical practice guidelines. This approval is valid for a period of five years. NHMRC is satisfied that the guidelines (recommendations) are systematically derived, based on the identification and synthesis of the best available scientific evidence, and developed for health professionals practising in an Australian health care setting.This publication reflects the views of the authors and not necessarily the views of the Australian Government.
Decision support interventions and/or decision aids aim to help people make an informed decision about testing or treatment by providing information about the benefits, harms, limitations and uncertainty associated with the choice. They are defined as interventions designed to help people make specific and deliberative choices among options (including the status quo) by providing, at a minimum, both information on the options and outcomes relevant to a person’s health status, and implicit methods to clarify values. Decision support interventions/decision aids may be implemented in a variety of formats, including written hardcopy (e.g. pamphlet/booklet), multimedia (e.g. computer, DVD, internet-based), or in person (e.g. counselling by nurse or physician).
A total of 13 randomised controlled trials (eight at high risk of bias and five at moderate risk of bias) examined the impact of decision support interventions and/or decision aids for men making a decision whether to undergo PSA testing for early detection of prostate cancer. The comparator was information only in six studies, usual care in two studies, and no intervention in five studies. The search strategy, inclusion and exclusion criteria, and quality assessment are described in detail in the Technical report.
The majority of the 13 randomised controlled trials demonstrated that the use of decision support interventions and/or decision aids was associated with a significant improvement in patient knowledge and a significant reduction in patient decision-related distress (anxiety and reported worry about developing prostate cancer and/or death from prostate cancer, as measured by the Decisional Conflict Scale). Of the five randomised controlled trials that measured men’s satisfaction about their decision-making, three reported significant increases in satisfaction. Of the four studies that measured men’s uncertainty about the decision (using the uncertainty subscale of Decisional Conflict Scale), none demonstrated decreases in uncertainty.
Evidence summary and recommendations
|Use of a decision support intervention/decision aid, compared with usual care or minimally enhanced usual care, improved men’s knowledge about the benefits and harms of PSA testing.||II||, , , , , , , , , , , , |
|Use of a decision support intervention/decision aid, compared with usual care or minimally enhanced usual care, decreased the decisional conflict/distress men experienced when considering the benefits and harms of PSA testing.||II||, , , , , , , , , |
|Use of a decision support intervention/decision aid, compared with usual care or minimally enhanced usual care, improved men’s satisfaction with their choice about whether or not to undertake a PSA test.||II||, , , , |
|Use of a decision support intervention/decision aid, compared with usual care or minimally enhanced usual care, had no demonstrable benefit on the decisional uncertainty men experienced when considering the benefits and harms of PSA testing.||II||, , , |
|Offer evidence-based decisional support to men considering whether or not to have a PSA test, including the opportunity to discuss the benefits and harms of PSA testing before making the decision.||C|
Familiarity with the NHMRC fact sheet PSA testing for prostate cancer in asymptomatic men. Information for health practitioners, which summarises evidence on the benefits and harms of PSA testing, should help health practitioners to accurately inform men about PSA testing.
Health system implications of these recommendations
Decision aids are not currently used routinely in primary care when discussing PSA testing. Usual care will need to incorporate the use of decision aids, either as part of the consultation with the main clinician (e.g. GP), a separate consultation with the primary care nurse (e.g. practice nurse) or health educator, or self-directed engagement with a decision aid.
Community-wide strategies will be needed to increase public awareness of decision aids for PSA testing and to improve their accessibility.
Some decision aids require a health professional (e.g. practice nurse or health educator) to ‘coach’ men. Implementing this type of decision aid would require a training program on PSA testing and counselling to be incorporated into nursing/health science courses, or upskilling of existing professionals with the appropriate skills and knowledge.
Decision aids are produced across a variety of modalities, yet not all are readily accessible. It will be necessary to ensure that decision aids are available in primary care and to the community.
Health professionals will need appropriate training in the use of these aids. For example, coaching or counselling of patients is a component of some decision aids.
Barriers to implementation
Perceived lack of accessibility of decision aids by health professionals and consumers may be a barrier to its implementation. If the use of decision aids is to be incorporated into consultations in general practice, limited GP time may also be a barrier for implementation. These barriers may be potentially overcome by providing greater infrastructure and partnerships between primary practice, community care and peak bodies (e.g. the Royal Australian College of General Practitioners, Cancer Council Australia).
i Clinical questions were translated into the PICO framework: population, intervention (or exposure), comparator and outcome (see Appendix 3).
- Stacey D, Légaré F, Col NF, Bennett CL, Barry MJ, Eden KB, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2014 Jan 28;1:CD001431 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24470076.
- Allen JD, Othus MK, Hart A Jr, Tom L, Li Y, Berry D, et al. A randomized trial of a computer-tailored decision aid to improve prostate cancer screening decisions: results from the take the wheel trial. Cancer Epidemiol Biomarkers Prev 2010 Sep;19(9):2172-86 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20716619.
- Evans R, Joseph-Williams N, Edwards A, Newcombe RG, Wright P, Kinnersley P, et al. Supporting informed decision making for prostate specific antigen (PSA) testing on the web: an online randomized controlled trial. J Med Internet Res 2010 Aug 6;12(3):e27 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20693148.
- Gattellari M, Ward JE. Does evidence-based information about screening for prostate cancer enhance consumer decision-making? A randomised controlled trial. J Med Screen 2003;10(1):27-39 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/12790313.
- Partin MR, Nelson D, Radosevich D, Nugent S, Flood AB, Dillon N, et al. Randomized trial examining the effect of two prostate cancer screening educational interventions on patient knowledge, preferences, and behaviors. J Gen Intern Med 2004 Aug;19(8):835-42 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/15242468.
- Watts KJ, Meiser B, Wakefield CE, Barratt AL, Howard K, Cheah BC, et al. Online Prostate Cancer Screening Decision Aid for At-Risk Men: A Randomized Trial. Health Psychol 2013 Nov 25 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24274808.
- Taylor KL, Williams RM, Davis K, Luta G, Penek S, Barry S, et al. Decision Making in Prostate Cancer Screening Using Decision Aids vs Usual Care: A Randomized Clinical Trial. JAMA Intern Med 2013 Jul 29 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/23896732.
- Williams RM, Davis KM, Luta G, Edmond SN, Dorfman CS, Schwartz MD, et al. Fostering informed decisions: A randomized controlled trial assessing the impact of a decision aid among men registered to undergo mass screening for prostate cancer. Patient Educ Couns 2013 Jun;91(3):329-36 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/23357414.
- Volk RJ, Jibaja-Weiss ML, Hawley ST, Kneuper S, Spann SJ, Miles BJ, et al. Entertainment education for prostate cancer screening: a randomized trial among primary care patients with low health literacy. Patient Educ Couns 2008 Dec;73(3):482-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/18760888.
- Gattellari M, Ward JE. A community-based randomised controlled trial of three different educational resources for men about prostate cancer screening. Patient Educ Couns 2005 May;57(2):168-82 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/15911190.
- Lepore SJ, Wolf RL, Basch CE, Godfrey M, McGinty E, Shmukler C, et al. Informed decision making about prostate cancer testing in predominantly immigrant black men: a randomized controlled trial. Ann Behav Med 2012 Dec;44(3):320-30 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/22825933.
- Myers RE, Daskalakis C, Kunkel EJ, Cocroft JR, Riggio JM, Capkin M, et al. Mediated decision support in prostate cancer screening: a randomized controlled trial of decision counseling. Patient Educ Couns 2011 May;83(2):240-6 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20619576.
- Sheridan SL, Golin C, Bunton A, Lykes JB, Schwartz B, McCormack L, et al. Shared decision making for prostate cancer screening: the results of a combined analysis of two practice-based randomized controlled trials. BMC Med Inform Decis Mak 2012 Nov 13;12:130 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/23148458.
- Chan EC, McFall SL, Byrd TL, Mullen PD, Volk RJ, Ureda J, et al. 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. Patient Educ Couns 2011 Aug;84(2):e44-51 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/21237611.