Article Text

Download PDFPDF

Assessment of the effects of decision aids about breast cancer screening: a systematic review and meta-analysis
  1. Montserrat Martínez-Alonso1,2,
  2. Misericòrdia Carles-Lavila2,3,4,
  3. Maria José Pérez-Lacasta2,3,
  4. Anna Pons-Rodríguez5,
  5. Montse Garcia6,
  6. Montserrat Rué1,2,3,7
  7. on behalf of the InforMa Group
  1. 1 Department of Basic Medical Sciences, University of Lleida-IRBLLEIDA, Lleida, Spain
  2. 2 Research Group on Economic Evaluation and Health (GRAES), Reus, Spain
  3. 3 Department of Economics, University Rovira i Virgili, Reus, Spain
  4. 4 Research Centre on Industrial and Public Economics (CREIP), Reus, Spain
  5. 5 Lleida Biomedical Research Institute (IRBLLEIDA), Lleida, Spain
  6. 6 Cancer Prevention and Control Program, Catalan Institute of Oncology-IDIBELL, L’Hospitalet de Llobregat, Spain
  7. 7 Health Services Research on Chronic Patients Network (REDISSEC), Madrid, Spain
  1. Correspondence to Professor Montserrat Rué; montse.rue{at}


Objective The aim of this systematic review and meta-analysis of randomised controlled trials (RCTs) and observational studies is to assess the effect of decision aids (DAs) in women aged 50 and below facing the decision to be screened for breast cancer.

Setting Screening for breast cancer.

Intervention DAs aimed to help women make a deliberative choice regarding participation in mammography screening by providing information on the options and outcomes.

Eligible studies We included published original, non-pilot, studies that assess the effect of DAs for breast cancer screening. We excluded the studies that evaluated only participation intention or actual uptake. The studies’ risk of bias was assessed with the Cochrane Collaboration’s tool for RCTs and the National Institutes of Health Quality Assessment Tool for non-RCTs.

Primary and secondary outcomes The main outcome measures were informed choice, decisional conflict and/or confidence, and knowledge. Secondary outcomes were values, attitudes, uncertainty and intention to be screened.

Results A total of 607 studies were identified, but only 3 RCTs and 1 before-after study were selected. The use of DAs increased the proportion of women making an informed decision by 14%, 95% CI (2% to 27%) and the proportion of women with adequate knowledge by 12%, 95% CI (7% to 16%). We observed heterogeneity among the studies in confidence in the decision. The meta-analysis of the RCTs showed a significant decrease in confidence in the decision and in intention to be screened.

Conclusions Tools to aid decision making in screening for breast cancer improve knowledge and promote informed decision; however, we found divergent results on decisional conflict and confidence in the decision. Under the current paradigm change, which favours informed choice rather than maximising uptake, more research is necessary for the improvement of DAs.

  • breast cancer
  • decision aid
  • mammography
  • screening
  • shared decision making

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

View Full Text

Statistics from


  • Contributors MMA, MCL and MR designed the study. All authors contributed towards the execution of the study. MMA provided methodological expertise in systematic reviews and searching strategies. The selection and risk of bias assessment of each study was independently conducted in pairs by four reviewers (MCL, MJPL, MMA and MR). APR contributed to extracting the information of the identified studies and assessing the inclusion criteria. MMA and MR wrote the first draft with guidance and contributions from MCL, MJPL and MG. All authors read, provided critical feedback and approved the final manuscript.

  • Funding This study was supported by the research grant ‘Women participation in decisions and strategies on early detection of breast cancer’ (PI14/00113) from the Instituto de Salud Carlos III and cofunded by Fondo Europeo de Desarrollo Regional (FEDER) ‘Una manera de hacer Europa’. APR received a grant for PhD students from the Lleida Biomedical Research Institute (IRBLLEIDA). All authors declare funding from the Spanish Ministry of Health and the Biomedical Research Institute of Lleida (IRBLLEIDA).

  • Competing interests None declared.

  • Ethics approval The study was approved by the Ethics Committee of the Hospital Universitari Arnau de Vilanova in the city of Lleida (Spain).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement No additional data available.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.