Does educational printed material manage to change compliance with prostate cancer screening?

Educational pamphlets for improving uptake of cancer screening: a systematic review

INTRODUCTION The effectiveness of cancer screening programmes is highly dependent on screening uptake. Many interventions have been tested to increase screening uptake. AIM The goal of this study was to evaluate the effectiveness of cancer screening pamphlets as a standalone intervention. The outcome of interest was uptake of cancer screening tests. METHODS A systematic review was performed on the effectiveness of pamphlets compared to usual care without pamphlets. We searched five databases for research papers in English from 2000 up to May 2019. Randomised controlled trials were included. This research group independently selected studies, extracted data, assessed risk of bias and then compared the information as a group. RESULTS A total of nine trials involving 4912 participants met our inclusion criteria, of which five were about colorectal cancer screening, three were about prostate cancer screening and one was about lung cancer screening. Five of the nine trials showed that pamphlets alone increased uptake significantly, while the remaining four trials did not show significant effects. DISCUSSION There is some evidence that pamphlets increase uptake for cancer screenings, especially for colorectal cancer. Due to the small number of studies in this area, generalisability could be limited.

Improving Health Screening Uptake in Men: A Systematic Review and Meta-analysis

CONTEXT

Globally, uptake of health screening in men remains low and the effectiveness of interventions to promote screening uptake in men is not well established. This review aimed to determine the effectiveness of interventions in improving men's uptake of and intention to undergo screening, including interventions using information and communication technology and a male-sensitive approach.

EVIDENCE ACQUISITION

Studies were sourced from five electronic databases (October 2015), experts, and references of included studies. This study included RCTs or cluster RCTs that recruited men and reported uptake of or intention to undergo screening. Two researchers independently performed study selection, appraisal, and data extraction. The interventions were grouped into those that increase uptake and those that promote informed decision making. They were further sub-analyzed according to types of intervention, male-sensitive, and web- and video-based interventions. The analysis was completed in December 2016.

EVIDENCE SYNTHESIS

This review included 58 studies. Most studies were on prostate cancer (k=31) and HIV (k=11) screening. Most of the studies had low methodologic quality (79.3%) and after excluding them from the analysis, one study found that educational intervention (which was also male-sensitive) was effective in improving men's intention to screen (risk ratio=1.36, 95% CI=1.23, 1.50, k=1) and partner educational intervention increased men's screening uptake (risk ratio=1.77, 95% CI=1.48, 2.12, k=1). Video-based educational interventions reduced prostate cancer screening uptake (risk ratio=0.89, 95%CI=0.80, 0.99, k=1) but web-based interventions did not change men's screening intention or uptake.

CONCLUSIONS

This review highlights the need to conduct more robust studies to provide conclusive evidence on the effectiveness of different interventions to improve men's screening behavior.

Informed decision making before prostate-specific antigen screening: Initial results using the American Cancer Society (ACS) Decision Aid (DA) among medically underserved men

BACKGROUND

The American Cancer Society (ACS) recommends men have the opportunity to make an informed decision about screening for prostate cancer (PCa). The ACS developed a unique decision aid (ACS-DA) for this purpose. However, to date, studies evaluating the efficacy of the ACS-DA are lacking. The authors evaluated the ACS-DA among a cohort of medically underserved men (MUM).

METHODS

A multiethnic cohort of MUM (n = 285) was prospectively included between June 2010 and December 2014. The ACS-DA was presented in a group format. Levels of knowledge on PCa were evaluated before and after the presentation. Participants' decisional conflict and thoughts about the presentation also were evaluated. Logistic regression analyses were performed to determine factors associated with having an adequate level of knowledge.

RESULTS

Before receiving the ACS-DA, 33.1% of participants had adequate knowledge on PCa, and this increased to 77% after the DA (P < .0001). On multivariate analysis, higher education level (odds ratio, 11.19; P = .001) and history of another cancer (odds ratio, 7.45; P = .03) were associated with having adequate knowledge after receiving the DA. Levels of decisional conflict were low and were correlated with levels of knowledge after receiving the DA. The majority of men also rated the presentation as favorable and would recommend the ACS-DA to others.

CONCLUSIONS

Use of the ACS-DA was feasible among MUM and led to increased PCa knowledge. This also correlated with low levels of decisional conflict. The ACS-DA presented to groups of men may serve as a feasible tool for informed decision making in a MUM population. Cancer 2017;123:583-591. © 2016 American Cancer Society.

Baseline Attitudes About Prostate Cancer Screening Moderate the Impact of Decision Aids on Screening Rates

BACKGROUND

The impact of decision aids on prostate cancer screening outcomes has been inconsistent.

PURPOSE

We assessed whether pre-existing attitudes moderated the impact of decision aids on screening.

METHODS

Men aged 45-70 (56.2% Caucasian, 39.9% African-American) were randomly assigned to a print decision aid (N = 630), a web decision aid (N = 631), or usual care (N = 632). Telephone interviews assessed pro/con screening attitudes and screening behaviors at baseline, 1-month and 13-months post-randomization.

RESULTS

Logistic regression analyses revealed significant arm by attitude interactions: Higher baseline cons scores predicted lower screening in the print (OR = 0.60 (95% CI: 0.40, 0.92)) and web (OR = 0.61 (95% CI: 0.40, 0.91)) arms but not in usual care (OR = 1.34 (95% CI: 0.90, 2.00)).

CONCLUSIONS

The decision aids amplified the impact of men's baseline attitudes about limitations of screening: Compared to the usual care arm, men in both decision aid arms were less likely to be screened when they perceived more limitations of screening.

Decision making in prostate cancer screening using decision aids vs usual care: a randomized clinical trial

IMPORTANCE

The conflicting recommendations for prostate cancer (PCa) screening and the mixed messages communicated to the public about screening effectiveness make it critical to assist men in making informed decisions.

OBJECTIVE

To assess the effectiveness of 2 decision aids in helping men make informed PCa screening decisions.

DESIGN, SETTING, AND PARTICIPANTS

A racially diverse group of male outpatients aged 45 to 70 years from 3 sites were interviewed by telephone at baseline, 1 month, and 13 months, from 2007 through 2011. We conducted intention-to-treat univariate analyses and multivariable linear and logistic regression analyses, adjusting for baseline outcome measures.

INTERVENTION

Random assignment to print-based decision aid (n = 628), web-based interactive decision aid (n = 625), or usual care (UC) (n = 626).

MAIN OUTCOMES AND MEASURES

Prostate cancer knowledge, decisional conflict, decisional satisfaction, and whether participants underwent PCa screening.

RESULTS

Of 4794 eligible men approached, 1893 were randomized. At each follow-up assessment, univariate and multivariable analyses indicated that both decision aids resulted in significantly improved PCa knowledge and reduced decisional conflict compared with UC (all P <.001). At 1 month, the standardized mean difference (Cohen’s d) in knowledge for the web group vs UC was 0.74, and in the print group vs UC, 0.73. Decisional conflict was significantly lower for web vs UC (d = 0.33) and print vs UC (d = 0.36). At 13 months, these differences were smaller but remained significant. At 1 month, high satisfaction was reported by significantly more print (60.4%) than web participants (52.2%; P = .009) and significantly more web (P = .001) and print (P = .03) than UC participants (45.5%). At 13 months, differences in the proportion reporting high satisfaction among print (55.7%) compared with UC (49.8%; P = .06) and web participants (50.4%; P = .10) were not significant. Screening rates at 13 months did not differ significantly among groups.

CONCLUSIONS AND RELEVANCE

Both decision aids improved participants’ informed decision making about PCa screening up to 13 months later but did not affect actual screening rates. Dissemination of these decision aids may be a valuable public health tool.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00196807.

Fostering informed decisions: a randomized controlled trial assessing the impact of a decision aid among men registered to undergo mass screening for prostate cancer

OBJECTIVE

Screening asymptomatic men for prostate cancer is controversial and informed decision making is recommended. Within two prostate cancer screening programs, we evaluated the impact of a print-based decision aid (DA) on decision-making outcomes.

METHODS

Men (N=543) were 54.9 (SD=8.1) years old and 61% were African-American. The 2(booklet type: DA vs. usual care (UC))× 2(delivery mode: Home vs. Clinic) randomized controlled trial assessed decisional and screening outcomes at baseline, 2-months, and 13-months.

RESULTS

Intention-to-treat linear regression analyses using generalized estimating equations revealed that DA participants reported improved knowledge relative to UC (B=.41, p<.05). For decisional conflict, per-protocol analyses revealed a group by time interaction (B=-.69, p<.05), indicating that DA participants were less likely to report decisional conflict at 2-months compared to UC participants (OR=.49, 95% CI: .26-.91, p<.05).

CONCLUSION

This is the first randomized trial to evaluate a DA in the context of free mass screening, a challenging setting in which to make an informed decision. The DA was highly utilized by participants, improved knowledge and reduced decisional conflict.

PRACTICE IMPLICATIONS

These results are valuable in understanding ways to improve the decisions of men who seek screening and can be easily implemented within many settings.

Screening for prostate cancer

BACKGROUND

Any form of screening aims to reduce disease-specific and overall mortality, and to improve a person's future quality of life. Screening for prostate cancer has generated considerable debate within the medical and broader community, as demonstrated by the varying recommendations made by medical organizations and governed by national policies. To better inform individual patient decision-making and health policy decisions, we need to consider the entire body of data from randomised controlled trials (RCTs) on prostate cancer screening summarised in a systematic review. In 2006, our Cochrane review identified insufficient evidence to either support or refute the use of routine mass, selective, or opportunistic screening for prostate cancer. An update of the review in 2010 included three additional trials. Meta-analysis of the five studies included in the 2010 review concluded that screening did not significantly reduce prostate cancer-specific mortality. In the past two years, several updates to studies included in the 2010 review have been published thereby providing the rationale for this update of the 2010 systematic review.

OBJECTIVES

To determine whether screening for prostate cancer reduces prostate cancer-specific mortality or all-cause mortality and to assess its impact on quality of life and adverse events.

SEARCH METHODS

An updated search of electronic databases (PROSTATE register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CANCERLIT, and the NHS EED) was performed, in addition to handsearching of specific journals and bibliographies, in an effort to identify both published and unpublished trials.

SELECTION CRITERIA

All RCTs of screening versus no screening for prostate cancer were eligible for inclusion in this review.

DATA COLLECTION AND ANALYSIS

The original search (2006) identified 99 potentially relevant articles that were selected for full-text review. From these citations, two RCTs were identified as meeting the inclusion criteria. The search for the 2010 version of the review identified a further 106 potentially relevant articles, from which three new RCTs were included in the review. A total of 31 articles were retrieved for full-text examination based on the updated search in 2012. Updated data on three studies were included in this review. Data from the trials were independently extracted by two authors.

MAIN RESULTS

Five RCTs with a total of 341,342 participants were included in this review. All involved prostate-specific antigen (PSA) testing, with or without digital rectal examination (DRE), though the interval and threshold for further evaluation varied across trials. The age of participants ranged from 45 to 80 years and duration of follow-up from 7 to 20 years. Our meta-analysis of the five included studies indicated no statistically significant difference in prostate cancer-specific mortality between men randomised to the screening and control groups (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.86 to 1.17). The methodological quality of three of the studies was assessed as posing a high risk of bias. The European Randomized Study of Screening for Prostate Cancer (ERSPC) and the US Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial were assessed as posing a low risk of bias, but provided contradicting results. The ERSPC study reported a significant reduction in prostate cancer-specific mortality (RR 0.84, 95% CI 0.73 to 0.95), whilst the PLCO study concluded no significant benefit (RR 1.15, 95% CI 0.86 to 1.54). The ERSPC was the only study of the five included in this review that reported a significant reduction in prostate cancer-specific mortality, in a pre-specified subgroup of men aged 55 to 69 years of age. Sensitivity analysis for overall risk of bias indicated no significant difference in prostate cancer-specific mortality when referring to the meta analysis of only the ERSPC and PLCO trial data (RR 0.96, 95% CI 0.70 to 1.30). Subgroup analyses indicated that prostate cancer-specific mortality was not affected by the age at which participants were screened. Meta-analysis of four studies investigating all-cause mortality did not determine any significant differences between men randomised to screening or control (RR 1.00, 95% CI 0.96 to 1.03). A diagnosis of prostate cancer was significantly greater in men randomised to screening compared to those randomised to control (RR 1.30, 95% CI 1.02 to 1.65). Localised prostate cancer was more commonly diagnosed in men randomised to screening (RR 1.79, 95% CI 1.19 to 2.70), whilst the proportion of men diagnosed with advanced prostate cancer was significantly lower in the screening group compared to the men serving as controls (RR 0.80, 95% CI 0.73 to 0.87). Screening resulted in a range of harms that can be considered minor to major in severity and duration. Common minor harms from screening include bleeding, bruising and short-term anxiety. Common major harms include overdiagnosis and overtreatment, including infection, blood loss requiring transfusion, pneumonia, erectile dysfunction, and incontinence. Harms of screening included false-positive results for the PSA test and overdiagnosis (up to 50% in the ERSPC study). Adverse events associated with transrectal ultrasound (TRUS)-guided biopsies included infection, bleeding and pain. No deaths were attributed to any biopsy procedure. None of the studies provided detailed assessment of the effect of screening on quality of life or provided a comprehensive assessment of resource utilization associated with screening (although preliminary analyses were reported).

AUTHORS' CONCLUSIONS

Prostate cancer screening did not significantly decrease prostate cancer-specific mortality in a combined meta-analysis of five RCTs. Only one study (ERSPC) reported a 21% significant reduction of prostate cancer-specific mortality in a pre-specified subgroup of men aged 55 to 69 years. Pooled data currently demonstrates no significant reduction in prostate cancer-specific and overall mortality. Harms associated with PSA-based screening and subsequent diagnostic evaluations are frequent, and moderate in severity. Overdiagnosis and overtreatment are common and are associated with treatment-related harms. Men should be informed of this and the demonstrated adverse effects when they are deciding whether or not to undertake screening for prostate cancer. Any reduction in prostate cancer-specific mortality may take up to 10 years to accrue; therefore, men who have a life expectancy less than 10 to 15 years should be informed that screening for prostate cancer is unlikely to be beneficial. No studies examined the independent role of screening by DRE.

Characteristics of Educational Leaflets that Attract Pregnant Women

Background

Many health service sectors produce leaflets for health education, but specific issues such as their overall content and design (layout, graphics, illustrations) are seldom discussed. Important features contributing to the effectiveness of any leaflet is the extent to which it is read by its target audience. The purpose of this study was to examine the acceptability of two different leaflets on abstinence from alcohol during pregnancy.

Methods

Four semistructured group discussions were conducted among 33 pregnant women. They were asked if they would take, read, and save the leaflets, and to give a reason for their decision. The reasons were discussed according to the components of the leaflet, including its front cover, content, and illustrations.

Results

The design of a leaflet's front cover plays a key role in attracting pregnant women, and, in the event that readers are interested in the topic, they prefer a leaflet with detailed content, and a real-life example, eg, a photograph of a child with fetal alcohol syndrome.

Conclusion

Positive key characteristics should be incorporated into educational leaflets to enhance the attention given to the material by pregnant women, as well as to facilitate retention of the information.

Collaborative quality improvement to manage pain in acute care hospitals

OBJECTIVE

Collaborative quality improvement programs have been successfully used to manage chronic diseases in adults and acute lung complications in premature infants. Their effectiveness to improve pain management in acute care hospitals is currently unknown. The purpose of this study was to determine whether a collaborative quality improvement program implemented at hospital level could improve pain management and overall pain relief.

DESIGN

To assess the effectiveness of the program, we performed a before-after trial comparing patient's self-reported pain management and experience before and after program implementation. We included all adult patients hospitalized for more than 24 hours and discharged either to their home or to a nursing facility, between March 1, 2001 and March 31, 2001 (before program implementation) and between September 15, 2005 and October 15, 2005 (after program implementation).

SETTING

A teaching hospital of 2,096 beds in Geneva, Switzerland.

PATIENTS

All adult patients hospitalized for more than 24 hours and discharged between 1 to 31 March 2001 (before program) and 15 September to 15 October 2005 (after program implementation).

INTERVENTIONS

Implementation of a collaborative quality improvement program using multifaceted interventions (staff education, opinion leaders, patient education, audit, and feedback) to improve pain management at hospital level.

OUTCOME MEASURES

Patient-reported pain experience, pain management, and overall hospital experience based on the Picker Patient Experience questionnaire, perceived health (SF-36 Health survey).

RESULTS

After implementation of the program only 2.3% of the patients reported having no pain relief during their hospital stay (vs 4.5% in 2001, P=0.05). Among nonsurgical patients, improvements were observed for pain assessment (42.3% vs 27.9% of the patients had pain intensity measured with a visual analog scale, P=0.012), pain management (staff did everything they could to help in 78.9% vs 67.9% of cases P=0.003), and pain relief (70.4% vs 57.3% of patients reported full pain relief P=0.008). In surgical patients, pain assessment also improved (53.7.3% vs 37.6%) as well as pain treatment. More patients received treatments to relieve pain regularly or intermittently after program implementation (95.1% vs 91.9% P=0.046).

CONCLUSION

Implementation of a collaborative quality improvement program at hospital level improved both pain management and pain relief in patients. Further studies are needed to determine the overall cost-effectiveness of such programs.

The development of a web- and a print-based decision aid for prostate cancer screening

BACKGROUND

Whether early detection and treatment of prostate cancer (PCa) will reduce disease-related mortality remains uncertain. As a result, tools are needed to facilitate informed decision making. While there have been several decision aids (DAs) developed and tested, very few have included an exercise to help men clarify their values and preferences about PCa screening. Further, only one DA has utilized an interactive web-based format, which allows for an expansion and customization of the material. We describe the development of two DAs, a booklet and an interactive website, each with a values clarification component and designed for use in diverse settings.

METHODS

We conducted two feasibility studies to assess men's (45-70 years) Internet access and their willingness to use a web- vs. a print-based tool. The booklet was adapted from two previous versions evaluated in randomized controlled trials (RCTs) and the website was created to closely match the content of the revised booklet. Usability testing was conducted to obtain feedback regarding draft versions of the materials. The tools were also reviewed by a plain language expert and the interdisciplinary research team. Feedback on the content and presentation led to iterative modifications of the tools.

RESULTS

The feasibility studies confirmed that the Internet was a viable medium, as the majority of men used a computer, had access to the Internet, and Internet use increased over time. Feedback from the usability testing on the length, presentation, and content of the materials was incorporated into the final versions of the booklet and website. Both the feasibility studies and the usability testing highlighted the need to address men's informed decision making regarding screening.

CONCLUSIONS

Informed decision making for PCa screening is crucial at present and may be important for some time, particularly if a definitive recommendation either for or against screening does not emerge from ongoing prostate cancer screening trials. We have detailed our efforts at developing print- and web-based DAs to assist men in determining how to best meet their PCa screening preferences. Following completion of our ongoing RCT designed to test these materials, our goal will be to develop a dissemination project for the more effective tool.

TRIAL REGISTRATION

NCT00623090.

Screening for prostate cancer

BACKGROUND

Any form of screening aims to reduce mortality and increase a person's quality of life. Screening for prostate cancer has generated considerable debate within the medical community, as demonstrated by the varying recommendations made by medical organizations and governed by national policies. Much of this debate is due to the limited availability of high quality research and the influence of false-positive or false-negative results generated by use of the diagnostic techniques such as the digital rectal examination (DRE) and prostate specific antigen (PSA) blood test.

OBJECTIVES

To determine whether screening for prostate cancer reduces prostate cancer mortality and has an impact on quality of life.

SEARCH STRATEGY

Electronic databases (PROSTATE register, CENTRAL the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CANCERLIT and the NHS EED) were searched electronically in addition to hand searching of specific journals and bibliographies in an effort to identify both published and unpublished trials.

SELECTION CRITERIA

All randomised controlled trials of screening versus no screening or routine care for prostate cancer were eligible for inclusion in this review.

DATA COLLECTION AND ANALYSIS

The search identified 99 potentially relevant articles that were selected for full text review. From these 99 citations, two randomised controlled trials were identified as meeting the review's inclusion criteria. Data from the trials were independently extracted by two authors.

MAIN RESULTS

Two randomised controlled trials with a total of 55,512 participants were included; however, both trials had methodological weaknesses. Re-analysis using intention-to-screen and meta-analysis of results from the two randomised controlled trials indicated no statistically significant difference in prostate cancer mortality between men randomised for prostate cancer screening and controls (RR 1.01, 95% CI: 0.80-1.29). Neither study assessed the effect of prostate cancer screening on quality of life, all-cause mortality or cost effectiveness.

AUTHORS' CONCLUSIONS

Given that only two randomised controlled trials were included, and the high risk of bias of both trials, there is insufficient evidence to either support or refute the routine use of mass, selective or opportunistic screening compared to no screening for reducing prostate cancer mortality. Currently, no robust evidence from randomised controlled trials is available regarding the impact of screening on quality of life, harms of screening, or its economic value. Results from two ongoing large scale multicentre randomised controlled trials that will be available in the next several years are required to make evidence-based decisions regarding prostate cancer screening.