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. 2022 Oct 18;31(6):e13738. doi: 10.1111/ecc.13738

Systematic review of shared decision‐making in guidelines about colorectal cancer screening

Marta Maes‐Carballo 1,2,3,✉, Manuel García‐García 1, Yolanda Gómez‐Fandiño 1, Carlos Roberto Estrada‐López 1, Andrés Iglesias‐Álvarez 4, Aurora Bueno‐Cavanillas 3,5,6, Khalid Saeed Khan 3,5
PMCID: PMC9786598  PMID: 36254840

Abstract

Introduction

We aimed to systematically evaluate quality of shared decision‐making (SDM) in colorectal cancer (CRC) screening clinical practice guidelines (CPGs) and consensus statements (CSs).

Methods

Search for CRC screening guidances was from 2010 to November 2021 in EMBASE, Web of Science, MEDLINE, Scopus and CDSR, and the World Wide Web. Three independent reviewers and an arbitrator rated the quality of each guidance using a SDM quality assessment tool (maximum score: 31). Reviewer agreement was 0.88.

Results

SDM appeared in 41/83 (49.4%) CPGs and 9/19 (47.4%) CSs. None met all the quality criteria, and 51.0% (52/102) failed to meet any quality items. Overall compliance was low (mean 1.63, IQR 0–2). Quality was better in guidances published after 2015 (mean 1, IQR 0–3 vs. mean 0.5, IQR 0–1.5; p = 0.048) and when the term SDM was specifically reported (mean 4.5, IQR 2.5–4.5 vs. mean 0.5, IQR 0–1.5; p < 0.001). CPGs underpinned by systematic reviews showed better SDM quality than consensus (mean 1, IQR 0–3 vs. mean 0, IQR 0–2, p = 0.040).

Conclusion

SDM quality was suboptimal and mentioned in less than half of the guidances, and recommendations were scarce. Guideline developers should incorporate evidence‐based SDM recommendations in guidances to underpin the translation of evidence into practice.

Keywords: ‘clinical practice guidelines’, ‘colorectal cancer screening’, ‘consensus’, ‘quality of guidelines’, ‘shared decision‐making’

INTRODUCTION

Colorectal cancer (CRC) incidence and mortality have decreased due to screening programmes, removing precancerous polyps with colonoscopy, and advances in management (Cotton et al., 1996; Zauber et al., 2012). In screening programmes, the patient's overall health, prior screening history, and preferences and values must be considered in selecting an individualised approach adapted to the patient's risk of acquiring CRC (Hoffmann et al., 2020; US Preventive Services Task Force et al., 2021). Shared decision‐making (SDM) is essential for decision‐making, weighing up risks vs. benefits for each individual patient (Schrager & Burnside, 2017). In recent years, health‐care policymaking has emphasised SDM as a cornerstone of evidence‐based and patient‐centred care (Barry & Edgman‐Levitan, 2012; Elwyn et al., 2010). Institutional promotion is fundamental for improving SDM application (Senate and House of Representatives, 2010), and clinical practice guidelines (CPGs) and consensus statements (CSs) should promote it and advise about its execution (Maes‐Carballo, Munoz‐Nunez, et al., 2020). Although CPGs and CSs increasingly support it (Gärtner et al., 2019), they remain unclear on accomplishing SDM in routine practice (Elwyn et al., 2012). Therefore, the analysis of the quality of SDM in guidances is critically essential. To the best of our knowledge, no systematic review has investigated SDM in CRC screening guidances.

Considering this background, this systematic review aimed to analyze SDM in CRC screening CPGs and CSs, evaluating the quality of recommendations about SDM.

1. METHODS

Following prospective registration (Prospero no: CRD42021286156), this systematic review was conducted following advocated methods for search, assessment and reporting of guidelines using the Preferred Reporting Items for Systematic Reviews and Meta‐Analysis (PRISMA) statement (see Appendix S1) (Liberati et al., 2009; Moher et al., 2009).

1.1. Search strategy, data sources, inclusion and exclusion criteria

A search for relevant publications covering major electronic databases (EMBASE, Web of Science, MEDLINE, Scopus and CDSR) was developed without language restrictions to capture peer‐reviewed and grey literature from 2010 until November 2021. We also searched 59 websites of important professional societies and eight guidance‐specific databases. We explored the World Wide Web to include professional societies from countries with global CRC scientific production bigger than 0.5% (Maes‐Carballo et al., 2021, 2022; Maes‐Carballo, Mignini, et al., 2020). A total of 85,932 ‘Colorectal Cancer and Health’ records were scrutinised from Scopus on 10 March 2022 to calculate the scientific production of each country. This decision is adhered to rules followed by other previous peer‐reviewed published systematic reviews (Maes‐Carballo et al., 2021, 2022; Maes‐Carballo, Mignini, et al., 2020; Maes‐Carballo, Munoz‐Nunez, et al., 2020). We revised references from the guidances retrieved to search for conceivable additional CPGs or CSs. The final search integrated MeSH terms ‘practice guidelines’, ‘guidelines’, ‘consensus’, ‘colorectal neoplasms’, ‘colorectal cancer’, ‘screening’ and including word alternatives. Details of the search strategy were documented in Appendix S2. Endnote X9 software was employed to handle the searches downloaded.

Selection criteria captured eligible guidances about CRC screening produced by national or international professional organisations and societies or governmental agencies. Those guidances in which screening was the central issue and those in which there was a section dedicated to screening or prevention were included in our systematic review. We excluded protocols or screening programme documents, CPGs and CSs about diagnosis and treatment, out‐of‐date guidelines replaced by updates from the same organisation, and CPG and CSs for education and information purposes, randomised controlled trials, observational studies, narrative reviews, scientific reports, discussion papers, conference abstracts, and posters.

Studies were chosen through a multi‐step approach, including deleting duplicates, reading titles and abstracts, and assessing full texts. Initially, titles and abstracts were considered for eligibility by two reviewers (CR‐E and AI‐A). Then, full texts were appraised for eligibility also by these two reviewers. Potential disagreements or inconsistencies were decided by arbitration of another reviewer (MM‐C). Articles in duplication were recognised and excluded. When several versions of the same guidance were discovered, the most updated version was incorporated. Data were extracted independently and duplicated by three reviewers (YG‐F, CR‐E and AI‐A). Disagreements were solved by consensus or arbitration (MM‐C).

1.2. Quality appraisal of guidances and data extraction

The included guidance's characteristics and quality were extracted into a piloted electronic data extraction sheet. The methodological quality assessment was estimated using an already published appraisal tool consisting of a 31‐item checklist grouped into 11 domains (Maes‐Carballo, Munoz‐Nunez, et al., 2020). Three reviewers (YG‐F, CRE‐L and AI‐A) evaluated the quality of SDM in CRC screening guidances (Appendix S3). The 11 domains were basic information (items 1–4), background (items 5–7), selection criteria (items 8–9), strengths and limitations (items 10–14), recommendations about SDM (items 15–17), facilitators and barriers (items 18–19), implementation (items 20–21), resource implications (items 22–24), monitoring and auditing criteria (items 25–27), recommendations for further research and limitations about these recommendations described (items 28–29), and editorial independence and declaration of interest (items 30–31). In those general guidances on the management of CRC, SDM was only considered if it was covered in the screening section. The questions were designed for a binary ‘yes/no’ answer: ‘Yes’ or 1 if the item was met and ‘no’ or ‘0’ if the criterion was not accomplished. The high quality was related to a higher quantity of items completed in the CPG or CS evaluated. No formal score or cut‐off point was specified to determine the quality (Maes‐Carballo, Munoz‐Nunez, et al., 2020). All three reviewers (YG‐F, CRE‐L and AI‐A) had a prior meeting receiving a training seminar and workshop from the arbitrator and creator of the tool (MM‐C) that included education on SDM and the process and application of the SDM tool.

1.3. Evidence synthesis, investigation of heterogeneity and data analysis

A descriptive analysis of the characteristics and quality of the selected guidances was conducted. Statistical data analysis was completed using Stata 16. The Kruskal–Wallis test was utilised to compare scores and stratify for factors or characteristics that may influence the quality of SDM in CPGs and CSs. Values were assessed statistically significant when p < 0.05. Inter‐rater reliability between reviewers in data extraction was calculated using the intra‐class correlation coefficient (ICC). A result of more than 0.75 was considered good (Koo & Li, 2016).

2. RESULTS

2.1. Study selection

The study selection process is illustrated in the flow diagram in Figure 1. The initial search identified 8229 citations. We removed 439 duplicates and 7676 records for not meeting the selection criteria (inappropriate population, publication, development group or outdated guidance). A total of 114 records were filtered through reviews of titles and abstracts. Later, we obtained the full text of 114 citations for eligibility assessment, and finally, 102 guidances (83 CPGs) (Alberta, 2020; Alsanea et al., 2015; Aranda et al., 2015; Aranda‐Hernandez et al., 2016; Atkin et al., 2012; Austoker et al., 2012; Benton et al., 2016; Bo In Lee et al., 2012; Brenner et al., 2017; Brouwers et al., 2011; Canadian task Force on preventive health C, 2016; Clarke & Feuerstein, 2019; Cubiella et al., 2018; Day et al., 2011; Del Giudice et al., 2014; Duffy et al., 2014; European Colorectal Cancer Screening Guidelines Working Group et al., 2013; European Commission, 2010; Fabio Leonel Gil Parada et al., 2015; Gupta et al., 2019; Halloran et al., 2012; Hassan et al., 2013; Helsingen et al., 2019; Hospital provincial Neuquén, 2016; Instituto Mexicano del Seguro Social. Guía de Práctica Clínica, 2010; Instituto Nacional del Cáncer, 2015; Jenkins et al., 2018; Jenkinson & Steele, 2010; Jover et al., 2012; Kwaan & Jones‐Webb, 2018; Lam et al., 2018; Lansdorp‐Vogelaar et al., 2012; Leddin et al., 2013; Lee et al., 2012; Leong et al., 2017; Lieberman, 2012; Lopes et al., 2018; Malila et al., 2012; Ministry of Health, 2010, 2016; Minozzi et al., 2012; Monahan et al., 2019; Moreno et al., 2018; Moss et al., 2012; Network NCC, 2021; New Brunswick Colon Cancer Screening, 2013; NHS, 2021; Ong et al., 2014; Provenzale et al., 2016; Qaseem et al., 2019; Quirke et al., 2011, 2012; Recommended Cancer Screenings, 2013; Regula & Kaminski, 2010; Rex et al., 2017; Rubeca et al., 2017; Salzman et al., 2016; SemFYC AEdG, 2018; Seppälä et al., 2021; Shaukat et al., 2021; Society AC, 2018; Spada et al., 2014; Steele, Pox et al., 2012; Steele, Rey et al., 2012; Steinwachs et al., 2010; Stoffel et al., 2015; Tanaka et al., 2015; Telford, 2011; Tinmouth et al., 2014; Uruguay MdSd. Ministerio de Salud de Uruguay, 2018; US Preventive Services Task Force et al., 2021; Valori et al., 2012; Vasen et al., 2014; Vieth et al., 2012; von Karsa et al., 2012; Washington KFHPo, 2021; Wilkins et al., 2018; Wilkinson et al., 2019; Wolf et al., 2018; Wong et al., 2015; Yang et al., 2020; Zeimet et al., 2017; 손대경 김, 박윤희, 서민아, 신애선, 이희영, 임종필, 조현민, 홍성필, 김백희, 김용수, 김정욱, 김현수, 남정모, 박동일, 엄준원, 오순남, 임환섭, 장희진, 함상근, 정지혜, 김수영, 김열, 이원철, 정승용, 2015) and 19 CSs (Asociación Mexicana de Endoscopia Gastrointestinal y Colegio de Profesionistas, 2016; ANM. Programa Nacional de Consensos Inter‐Sociedades, 2010; Basu et al., 2021; García‐Carbonero et al., 2017; Giardiello et al., 2014; Hadjiliadis et al., 2018; Heresbach et al., 2016; Hyer et al., 2019; Johnson et al., 2014; Leddin et al., 2010, 2018; Lieberman et al., 2012; Rembacken et al., 2012; Robertson et al., 2017; Schmiegel et al., 2010; Schmoll et al., 2012; Sollano et al., 2017; Sung et al., 2015; 中国抗癌协会肿瘤内镜学专业委员会 国上国中医中中消中中中金国, 2019) were included in our study for the last appraisal.

FIGURE 1.

FIGURE 1

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The flow diagram detailing the study selection

2.2. Characteristics of guidances and quality appraisal

The guidance's characteristics (type of document, entity, country, year, journal of publication, version and evidence analysis) were reported in Table 1. The guidances' mean number of items related to SDM was 1.63 (IQR 0–2). The quality assessment results using the SDM instrument are shown in Figure 2 and Appendix S4. No significant differences were obtained between CPGs and CSs concerning the SDM quality (p = 0.959). A total of 50 guidances (49.0%), 41/83 (49.4%) CPGs and 9/19 (47.4%) CSs, reported something about SDM. None of the guidelines met all the quality criteria, and 51.0% of the guidelines accomplished 0 items, and only 5.9% of them accomplished more than 25% items (8/31). When the SDM term was specifically cited in the guidance (n = 13), the quality of the CPG or CSs concerning SDM was better than when it did not appear (n = 89) (mean 4.5, IQR 2.5–4.5 vs. mean 0.5, IQR 0–1.5; p < 0.001).

TABLE 1.

Description of the screening clinical practice guidelines (CPGs) and consensus (CSs) (n=102) selected for the systematic review on the quality of reporting for SDM

Name of the CPG or protocol Abbreviated name Type of document Entity Country Year Publication in a journal Version Evidence analysis Quality tool referral Type of cancer Last updated date (months)
1 Screening for colorectal cancer. US preventive services task Force recommendation statement 2021 USPSTF CRC screening CPG USPSTF USA 2021 JAMA 5 Systematic review No CRC 4
2 Bowel cancer screening: Pathology guidance on reporting lesions 2021 UK government CRC screening CPG UK government UK 2021 Not published 3 Review No CRC 8
3 NCCN clinical practice guidelines in oncology (NCCN Guidelines). Colorectal Cancer Screening 2021 NCCN CRC screening CPG NCCN USA 2021 Not published 2 Systematic review, consensus No CRC 8
4 Colorectal cancer screening guideline 2021 KFHPW CRC screening CPG KFHPW USA 2021 Not published 2 Not reported No CRC 3
5 European guidelines from the EHTG and ESCP for Lynch syndrome: An updated third edition of the Mallorca guidelines based on gene and gender 2021 EHTG/ESCP Lynch syndrome CPG EHTG/ESCP Europe 2021 BJS 3 Systematic review, Delphi consensus Yes CRC 7
6 Cancer screening in the coronavirus pandemic era: Adjusting to a new situation 2021 COVID pandemic cancer screening CS ASCO USA 2021 JCO global oncology 1 Scoping review No CRC/breast/cervical 7
7 ACG clinical guidelines: Colorectal cancer screening 2021 2021 ACG CRC Screening CPG ACG USA 2021 Am J Gastroenteroly 3 Systematic review, GRADE No CRC 9
8 Colorectal cancer screening. Clinical practice guideline. Nov 2013 (Revised 2020) 2020 CCAl CRC screening CPG CCAl Canada 2020 Not published 6 Not reported No CRC 23
9 American Society for Gastrointestinal Endoscopy guideline on the role of endoscopy in familial adenomatous polyposis syndromes 2020 ASGE polyposis syndromes CPG ASGE USA 2020 Gastrointest Endosc 1 Systematic review, consensus No CRC 18
10 Colorectal cancer screening 2019 USMSTF CRC screening CPG USMSTF USA 2019 JAMA 1 Systematic review, GRADE No CRC 31
11 Colorectal cancer screening for patients with a family history of colorectal cancer or adenomas 2019 Ottawa CRC screening CPG University of Ottawa Canada 2019 CFP 1 Systematic review, meta‐analysis, GRADE No CRC 25
12 Colorectal cancer screening with faecal immunochemical testing, sigmoidoscopy or colonoscopy: a clinical practice guideline 2019 MAGIC CRC screening CPG MAGIC UK 2019 BMJ 1 Systematic review, GRADE No CRC 34
13 Management of familial adenomatous polyposis in children and adolescents: Position paper from the ESPGHAN polyposis working group 2019 ESPGHAN polyposis syndromes CS ESPGHAN Europe 2019 JPGN 1 Systematic literature, GRADE No CRC 33
14 Colorectal cancer surveillance in inflammatory bowel disease: Practice guidelines and recent developments 2019 CRC in IBD CPG HMS USA 2019 WJG 2 Not reported No CRC 28
15 中国早期结直肠癌筛查流程专家共识意见(2019, 上海) 2019 Chinese CRC screening CS CS SMMU China 2019 CGP 1 Not reported No CRC 25
16 Guidelines for the management of hereditary colorectal cancer from the British Society of Gastroenterology (BSG)/Association of Coloproctology of Great Britain and Ireland (ACPGBI)/United Kingdom Cancer Genetics Group (UKCGG) 2019 BSG/ACPGBI/UKCGG CRC screening CPG BSG/ACPGBI/UKCGG UK 2019 BMJ 1 Systematic review, GRADE, Delphi consensus No CRC 26
17 Clinical practice guideline. Diagnosis and prevention of colorectal cancer. 2018 update 2019 ACP CRC screening CPG CPG ACP USA 2019 Ann Intern Med 2 Not reported No CRC 29
18 Screening for Colorectal Cancer in asymptomatic average‐risk adults: A guidance statement from the American College of Physicians 2019 ACP average‐risk CRC screening CPG ACP USA 2019 Ann Intern Med 1 Review Yes CRC 25
19 Guía de práctica clínica de tamizaje del cáncer colo‐rectal 2018 2018 Uruguay CRC screening CPG Ministerio de Salud. Uruguay Uruguay 2018 Not published 2 Systematic review Yes CRC 48
20 Recommendations on prevention and screening for colorectal cancer in Hong Kong 2018 Hong Kong CRC screening CPG CEWGCPS China 2018 Hong Kong med J 3 Not reported No CRC 36
21 Early detection for colorectal cancer: ASCO resource‐stratified guideline 2018 early detection for CRC CPG ASCO USA 2018 JGO 1 Review, consensus Yes CRC 36
22 Cystic fibrosis colorectal cancer screening consensus recommendations 2018 cystic fibrosis CRC screening CS AGA USA 2018 Gastroenterology 1 Systematic review, consensus No CRC 46
23 Colorectal Cancer Screening in black men: Recommendations for best practices 2018 CRC screening in black men CPG NIH USA 2018 Am J Prev Med 1 Review No CRC 38
24 Colorectal Cancer Screening and prevention 2018 CRC Screening and prevention CPG AAFP USA 2018 Not published 1 Not reported No CRC 42
25 Clinical practice guideline on screening for colorectal cancer in individuals with a family history of non‐hereditary colorectal cancer or adenoma: The Canadian Association of Gastroenterology Banff Consensus 2018 Banff consensus CS CAG Canada 2018 Gastroenterology 1 Systematic review, GRADE, consensus No CRC 37
26 Revised Australian national guidelines for colorectal cancer screening: Family history 2018 Australian CRC screening CPG CCA Australia 2018 MJA 2 Systematic review, consensus No CRC 36
27 Diagnóstico y prevención del Cáncer Colorectal 2018 AEC CRC screening CPG AEG Spain 2018 Not published 2 Review, GRADE No CRC 38
28 Detección temprana, diagnóstico y clasificación por etapas 2018 ACS CRC screening CPG ACS USA 2018 Not published 3 Not reported No CRC 46
29 Colorectal cancer screening for average‐risk adults: 2018 guideline update from the American Cancer Society 2018 ACS average‐risk CRC screening CPG ACS USA 2018 CA Cancer J Clin 2 Systematic review, GRADE No CRC 31
30 ACR appropriateness criteria. Colorectal cancer screening 2018 ACR CRC Screening CPG ACR USA 2018 ACR 2 Systematic review, GRADE No CRC 38
31 Recommendations on faecal immunochemical testing to screen for colorectal neoplasia: A consensus statement by the US multi‐society task force on colorectal cancer 2017 USPSTF FOBT CS USPSTF USA 2017 Gastroenterology 1 Review, consensus No CRC 58
32 Colorectal cancer screening: Recommendations for physicians and patients from the U.S. multi‐society task force on colorectal cancer 2017 USPSTF CRC screening CPG USPSTF USA 2017 Am J Gastroenterol 2 Systematic review, GRADE No CRC 52
33 The Joint Philippine Society of Gastroenterology (PSG) and Philippine Society of Digestive Endoscopy (PSDE) Consensus Guidelines on the Management of Colorectal Carcinoma 2017 Philippine CRC screening CS CS PSG, PSDE Philippines 2017 PJIM 1 Review, consensus No CRC 55
34 Guidance for faecal occult blood testing: quantitative immunochemical method (FIT‐HB) in colorectal cancer screening programmes 2017 Italian FOBT CRC screening CPG Grupo Italiano Screening Colorettale Italy 2017 Not published 1 Systematic review No CRC 48
35 AGO Austria recommendation on screening and diagnosis of Lynch syndrome (LS) 2017 AGO Lynch CRC screening CS AGO Austria 2017 Arch Gynecol Obstet 1 Consensus No CRC 54
36 Association of coloproctology of Great Britain and Ireland (ACPGBI): Guidelines for the management of cancer of the colon, rectum and anus (2017) – Diagnosis, investigations and screening 2017 ACPGBI CRC and anal cancer CPG ACPGBI UK, Ireland 2017 Colorectal disease 1 Not reported No CRC, anal cancer 58
37 Colorectal cancer screening in average risk patients 2017 CRC average risk patients CPG University of North Carolina USA 2017 Med Clin North Am. 1 Review No CRC 53
38 Turkey Cancer Control Programme 2016 Turkey CRC screening CPG Ministry of Health. Turkey Turkey 2016 Not published 1 Not reported No CRC/breast/cervical 70
39 Prévention du cancer colorectal par coloscopie, en dehors du dépistage en population. Consensus et position de la SFED 2016 SFED CRC screening CS SFED France 2016 Acta Endosc 2 Consensus No CRC 70
40 NICE referral guidelines for suspected cancer: Colorectal cancer and faecal occult blood testing 2016 NICE CRC screening CPG NICE UK 2016 Annals of Clinical Biochemistry 1 Review No CRC 70
41 Guías de prevención y manejo endoscópico del cáncer colorrectal 2016 Mexico CRC screening CS AMEG Mexico 2016 Not published 1 Review, consensus, GRADE No CRC 70
42 Genetic/familial high‐risk assessment: Colorectal. Version 1.2016 2016 JNCCN CRC high risk CPG NCCN USA 2016 JNCCN 1 Systematic review No CRC 65
43 Detección temprana de Cáncer Colorectal en población adulta 2016 HPN CRC screening CPG HPN Argentina 2016 Not published 1 Systematic review AGREE II CRC 70
44 2016 gastrointestinal endoscopy: Global view. Seeing better – Evidence based recommendations on optimising colonoscopy adenoma detection rate 2016 GI endoscopy CPG University of Toronto Canada 2016 WJG 1 Review No CRC 69
45 Cancer screening in older patients 2016 CRC screening old patients CPG Thomas Jefferson University USA 2016 American Family Physician 1 Review No CRC 67
46 Guía de práctica clínica para la tamización de cáncer colorrectal 2016 Colombia CRC screening CPG ACGEDCH Colombia 2016 Rev Col Gastroenterol 1 Systematic review, GRADE AGREE II CRC 62
47 Recommendations on screening for colorectal cancer in primary care 2016 Canadian task force screening CPG CTFPHC Canada 2016 CMAJ 1 Systematic review, GRADE No CRC 66
48 SEOM/SERAM consensus statement on radiological diagnosis, response assessment and follow‐up in colorectal cancer 2015 SEOM SERAM CRC screening CS SEOM, SERAM Spain 2015 Clin Transl Oncol 1 Consensus No CRC 78
49 SEOM clinical guidelines for diagnosis and treatment of metastatic colorectal cancer 2015 2015 SEOM CRC screening CPG SEOM Spain 2015 Clin Transl Oncol 1 Review, GRADE No CRC 72
50 National Guidelines for Colorectal Cancer Screening in Saudi Arabia with strength of recommendations and quality of evidence 2015 Saudi Arabia CSC screening CPG SSCRS/ SGA/SOS/MH Saudi Arabia 2015 Ann Saudi Med 1 Systematic review No CRC 77
51 대장암 검진 권고안 2015 Korea CRC screening CPG NCCK Korea 2015 J Korean Med Assoc 1 Review No CRC 77
52 Evidence‐based clinical practice guidelines for management of colorectal polyps 2015 JSGE CR polyps CPG JSGE Japan 2015 J Gastroenterol 1 Review, consensus No CRC 81
53 Targeted screening for colorectal cancer in high‐risk individuals 2015 CRC screening high‐risk CPG CUHK China 2015 Best Practice and Research Clinical Gastroenterology 1 Review No CRC 82
54 Colorectal cancer surveillance after index colonoscopy: Guidance from the Canadian Association of Gastroenterology 2015 CAG CRC surveillance CPG CAG Canada 2015 Can J Gastroenterol 1 Review, consensus No CRC 82
55 Hereditary colorectal cancer syndromes: American Society of Clinical Oncology clinical practice guideline endorsement of the familial risk–colorectal cancer: European Society for Medical Oncology Clinical Practice Guidelines 2015 ASCO hereditary CRC CPG ASCO USA 2015 JCO 1 Review AGREE II CRC 82
56 GUÍA PARA EQUIPOS DE ATENCIÓN PRIMARIA DE LA SALUD. Información para la prevención y detección temprana del cáncer colorrectal 2015 Argentinian CRC screening CPG Ministerio de Salud. Argentina Argentina 2015 Not published 1 Not reported No CRC 78
57 Guidelines on genetic evaluation and management of Lynch syndrome: A consensus statement by the US multi‐society task force on colorectal cancer 2014 USPSTF Lynch syndrome CPG USPSTF USA 2014 American journal of GASTROENTEROLOGY 1 Systematic review No CRC 87
58 Optimising adequacy of bowel cleansing for colonoscopy: Recommendations from the US multi‐society task force on colorectal cancer 2014 USPSTF bowel cleansing CS USPSTF USA 2014 Gastroenterology 1 Systematic review, GRADE No CRC 94
59 Colonoscopy quality assurance in Ontario: Systematic review and clinical practice guideline 2014 Ontario CRC screening CPG CCO Canada 2014 Can J Gastroenterol Hepatol 1 Systematic review AGREE II CRC 89
60 Clinical indications for computed tomographic colonography: European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Gastrointestinal and Abdominal Radiology (ESGAR) guideline 2014 ESGE ESGAR CTC CPG ESGE, ESGAR Europe 2014 Endoscopy 1 Review, GRADE No CRC 86
61 Guideline for referral of patients with suspected colorectal cancer by family physicians and other primary care providers 2014 CRC screening primary care CPG SAFHT Canada 2014 Can Fam Physician 1 Systematic review No CRC 84
62 An updated Asia Pacific consensus recommendations on colorectal cancer screening 2014 Asia Pacific CRC screening CS CS APWGCRCS Asia 2014 Gut 2 Consensus No CRC 91
63 Regional and national guideline recommendations for digital ano‐rectal examination as a means for anal cancer screening in HIV positive men who have sex with men: A systematic review 2014 ano‐rectal screening CPG University of Melbourne Australia 2014 BMC Cancer 1 Systematic review No Anal and rectal cancer 95
64 Recommended Cancer screenings 2013 Swedish CRC screening CPG Swedish Cancer institute Sweden 2013 Not published 1 Not reported No CRC 106
65 New Brunswick colon cancer screening. Clinical practice guidelines 2013 NBCN CRC screening CPG NBCN Canada 2013 Not published 1 Review No CRC 98
66 Guidelines for surveillance of individuals with constitutional mismatch repair‐deficiency proposed by the European Consortium ‘Care for CMMR‐D’ (C4CMMR‐D) 2013 Lynch CRC screening CPG LUMC Netherlands 2013 J Med Genet 1 Not reported No CRC 96
67 Post‐polypectomy colonoscopy surveillance: European Society of Gastrointestinal Endoscopy (ESGE) guideline 2013 ESGE endoscopy CPG ESGE Europe 2013 Endoscopy 1 Systematic review No CRC 96
68 Tumour markers in colorectal cancer, gastric cancer and gastrointestinal stromal cancers: European group on tumour markers 2014 guidelines update 2013 EGTM CRC tumour makers CPG University College Dublin Ireland 2013 IJC 1 Not reported No CRC 96
69 Guidelines for colonoscopy surveillance after screening and polypectomy: A consensus update by the US multi‐society task force on colorectal cancer 2012 USPSTF screening surveillance CS USPSTF USA 2012 Gastroenterology 2 Review, consensus No CRC 118
70 Clinical practice guidelines: Quality of colonoscopy in colorectal cancer screening 2012 SEED AEG colonoscopy CPG SEED, AEG Spain 2012 Endoscopy 1 Review No CRC 118
71 Colorectal cancer screening: Practice guidelines 2012 Oregon CRC screening CPG OHSU USA 2012 Dig Dis 1 Review No CRC 119
72 대장암 선별과 대장폴립 진단검사 가이드라인 2012 Korean CRC screening CPG Universidad de Yonsei Korea 2012 Korean J Gastroenterol Vol 1 Systematic review, meta‐analysis No CRC 118
73 Korean guidelines for colorectal cancer screening and polyp detection 2012 Korea CRC screening CPG Yonsei University Korea 2012 Clin Endosc 1 Review No CRC 118
74 ESMO consensus guidelines for management of patients with colon and rectal cancer. A personalised approach to clinical decision‐making 2012 ESMO CRC screening CS ESMO Europe 2012 Annals of Oncology 1 Consensus, GRADE No CRC 112
75 Quality in screening colonoscopy: Position statement of the European Society of Gastrointestinal Endoscopy (ESGE) 2012 ESGE quality in CRC screening CS ESGE Europe 2012 Endoscopy 1 Review No CRC 118
76 European guidelines for quality assurance in colorectal cancer screening and diagnosis. First edition professional requirements and training 2012 EC CRC screening. Training CPG European Commission Europe 2012 Endoscopy 1 Systematic review No CRC 118
77 European guidelines for quality assurance in colorectal cancer screening and diagnosis. First edition colonoscopic surveillance following adenoma removal 2012 EC CRC screening. Surveillance CPG European Commission Europe 2012 Endoscopy 1 Systematic review No CRC 118
78 European guidelines for quality assurance in colorectal cancer screening and diagnosis: Overview and introduction to the full supplement publication 2012 EC CRC screening. Supplement CPG European Commission Europe 2012 Endoscopy 1 Systematic review No CRC 109
79 European guidelines for quality assurance in colorectal cancer screening and diagnosis. First edition executive summary 2012 EC CRC screening. Summary CPG European Commission Europe 2012 Endoscopy 1 Systematic review No CRC 118
80 European guidelines for quality assurance in colorectal cancer screening and diagnosis. First edition quality assurance in pathology in colorectal cancer screening and diagnosis 2012 EC CRC screening. Pathology CPG European Commission Europe 2012 Endoscopy 1 Systematic review No CRC 118
81 European guidelines for quality assurance in colorectal cancer screening and diagnosis. First edition organisation 2012 EC CRC screening. Organisation CPG European Commission Europe 2012 Endoscopy 1 Systematic review No CRC 118
82 European guidelines for quality assurance in colorectal cancer screening and diagnosis. First edition management of lesions detected in colorectal cancer screening 2012 EC CRC screening. Lesions CPG European Commission Europe 2012 Endoscopy 1 Systematic review No CRC 118
83 European guidelines for quality assurance in colorectal cancer screening and diagnosis. First edition introduction 2012 EC CRC screening. Introduction CPG European Commission Europe 2012 Endoscopy 1 Systematic review No CRC 118
84 European guidelines for quality assurance in colorectal cancer screening and diagnosis. First edition faecal occult blood testing 2012 EC CRC screening. FOBT CPG European Commission Europe 2012 Endoscopy 1 Systematic review No CRC 118
85 European guidelines for quality assurance in colorectal cancer screening and diagnosis. First edition evaluation and interpretation of screening outcomes 2012 EC CRC screening. Evaluation CPG European Commission Europe 2012 Endoscopy 1 Systematic review No CRC 118
86 European guidelines for quality assurance in colorectal cancer screening and diagnosis. First edition quality assurance in endoscopy in colorectal cancer screening and diagnosis 2012 EC CRC screening. Endoscopy CPG European Commission Europe 2012 Endoscopy 1 Systematic review No CRC 118
87 European guidelines for quality assurance in colorectal cancer screening and diagnosis. First edition annotations of colorectal lesions 2012 EC CRC screening. CRC lesions CPG European Commission Europe 2012 Endoscopy 1 Systematic review No CRC 118
88 European guidelines for quality assurance in colorectal cancer screening and diagnosis. First edition communication 2012 EC CRC screening. Communication CPG European Commission Europe 2012 Endoscopy 1 Systematic review No CRC 118
89 European guidelines for quality assurance in colorectal cancer screening and diagnosis. First edition principles of evidence assessment and methods for reaching recommendations 2012 CPO CRC screening principles CPG CPO Piemonte Europe 2012 Endoscopy 1 Systematic review No CRC 118
90 Effective interventions to facilitate the uptake of breast, cervical and colorectal cancer screening: An implementation guideline 2011 CCO effective interventions CPG CCO Canada 2011 BMC 1 Systematic review AGREE CRC 130
91 Canadian guidelines for colorectal cancer screening 2011 Canadian CRC screening CPG University of British Columbia Canada 2011 Can J Gastroenterol 1 Not reported No CRC 120
92 Colorectal cancer screening and surveillance in the elderly patient 2011 ACG CRC screening in old CPG ACG USA 2011 Am J Gastroenterol 1 Review No CRC 125
93 Cancer screening 2010 Singapore CRC screening CPG Ministry of Health. Singapore Singapore 2010 Not published 1 Systematic review No CRC 140
94 Quality assurance in pathology in colorectal cancer screening and diagnosis—European recommendations 2010 quality assurance CRC CPG University of Leeds UK 2010 Virchows Arch 1 Review, consensus No CRC 142
95 Targeting risk groups for screening 2010 Poland risk groups screening CPG Institute of Oncology, roentgen Poland 2010 Best Practice and Research Clinical Gastroenterology 1 Not reported No CRC 142
96 NIH state‐of‐the‐science conference statement on enhancing use and quality of colorectal cancer screening 2010 NIH CRC screening CPG NIH UK 2010 Not published 1 Systematic review No CRC 142
97 Guía de Práctica Clínica. Detección Oportuna y Diagnóstico de Cáncer de Colon y Recto no Hereditario en Adultos en Primero, Segundo y Tercer Nivel de Atención 2010 Mexico CRC screening CPG AMC Mexico 2010 Not published 1 Systematic review No CRC 138
98 European guidelines for quality assurance in colorectal cancer screening and diagnosis. First edition 2010 EC CRC screening CPG European Commission Europe 2010 Not published 1 Systematic review No CRC 142
99 Colorectal cancer screening—Methodology 2010 Dundee CRC screening CPG University of Dundee UK 2010 The Surgeon 1 Review No CRC 142
100 S3 Guidelines for colorectal carcinoma results of an evidence‐based consensus conference on February 6/7, 2004 and June 8/9, 2007 (for the topics IV, VI and VII) 2010 CRC screening CS Ruhr‐Universität Bochum Germany 2010 Z Gastroenterol 3 Consensus, GRADE No CRC 142
101 Canadian Association of Gastroenterology position statement on screening individuals at average risk for developing colorectal cancer: 2010 2010 CAG risk CRC screening CS CS CAG Canada 2010 Can J Gastroentero 2 Not reported No CRC 130
102 Programa Nacional de Consensos Inter‐Sociedades. Programa Argentino de Consensos de Enfermedades Oncológicas. GUÍA DE RECOMENDACIONES PARA LA PREVENCIÓN Y DETECCIÓN PRECOZ DEL CÁNCER COLORRECTAL. Septiembre 2010 2010 Argentinian CRC screening CS CS ANM Argentina 2010 Not published 1 Consensus AGREE II CRC 133
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FIGURE 2.

FIGURE 2

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The compliance of the items with the SDM quality and reporting analysis tool

The best‐scored domains were basic information (domain 1) with a range of guidances accomplishing items from 3 to 50, background (domain 2) with a range from 1 to 15, and recommendations (domain 5) with a range from 5 to 13. Resource implications (domain 8), monitoring and auditing criteria (domain 9), and independence and conflict of interest (domain 11) did not appraise any of the items in any guidance. Only 13/102 (12.7%), 10/102 (9.8%) and 3/102 (2.9%) guidances informed SDM in their executive summary, table of content, glossary, abbreviations, acronyms or topic indexes. SDM concept was only explained in one (1.0%) guidance. Both the primary population and patient subgroups with special consideration were characterised in 15/102 (14.7%). The search strategy and the study design and methodology limitations were reported in 2/102 (2.0%), respectively. The importance of the outcomes and the consistency of the results were detailed in only one guidance (1.0%) each. No PICO question was identified in any guidance. The benefits vs. harms of SDM in CRC screening were considered only in 3/102 (2.9%). The evidence of using SDM was exhibited in 2/102 (2.0%). Recommendations about SDM use were clear, precise and reliable in only 7/102 (6.9%) guidance documents, and these recommendations were well‐reported regarding specific subgroups in 5/102 (4.9%) guidances. Facilitators and barriers for SDM application were well‐described in 4/102 (3.9%), advice on applying SDM in clinical routine in 7/102 (6.9%), and additional materials were provided in other 7/102 (6.9%). Suggestions for further research were located in 2/102 (2.0%), and limitations about SDM recommendations were also described in 2/102 (2.0%). No information about SDM implementation cost, any criteria to assess and measure SDM adherence, conflict of interest regarding SDM or a declaration of the value of SDM in clinical practice. The European Commission (Austoker et al., 2012; European Commission, 2010) guidances and the American Cancer Society (ACS) (Wolf et al., 2018) CPG achieved the highest number of quality SDM items completed (Appendix S4).

2.3. Analysis of guidances' characteristics

The countries' distribution concerning SDM was erratic. Most of the guidances were from Europe (41/102; %) or North America (40/102; %). Table 2 shows factors than may influence the SDM quality of the guidances. Two CPGs or CSs were from Africa or Oceania (2/102; %). Asia and South America had 12/102 (%) and 5/12 (%), respectively. The quality of SDM did not vary between continents (p = 0.233).

TABLE 2.

Factors that may influence the SDM quality and reporting of the CRC screening guidances

Variable Mean (items) IQR range p value
Type of document
CPGs 1 0–2
CSs 1 0–2 p = 0.959
Country
Europe 0.5 0–1.5
North America 1 0–3
Other countries 1 0–1.5 p = 0.233
Publication year
Before or in 2015 0.5 0–1.5
After 2015 1 0–3 p = 0.048
Publication in a journal
Yes 0.5 0–2
No 1 0.3–3.5 p = 0.131
Version number
1 0.8 0–2
2 or more 1 0–3 p = 0.416
Evidence analysis
Systematic review 1 0–3 p = 0.040
Consensus or reviews 0 0–2
Not reported 0 0–1
Quality tool referral
Yes 0.8 0–1.5
No 1 0–2 p = 0.902
SDM specifically named
Yes 4.5 2.5–4.5
No 0.5 0–1.5 p < 0.001
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A greater tendency to introduce and recommend SDM was observed in the most recent guidances (Figure 3). The publication year after 2015 had an important influence on the quality than older publications (mean 1, IQR 0–3 vs. mean 0.5, IQR 0–1.5; p = 0.048). The publication in a journal (p = 0.131), and the version number (p = 0.416). The specific quality tool referral increased the quality and reporting of SDM on guidances (p < 0.001). CPGs following systematic reviews had better quality than consensus or literature reviews or when it was not reported (mean 1, IQR 0–3 vs. mean 0, IQR 0–2 vs. mean 0, IQR 0–1; p = 0.040).

FIGURE 3.

FIGURE 3

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Appearance of SDM concerning the published year of the guidance document

3. DISCUSSION

3.1. Main findings

Our results showed that CPGs and CSs for SDM in CRC screening were of low quality, with variation between guidances and across domains. Recent guidances had better quality, but there is extensive room for improvement. CPGs based on systematic reviews scored better than CSs or guidances that did not report any of it for evidence analysis. Guidances that contained a description of the use of a specific quality tool such as AGREE II or RIGHT demonstrated higher quality.

3.2. Strengths and weaknesses

To the best of our knowledge, this systematic review is the first to investigate the quality of SDM in CRC screening guidances. One of the main strengths of our review was its comprehensive search based on a broad conceptual framework with no language barriers. SDM is a trendy term of relatively recent appearance. Most methodological recommendation manuals remark a 2‐ to 3‐year window for guidance renovation (Vernooij et al., 2014). However, for studying it, we included more than 10 years of published guidance documents to scrutinise the situation of SDM through time. Our study contained guidance documents of professional organisations from scientifically active nations with more than 0.5% of the global CRC research production.

A rigorous methodology in conducting systematic reviews is mandatory to guarantee reliable results. In this concern, the trustworthiness of the study selection and the data extraction process is critical. As in similar investigations that use this SDM instrument, there is a possibility of empirical limitations related to the subjectivity of quality data extraction. To minimise this inconvenience, four reviewers performed a preliminary meeting to explain and understand the tool where doubts were solved; and three reviewers worked independently and in duplicate, with double checks included throughout the work. Arbitration was accomplished by a fourth experienced reviewer and creator of the SDM instrument used. The reviewer agreement was good (ICC = 0.88), implying reliable results (Appendix S5).

Our systematic review aimed to study the quality of SDM. We are conscious that ‘not all the items can have the same relevance and weight’ (Maes‐Carballo, Munoz‐Nunez, et al., 2020). This procedure involving a quality assessment instrument specifies if SDM was cited and which aspects were often considered. Further studies should focus on rating quality.

3.3. Implications

CRC early diagnosis could decrease morbimortality by discovering less invasive lesions and permitting more efficient treatments. Furthermore, the debate about the effectiveness and overtreatment due to false‐positive results has appeared on the scene. CRC screening is costly and annoying and could increase the risk of false positives or negatives, which may incur unnecessary stress or procedures and a false sense of security. The mortality reduction is not statistically significant at all ages, and the benefit vs. harm balance is unknown. So, screening should be tailored to the characteristics (age, genetic factors, race, etc.), desires and values of women. Screening programmes are an excellent area for SDM practice as there are different options with similar benefits and harms, and option choice might depend on the patient's values and preferences (Wieringa et al., 2017). The practice of SDM by clinicians could support evidence‐based decisions (Heen et al., 2021) and increase patient satisfaction and treatment engagement (Baca‐Dietz et al., 2020).

Our systematic review showed that SDM had gained notoriety over the years, with an increasing tendency of SDM presence and recommendations related to them. However, it has also demonstrated that SDM advice merits improvement in all the areas but specifically urgently in the reporting of the SDM resource implications and conflict of interest and the explanation of monitoring and auditing SDM use. It is essential its presence in CPGs and CSs, which hold the potential to influence the care delivered by health‐care providers and the outcomes for patients. Guidances should provide clear and reasonable recommendations for SDM applicability (Rabi et al., 2020; Woolf et al., 1999). More efforts should be made in SDM (Keating & Pace, 2018), and future guidelines should play a more important role in SDM implementation (Gärtner et al., 2019).

SDM is a new trend, and recent guidances are starting to increase recommendations about basic concepts, evidence and applicability. However, it merits consideration to keep working in that direction. The evidence analysis showed that guidances underpinned by systematic reviews had better quality than consensus or not reported. The referral to SDM term in guidances has shown an improvement in SDM quality, which seems logical as normally improved precision and clearance of recommendations.

3.4. Conclusions

This systematic review demonstrated that SDM quality in guidance documents was suboptimal as it did not appear in half of the guidances analyzed. SDM recommendations were scarce and unclear. Recent guidances following systematic reviews and referring to quality tools (e.g. AGREE II or RIGHT) had better SDM quality. Therefore, guideline developers, professional institutions, medical journals and policymakers should consider including evidence‐based SDM recommendations in trustworthy and well‐developed guidances to ensure proper translation of evidence into practice.

CONFLICTS OF INTEREST

There are no conflicts of interest.

Supporting information

Appendix S0: PRISMA 2020 Checklist

Click here for additional data file. (29.7KB, docx)

Appendix S1: Data sources and search strategy.

Click here for additional data file. (18.1KB, docx)

Appendix S2: Quality assessment tool for Shared Decision Making (SDM) recommendations in Breast Cancer Management Clinical Practice Guidelines (CPG) and consensus (CS).

Click here for additional data file. (29.8KB, docx)

Appendix S3: Quality assessment tool for Shared Decision Making (SDM) recommendations in Breast Cancer Management Clinical Practice Guidelines (CPG) and consensus (CS).

Click here for additional data file. (23.9KB, docx)

Appendix S4: Data extraction analysis.

Click here for additional data file. (508.5KB, doc)

Appendix S5: The reviewer agreement calculated using the intra‐class correlation coefficient (corr).

Click here for additional data file. (3.5MB, tif)

ACKNOWLEDGEMENTS

KSK is a Distinguished Investigator funded by the Beatriz Galindo (senior modality) Programme grant given to the University of Granada by the Ministry of Science, Innovation, and Universities of the Spanish Government. Funding for open access charge: Universidad de Granada / CBUA.

Maes‐Carballo, M. , García‐García, M. , Gómez‐Fandiño, Y. , Estrada‐López, C. R. , Iglesias‐Álvarez, A. , Bueno‐Cavanillas, A. , & Khan, K. S. (2022). Systematic review of shared decision‐making in guidelines about colorectal cancer screening. European Journal of Cancer Care, 31(6), e13738. 10.1111/ecc.13738

Funding information None declared.

DATA AVAILABILITY STATEMENT

All the supporting information can be accessed upon request via email to the corresponding authors of this review.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Appendix S0: PRISMA 2020 Checklist

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Appendix S1: Data sources and search strategy.

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Appendix S2: Quality assessment tool for Shared Decision Making (SDM) recommendations in Breast Cancer Management Clinical Practice Guidelines (CPG) and consensus (CS).

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Appendix S3: Quality assessment tool for Shared Decision Making (SDM) recommendations in Breast Cancer Management Clinical Practice Guidelines (CPG) and consensus (CS).

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Appendix S4: Data extraction analysis.

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Appendix S5: The reviewer agreement calculated using the intra‐class correlation coefficient (corr).

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Data Availability Statement

All the supporting information can be accessed upon request via email to the corresponding authors of this review.

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