Decision aids and prostate cancer: how useful are they?

Your sitemaster has long had concerns about the real value of decision aids in helping men to think about and come to conclusions about controversial issues in the diagnosis and management of prostate cancer.

This does not mean that Prostate Cancer international believes that decision aids are unhelpful. But what it does mean is that we believe they have to be used judiciously and in combination with other forms of information transfer if individual patients are to come to the best possible conclusions about such things as whether they want or need to

  • Be screened for risk of prostate cancer
  • Have a biopsy on the basis of their PSA data
  • Select one specific form of management or treatment over another after a diagnosis of prostate cancer.

Sound shared decision-making, in our opinion, cannot be accomplished through the use of decision aids alone.

A newly published meta-analysis by Riikonen et al. in the journal JAMA Internal Medicine appears to come to similar conclusions, based on data from 19 different randomized trials of decision aids (involving > 12,000 men) in helping them come to conclusions about prostate cancer screening. This paper — and an associated editorial by Scherer and Lin — are discussed in some detail in an article entitled “Low marks for decision aids in prostate cancer screening” on the MedPage Today web site.

In their original article, Riikonen et al. conclude that their study provides only:

… moderate-quality evidence that decision aids compared with usual care are associated with a small decrease in decisional conflict and low-quality evidence that they are associated with an increase in knowledge but not with whether physicians and patients discussed prostate cancer screening or with screening choice. Results suggest that further progress in facilitating effective shared decision-making may require decision aids that not only provide education to patients but are specifically targeted to promote shared decision-making in the patient-physician encounter.

In their editorial, Scherer and Lin also note a whole host of reasons why the use of decision aids may be able to assist patients in the shared decision-making process but cannot replace it.

Rather than repeat all of the issues addressed in the above-mentioned MedPage Today article, we suggest that interested readers review this for themselves.

We would emphasize, once again, that available data do not provide a compelling rationale for mass, population-based screening for risk of prostate cancer. Conversely, screening for prostate cancer among groups of men known to be at a relatively higher risk for this disorder than the general male population is almost certainly a good idea. Similarly, we have little to no compelling evidence as to the relative benefits and risks of any one form of management over all the other ones for men diagnosed with intermediate and high-risk forms of prostate cancer.

In both of these cases, in the end, a patient has to come to his own conclusion about what he wants to do, and he may quite commonly feel the need to come to a conclusion that meets the “needs” of his doctor or a family member as opposed to his own personal needs. Decision aids take little to no account of such pressures.

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