Shared decision-making for supporting women's decisions about breast cancer screening.

BACKGROUND: In breast cancer screening programmes, women may have discussions with a healthcare provider to help them decide whether or not they wish to join the breast cancer screening programme. This process is called shared decision-making (SDM) and involves discussions and decisions based on the evidence and the person's values and preferences. SDM is becoming a recommended approach in clinical guidelines, extending beyond decision aids. However, the overall effect of SDM in women deciding to participate in breast cancer screening remains uncertain. OBJECTIVES: To assess the effect of SDM on women's satisfaction, confidence, and knowledge when deciding whether to participate in breast cancer screening. SEARCH METHODS: We searched the Cochrane Breast Cancer Group's Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform on 8 August 2023. We also screened abstracts from two relevant conferences from 2020 to 2023. SELECTION CRITERIA: We included parallel randomised controlled trials (RCTs) and cluster-RCTs assessing interventions targeting various components of SDM. The focus was on supporting women aged 40 to 75 at average or above-average risk of breast cancer in their decision to participate in breast cancer screening. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed studies for inclusion and conducted data extraction, risk of bias assessment, and GRADE assessment of the certainty of the evidence. Review outcomes included satisfaction with the decision-making process, confidence in the decision made, knowledge of all options, adherence to the chosen option, women's involvement in SDM, woman-clinician communication, and mental health. MAIN RESULTS: We identified 19 studies with 64,215 randomised women, mostly with an average to moderate risk of breast cancer. Two studies covered all aspects of SDM; six examined shortened forms of SDM involving communication on risks and personal values; and 11 focused on enhanced communication of risk without other SDM aspects. SDM involving all components compared to control The two eligible studies did not assess satisfaction with the SDM process or confidence in the decision. Based on a single study, SDM showed uncertain effects on participant knowledge regarding the age to start screening (risk ratio (RR) 1.18, 95% confidence interval (CI) 0.61 to 2.28; 133 women; very low certainty evidence) and frequency of testing (RR 0.84, 95% CI 0.68 to 1.04; 133 women; very low certainty evidence). Other review outcomes were not measured. Abbreviated forms of SDM with clarification of values and preferences compared to control Of the six included studies, none evaluated satisfaction with the SDM process. These interventions may reduce conflict in the decision made, based on two measures, Decisional Conflict Scale scores (mean difference (MD) -1.60, 95% CI -4.21 to 0.87; conflict scale from 0 to 100; 4 studies; 1714 women; very low certainty evidence) and the proportion of women with residual conflict compared to control at one to three months' follow-up (rate of women with a conflicted decision, RR 0.75, 95% CI 0.56 to 0.99; 1 study; 1001 women, very low certainty evidence). Knowledge of all options was assessed through knowledge scores and informed choice. The effect of SDM may enhance knowledge (MDs ranged from 0.47 to 1.44 higher scores on a scale from 0 to 10; 5 studies; 2114 women; low certainty evidence) and may lead to higher rates of informed choice (RR 1.24, 95% CI 0.95 to 1.63; 4 studies; 2449 women; low certainty evidence) compared to control at one to three months' follow-up. These interventions may result in little to no difference in anxiety (MD 0.54, 95% -0.96 to 2.14; scale from 20 to 80; 2 studies; 749 women; low certainty evidence) and the number of women with worries about cancer compared to control at four to six weeks' follow-up (RR 0.88, 95% CI 0.73 to 1.06; 1 study, 639 women; low certainty evidence). Other review outcomes were not measured. Enhanced communication about risks without other SDM aspects compared to control Of 11 studies, three did not report relevant outcomes for this review, and none assessed satisfaction with the SDM process. Confidence in the decision made was measured by decisional conflict and anticipated regret of participating in screening or not. These interventions, without addressing values and preferences, may result in lower confidence in the decision compared to regular communication strategies at two weeks' follow-up (MD 2.89, 95% CI -2.35 to 8.14; Decisional Conflict Scale from 0 to 100; 2 studies; 1191 women; low certainty evidence). They may result in higher anticipated regret if participating in screening (MD 0.28, 95% CI 0.15 to 0.41) and lower anticipated regret if not participating in screening (MD -0.28, 95% CI -0.42 to -0.14). These interventions increase knowledge (MD 1.14, 95% CI 0.61 to 1.62; scale from 0 to 10; 4 studies; 2510 women; high certainty evidence), while it is unclear if there is a higher rate of informed choice compared to regular communication strategies at two to four weeks' follow-up (RR 1.27, 95% CI 0.83 to 1.92; 2 studies; 1805 women; low certainty evidence). These interventions result in little to no difference in anxiety (MD 0.33, 95% CI -1.55 to 0.99; scale from 20 to 80) and depression (MD 0.02, 95% CI -0.41 to 0.45; scale from 0 to 21; 2 studies; 1193 women; high certainty evidence) and lower cancer worry compared to control (MD -0.17, 95% CI -0.26 to -0.08; scale from 1 to 4; 1 study; 838 women; high certainty evidence). Other review outcomes were not measured. AUTHORS' CONCLUSIONS: Studies using abbreviated forms of SDM and other forms of enhanced communications indicated improvements in knowledge and reduced decisional conflict. However, uncertainty remains about the effect of SDM on supporting women's decisions. Most studies did not evaluate outcomes considered important for this review topic, and those that did measured different concepts. High-quality randomised trials are needed to evaluate SDM in diverse cultural settings with a focus on outcomes such as women's satisfaction with choices aligned to their values.

Developing a breast cancer screening decision aid in Spanish for average-risk women: a mixed methods study.

Introduction: We aimed to develop a decision aid to support shared-decision making between physicians and women with average breast cancer risk when deciding whether to participate in breast cancer screening. Methods: We included women at average risk of breast cancer and physicians involved in supporting the decision of breast cancer screening from an Academic Hospital in Buenos Aires, Argentina. We followed the International Patient Decision Aid Standards to develop our decision aid. Guided by a steering group and a multidisciplinary consultancy group including a patient advocate, we reviewed the evidence about breast cancer screening and previous decision aids, explored the patients' information needs on this topic from the patients' and physicians' perspective using semi-structured interviews, and we alpha-tested the prototype to determine its usability, comprehensibility and applicability. Results: We developed the first prototype of a web-based decision aid to use during the clinical encounter with women aged 40 to 69 with average breast cancer risk. After a meeting with our consultancy group, we developed a second prototype that underwent alpha-testing. Physicians and patients agreed that the tool was clear, useful and applicable during a clinical encounter. We refined our final prototype according to their feedback. Conclusion: We developed the first decision aid in our region and language on this topic, developed with end-users' input and informed by the best available evidence. We expect this decision aid to help women and physicians make shared decisions during the clinical encounter when talking about breast cancer screening.

Developing a breast cancer screening decision aid in Spanish for average-risk women: a mixed methods study / Estudios originales Publicado el 14 de marzo de 2024 | http://doi.org/10.5867/medwave.2024.02.2726 Developing a breast cancer screening decision aid in Spanish for average-risk women: a mixed methods study Desarrollo de una herramienta en español para ayudar en la toma de decisiones del cribado de cáncer de mama para mujeres de riesgo promedio: un estudio de métodos mixtos

Introduction We aimed to develop a decision aid to support shared-decision making between physicians and women with average breast cancer risk when deciding whether to participate in breast cancer screening. Methods We included women at average risk of breast cancer and physicians involved in supporting the decision of breast cancer screening from an Academic Hospital in Buenos Aires, Argentina. We followed the International Patient Decision Aid Standards to develop our decision aid. Guided by a steering group and a multidisciplinary consultancy group including a patient advocate, we reviewed the evidence about breast cancer screening and previous decision aids, explored the patients' information needs on this topic from the patients' and physicians' perspective using semi-structured interviews, and we alpha-tested the prototype to determine its usability, comprehensibility and applicability. Results We developed the first prototype of a web-based decision aid to use during the clinical encounter with women aged 40 to 69 with average breast cancer risk. After a meeting with our consultancy group, we developed a second prototype that underwent alpha-testing. Physicians and patients agreed that the tool was clear, useful and applicable during a clinical encounter. We refined our final prototype according to their feedback. Conclusion We developed the first decision aid in our region and language on this topic, developed with end-users' input and informed by the best available evidence. We expect this decision aid to help women and physicians make shared decisions during the clinical encounter when talking about breast cancer screening.

Shared decision-making in Argentina in 2022.

Argentina is an upper-middle income country located in South America with an estimated population of 46.2 million inhabitants. There is no unified research agenda or government initiatives encouraging the implementation and research of Shared Decision-Making (SDM). Our working group at the Family and Community Medicine Division of the Hospital Italiano de Buenos Aires is the leading centre for research and implementation of SDM in the country. The implementation strategy is articulated in undergraduate, postgraduate and continuous medical education. However, it is challenged by the professionals' perception that they are already doing it or lack time during consultations. We have advanced research to understand how to adapt tools to measure and implement SDM in our settings. Still, we face additional challenges related to funding, accessing diverse populations beyond the reach of our institution and incorporating patients in the co-production of research. While most of our efforts arise from the voluntary work of our healthcare professionals, we believe this is a strength since SDM research and implementation are then directly linked to patient care.

Are shared decision making studies well enough described to be replicated? Secondary analysis of a Cochrane systematic review.

BACKGROUND: Interventions to change health professionals' behaviour are often difficult to replicate. Incomplete reporting is a key reason and a source of waste in health research. We aimed to assess the reporting of shared decision making (SDM) interventions. METHODS: We extracted data from a 2017 Cochrane systematic review whose aim was to determine the effectiveness of interventions to increase the use of SDM by healthcare professionals. In a secondary analysis, we used the 12 items of the Template for Intervention Description and Replication (TIDieR) checklist to analyze quantitative data. We used a conceptual framework for implementation fidelity to analyze qualitative data, which added details to various TIDieR items (e.g. under "what materials?" we also reported on ease of access to materials). We used SAS 9.4 for all analyses. RESULTS: Of the 87 studies included in the 2017 Cochrane review, 83 were randomized trials, three were non-randomized trials, and one was a controlled before-and-after study. Items most completely reported were: "brief name" (87/87, 100%), "why" (rationale) (86/87, 99%), and "what" (procedures) (81/87, 93%). The least completely reported items (under 50%) were "materials" (29/87, 33%), "who" (23/87, 26%), and "when and how much" (18/87, 21%), as well as the conditional items: "tailoring" (8/87, 9%), "modifications" (3/87, 4%), and "how well (actual)" (i.e. delivered as planned?) (3/87, 3%). Interventions targeting patients were better reported than those targeting health professionals or both patients and health professionals, e.g. 84% of patient-targeted intervention studies reported "How", (delivery modes), vs. 67% for those targeting health professionals and 32% for those targeting both. We also reported qualitative analyses for most items. Overall reporting of items for all interventions was 41.5%. CONCLUSIONS: Reporting on all groups or components of SDM interventions was incomplete in most SDM studies published up to 2017. Our results provide guidance for authors on what elements need better reporting to improve the replicability of their SDM interventions.

Patients benefit from mentoring students in an interprofessional health mentors program: A contextual-developmental analysis.

PURPOSE: Mentorship programs in health professional education are often characterized as a mutually beneficial relationship between mentor and mentee, but little is known about benefits for mentors. Mentors can be health professionals, academic faculty, other students (peers), and patients (health mentors). We studied the benefits that health mentors (people with chronic health conditions or disabilities, or a caregiver) get from mentoring students, and the contextual factors that contribute to, or explain these benefits. METHODS: We surveyed 72 health mentors who had mentored between one and eight cohorts of students from different health professions in the health mentors program at the University of British Columbia. Using a contextual-developmental framework of mentorship, we analyzed mentors' responses to open-ended questions about how they benefit from the program. RESULTS: Benefits fit into three categories: generativity (guiding the next generation), transformation (personal growth and reflection), and 'career' development (new activities resulting from increased self-efficacy). Contextual factors that contributed to benefits included the non-clinical setting, informality of meetings and reciprocal learning, and feeling valued by the program and students. CONCLUSIONS: Health mentors perceive benefits in passing on their lived experiences to students, leading to personal growth and new activities. Their perspectives offer unique insights into the workings of effective mentorship relationships. There is much to be learned about how benefits of mentoring are linked to program design.

Factores motivacionales que influyen sobre las mujeres en la realización de mamografías de tamizaje de cáncer de mama / Motivating Factors Influencing Women on Undergoing Mammograms for Breast Cancer Screening

INTRODUCCIÓN: La recomendación de tamizaje mamográfico de cáncer mamario se encuentra en discusión debido al riesgo de falsos positivos y de sobrediagnóstico. Algunas asociaciones científicas, que comenzaron a reevaluar su indicación, propician suministrar información e involucrar a las pacientes en la toma de decisión. OBJETIVOS: Comprender las motivaciones y opiniones de las mujeres a la hora de realizarse una mamografía de tamizaje. MÉTODOS: Se realizó un estudio cualitativo, con 16 entrevistas en profundidad a mujeres con una media de edad de 59 años, que estaban afiliadas a un seguro privado de salud de la ciudad de Buenos Aires. RESULTADOS: La motivación se construye en el marco de la creencia de que es mejor prevenir que curar, inscripta en una relación médicopaciente asimétrica a favor del saber médico y con una fuerte influencia de los medios de comunicación, que promueven los beneficios de la técnica e invisibilizan sus potenciales riesgos. CONCLUSIONES: Dado que muchas mujeres entrevistadas se mostraron interesadas en recibir información completa acerca del rastreo mamográfico, se sugiere mejorar el proceso de toma de decisiones de las prácticas preventivas de salud

Evidencia orientada al paciente: tratamiento de fracturas desplazadas de húmero proximal en adultos / Treatment of displaced fractures of the proximal humerus in adults

El tratamiento de fracturas desplazadas de húmero proximal puede realizarse de manera conservadora o quirúrgica. A partir de una viñeta clínica en la cual una señora adulta mayor tiene una fractura de húmero proximal por una caída de su propia altura se realizó una búsqueda bibliográfica que identificó una revisión sistemática Cochrane que compara ambas alternativas de tratamiento. Los resultados clínicos que resume esta revisión indican que el tratamiento quirúrgico no sería superior al tratamiento conservador y se asociaría a un número mayor de procedimientos quirúrgicos adicionales. (AU)

The treatment of displaced fracture of the proximal humerus can be managed surgically or conservatively. From a clinical vi-gnette in which an elderly woman suffers a proximal fracture of the humerus due to a fall from her own height, a bibliographic search was run and identified a Cochrane systematic review which compared both treatment options. The clinical results sum-marized in this review indicated that surgical treatment would not be superior to conservative management. Furthermore, surgi-cal treatment would be associated with a greater number of additional surgical procedures. (AU)