PDA Impact in Advanced Larynx Cancer | 141 5 This might lead to a situation in which treatment choices are based on personal preferences and informed decisions, which not only fosters a sense of autonomy but also reduces the risk of decisional regret and associated psychological distress, such as depression44. Limitations Due to the low incidence of T3/T4 larynx cases in the Netherlands (approximately 300 cases per year45), we chose to concurrently start inclusion for the usual care arm during development of the PDA. However, this pre/post design can introduce bias compared to a randomized controlled trial (RCT). We tried to counter potential bias by using propensity score correction. Patients in the intervention arm utilized the PDA at their own discretion and in their own setting. Unfortunately, data is not available on whether patients completed the entire PDA on their own, frequency of use, or if information was discussed with relatives. For patients (n=11) without internet access, the PDA was accessed on a hospital computer, potentially influencing their engagement, as they used the PDA just after the counseling consultation, potentially creating an overload of information. This study did not explore whether patients altered their treatment preferences after utilizing the PDA, nor did it assess the effect of the PDA on patient involvement and decision regret. This limits our insights into the effectiveness of the PDA. Finally, SDM was only measured using self-report. We have no data on the frequency and quality of actual SDM behavior during consultations.
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