Use of patient decision aids increased younger women’s reluctance to begin screening mammography: a systematic review and meta-analysis

  • Ilya Ivlev
  • Erin N. Hickman
  • Marian S. McDonagh
  • Karen B. Eden
Review Paper

DOI: 10.1007/s11606-017-4027-9

Cite this article as:
Ivlev, I., Hickman, E.N., McDonagh, M.S. et al. J GEN INTERN MED (2017). doi:10.1007/s11606-017-4027-9



As breast cancer screening guidelines have changed recently, additional investigation is needed to understand changes in women’s behavior after using breast cancer screening patient decision aids (BCS-PtDAs) and the potential effect on mammography utilization. This systematic review and meta-analysis sought to evaluate the effect of BCS-PtDAs on changes in women’s intentions to undergo screening mammography and whether women deciding to begin or discontinue screening mammography displayed similar changes in screening intentions after using a BCS-PtDA.


We searched Medline, Scopus, PsycINFO, CENTRAL, Health and Psychosocial Instruments, Health Technology Assessment Database, PsycARTICLES, and cited references in eligible papers for randomized controlled trials (RCTs) and observational studies, published through August 24, 2016. The proportions of women who did and not intend to undergo screening and who were uncertain about undergoing screening mammography were pooled, using risk ratios (RR) and random effects. According to the protocol, RCTs or observational studies and any language were considered eligible for systematic review if they included data about women for which shared decision making is recommended.


We ultimately included six studies with screening intention data for 2040 women. Compared to usual care, the use of BCS-PtDAs in three RCTs resulted in significantly more women deciding not to undergo screening mammography (RR 1.48 [95% CI 1.04–2.13]; P = 0.03), particularly for younger (38–50 years) women (1.77 [1.34-2.34]; P < 0.001). The use of BCS-PtDAs had a non-significant effect on the intentions of older women (69–89 years) to discontinue screening.


The use of BCS-PtDAs increased younger women’s reluctance to undergo screening for breast cancer. The implementation of such BCS-PtDAs in clinical practice would be expected to result in a 77% increase in the number of younger women (aged 38–50) who do not intend to be screened, and as a consequence, may reduce utilization of screening mammography.


The protocol of this review is registered in the PROSPERO database, #CRD42016036695.


breast cancer screening mammography decision support techniques patient decision aid intention utilization of screening mammography 



breast cancer screening patient decision aid


Cochrane Central Register of Controlled Trials


International Patient Decision Aid Standards


key question


patient decision aid


randomized controlled trial


risk ratio

Supplementary material

11606_2017_4027_MOESM1_ESM.docx (2.3 mb)
ESM 1(DOCX 2366 kb)

Copyright information

© Society of General Internal Medicine 2017

Authors and Affiliations

  • Ilya Ivlev
    • 1
  • Erin N. Hickman
    • 1
  • Marian S. McDonagh
    • 1
    • 2
  • Karen B. Eden
    • 1
    • 2
  1. 1.Department of Medical Informatics & Clinical EpidemiologyOregon Health & Science UniversityPortlandUSA
  2. 2.Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics & Clinical EpidemiologyOregon Health & Science UniversityPortlandUSA