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Evidence-based Practice Center Systematic Review Protocol Project Title: Decision support tools for screening and treatment decisions in early cancer I. Background and Objectives for the Systematic Review Complex Decisions and Decision Support Tools for Health Care Consumers

Some health care decisions do not have an obvious “optimal choice.” For example, while it is clear that a person with a ruptured appendix must have immediate surgery or that someone with bacterial pneumonia must receive antibiotics, it is not clear whether a 55-year-old man with a localized low-grade prostatic malignancy should opt for treatments that remove or destroy the cancer, for active surveillance, or for watchful waiting. In the examples with a clear “optimal” choice, the likelihood of death or very serious complications is much smaller with the optimal treatment, and the benefits of the intervention outweigh the risks for most if not all patients. In the case of conditions for which there is not an optimal treatment choice, such as localized lowgrade prostate cancer, the difference in the expected survival or other serious health outcomes between the available options is small enough for other considerations to take the forefront. For example, choosing to remove or destroy a low-grade prostatic malignancy can lead to complications, such as urinary or bowel incontinence and sexual dysfunction, while choosing active surveillance can cause anxiety about not treating the condition, inconvenience associated with regular testing, and a higher risk of disease progression. Individual patients and those close to them place different values on these outcomes and can therefore have different assessments of the balance of benefits and harms associated with each option. In other words, no universally “optimal” choice exists; the “optimal” choice is the one that best corresponds to the values of the health care consumer facing the decision. Decision support tools (DSTs) are designed to aid health care consumers facing complex decisions. They are not meant to replace health care providers but to supplement the consumerprovider interaction and promote shared decisionmaking. 2 DSTs may include brochures, audiovisual materials, educational sessions, counseling sessions, computer programs, interactive Web sites or media, or combinations thereof. They may be used to prepare the health care consumer for a consultation with the provider or during the consultation between the consumer and the provider. According to the International Patient Decision Aids Standards (IPDAS) Collaboration, a DST aims to improve the quality of decisions, that is, the extent to which the choices of health care consumers are congruent with their informed and considered values in the presence of uncertainty.