Briefly describe a specific question, or set of related questions, about a health care test or treatment that this program should consider.

What is the comparative effectiveness of using versus not using clinical decision support tools to select immediate treatment versus observation and improve net health outcomes for patients with premalignancies (e.g., ductal carcinoma in situ (DCIS)) or very early-stage malignancies (e.g., indolent non-Hodgkin lymphoma when initially diagnosed and with low tumor burden, low-risk early prostate cancer)?

Which types of decision support tools are most effective, and what is the best way to use them (e.g., viewed by patient alone, shared decision-making)?

What is known about how patients and their physicians choose between management strategies for premalignancies (e.g., DCIS) or very early-stage malignancies (e.g., indolent non-Hodgkin lymphoma when initially diagnosed and with low tumor burden, low-risk early prostate cancer)?

[NOTE: These last two questions were added to the original question to broaden the scope of the comparative effectiveness review and help inform future decision support.]

Does your question include a comparison of different health care approaches? (If no, your topic will still be considered.)

yes

If yes, explain the specific technologies, devices, drugs, or interventions you would like to see compared:

Comparing using versus not using different types of decision support tools and various ways of using them for patients making treatment decisions on premalignancies or very early-stage malignancies where there is controversy on recommendations and the potential for overtreatment.

What patients or group(s) of patients does your question apply to? (Please include specific details such as age range, gender, coexisting diagnoses, and indications for therapy.)

Patients with premalignancies (e.g., DCIS) or very early-stage malignancies (e.g., indolent non-Hodgkin lymphoma when initially diagnosed and with low tumor burden, low-risk early prostate cancer) where there is disagreement on treatment recommendations and the potential for overtreatment exists.

Are there subgroups of patients that your question might apply to? (For example, an ethnic group, stage or severity of a disease.)

Already indicated above; generally, premalignancy or early stage disease where the most effective treatment is unclear or there are tradeoffs where patient preferences may play an important role. Other subgroups may be identified by level of education; socioeconomic status; involvement of primary care physician in decision-making; type(s) of specialists consulted (medical, surgical, or radiation oncologist; urologist; gynecologic oncologist; hematologist, etc); whether consulted single specialist versus multidisciplinary team.

Describe the health-related benefits you are interested in. (For example, improvements in patient symptoms or problems from treatment or diagnosis.)

Improved confidence in treatment decision, greater patient satisfaction, improved

quality of life.

Describe any health-related risks, side effects, or harms that you are concerned about.

Increased anxiety about treatment decision, less patient satisfaction, reduced quality of

life.

Appropriateness for EHC Program

Does your question include a health care drug, intervention, device, or technology available (or likely to be available) in the U.S.?

yes

Which priority area(s) and population(s) does this topic apply to? (check all that apply)

EHC Priority Conditions (updated in 2008)

• Cancer

AHRQ Priority Populations

• Low income groups
• Minority groups
• Women
• Elderly

Federal Health Care Program

• Medicaid
• Medicare

Importance

Describe why this topic is important.

For some time now, patients and their advocates have stressed the need to involve patients in treatment decision-making, particularly in cases where there are tradeoffs between potential benefits and harms or between different types of harms. Yet it appears that there is often a gap between the goal of including patients and actual practice. For example, a recent article on patients with newly diagnosed localized prostate cancer found that the main predictor of treatment selection was the specialty of the physician (e.g., urologist versus radiation oncologist; Jang et al. 2010). The impact of decision support tools, and which approaches for their design and use are most effective, warrants further examination. A systematic review and CER will provide an examination of the current state of the art.

Jang TL, Bekelman JE, Liu Y, et al. Physician visits prior to treatment for clinically localized prostate cancer. Arch Intern Med 2010; 170:440-449.

What specifically motivated you to ask this question? (For example, you are developing a clinical guideline, working with a policy with large uncertainty about the appropriate approach, costly intervention, new research you have read, items in the media you may have seen, a clinical practice dilemma you know of, etc.)

This topic was assigned a high priority by a multi-disciplinary stakeholder panel (including patient advocates/representatives) convened to identify and select research questions on cancer of importance for systematic review. It is also of particular interest to patient advocacy groups and to employers.

Does your question represent uncertainty for clinicians and/or policy-makers? (For example, variations in clinical care, controversy in what constitutes appropriate clinical care, or a policy decision.)

yes

If yes, please explain:

Although decision support tools have been developed for a number of years, uncertainty remains on which are the best approaches to use and how best to incorporate them into clinical practice.

Potential Impact

How will an answer to your research question be used or help inform decisions for you or your group?

A report would inform clinical decision-making for patients, payers and providers.

Describe the timeframe in which an answer to your question is needed.

Describe any health disparities, inequities, or impact on vulnerable populations your question applies to.

Providing useful information to patients is more difficult when patients have lower literacy and numeracy. Whether these characteristics are more commonly found in certain communities or whether there are cultural differences in preferences and trust in the source of information, etc., must also be taken into account.

Nominator Information

Other Information About You: (optional)

Please choose a description that best describes your role or perspective: (you may select more than one category if appropriate)

A report would inform clinical decision-making for patients, payers and providers.

Are you making a suggestion as an individual or on behalf of an organization?

Organization

Please tell us how you heard about the Effective Health Care Program

The BlueCross BlueShield Association Technology Evaluation Center is an Evidence-based Practice Center of AHRQ.