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10 Chapter 1 At the start of the research project described in this dissertation, no patient DA including all active treatment options as well as the choice option not to start active treatment right away, was available and routinely used in care for prostate cancer patients in the Netherlands, even though prostate cancer is the most common cancer in man in the western world, including the Netherlands 11, 12 . The main goals of the project described in this dissertation were therefore: (1) Develop, (2) implement and (3) evaluate a DA for patients newly diagnosed with early-stage prostate cancer in everyday care in multiple healthcare centers in the Netherlands. For the purpose of improving national implementation, a consortium (JIPPA) was formed, consisting of three regional DA research groups that had each developed a DA for prostate cancer patients. Within the consortium, the samemethods for patient evaluations anddetermining implementation rates were used, to facilitate comparison across the three studies. Toset thestage, theresearchdescribed inthisdissertationalsopresents (1) a retrospective analysis of decision roles and information satisfaction as reported by prostate cancer patients who are long after their initial treatment decision and who received care before the start of the JIPPA implementation project, as well as (2) an analysis of the change in patients´ self-reported health-related quality of life in the period before and after prostate cancer diagnosis, before treatment onset. The DA was tested within a cluster randomized trial. Novelty of this trial included a pragmatic approach, a long-term follow- up (12 months), and a detailed analysis of DA implementation and usage rates. The current chapter aims to describe the theoretical background and models underlying these studies. Prostate cancer Prostate cancer (Pca) is the most common cancer in men in the western world, and is diagnosedmostly inmen between the ages of 50 and 70 11,12 . In the Netherlands, around 10,000 men are diagnosed with Pca every year (www.cijfersoverkanker.nl) . In many patients, Pca is detected at an early stage 13 . At this stage, multiple medically equivalent treatment options are available 14 . Deciding between those options is challenging: a doctor can often not present a single superior option from a purely medical perspective, and patients are often not aware of differences between available treatments or their own preferences associated to these treatments 15, 16 . Careful treatment counseling is therefore required, which should at least include adequate information provision and elicitation of patient-preferences 9 . The prostate is part of the male reproductive system and is located below the urinary bladder and surrounds the urethra. The main function of the prostate is the production of prostate fluid for the transportation of semen 17 . Growth of the prostate starts