Shared Decision-Making in Cancer Screening

Shared decision-making in cancer screening is the process by which a clinician and a patient consider together whether to undertake a screening test, drawing on the best evidence about its benefits and harms and on the patient's own values and preferences. It is especially relevant when benefits and harms are closely balanced, as in several cancer screening decisions, so that there is no single right choice for everyone.

Definition

Shared decision-making is a collaborative process in which clinician and patient jointly make a health decision after discussing the options, the evidence on their benefits and harms, and the patient's preferences, used in screening when the balance of benefits and harms is close or value-dependent.

Scope

This topic covers what shared decision-making means, why it is invoked for preference-sensitive screening choices, and the role of evidence communication and decision aids in supporting it. It is a conceptual reference rather than a script for any particular consultation, and it gives no recommendation about whether an individual should be screened.

Core questions

• What distinguishes shared decision-making from simply informing a patient or from the clinician deciding alone?
• Which cancer screening decisions are preference-sensitive enough to call for shared decision-making?
• How can the benefits and harms of screening be communicated so that a patient's values can guide the choice?

Key concepts

• Preference-sensitive decisions
• Patient values and preferences
• Informed choice
• Decision aids
• Risk communication
• Balance of benefits and harms
• Equipoise in screening

Mechanisms

Shared decision-making treats a screening choice as a decision requiring at least two participants who exchange information and deliberate together: the clinician contributes evidence on the options and their benefits and harms, and the patient contributes the values by which those outcomes are weighed (Charles, 1997). Operational models describe stages such as introducing choice, describing options with their benefits and harms, and exploring the patient's preferences before reaching a decision, often supported by patient decision aids that present numerical risks in an understandable form (Elwyn, 2012). In screening, this matters when the net benefit is small or uncertain, so that whether to screen depends on how an individual weighs, for example, a reduction in cancer death against the chance of a false positive or of overdiagnosis.

Clinical relevance

Because several cancer screening decisions involve a close or value-dependent balance of benefits and harms, such as the trade-off between mortality benefit and overdiagnosis in breast screening, guideline bodies increasingly frame these as preference-sensitive and recommend shared decision-making (Marmot, 2012). This entry describes the concept and its rationale for reference; it does not advise any individual on whether to be screened.

History

The modern concept of shared decision-making was articulated in the 1990s, notably by Charles, Gafni and Whelan, who distinguished it from both paternalistic and purely informed models and emphasized that it requires participation by both clinician and patient (Charles, 1997). The approach was later elaborated into practical models and linked to patient decision aids (Elwyn, 2012), and was taken up in cancer screening as evidence on overdiagnosis and finely balanced benefits made the choice to screen increasingly recognized as preference-sensitive.

Debates

When should screening be a shared decision rather than a default recommendation?

For screening with a clear net benefit, a straightforward recommendation may suffice, whereas for finely balanced or value-dependent decisions shared decision-making is advocated; where the threshold lies, and how to support genuine deliberation within limited consultation time, remains debated.

Key figures

• Cathy Charles
• Amiram Gafni
• Glyn Elwyn

Seminal works

• charles-1997
• elwyn-2012

Frequently asked questions

Why is shared decision-making emphasized for cancer screening in particular?

Several screening decisions involve benefits and harms that are closely balanced or depend on personal values, such as weighing a possible reduction in cancer death against false positives or overdiagnosis; in these preference-sensitive situations there is no single right choice, so the patient's values should help guide the decision.

Is shared decision-making the same as informing the patient?

No; giving information is one part, but shared decision-making also requires that both clinician and patient deliberate together and that the patient's preferences are actively elicited and used in reaching the decision.