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218 Chapter 11 and procedures. Often, additional information is provided from national organizations (e.g. Dutch Cancer Society, patient association), and are patients referred to additional websites (e.g. Dutch urology association). Besides the information that is received at the hospital, various other sources are available to the patient as well (e.g. general practitioner, health insurer, own searches for (online) information, and personal networks). In this overwhelming availability of information of varying quality, it can be challenging for patients to determine which source is the most reliable or helpful 42 . Instead of piling new information sources on existing materials, it should be considered to introduce the DA as primary information and decision tool, and adjust or incorporate existing (hospital) information materials into the DA. Implications for clinical practice and future directions The PCPCC trial did not replicate effects that are typically found in DA studies (i.e. lower decisional conflict, higher information satisfaction, more knowledge) 2 . Partly this was due to unexpected positive outcomes in our control arm (chapter 6). As discussed in previous sections, this could have been caused by care provider effects or selection bias. However, it couldalsobe that current routinePca care inTheNetherlands already involves patients better into the decision process and informs them better compared to what we reported in the retrospective cohort of Pca survivors (chapter 2) or control groups included in previous international studies 2 . Moreover, SDM has emerged in the past decade in The Netherlands, not only by endorsement from researchers and clinicians, but implementation of SDM is also encouraged by government, health insurers, and patients associations 43 . Therefore, with the wide body of evidence available on the beneficial effects of DAs, and still increasing awareness for SDM, make it likely that DAs in some format will continue to be included in clinical practice 2, 43 . In this context, an important continuation of the studies presented in this thesis relate to the role of DAs in the broader context of SDM. Many other studies have looked into the effects of DAs on patient-reported outcomes (e.g. decisional conflict, and perceived SDM) and decision outcomes (e.g. selected treatment) for other diseases and screening decisions; the latest Cochrane review (2017) included 105 studies 2 . And apart from these DA studies, much more literature is available that describes the model, and benefits of SDM itself 44-47 . As also explained in this dissertation, it is often assumed that DAs help to initiate SDM, and that the beneficial effects after DA use are the result of more SDM occurring. Consequently, it is often advised that more DAs are needed in order initiate and facilitate SDM. It can however be questioned if beneficial effects from DAs are the result of (more) SDM occurring, or solely effects from the DA itself (e.g. more knowledge, increased self-efficacy) 48 . The studies included in this dissertation did not