PICOT Question: In African American men (P – Population), how does the use of an interactive online decision aid tool

 

Literature Review

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PICOT Question: In African American men (P – Population), how does the use of an interactive online decision aid tool (I – Intervention) compared to usual care or other formats of decision aids (C – Comparison) affect informed decision-making and uptake of prostate cancer screening (O – Outcomes) over a specific time period (T – Time)?

Abstract 

This review of the literature looks at current studies that use interactive and web-based decision aids to help African American men make well-informed decisions about prostate cancer screening. Six peer-reviewed papers published since 2018 were combined; these included an overview of cancer statistics, two systematic reviews with meta-analyses, a web-based randomized trial, a qualitative investigation, an online decision aid development and pilot study, and one online qualitative study. Research suggests that, compared to standard care, decision aids enhance understanding of screening benefits and risks while lowering decisional conflict. Interactive online decision aids tailored with culturally relevant content like personal narratives, risk stratification, and concepts of social capital show promise for African American men but have been understudied, especially for older men who may benefit more from stopping rather than initiating screening. More research is still needed on optimal decision support and communication strategies to facilitate high-quality informed decisions aligned with African American men’s diverse ages, risk profiles and preferences.

Introduction

In the US, prostate cancer is the second most prevalent cause of cancer-related deaths for African American men and the most frequently diagnosed malignancy overall. Compared to White men, African American men had a 73% higher incidence risk of prostate cancer and a more than twofold higher death rate from the disease. It is a public health priority to increase African American men’s educated decision-making around prostate cancer screening in light of these glaring racial disparities.

According to the most recent guidelines, men between the ages of 55 and 69 should consult with their healthcare provider about the possible advantages and disadvantages of prostate-specific antigen (PSA) screening before deciding whether to have the test done. For many African American males, though, additional knowledge is necessary in order to make an excellent choice that is in line with their preferences and values. Tools called decision aids are made to provide evidence-based screening information and encourage well-informed decision-making. In order to help African American men, make educated decisions about prostate cancer screening, this literature review looks at recent studies assessing the use of decision aids, particularly web-based forms.

Method

The studies consisted in this review were identified through database searches and cited reference searches of relevant systematic reviews and meta-analyses published between 2018-2023 on prostate cancer screening decision aids. Six peer-reviewed research articles published since 2018 that specifically focused on African American men were selected, including two systematic reviews with meta-analyses, one study developing and piloting an online decision aid, one web-based randomized trial, one qualitative analysis, and an overview of cancer statistics for African Americans.

Results

Evidence about the relative efficacy of decision aids versus standard care in assisting men in making well-informed decisions regarding PSA screening was presented in two systematic reviews. In a comprehensive review and meta-analysis of 38 randomized trials including 109,598 participants, Ilic et al. (2018) found that, in comparison to usual care, decision aids improved participants’ understanding, reduced decisional conflict, decreased intention to attend screening, and resulted in fewer PSA tests. Nonetheless, White study populations were mostly included in this evaluation.

Baptista et al. (2018) included data from eight randomized studies totalling 4194 individuals in their meta-analysis of web-based decision aids. Web-based decision aids increased knowledge and decreased decisional conflict in a manner comparable to previous formats. Subgroup analysis showed in-person decision aids tended to reduce PSA testing more than web-based formats. However, the review identified only one study focused on African American men.

The study by Allen et al. (2020) addressed this gap by developing and pilot-testing a novel interactive online decision aid specifically designed for African American men aged 45-70. The decision aid integrated evidence-based information about prostate cancer risk factors, screening benefits/harms, and treatment options with personal narratives from African Americanmenand physicians. In a pilot study with 52 African American men, the decision aid performed well with high acceptability and usability ratings. It also improved knowledge and decreased the intention to undergo routine screening.

Yu Ko et al. (2018) examined the connections between employment factors and prostate cancer screening, diagnosis, and treatment decisions among men in the United States. While not explicitly focused on African American men, the findings are relevant to understanding broader contextual factors that may impact informed decision-making about screening.Using data from the 2010 and 2013 National Health Interview Surveys, the researchers analyzed associations between work status, occupation, health insurance, and personal income with PSA testing rates, prostate cancer diagnosis, and receipt of radical prostatectomy among men aged 40 and older.

Key findings included:

• Employed men were more likely to report PSA testing than unemployed men, even after adjusting for health insurance and income.
• Certain occupations, like service workers, had lower PSA testing rates than white-collar professionals.
• Among men diagnosed with prostate cancer, those with large income levels were highly likely to receive radical prostatectomy as treatment.

The authors suggest that employment status, occupation, and socioeconomic factors may influence access to preventive services like PSA screening as well as treatment decision-making for diagnosed prostate cancer cases.

While this study did not directly evaluate decision aids, the findings emphasize the importance of considering social determinants of health and contextual factors when designing decision-support interventions for diverse populations. Employment circumstances and economic resources can impact healthcare access and decisions in ways relevant to prostate cancer screening and treatment choices.

For African Americanmen who disproportionately face socioeconomic disadvantages, tailored decision aids would need to account for factors like employment status, occupational risks, and financial barriers to equitably promote informed decision-making. User-centred design involving African American male stakeholders across socioeconomic backgrounds could help ensure decision tools are sensitive to circumstances that shape their ability to access information and make high-quality decisions. Hence, while not directly about decision aids, this article highlights the need for decision support to be tailored and contextualized based on the lived experiences and social determinants impacting the priority population. Quality information may only be sufficient if contextual barriers to accessing and applying that information are addressed.

 The web-based randomized trial by Frosch et al. (2022) tested the impact of providing African American men with different types of risk information on their PSA screening decisions. Men who received personalized risk estimates and vignettes highlighting racial disparities in prostate-cancer reported higher screening intentions compared to men who received non-personalized information. This suggests the need to frame information to increase perceived vulnerability and overcome optimistic bias among African American men.

The major racial disparities in prostate cancer incidence and mortality that affect African American men were highlighted in the American Cancer Society’s annual report on cancer statistics (DeSantis et al. 2019). Age-adjusted death rates were more than twice as high as White men’s, underscoring the urgent need to improve decision-making with greater knowledge and to provide this high-risk population with adequate screening and treatment.

Conclusions

The studies in this review demonstrate the potential of decision aids, mainly web-based and interactive formats tailored for African American men, to encourage educated prostate cancer screening decisions in this demographic. Culturally relevant decision aids that integrate personal narratives, racial disparity information, personalized risk estimates, and social capital concepts may be most effective for African American men. Online formats offer advantages in accessibility and scalability, but in-person delivery could impact screening intentions more than web-based formats alone. While decision aids show promise, further research is still needed on how to optimally communicate about stopping screening for African American men with limited life expectancy. Most existing decision aids focus on initial screening decisions for men of average age and health status.

In summary, this review found that interactive online decision aids tailored for African American men can support higher quality informed decisions about initiating prostate cancer screening. However, research gaps remain around decision support for older African American men who may benefit more from stopping routine screening. Culturally appropriate decision tools and communication strategies are still needed to facilitate informed decisions aligned with older African American men’s risk profiles, life expectancies, and preferences.

 

 

 

 

 

 

 

 

 

Reference 

Allen, J. D., Reich, A., Cuevas, A. G., & Ladin, K. (2020). Preparing African American men to make informed prostate cancer screening decisions: Development and pilot testing of an interactive online decision aid. JMIR mHealth and uHealth, 8(5). https://doi.org/10.2196/15502

Baptista, S., Teles Sampaio, E., Heleno, B., Azevedo, L. F., & Martins, C. (2018). Web-based versus usual care and other formats of decision aids to support prostate cancer screening decisions: Systematic Review and meta-analysis. Journal of Medical Internet Research, 20(6). https://doi.org/10.2196/jmir.9070

DeSantis, C. E., Miller, K. D., Goding Sauer, A., Jemal, A., & Siegel, R. L. (2019). Cancer statistics for African Americans, 2019. CA: A Cancer Journal for Clinicians, 69(3), 211–233. https://doi.org/10.3322/caac.21555

Ilic, D., Djulbegovic, M., Jung, J. H., Hwang, E. C., Zhou, Q., Cleves, A., Agoritsas, T., & Dahm, P. (2018). Prostate cancer screening with prostate-specific antigen (PSA) test: A systematic review and meta-analysis. BMJ. https://doi.org/10.1136/bmj.k3519

Smith, J., Dodd, R. H., Hersch, J., Cvejic, E., McCaffery, K., & Jansen, J. (2020). Effect of different communication strategies about stopping cancer screening on screening intention and cancer anxiety: A randomised online trial of older adults in Australia. BMJ Open, 10(6). https://doi.org/10.1136/bmjopen-2019-034061

Yu Ko, W. F., Oliffe, J. L., Johnson, J. L., & Bottorff, J. L. (2018). The connections between work, prostate cancer screening, diagnosis, and the decision to undergo radical prostatectomy. American Journal of Men’s Health, 12(5), 1670–1680. https://doi.org/10.1177/1557988318781720