Review: cancer-related decision aids improve patient knowledge overall and reduce anxiety in screening settings
Are decisions aids (DAs) effective in patients with cancer or at risk of cancer?
Included studies evaluated DAs in patients who had cancer or were at increased risk of cancer. DAs were defined as interventions to help patients, alone or with clinicians, in making cancer-related healthcare decisions related to screening, prevention, and treatment options. Studies published before 1976, in abstract form only, or evaluating DAs for clinicians only were excluded. Outcomes included patient knowledge, anxiety, and decisional conflict.
Medline (to Mar 2007); CINAHL, EMBASE/Excerpta Medica, HealthStar, CancerLit, PsycInfo, Sociological Abstracts, and Cochrane Library (all to Jun 2006); and reference lists were searched for randomised controlled trials (RCTs). Authors were contacted for missing data. 34 RCTs (46 comparisons) met the selection criteria: 22 RCTs were done in screening settings, 5 in high-risk prevention settings, and 7 in treatment settings. 24 RCTs compared DAs with usual practice, 6 compared different DAs, and 4 did both. DA interventions varied.
Meta-analysis showed that DAs improved patient knowledge more than usual practice in all settings and reduced anxiety in screening settings; groups did not differ for decisional conflict (table). Meta-analysis showed that more v less intensive DAs improved patient knowledge in prevention/treatment settings but not in screening settings (table); groups did not differ for decisional conflict (weighted mean effect size −0.07, 95% CI −0.22 to 0.09). 4 individual studies found no difference between DAs for anxiety.
Cancer-related decision aids improve patient knowledge overall and reduce anxiety in screening settings.
O’Brien MA, Whelan TJ, Villasis-Keever M, et al. Are cancer-related decision aids effective? A systematic review and meta-analysis. J Clin Oncol 2009;27:974–85.
Clinical impact ratings: Family/general practice 6/7; Health promotion 5/7; Oncology 5/7; Patient education 6/7
O’Brien et al assert that the goals of using DAs include improved communication and improved patient involvement in the decision-making (DM) process. If communication is primarily the transfer of information, then the results of this review suggest that DAs are useful tools. Patient knowledge increased after using DAs in screening and intervention situations. The premise that knowledge does not necessarily reduce anxiety in all situations is also supported. Only 3 screening and 4 prevention/treatment studies (8 comparisons) assessed the patient’s role in DM; 4 comparisons showed increased patient involvement in DM with use of DAs. A review of these studies might reveal what worked to enhance patients’ involvement.
Patients vary in degrees of their desired involvement in DM. Evidence suggests that older patients prefer less active roles than younger patients, and more educated patients prefer more active roles than those who are less educated.1 Individualising care to patients’ experiences, behaviours, feelings, and perceptions2 may be appropriate when using DAs with the goal of involving patients in DM and behaviour change. A meta-analysis of 57 studies showed that individualised print materials changed health behaviours, an effect that held for the subgroup of studies of cancer screening behaviours.3
The effectiveness of DAs in practice depends ultimately on their adoption into clinical care. Factors that affect adoption include readiness of clinicians to use DAs (eg, DA knowledge, implementation skills, and attitudes), organisational commitment (eg, increased time per patient visit for DA use), and the instruments themselves (eg, cultural appropriateness, updates with new knowledge advances). Research in each of these areas is warranted.