Web-Based Personalized Machine Learning Recommendations to Enhance Shared Decision-Making in Prostate-Specific Antigen Screening: Randomized Controlled Trial

Background: Prostate‑specific antigen (PSA) screening involves complex trade‑offs between early detection and the risks of overdiagnosis. For older adults (aged ≥50 years), shared decision‑making (SDM) is often hindered by limited health literacy, sensory or cognitive impairments, and multimorbidity, which complicate risk comprehension. Traditional decision aids provide foundational knowledge but are often nonpersonalized. Machine learning (ML) may offer individualized recommendations, yet the psychological and behavioral effects of ML‑assisted SDM in geriatric populations remain poorly characterized. Objective: This study aimed to develop and evaluate a web‑based, ML‑driven decision aid integrated into an SDM workflow to provide personalized PSA screening recommendations and to assess its effects on decisional conflict (primary outcome), state anxiety, and decision satisfaction among middle‑aged and older men. Methods: The study followed a 2‑stage design. First, a model establishment group (n=507) was used to train and evaluate 6 ML algorithms based on clinical and values‑clarification data. A random forest model was selected for its superior performance (mean area under the curve 0.933, SD 0.350; 95% CI 0.902-0.963). Second, a randomized controlled trial was conducted with 367 participants (mean age 64.34, SD 10.30 years) randomly assigned 1:1 to the ML suggestion group (MLSG; n=185) or the control group (CG; n=182). Both groups received video‑based education, counseling, and values clarification; only the MLSG received an ML‑generated "second opinion" recommendation. Primary and secondary outcomes were assessed using the Decisional Conflict Scale (DCS), Spielberger State‑Trait Anxiety Inventory (STAI), and Satisfaction with Decision scale. Results: In the randomized controlled trial (n=367), the MLSG reported significantly lower decisional conflict than the CG (total DCS score: mean difference [MD] -3.77, 95% CI -5.55 to -1.99; Cohen d=-0.44; P<.001). The MLSG reported greater perceived support (DCS7: adjusted P=.03), more adequate advice (DCS9: adjusted P<.001), and higher decision confidence (DCS10: adjusted P=.03; DCS11: adjusted P<.001). Regarding psychological well‑being, although total anxiety scores did not differ, the MLSG reported reduced worry (STAI item 6: MD -0.98, 95% CI -1.20 to -0.76; d=-0.89; adjusted P<.001) and increased calmness (STAI item 1: MD 0.30, 95% CI 0.06-0.54; d=0.25; adjusted P=.01). Decision satisfaction was higher in the MLSG across all items (total Satisfaction with Decision score: MD -7.38, 95% CI -8.54 to -6.18; P<.001). Behavioral choices were strongly influenced by the ML recommendation: participants in the MLSG who received an "accept" recommendation were more likely to select "accept" (34/67, 50.7%) than those in the CG (44/182, 24.2%; P<.001). When the system suggested "not now," only 17.8% (21/118) chose "accept," which was lower than in the CG. Conclusions: Integrating personalized ML recommendations into SDM workflows provides emotional scaffolding for older men, reducing decisional distress and enhancing confidence without undermining autonomy. By addressing geriatric‑specific vulnerabilities through a facilitated digital interface, this ML‑driven approach complements traditional clinical consultations. These findings support the scalable integration of artificial intelligence-assisted decision support to foster patient‑centered care in aging populations.