15250-m-cuypers

124 Chapter 6 that some participants might have had other expectations from the DA was found in the proportion of patients who indicated they would like to have received an explicit treatment advice from the DA, while this was not provided by the DA. Some evidence for an effect of the DA on knowledge was found. Firstly, participants with a DA perceived themselves to be more knowledgeable. Secondly, participants in the DA group scored equally well on the knowledge test, regardless of the number of eligible treatments, while in the control group test scores were lower if the number of eligible treatment options increased. This could indicate that when more treatments are considered, the DA helps to gain more knowledge about all options resulting in a better informed treatment decision, while in the control group there might have been more focus on a single treatment 43 . Not all participants seemed equally suited to receive the DA in its current online format. Older and lower educated participants indicated more often that a print DA was preferred over the current online format. Having internet access is common in The Netherlands, also among elderly, of all people aged up to 75 years, 97% has internet access at home (statline.cbs.nl ). However, with increasing age, actual usage and comfort in using internet is lower, which could explain some hesitation among participants to engage in an online tool for making a high impact treatment decision 47 . Participants with anxiety and depression symptoms showed more decisional conflict and less information satisfaction with the DA compared to participants with similar symptoms from the control condition. Anxiety and depression is common after a cancer diagnosis 40 . However, for participants in the control condition, we did not find a moderating role of anxiety and depression symptoms on decisional conflict or information satisfaction. This could indicate that without a DA, care providers were able to tailor their counseling according to the estimated level of anxiety and depression, while with the DA, all information about risks and side-effects was presented equally explicit to all patients. Communicating uncertainty can lead to lower satisfaction, in particular if patients are more sensible to this because of anxiety or depression 45 . Further research is needed to determine if these groups require further tailored information provision or more guidance in using a DA. The role of the DA in tailored information should be investigated in future research. During the current trial, most men received the DA soon after diagnosis, and were instructed to use the DA after consultation, regardless of any psychosocial distress from receiving the Pca diagnosis. Distress could have hindered uptake of new information from the DA and the decision-making process 48 . Possibly, some patients benefit from more extensive nurse counseling throughout the decision process and emotions caused