Cancer Screening: Promoting Informed Decision Making for Cancer Screening – Inactive

Inactive Community Guide Review

The reviews and findings listed on this page are inactive. Inactive reviews and findings are not scheduled for an update at this time, though they may be updated in the future. Findings become inactive when reviewed interventions are no longer commonly used, when other organizations begin systematically reviewing the interventions, or as a result of conflicting priorities within a topic area.

Summary of CPSTF Finding

The Community Preventive Services Task Force (CPSTF) finds insufficient evidence to determine the effectiveness of informed decision making interventions for:
  • Individuals in healthcare settings (based on mixed results and small effect sizes)
  • Community members outside of healthcare settings (based on a small number of studies)
  • Interventions targeted to healthcare systems and providers (based on a small number of studies)


Informed decision making (IDM) interventions help educate clients about cancer screening and make decisions with respect to their preferences. The aims of IDM interventions are to increase client participation in decision making at a level desired by the client and to promote decisions consistent with client values. These interventions can be delivered in many ways, such as group education or the mass media, and can include the use of decision aids. IDM is not the same as the “shared decision making” between doctors and clients that takes place in clinical settings, but one supports the other. For more on shared decision making, see the report from a working group of the U.S. Preventive Services Task Force.

CPSTF Finding and Rationale Statement

Read the CPSTF finding.

About The Systematic Review

The CPSTF finding is based on evidence from a systematic review of 11 studies (search period 1966 – 2002). The review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to cancer prevention and control.

Summary of Results

Eleven studies qualified for the systematic review.

There was generally consistent evidence that IDM interventions improve:

  • Knowledge
  • Accuracy of beliefs
  • Risk perceptions
  • A combination of these

However, there was little or no evidence about whether these interventions:

  • Result in individuals participating in decision making at a level they desire
  • Result in decisions that are consistent with individual values and preferences
  • Affect screening rates, especially among high-risk populations (e.g., older, non-white, low-income)


Applicability of this intervention across different settings and populations was not assessed because CPSTF did not have enough information to determine if the intervention works.

Evidence Gaps

CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are evidence gaps?)

Results from the Community Guide review indicate that there were not enough studies to determine the effectiveness of informed decision making (IDM). Thus, numerous research issues remain.

More work is needed on the effect of these interventions on all of the outcomes in the conceptual framework, especially on recommendation outcomes other than knowledge, beliefs, and perceptions of risk. Few studies reported individuals’ participation in decision making, and only one of those reported whether participation was at a desired level. It is not possible to know from the published reports whether questions about this issue were not asked or whether current instruments are not sufficiently sensitive to discriminate different levels of patient interest in participation, causing investigators not to report the data. If the problem is the latter, more sensitive measures of patient desire for participation should be developed.

The medical decision-making field has given considerable attention to assessing patient preferences for health states that is, the quality of life in a particular health situation. Health economists call these preferences “utilities” and use them, among other purposes, to inform cost-utility analyses. This research needs, however, to be extended to accurate and feasible ways to assess preferences in clinical encounters and to ensure that patient decisions are congruent with individual preferences and values.

Because most of the included studies in this review addressed prostate cancer, additional work on other cancer screenings would be welcome. Additional studies are needed in community contexts outside of clinical settings. Similarly, studies are needed that focus on providers and healthcare systems to promote shared decision making (SDM) instead of, or in addition to, directly targeting individuals. Studies with providers and in healthcare systems should measure provider and system outcomes, but should also measure the client outcomes that are the ultimate goal of these programs and policies.

Social and demographic variables have been shown to affect individuals’ desire for involvement in healthcare decisions and may also affect the effectiveness of IDM interventions. To date, IDM seems to be more acceptable to younger and more educated patients. However, this may be a consequence both of how questions are asked and of patients’ confidence. More empirical work is needed in diverse populations, such as nonwhite, older, and medically underserved populations. Achieving IDM in such populations is a challenging but desirable goal.

Although the study designs and executions of available studies in this review were generally strong, some measurement issues need additional attention. Sensitive, appropriate measures are still needed of individual involvement in decision making and the match between decisions and preferences or values. In addition, work is needed on how best to elicit patient preferences and respond to them in nonthreatening, time-sensitive, and culturally appropriate ways.

Although much work has already been published in the risk communication literature about how to communicate complex information involving probabilities to individuals, additional work is still needed on appropriate and feasible ways of communicating technical information so that it is helpful and not overwhelming. Additional empirical work on people’s information needs and preferences for level of involvement in decision making, how those needs and preferences might evolve over time, and how best to meet those needs and preferences would also be useful. Finally, more work is needed on whether IDM or SDM increases or decreases the use of effective services.

It is known that, at least for some diseases (e.g., breast cancer), individuals overestimate both the disease risks and the benefits of screening. IDM could help patients achieve a more realistic perspective on risks and benefits. In particular, quantitative risk models, which clearly show patients the risks and benefits of screening in terms of their personal characteristics, would allow patients to take personal risk factors into account when making healthcare decisions. Such techniques, which permit individualization of the risks and benefits, might help people to make better-informed decisions.

Study Characteristics

  • Of the 15 included intervention arms, ten addressed prostate cancer screening, three addressed colorectal cancer screening, and two addressed mammography screening.
  • Only three of the intervention arms evaluated interventions implemented outside of clinical settings, and only one study included an intervention component oriented to providers or healthcare systems.
  • Thirteen intervention arms measured patients’ knowledge, beliefs, or perceptions about the risk or natural history of the disease, or about the performance of the preventive service.

Analytic Framework

Effectiveness Review

Analytic Framework see Figure 1 on page 67

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Summary Evidence Table

Effectiveness Review

No content is available for this section.

Included Studies

The number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained in several publications).

Effectiveness Review

Davison BJ, Kirk P, Degner LF, Hassard TH. Information and patient participation in screening for prostate cancer. Patient Educ Counseling 1999;37:255 63.

Dolan JG, Frisina S. Randomized controlled trial of a patient decision aid for colorectal cancer screening. Med Decis Making 2002;22:125 39.

Flood A, Wennberg J, Nease R, Fowler F, Ding J, Hynes L. The importance of patient preference in the decision to screen for prostate cancer. J Gen Intern Med 1996;11:342 9.

Frosch DL, Kaplan RM, Felitti V. The evaluation of two methods to facilitate shared decision making for men considering the prostate-specific antigen test. J Gen Intern Med 2001;16:391 8.

Pignone M, Harris R, Kinsinger L. Videotape-based decision aid for colon cancer screening. A randomized, controlled trial. Ann Intern Med 2000;133:761 9.

Rimer BK, Halabi S, Sugg SC, et al. Effects of a mammography decision making intervention at 12 and 24 months. Am J Prev Med 2002;22:247 57.

Rimer BK, Halabi S, Sugg SC, et al. The short-term impact of tailored mammography decision-making interventions. Patient Educ Counseling 2001;43:269 85.

Schapira MM, VanRuiswyk J. The effect of an illustrated pamphlet decision aid on the use of prostate cancer screening tests. J Fam Pract 2000;49:418 24.

Volk R, Cass A, Spann S. A randomized controlled trial of shared decision making for prostate cancer screening. Arch Fam Med 1999;8:333 40.

Wilt TJ, Paul J, Murdoch M, Nelson D, Nugent S, Rubins HB. Educating men about prostate cancer screening. A randomized trial of a mailed pamphlet. Eff Clin Practice 2001;4:112 20.

Wolf AM, Nasser JF, Wolf AM, Schorling JB. The impact of informed consent on patient interest in prostate-specific antigen screening. Arch Intern Med 1996;156:1333 6.

Wolf AM, Schorling JB. Does informed consent alter elderly patients’ preferences for colorectal cancer screening? Results of a randomized trial. J Gen Intern Med 2000;15:24 30.

Wolf AM, Schorling JB. Preferences of elderly men for prostate-specific antigen screening and the impact of informed consent. J Gerontol A Biol Sci Med Sci 1998;53:M195 200.

Search Strategies

Electronic searches for literature were conducted in MEDLINE, National Library of Medicine’s Bioethicsline, PsychINFO, and the Chronic Disease Prevention databases. Also reviewed were the references listed in all retrieved articles, as well as other key systematic reviews and review articles. In addition, we consulted with experts on the systematic review development team and elsewhere.

Only journal articles were included. To be included in the reviews, studies had the following characteristics:

  • Publication date of 1966 through 2002
  • Primary study rather than a guideline or review
  • Took place in a developed country or countries
  • Met the systematic review development team’s definition of the intervention
  • Provided information on one or more outcomes related to the analytic framework
  • Compared a group exposed to the intervention with a group not exposed or less exposed (comparisons could be concurrent or in the same group over a period of time)

Considerations for Implementation

CPSTF did not have enough evidence to determine whether the intervention is or is not effective. This does not mean that the intervention does not work, but rather that additional research is needed to determine whether or not the intervention is effective.


Evidence-Based Cancer Control Programs (EBCCP)

Evidence-Based Cancer Control Programs icon Find programs from the EBCCP website that align with this systematic review. (What is EBCCP?)