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New decision aids needed for prostate cancer screening
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Current decision aids for prostate cancer screening were only modestly associated with improved patient knowledge and reduced decision conflict, and did not increase shared decision-making between patients and physicians, according a study published in JAMA Internal Medicine.
“The benefit of prostate cancer screening with [prostate-specific antigen] is small and uncertain and there are clear harms,” Jarno M. Riikonen, MD, PhD, of the department of urology at the Tampere University Hospital and faculty of medicine and life science at the University of Tampere, Finland, and Kari A. Tikkinen, MD, PhD, of the department of urology at Helsinki University Hospital and the department of public health at the University of Helsinki, Finland, told Healio Primary Care. “Furthermore, there is considerable variability among men's values and preferences regarding prostate cancer screening. Shared decision-making is therefore needed for men considering screening. This includes that men should be informed about potential benefits, harms and uncertainties.”
Researchers conducted a systematic review and meta-analysis of randomized clinical trials among men who were considering prostate cancer screening that compared decision-aid interventions with usual care.
Trials published between 1999 and 2017 were reviewed to determine if decision aids affected patient knowledge on prostate cancer screening, discussions about screening between patients and physicians, actual screening decisions and patient satisfaction with their decision.
To evaluate different decision aids, researchers used standardized scores that ranged from zero to 100 based on characteristics of the decision aid. The quality of evidence was assessed and classified with the Grading of Recommendations, Assessment, Development and Evaluations approach.
After a full text screening, 19 studies including 12,781 men with a median age of 59 years were included in the analysis. Twelve different decision aids, including printed materials, education, and computer-based tools, were compared.
Researchers found that decision aids were modestly associated with increased patient knowledge on prostate cancer screening, (RR = 1.38; 95% CI, 1.09-1.73; I2 =67%; risk difference, 12.1; low quality). They also found that decision aids may have been associated with a decrease in decisional conflict based on the 100-point scale (mean difference = –4.19; 95% CI, –7.06 to –1.33; I2 = 75%; moderate quality).
In addition, decision aids may not have been associated with whether patients and physicians discussed prostate cancer screening (RR = 1.12; 95% CI, 0.9-1.39; I2 = 60%; low quality) or with patients’ decision to undergo prostate cancer screening (RR = 0.95; 95% CI, 0.88-1.03; I2 =36%; low quality).
“Although decision aids were shown to be helpful for communicating evidence to patients, they were insufficient for fostering shared decision-making,” Riikonen and Tikkinen said.
“Future decision aids should promote shared decision-making in the patient-physician encounter,” they continued. “Furthermore, decision aids need to be regularly updated with the most recent research results. The development of decision aid should follow accepted standards, such as the International Patient Decision Aid Standards (IPDAS) Collaboration guidelines.” – by Erin Michael
Disclosures: Riikonen reports receiving reimbursement from Astellas and Ferring for attending scientific meetings and participating in trials for Astellas, Bayer, Ferring, Myovant, and Pfizer. Tikkinen reports no financial disclosures. Please see study for all other authors’ relevant financial disclosures.
Perspective
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Alexander Kutikov, MD, FACS
Controversy that surrounds prostate cancer screening stems from risks that surround this decision. Men who forgo screening are likely at higher risk for passing from prostate cancer. Meanwhile, men who choose to be screened are exposed to inconveniences and complications of a biopsy that is generally performed through the rectum and is associated with small risks for bleeding, infection and inability to urinate. Moreover, many prostate cancers that are diagnosed are not destined to cause harm, while treatment of such low risk cancers may lead to impotence and incontinence. Hence, decision tools such as the ones reviewed in the study harbor promise in helping patients and physicians make critical clinical choices regarding screening. The true utility of such tools; however, is debated. Moreover, the degree of clinical traction that these tools have achieved is unclear.
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