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 2019 Feb 20]. Available from: https://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).
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