Communicative aspects of decision aids for localized prostate cancer treatment – A systematic review

Highlights

• Decision aids (DAs) have been developed for patients with localized prostate cancer.

• DAs were reviewed for the International Patient Decision Aid Standards criteria and various communicative aspects (CAs).

• Adherence to the International Patient Decision Aid Standards criteria varied greatly across the DAs.

• The use of CAs varied substantially by the DAs.

• CAs such as personalization, interaction, and multimodality can further improve DAs for localized prostate cancer.

Abstract

Context

Despite increasing interest in the development and use of decision aids (DAs) for patients with localized prostate cancer (LPC), little attention has been paid to communicative aspects (CAs) of such tools.

Objective

To identify DAs for LPC treatment, and review these tools for various CAs.

Materials and methods

DAs were identified through both published literature (MEDLINE, Embase, CINAHL, CENTRAL, and PsycINFO; 1990–2018) and online sources, in compliance with the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. Identified DAs were reviewed for the International Patient Decision Aid Standards criteria, and analyzed on CAs, including information presentation, personalization, interaction, information control, accessibility, suitability, and source of information. Nineteen DAs were identified.

Results

International Patient Decision Aid Standards scores varied greatly among DAs. Crucially, substantial variations in use of CAs by DAs were identified: (1) few DAs used visual aids to communicate statistical information, (2) none were personalized in terms of outcome probabilities or mode of communication, (3) a minority used interactive methods to elicit patients’ values and preferences, (4) most included biased cross tables to compare treatment options, and (5) issues were observed in suitability and accessibility that could hinder implementation in clinical practice.

Conclusions

Our review suggests that DAs for LPC treatment could be further improved by adding CAs such as personalized outcome predictions and interaction methods to the DAs. Clinicians who are using or developing such tools might therefore consider these CAs in order to enhance patient participation in treatment decision-making.

Introduction

Men newly diagnosed with localized prostate cancer (LPC) are facing difficult decisions regarding treatment. They need to choose from a range of treatment options (e.g., surgery, external beam radiotherapy, brachytherapy, or active surveillance) [1], which have equivalent survival outcomes but differ in the risk of adverse outcomes [2], [3]. This scenario calls for shared decision-making (SDM), a 3-step process by which clinician and patient (1) discuss treatment options, (2) compare risks and benefits, and (3) make sure that the final decision is preference based [4], [5]. SDM may involve decision aids (DAs), which are tools (e.g., booklets or websites) that provide balanced information about options and the associated risks and benefits, and help patients to clarify values and preferences and how to communicate these with their clinician [6]. Today, there are hundreds of patient DAs in various health domains, ranging from cancer to heart disease [7]. Even though DAs have potential [7], systematic reviews have shown variability in the effects of DAs for LPC treatment on decisional outcomes (including decisional conflict and knowledge) and treatment choice [8], [9], [10].

An explanation for the inconsistent effects may be that DAs have been developed and implemented without taking into account the communicative process in which SDM occurs [11]. Classic models of this process assume that communication requires a sender and a receiver who are exchanging information through a certain channel [12]. In addition, this communication process can involve aspects such as feedback (i.e., the receiver's response to a message) or noise (i.e., anything not intended by the sender). Seen from this perspective, SDM is a similar 2-way communicative process in which both clinician and patient convey and receive messages through available channels in order to reach a decision regarding treatment [13]. Indeed, communication models of SDM also acknowledge the role of DAs in this communication process [14]. Therefore, it is important to look into communicative aspects (CAs) of DAs that could potentially influence elements of the communication process between clinician and patient.

These CAs include, first of all, the channels through which DAs communicate to patients, which can either be unimodal (e.g., using text or pictures alone) or multimodal (e.g., using text with pictures or audiovisual information) [15], [16], [17]. The latter is particularly important for complex topics such as explaining surgical procedures or statistical information [18], [19]. Another aspect is that DAs can signal information based on interactions with the patient, for instance, by clarifying values or preferences, or by providing personalized information for a specific receiver based on input of that receiver [20], [21]. Moreover, information provided by DAs may also be less suitable or accessible because of various forms of noise such as complex language use (e.g., jargon), or biased presentations of risks and benefits of treatments [22]. Despite the importance of communication characteristics of DAs, no research exists that has systematically reviewed such patient tools for LPC treatment from a communication point of view.

When reviewing the quality of DAs, researchers often make use of a standardized quality checklist developed by the International Patient Decision Aids Standards (IPDAS) Collaboration [6], [23]. Nevertheless, even though the IPDAS checklist is seen as the golden standard for developing and evaluating DAs [24], it is also important to consider other aspects of the communication process that are not covered by the IPDAS. Until now, only one systematic review by Adsul et al. has reviewed the quality of DAs for LPC treatment by using additional items related to implementation (e.g., health literacy) [25]. Although their results lead to a global understanding of the variability in characteristics and quality of DAs, more in-depth analyses of some CAs are still required to get a more complete understanding of DAs as a communicative tool in the context of SDM.

The objectives of this review are to (1) systematically identify currently available DAs for LPC treatment through both academic and online sources, (2) review these tools for IPDAS criteria and, crucially, (3) assess them on a range of aspects deemed to be important for the communication process. By doing so, this review will both update and extend previous work [25], and will also take a closer look at various CAs of DAs.