JMIR Publications

ABSTRACT

Background:

The ‘online’ nature of decision aids (DAs) or related e–tools helping women’s decision to undergo breast cancer screening (BCS) by mammography, may facilitate wider access and therefore interesting to be implemented within BCS programs.

Objective:

We conducted a systematic review and meta-analysis to assess the scientific evidence on the impacts of those e–tools and to provide a comprehensive assessment of factors associated with their greater utility and efficacy.

Methods:

We followed the 2020 PRISMA guidelines. We searched Medline, PsycINFO, Embase, CINAHL and Web of Science databases from August 2010 to April 2023. We included papers reporting study populations at average–risk–of–breast–cancer, using DA or related e–tool and assessing as primary or secondary outcomes women’s participation in BCS by mammography and/or other main cognitive determinants of decision–making. We conducted meta-analyses of the identified RCTs assessed with the revised Cochrane–risk–of–bias–2–for–randomized-trials (Rob2) instrument. Intermediate-and-high-heterogeneity between studies was further explored to strengthen the validity of our results.

Results:

In total, 22 different e–tools were identified through 31 papers. The tailoring degree of e–tools, with the e–tool being fully tailored or features-with-tailoring, appeared to be the most influential in women’s decision–making–about–BCS. Compared with the control groups, tailored e–tools did increase women’s participation in BCS assessed at long term (RR 1.14, 95% CI 1.07-1.23, P<.001, I2 0%). Tailored to breast–cancer–risk e–tools increased women’s level of worry (MD 0.31, 95% CI 0.13-0.48, P<.001, I2 0%). E–tools increased women adequate knowledge of BCS, with features–with–tailoring e–tools designed and tested with the general population being more effective than tailored e–tools designed for/tested with non-BCS-participants. Features–with–tailoring e–tools did increase the rate of women who intended not to undergo BCS (RR 1.88, 95% CI 1.43-2.48, p<0.001, I2 0%) and who had made an informed choice about intention to undergo BCS (RR 1.60, 95% CI 1.09-2.33 P=.02, I2 91%), and decreased the proportion of women with decision conflict (RR 0.77, 95% CI 0.65-0.91, P=.002, I2 0%). Shared–decision–making was not formally evaluated. This review is limited by the low samples size including a few studies in the meta-analysis with some of high risk of bias, and high heterogeneity between the studies and e–tools.

Conclusions:

Features–with–tailoring e–tools could potentially negatively impact BCS program by driving negative intention and attitudes towards BCS participation. Tailored–to–risk e–tools would increase women’s participation in BCS but also women’s worry. To maximize effects of e–tools while minimizing potential negative impacts, we advocate for e–tools using a layered ‘on demand’ approach. PROSPERO registration number: CRD42020164479