Informed decision making with prostate cancer screening options: ‘WHY’?

The focus of prostate cancer prevention research has switched FROM advocating for screening TO advocating for informed decision-making among men. In other words, we are now trying to inform men of their options and advocate that they have an open and honest dialogue with their physician on their treatment options. Joseph-Williams et al (2010) looks at the relationship between informed decision making and usage of decision aids.

Decision aids, which are often web or computer based, are being used more often in intervention research as they play a key role in patient participation. However, not enough research has been done to test the effectiveness of these aids or how to develop the best methods for implementation. In other words, we need to know ‘WHY’ these aides work so well more so than anything. But we are getting ahead of ourselves…

We know that decision aids lead to increased knowledge and sometimes prevent patients from making immediate actions regarding their health. In the reviewed study, the authors observed the use of Prosdex, a web-based decision aid that helps men decide whether or not to have a PSA (prostate-specific antigen) test. Prosdex kept a web-log of all users. All 129 participants were men, 50-75 years old, had access to the internet and were recruited by general practitioners in South Wales, United Kingdom. After participants had a chance to view Prosdex, they filled out a questionnaire that assessed informed decision making. The Prosdex site contained three modules: “The PSA Test”, “It’s Your Choice,” and “Prostate Cancer.” Each of these modules has numerous sections with content pertaining to the topic. There is a five-point rating scale or “decision stacker” that allows participants to rate their views on PSA testing. A web-log was kept for each participant that included the amount of time spent viewing each page (the average viewing time was 20 minutes).

Results showed that the more pages the participants viewed online, the better their overall knowledge. Fine, nothing new there. However, more interestingly, but nothing new, there was a negative correlation between the total number of pages viewed and the person’s attitude toward screening, meaning that the more pages the participant viewed, the less favorable his attitude to have a PSA test. Overall, we can state that viewing Prosdex led to more informed decision making, but in ways that a few years ago researchers would probably not have guessed.

One major limitation of this study has to do with access. About 47 participants had trouble accessing the website, partly due to software issues, which led to high dropout rates. The participants were not a homogenous group; the users were categorized by their levels of participation. Lower access users tend to look at only key information, whereas higher access users are more likely to look at detailed information, interactive features, videos, animations, etc. This implies that decision aids should be adjusted accordingly because one intervention does not fit all. Decision aids should be designed in a manner that would allow even the low access groups to be able to receive and understand the necessary information, while providing additional and, perhaps, more complex resources for interested groups. This is called a stratum approach, or tailored messaging.

As the field is moving from interventions solely promoting prostate cancer screening to increasing informed decision-making among patients, a major issue not addressed is WHY attitudes toward PSA testing become more negative with increased knowledge. We could speculate that the uncertainties of screening outcomes, associated anxiety/fear, and potential unnecessary treatments would predict such behaviors. The desire to seek preventive care can also reflect the individual’s attitude toward his own well-being and the perceived amount of control he has over his health. However, nothing concretely suggests the WHY with informed decision-making research, especially not in this study. We challenge the field to figure this out.

By: Michael J Rovito, Ph.D and Janna Manjelievskaia

SOURCE: Joseph-Williams, N., Evans, R., Edwards, A., Newcombe, R.G., Wright, P., Grol, R., et al. (2010, May 26). Supporting informed decision making online in 20 minutes: An observational web-log study of a PSA test decision aid. Journal of Medical Internet Research, 12(2): e15.