Lee JG, Reissmann ME, Parkomenko E and Wang DS: Evaluating the quality of online health information about prostate cancer treatment. Urol Pract 2021; 8: 1

In 2006, “Google” officially became a verb in the Oxford English Dictionary thanks to the dominance of the search engine and its ability to find an answer to just about anything. Its application has also extended to health care. The Internet has become a popular medical resource for patients, with a national study finding 80% of Internet users searched for health information.¹

Navigating treatment options for any disease can be difficult for patients, particularly during the time of initial diagnosis. Prostate cancer is no exception. Despite our best efforts to provide counseling during the initial diagnosis appointment, some patients do not fully understand the treatment options due to limited appointment time, forgotten questions and potential embarrassment.² As a result, patients often rely on the Internet for answers due to convenience and privacy.³

It is difficult to regulate online health information due to freedom of speech because legal intervention is reserved for information that is deemed obviously dangerous to the public.⁴ Consequently, biased and even false information can be published by anyone. The readability of websites can also be problematic. Patients may not have enough health literacy to interpret medical jargon. Furthermore, approximately 90 million Americans have literacy skills at or below high school reading levels, according to national surveys.⁵ Patients with education levels below the 9th grade are more likely to misunderstand written health materials, which can be a barrier to patient care.⁶ The American Medical Association (AMA) and National Institutes of Health (NIH) recommend written health information should not exceed a 7th grade reading level.⁷

We performed a study to evaluate the readability and quality of online health information about prostate cancer treatment. Using 3 search engines—Google, Bing, and DuckDuckGo—the terms “prostate cancer” and “prostate cancer treatment” were queried. A total of 40 unique English-language websites were identified from the first 2 pages of search results. Websites sponsored to appear on the first page of search results were considered advertisements and included. After excluding websites with membership fees and publicly editable content, 26 websites were analyzed; 7 were advertisements.

Three formulas were used to assess readability: Flesch-Kincaid Reading Ease (FKRE), Flesch-Kincaid Grade Level (FKGL) and the SMOG (Simple Measure of Gobbledygook) Index. These formulas are based on the total number of words, sentences and syllables in a text (fig. 1).⁸ Our analysis showed that online information about prostate cancer treatment is on average written at the 10th to 11th grade reading level, which is well above the level recommended by the NIH/AMA (FKRE [t=–10.90, p <0.05], FKGL [t=8.81, p <0.05], SMOG [t=9.05, p <0.05]). Only 2 websites were written at or below a 7th grade reading level, neither of which belonged to a medical organization. These findings raise concern that most of the content online regarding prostate cancer treatment is at a more advanced reading level than the average patient can understand. Prior research regarding kidney and bladder cancers has shown similar results.⁹ When developing health care informational websites, it is important to simplify the language used and avoid excessive medical jargon.

Figure 1. Formulas for Flesch-Kincaid Reading Ease, Flesch-Kincaid Grade Level and SMOG Index.

The DISCERN questionnaire was used to evaluate website quality. DISCERN was developed by the University of Oxford Division of Public Health to evaluate the quality of written information about treatment choices (fig. 2).¹⁰ On average, the nonadvertisement websites were deemed “good” quality by the DISCERN tool. The AUA and American Cancer Society received “excellent” ratings. These findings indicate it is possible for a quick Internet search to yield some good quality websites that can supplement the information provided to patients during clinical consultation.

Figure 2. DISCERN questionnaire.

While there was no significant difference between the mean readability of nonadvertisement and advertisement websites, the quality of advertisements was significantly poorer (t=4.4, p <0.05; see table). Most of these websites were biased and did not properly review alternatives to the advertised products. One advertisement was promoting supplements for prostate health, not even prostate cancer. These websites can mislead patients that these products are actual treatments. Patients who are less familiar with the Internet, including the older demographic of prostate cancer patients, may not realize these websites are advertisements. Since companies pay for their websites to appear in optimal positions at the top of search pages, virtually all patients who seek health information online will come across these websites.

While we did not evaluate nonEnglish-language websites, we acknowledge that investigation of the availability, quality and readability of multilingual health sources regarding prostate cancer treatment would be valuable. It would be ideal for a clinician to know the available online resources for as many languages and health literacy levels as possible.

In conclusion, the Internet has dramatically altered how patients engage in their own health by seeking out self-education. Given the increasing accessibility of Internet-based medical advice to patients of all socioeconomic statuses and health literacy levels, it is important to evaluate these resources to ensure that patients are being exposed to valid and appropriate information. Increased accessibility to information on the Internet does not guarantee understanding.¹¹

Websites containing advertisements should not be relied on for medical advice, as they can be of significantly poorer quality. To discern the difference between advertisement and nonadvertisement may be challenging for an older, less Internet-savvy population. Not only do urologists have a duty to guide their patients to accurate and unbiased online resources, but they should also go a step further and contribute to the production of high quality Internet sources regarding prostate cancer treatment.