A Systematic Review: Shared Decision Making for Cancer Screening
Patient decisions about cancer screening have become increasingly complex. They must decide whether to get screened, and if so, what kind of screen, how often, and for how long. When such decisions are closely determined by individual values and preferences, most clinical practice guidelines call for some kind of shared decision making (SDM) that incorporates patient preferences with available evidence on benefits and harms. SDM interventions help patients understand screening risks and benefits, clarify their own values in relation to these risks, and participate in decisions based on these values.
The VA Evidence-Based Synthesis Program located at the Minneapolis VA Medical Center recently conducted an evidence review to examine the effects of SDM interventions for cancer screening in adults. The review found moderate evidence that SDM interventions for prostate, breast, and colorectal cancer screening improve patient knowledge, and these interventions may reduce decisional conflict. The review found low or insufficient evidence of effect on other measures. No studies evaluated SDM interventions for cervical or lung cancer screening. An overview of the findings and the strength of evidence is presented in Table 1 below.
Using categories from the Ottawa Decision Support Framework, a commonly-used theoretical model of decision making, the review distinguishes outcomes related to Decision Quality, Decision Impact, and Decision Action. Decision Quality includes knowledge, values clarity, and the degree to which patients participate in decision making. Decision Impact encompasses measures of personal uncertainty about course of action, use of services, and satisfaction with the decision. Decision Action includes screening intention and behavior. The review considered patient, provider, system, and multi-level SDM interventions, and was not limited to the patient-directed decision aids, the most commonly used SDM intervention.
Nominated by Linda Kinsinger MD, MPH, VA Chief Consultant for Preventive Medicine at the VA National Center for Health Promotion and Disease Prevention (NCP), the review is intended to inform NCP decisions on the types of interventions disseminated with its cancer screening guidelines.
While the report noted that findings are likely applicable to the development of future SDM interventions for cancer screening, there are limitations including the absence of studies of screening for cervical or lung cancer. Included SDM interventions often did not use the most recent findings from randomized screening trials (especially prostate cancer), modeling studies, or cost effectiveness analyses, and thus may not include the most up-to-date evidence or be fully applicable to current screening questions or published clinical practice guidelines. Studies did not address clinically important screening comparative effectiveness decisions, including the value of different screening strategy intensities (eg, annual versus biennial mammography, or cervical cancer screening with cytology alone every 3 years vs cytology plus HPV testing every 5 years for women ages 30-65).
Despite these limitations, the findings are relevant to future VA efforts regarding implementation of SDM interventions. Two studies specifically targeted a VA population. Though both studies evaluated SDM interventions for prostate cancer screening, they can be seen as a template upon which to guide current and future efforts, such as lung cancer screening. This outline of the effects of and required resources (specifically the human resource requirements) for SDM cancer screening interventions to date would help guide VA use and development of such interventions.
Lillie SE, Partin MR, Rice K, Fabbrini AE, Greer NL, Patel S, MacDonald R, Rutks I, Wilt, TJ. The Effects of Shared Decision Making on Cancer Screening - A Systematic Review. VA ESP Project #09-009; 2014.
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