Decision making

Do decision aids improve the understanding of the risk of infertility, fertility preservation options and improve the quality of decision making by people with cancer?

There is a growing body of evidence to suggest that decision aids (DAs) for cancer patients demonstrate significantly increased fertility preservation knowledge and decreased decisional conflict for patients.^[1] A randomised controlled trial of a DA developed in Switzerland found that women who used the online DA in addition to counselling experienced significantly lower decisional conflict compared to the control group who only received counselling.^[2] Similarly, women with newly diagnosed early-stage breast cancer who received a fertility-related decision aid, experienced reduced decisional conflict, decisional regret and improved knowledge of the impact of cancer on fertility.^[3] A pilot study of an interactive, computerised educational tool called Banking on Fatherhood found that patients who viewed the tool had significantly less decisional conflict about banking sperm than those who had not.^[4]

However, in some situations a DA may increase decisional conflict. A small randomised controlled trial comparing women who received brochures to others who completed the DA found that both approaches increased patient’s knowledge of fertility preservation, however the DA seemed to introduce slightly more decisional conflict.^[5] Further research is needed to explain why this occurred. Another challenge with the use of decision aids is that they are generally unable to provide personalised information about the risk of infertility after cancer treatment, due to the lack of evidence of the impact of specific treatments on fertility.

Decision support is not just for people with cancer. A small study of thirty-nine clinicians found that a fertility clinician decision support system would be beneficial to clinical practice.^[6] An online tool developed for patients also increased the knowledge of clinicians who viewed it.^[4] One group used medical illustrations and infographics in an electronic decision aid for parents of children and adolescents diagnosed with cancer. A pilot study suggests that the DA did not increase parental concern and would be useful for parents making a fertility preservation decision.^[7]

While there are a number of randomised clinical trials evaluating decision aids^[2][5][4] due to the difficulty in blinding the studies means that the risk of bias in these studies is high. More studies with larger numbers of patients and, if possible, blinding patients to allocation are needed to confirm that decision aids reduce decisional conflict for cancer patients.

However, there is a large body of evidence to show that health DAs developed using the Ottawa model results in improved decision-making outcomes.^[8] While more oncofertility studies are needed to provide evidence to inform implementation (especially in the young adolescents and children) it is quite clear that in principle DAs are effective in improving decision making. The Australian Commission on Safety and Quality in Health Care promotes the use of decision support tools by consumers to improve knowledge of benefits and harms and to support consumers when making decisions.

Evidence-based recommendation	Grade
The use of decision support tools, such as fertility preservation decision aids, should be offered where available as they may assist people with cancer with the decision-making process.	A