Systematic Review of Decision Aids for Newly Diagnosed Prostate Cancer Patients Making Treatment Decisions.

BACKGROUND - Despite established evidence for using patient decision aids, their use with newly diagnosed prostate cancer patients remains limited, partly due to variability in the characteristics of decision aids. The objective of this study was to systematically review decision aids for their content, development process, effectiveness and potential for implementation in routine urologic practice for newly diagnosed prostate cancer patients.

METHODS - Published peer-reviewed journal articles, unpublished literature on the Internet, and the Ottawa decision aids web repository were searched to identify decision aids designed for prostate cancer patients facing treatment decisions. A total of 14 decision aids were retrieved and included in the study. In addition, supplementary materials regarding the development of the decision aids and 4 published studies regarding the evaluation of these decisions aids were also included. Decision aids included in the study were those documents: designed to help patients make specific and deliberative choices among options and outcomes relevant to their health status; specific to the treatment of prostate cancer; and in English only. Decision aids were reviewed by 3 coders for the presence of the previously validated International Patient Decision Aid Standards (IPDAS) and additional standards deemed relevant to prostate cancer treatment decisions. Decision aids were also reviewed for novel criteria addressing their potential for implementation, including format and health literacy standards as identified through the review of current dissemination and implementation literature regarding decision aids. Acceptable inter-rater reliability (Krippendorff's alpha) was achieved at 0.82.

RESULTS - Of the 14 decision aids retrieved, 8 (57.1%) were developed in the United States. Six (42.8%) decision aids were print based, 5 (35.7%) were web-based or both. Only 4 (28.5%) decision aids had been updated since 2013. Ten (71.4%) aids were targeted to a specific stage of prostate cancer (i.e. early stage, advanced, metastatic). All decision aids discussed radiation, 12 (85.7%) aids discussed surgery, 9 (64.2%) discussed active surveillance and/or watchful waiting, and 7 (50%) discussed hormonal therapy. When information was available, most (64.2%) decision aids presented balanced perspectives about the benefits and risks of treatment and/or the outcome probabilities associated with each treatment option. Ten (71.4%) decision aids presented values clarification prompts for patients and outlined explicit steps to making treatment decisions. Although all decision aids mentioned the developer's credentials, none of the decision aids were field tested with physicians and only 4 (28.6%) were field tested with patients. Nine (64.2%) decision aids provided details about their data appraisal methods and only 4 (28.6%) decision aids commented on the quality of the evidence used in the development of the decision aids. Overall, only 4 (28.6%) decision aids had associated published journal articles that provided information regarding the effectiveness of decision aids when tested with patients. The only common outcome measure in all 4 studies was the changes in the patient's knowledge regarding treatment options for prostate cancer. Regarding criteria addressing implementation potential, in terms of format, 5 decision aids supplemented their print materials with audio recording or videos. Of the 8 decision aids that were web-based or computer-based, 7 (87.5%) provided patients with the opportunity to interact with the decision aids. All but 1 decision aid scored above the 9th grade reading level based on the SMOG formula. No evidence regarding the implementation of decision aids in routine practice was available for decision aids.

CONCLUSIONS - None of the decision aids reviewed in this study met all the International Patient Decision Aid Standards. Content, format and presentation of prostate cancer information within the decision aids varied substantially. Critical issues such as the risk of overtreatment and active surveillance were not covered in all decision aids. Aids were generally not written using plain language and very limited information was available regarding the effectiveness and implementation of these tools. As physicians look to adopt decision aids for their practice, they may base the choice of decision aid on characteristics that correlate well with the socioeconomic and educational status of their patient populations, their personal practice styles and their practice settings.

J Urol. 2015 Jun 5. pii: S0022-5347(15)04115-4. doi: 10.1016/j.juro.2015.05.093. [Epub ahead of print]

Adsul P1, Wray R2, Spradling K3, Darwish O3, Weaver N2, Siddiqui S3.

1 Department of Behavioral Science and Health Education, College for Public Health and Social Justice, Saint Louis University, Saint Louis, MO.
2 Department of Behavioral Science and Health Education, College for Public Health and Social Justice, Saint Louis University, Saint Louis, MO.
3 Division of Urologic Surgery, School of Medicine, Saint Louis University, Saint Louis, MO.