Critical appraisal:Wang Y, Anazodo A, Logan S 2019

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Critical Appraisal

Article being appraised

Wang Y, Anazodo A, Logan S. Systematic review of fertility preservation patient decision aids for cancer patients. Psychooncology 2019 Mar;28(3):459-467 Available from:

Applicable clinical question

Key Facts

Study Design

systematic review — - One study utilised mixed-methods design (questionnaires and interviews) - All others were quantitative (online or paper-based questionnaires)

Study aims:

To determine the effectiveness of patient decision aids (PtDAs) in supporting decision‐making about fertility preservation and indicate their current use in clinical care.

Number of Patients:


- Samples sizes ranged from nine to 337 (mean sample size = 64.3)

- Participants ranged from 18 to 43 years, and differed in stage of treatment
- 12 papers were included, detailing 11 studies
~ Ten studies recruited cancer patients, one study recruited survivors, and one recruited parents of cancer patients

~ Four studies recruited a variety of health professionals involved in the care of cancer patients to evaluate acceptability and usability of the PtDAs
Reported outcome(s):

- Objective 1: Assessing the effectiveness of fertility preservation PtDAs
~ Primary outcomes: Knowledge, Decisional Conflict, Satisfaction and acceptability
~ Secondary outcomes: Regret

- Objective 2: Current use of fertility preservation PtDAs in clinical care

Results of outcome(s):

- PtDAs found to improve female patients' and clinician's knowledge about the impacts of cancer on fertility and the options for fertility preservation
- PtDA use shown to lower decisional conflict in both female and male patients
- Overall, PtDAs were found to be both acceptable and helpful, contained relevant information, and patients reported a high level of satisfaction with their use.
- Decisional regret is significantly reduced in female patients at 12 months post intervention with PtDA use, although significance was not shown at earlier time points.

Comments on results:

Overall, these results are consistent with those reported in the Cochrane review of decision aids, in that PtDAs assist patients to feel more comfortable with their health treatment choices and compared with usual care, improve individual's perception of involvement in decision‐making via increased knowledge, and lower decisional conflict and decisional regret.

Current availability of these PtDA tools for clinical use is limited. Currently, only two of the tools reported within this review are likely available for clinical use, and a further tool's content has since been integrated into a web page. However, the literature also indicates that six other tools may be made available upon completion of development and evaluation in the future.

Includes an economic evaluation


Evidence ratings

Level of evidence


Risk of bias
Low risk of bias Comments: The titles and abstracts were screened by a single reviewer (Y.W.), identifying 37 potentially relevant studies. The full texts were then reviewed by two reviewers (Y.W. and S.L.) and disagreements were resolved through discussion and third‐party input (A.A.).

The quality and risk of bias of the remaining studies were assessed using the Mixed Methods Appraisal Tool (MMAT), on the domains of sampling, measurements, completion of data, and bias (see below).

The summary of included studies included type of study, methods, population and results of outcome measures.

Limitations including heterogeneity of study type, population, time of data collection, and outcome measures were recognised.

Size of effect
2 Reason for decision: Findings from this review may be limited in generalisability of data due to the small sample sizes of each study, heterogeneity of participant populations, and limited data on any particular output domain.

For example, there are inherent difficulties in assessing pooled data where participants include cancer survivors or healthy women, and newly diagnosed cancer patients as decision-making may vary (retrospective vs hypothetical vs prospective). Therefore, strong conclusions cannot be made from the data.

Relevance of evidence
1 Additional comments: One study was developmental, five contained both stages of development and efficacy, five were efficacy or effectiveness studies, and one was an implementation study.

Using MMAT, the majority of studies assessed reported sound quality (n = 4 scored 100%; n = 3 scored 75%; n = 2 scored 50%). One study's quality score was poor (25%), however, this was likely due to the review nature of the study being inadequately appraised by the MMAT, and as such, it was retained for final analysis. Two studies were considered “grey literature” in the form of conference abstracts and could not be assessed on quality.

Result of appraisal

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Completed by

Dr Michelle Peate

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Wang Y, Anazodo A, Logan S. Systematic review of fertility preservation patient decision aids for cancer patients. Psychooncology 2019 Mar;28(3):459-467 Available from:
Assigned to
Topic area
Guidelines:COSA:Cancer fertility preservation guidelines/Oncofertility service development
Clinical question
Form:Critical appraisal

Section below only relevant for Cancer Council Project Officer

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