Decision aids for prostate-cancer screening of limited value

By Megan Brooks

NEW YORK (Reuters Health) - 28/6/2019

Currently available decision aids for prostate-cancer screening provide a small reduction in a patient's uncertainty about which course of action to take and an increase in knowledge but have no impact on whether physicians discuss screening with men or whether men undergo screening, results of a systematic review and meta-analysis suggest.

"Practicing doctors therefore need to ensure they discuss the benefits and harms of prostate cancer screening with men considering screening, attending to their values and preferences before as they consider the possible benefits, and the harms and burdens, of screening," Dr. Kari Tikkinen of Helsinki University Hospital, in Finland, who worked on the study, told Reuters Health by email.

The results of this meta-analysis of decision aids (DAs) for prostate-cancer screening are "disappointing," write the authors of an editorial published online June 24 with the study in JAMA Internal Medicine.

Dr. Laura Scherer of the University of Colorado, Denver, and Dr. Grace Lin from University of California, San Francisco, say they agree that the data do not provide a "persuasive" case for use of the DAs included in the meta-analysis, but think it would be "premature to conclude on the basis of these data that DAs do not and could not affect prostate cancer screening decisions."

The Finnish team analyzed 19 randomized controlled trials comparing DAs for prostate cancer screening with usual care. They found that DAs are:

  • Possibly associated with improvement in knowledge (risk ratio, 1.38; 95% confidence interval, 1.09 to 1.73; low-quality evidence).
  • Probably associated with a small decrease in decisional conflict (mean difference on a 100-point scale, -4.19; 95% CI, -7.06 to -1.33; moderate-quality evidence).
  • Possibly not associated with whether physicians and patients discuss prostate-cancer screening (risk ratio, 1.12; 95% CI, 0.90 to 1.39; low-quality evidence) or with men's decision to undergo prostate cancer screening (risk ratio, 0.95; 95% CI, 0.88 to 1.03; low-quality evidence).

Looking ahead, Dr. Tikkinen told Reuters Health that "future decision aids should include provision for continuous updating of new evidence and not only provide education for patients, but also promote shared decision-making in the patient-physician encounter. Unfortunately this discussion is currently often lacking. We need training for physicians in the skills of shared decision-making, and tools to facilitate optimal interaction between men considering prostate-cancer screening and their clinicians."

The true potential of DAs for prostate cancer "remains unknown," Drs. Scherer and Lin write in their editorial. They note that randomized controlled trials of prostate-cancer-screening DAs versus usual care are heterogeneous in DA content, design, delivery and outcome measures.

"For example, the only information that was common to all the DAs was the purpose of prostate cancer screening. There was considerable variation in DA presentation and measurement of patient knowledge, from a 1-page flyer received by mail, with patients' knowledge assessed up to 3 weeks later, to an in-clinic DA intervention that included a 12-minute video and an 8-minute coaching session, with knowledge assessed immediately after these interventions," they point out.

"There was also heterogeneity in communication method (eg, booklets, leaflets, computer tools, video), how the DAs were implemented (eg, in clinic, by mail), and when and how the primary outcomes were assessed. Outcome measurements also varied among the studies, and the most robust outcome observed was a reduction in decisional conflict, the only outcome for which there was a standard, validated measure," write the editorialists.

"To know the true potential of DAs, we need to systematically test the influence of different types of DA design, implementation strategies, and patients' individual attributes (such as medical maximizing or minimizing) on shared decision-making (SDM) outcomes. Without such information, the true usefulness of DAs to sustainably facilitate SDM and serve patients' and clinicians' goals and needs remains unknown," they conclude.

The study had no commercial funding.

SOURCE: http://bit.ly/31ZUfaC and http://bit.ly/2XtbaDp

JAMA Intern Med 2019.

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