Decision Aids for Prostate Cancer Screening Choice: A Systematic Review and Meta-analysis

Key PointsQuestionWhat is the association of decision aids vs usual care with shared decision-making in men deciding whether to undergo prostate cancer screening? FindingsThis systematic review and meta-analysis of 19 randomized clinical trials comparing decision aids for prostate cancer screening (12781 men) found that decision aids are probably associated with a small reduction in decisional conflict and are possibly associated with an increase in knowledge. Decision aids are possibly not associated with whether physicians and patients discuss prostate cancer screening and are possibly not associated with actual screening decisions. MeaningRandomized clinical trials have failed to provide compelling evidence for the use of decision aids for men contemplating prostate cancer screening that have, up to now, undergone rigorous testing to determine their outcome. ImportanceUS guidelines recommend that physicians engage in shared decision-making with men considering prostate cancer screening. ObjectiveTo estimate the association of decision aids with decisional outcomes in prostate cancer screening. Data SourcesMEDLINE, Embase, PsycINFO, CINAHL, and Cochrane CENTRAL were searched from inception through June 19, 2018. Study SelectionRandomized trials comparing decision aids for prostate cancer screening with usual care. Data Extraction and SynthesisIndependent duplicate assessment of eligibility and risk of bias, rating of quality of the decision aids, random-effects meta-analysis, and Grading of Recommendations, Assessment, Development and Evaluations rating of the quality of evidence. Main Outcomes and MeasuresKnowledge, decisional conflict, screening discussion, and screening choice. ResultsOf 19 eligible trials (12781 men), 9 adequately concealed allocation and 8 blinded outcome assessment. Of 12 decision aids with available information, only 4 reported the likelihood of a true-negative test result, and 3 presented the likelihood of false-negative test results or the next step if the screening test result was negative. Decision aids are possibly associated with improvement in knowledge (risk ratio, 1.38; 95% CI, 1.09-1.73; I-2=67%; risk difference, 12.1; low quality), are 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; I-2=75%; moderate quality), and are possibly not associated with whether physicians and patients discuss prostate cancer screening (risk ratio, 1.12; 95% CI, 0.90-1.39; I-2=60%; low quality) or with men's decision to undergo prostate cancer screening (risk ratio, 0.95; 95% CI, 0.88-1.03; I-2=36%; low quality). Conclusions and RelevanceThe results of this study provide 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. This systematic review and meta-analysis of 19 randomized clinical trials estimates the association of decision aids with decisional outcomes in prostate cancer screening.Peer reviewe