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Learn more: PMC Disclaimer | PMC Copyright Notice Oral Dis . 2025 Sep 18;32(2):405–411. doi: 10.1111/odi.70098 Search in PMC Search in PubMed View in NLM Catalog Add to search Patient‐Centred Web‐Based Information on Head and Neck Squamous Cell Carcinoma: Quality and Readability Briana Jansen Briana Jansen 1 Oral Medicine and Oral Pathology, UWA Dental School, The University of Western Australia, Nedlands, Australia Find articles by Briana Jansen 1 , Stella Mullane Stella Mullane 1 Oral Medicine and Oral Pathology, UWA Dental School, The University of Western Australia, Nedlands, Australia Find articles by Stella Mullane 1 , Bryan Tan Bryan Tan 1 Oral Medicine and Oral Pathology, UWA Dental School, The University of Western Australia, Nedlands, Australia Find articles by Bryan Tan 1 , Bobby Joseph Bobby Joseph 1 Oral Medicine and Oral Pathology, UWA Dental School, The University of Western Australia, Nedlands, Australia Find articles by Bobby Joseph 1 , Mohammed Junaid Mohammed Junaid 2 Dental Public Health, UWA Dental School, The University of Western Australia, Nedlands, Australia Find articles by Mohammed Junaid 2 , Ramesh Balasubramaniam Ramesh Balasubramaniam 1 Oral Medicine and Oral Pathology, UWA Dental School, The University of Western Australia, Nedlands, Australia 3 Oral and Maxillofacial Biology & Diseases Research Stream, UWA Dental School, The University of Western Australia, Nedlands, Australia Find articles by Ramesh Balasubramaniam 1, 3 , Agnieszka Frydrych Agnieszka Frydrych 1 Oral Medicine and Oral Pathology, UWA Dental School, The University of Western Australia, Nedlands, Australia 3 Oral and Maxillofacial Biology & Diseases Research Stream, UWA Dental School, The University of Western Australia, Nedlands, Australia Find articles by Agnieszka Frydrych 1, 3 , Omar Kujan Omar Kujan 1 Oral Medicine and Oral Pathology, UWA Dental School, The University of Western Australia, Nedlands, Australia 3 Oral and Maxillofacial Biology & Diseases Research Stream, UWA Dental School, The University of Western Australia, Nedlands, Australia Find articles by Omar Kujan 1, 3, ✉ Author information Article notes Copyright and License information 1 Oral Medicine and Oral Pathology, UWA Dental School, The University of Western Australia, Nedlands, Australia 2 Dental Public Health, UWA Dental School, The University of Western Australia, Nedlands, Australia 3 Oral and Maxillofacial Biology & Diseases Research Stream, UWA Dental School, The University of Western Australia, Nedlands, Australia * Correspondence: Omar Kujan ( [email protected] ) ✉ Corresponding author. Revised 2025 Aug 25; Received 2025 Jul 20; Accepted 2025 Sep 5; Issue date 2026 Feb. © 2025 The Author(s). Oral Diseases published by John Wiley & Sons Ltd. This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes. PMC Copyright notice PMCID: PMC13077018 PMID: 40966670 ABSTRACT Introduction The internet is a widely used source of health information for patients with head and neck cancer. However, the quality and readability of online content remain inconsistent. This study evaluated the usefulness of web‐based resources by assessing their quality and readability. Methods Searches were conducted using Google, Bing, and Yahoo! with nine common anatomical terms related to head and neck cancer. The first 50 results from each search engine were screened, and eligible websites were evaluated for quality using the DISCERN instrument by three independent reviewers. Readability was assessed using the Flesch–Kincaid Reading Grade Level (FKRGL) and the Flesch Reading Ease Score (FRES). Descriptive and inferential statistics were applied. Results A total of 285 websites met the inclusion criteria. Of these, 46% were rated as poor quality (DISCERN score = 1). The median FKRGL was 8.6, and the median FRES was 55.7, both indicating reading levels above recommended thresholds for patient education materials. Conclusions Online information for patients with head and neck squamous cell carcinoma is often of low quality and too complex for the average reader. Improved, accessible, and reliable web‐based resources are needed to support patient understanding and informed healthcare decisions. Keywords: head and neck cancer, readability, search engines, web‐based information 1. Introduction Head and neck cancer describes malignancies arising in the tissues of the head and neck region, with over 90% classified as head and neck squamous cell carcinoma (HNSCC) (Argiris et al. 2008 ). HNSCC is the seventh most common cancer worldwide, with an estimated annual mortality of 450,000. It predominantly affects males (Sung et al. 2021 ). While the oral cavity is the most frequently involved site, other anatomical regions such as the larynx, nasopharynx, oropharynx, hypopharynx, nasal cavity, and paranasal sinuses may also be affected due to the widespread distribution of mucosal epithelium (Argiris et al. 2008 ; Chow 2020 ; Mahmutović et al. 2021 ). The clinical and biological heterogeneity of HNSCC, including variation in tumour site, disease stage, and underlying aetiology, presents significant diagnostic, prognostic, and therapeutic challenges (Chow 2020 ; Mahmutović et al. 2021 ). Tobacco and alcohol use remain the primary risk factors, although human papillomavirus (HPV) has emerged as a major etiological factor, particularly in the rising incidence of oropharyngeal cancers (Argiris et al. 2008 ). Treatment options for HNSCC depend on the tumour's location and stage at diagnosis and may include surgery, radiotherapy, chemotherapy, immunotherapy, or combinations thereof (Mahmutović et al. 2021 ). Alarmingly, approximately 75% of patients are diagnosed at stage III or IV, requiring aggressive multimodal treatment (Sung et al. 2021 ). Such interventions often lead to significant functional impairments, including difficulties with speech, breathing, eating, and drinking, which can profoundly affect quality of life (Chow 2020 ; Ziegler et al. 2004 ; Newell et al. 2004 ). Many patients often experience chronic pain, disfigurement, and psychological distress, contributing to a suicide rate nearly three times higher than that of the general population (Kam et al. 2015 ). Importantly, studies show that patients who feel adequately informed before treatment are better prepared to cope with the functional and psychosocial consequences of HNSCC (Husson et al. 2011 ; Howell et al. 2017 ; Ling et al. 2011 ; Jho et al. 2013 ). However, qualitative research also indicates that many patients still feel underprepared, even after pre‐treatment consultations with healthcare providers (Newell et al. 2004 ; Brockbank et al. 2015 ). This highlights the need for accessible, patient‐centered educational resources, particularly those that can be reviewed after treatment when clinical support may be limited. In Australia, 78% of adults use the internet to seek health‐related information (Australian Institute of Health and Welfare 2018 ). Patients frequently turn to the internet to validate health concerns, explore treatment options, and supplement clinical consultations (Stevenson et al. 2021 ; McMullan 2006 ). However, several studies have identified significant limitations in the quality and readability of online resources related to head and neck conditions (Grose et al. 2022 ; Alsoghier et al. 2018 ; Lorenzo‐Pouso et al. 2019 ; Patton et al. 2014 ). More than half of HNSCC patients report using the internet to learn about their treatment, making it the most common adjunct to clinical consultations (Jabbour et al. 2017 ; Rogers et al. 2012 ). Yet, many individuals affected by HNSCC have limited health literacy and may struggle to understand or apply online health information, potentially hindering shared decision‐making (Kelly et al. 2022 ; Wang et al. 2018 ). Moreover, higher quality websites are not necessarily written at a level accessible to the average patient. For instance, a recent analysis of online information about HPV‐related oropharyngeal cancer found that many reputable sites lacked readability, limiting their usefulness for patients (Schwarzbach et al. 2020 ). This study aims to evaluate the quality and readability of web‐based information about HNSCC treatment that is accessible through the most widely used search engines: Google, Yahoo!, and Bing. 2. Materials and Methods 2.1. Study Design The study was conducted in three phases: (1) identification of relevant websites using common search engines and patient‐friendly terminology; (2) evaluation of the quality and readability of the retrieved webpages; and (3) statistical analysis of the data. 2.2. Search Strategy To reduce the influence of personalized search results, all searches were conducted in incognito mode, with browsing history, cookies, and cached data cleared, and location services disabled before searching (Grose et al. 2022 ). The search was performed in November 2023 using three widely used search engines: Google, Yahoo!, and Bing. Nine search terms were used in each search engine to reflect the terminology most commonly used by patients when seeking information on head and neck cancers: “head and neck cancer”, “throat cancer”, “mouth cancer”, “nose cancer”, “sinus cancer”, “tongue cancer”, “tonsil cancer”, “lip cancer” , and “voice box cancer” . These terms were selected for their layperson familiarity, as opposed to technical medical nomenclature (Best et al. 2014 ). For each search term, the first 50 search results were retrieved, resulting in a total of 1350 webpages (3 search engines × 9 terms × 50 results). While previous studies have typically limited analysis to the first 10 results per search term (Best et al. 2014 ; Grose et al. 2022 ; Lorenzo‐Pouso et al. 2019 ), this study expanded the pool to 50 to account for daily fluctuations in website rankings and to improve the comprehensiveness of the resource pool. The following exclusion criteria were applied: duplicate pages; irrelevant or inappropriate content (e.g., resources focused on non‐squamous cell carcinomas such as melanoma); websites serving solely commercial purposes; scientific publications; discussion forums; videos; online medical dictionaries; broken links; non‐English websites; paywalled content; news articles; and webpages with fewer than 100 words. These exclusion criteria are consistent with those used in prior quality and readability assessments of patient‐oriented health information (Grose et al. 2022 ; Lorenzo‐Pouso et al. 2019 ). Each included website was classified by affiliation type into one of the following categories: non‐profit organizations, government‐based organizations, private websites, public medical centers, private medical centers, or commercial organizations. 2.3. Quality and Readability Assessment Website quality was assessed using the DISCERN instrument, a validated tool designed to evaluate the reliability and quality of written health information. It comprises 16 items across three sections, each rated on a 5‐point Likert scale (1 = lowest, 5 = highest), assessing factors such as reliability, treatment information, and overall quality (Grose et al. 2022 ; Lorenzo‐Pouso et al. 2019 ; Charnock and Shepperd 2004 ). For descriptive purposes, overall DISCERN quality ratings were grouped into three categories: low (Scores 1–2), moderate (Score 3), and high (Scores 4–5). Three independent assessors each evaluated a subset of the webpages. Before formal assessment, a calibration exercise was conducted: each assessor independently rated the same 10 webpages, after which scores were compared and discussed to ensure consistency in interpretation and scoring. Inter‐rater agreement was assessed to validate the consistency of ratings across assessors [kappa agreement: 0.82]. Readability was evaluated using two validated tools: the Flesch–Kincaid Reading Grade Level (FKRGL) and the Flesch Reading Ease Score (FRES). These formulas assess text complexity based on sentence length and syllable count, producing an estimated U.S. school grade level (FKRGL) and an ease‐of‐reading score on a scale of 0 to 100 (FRES). Both measures have been widely used in similar studies of health‐related web content (Grose et al. 2022 ; Lorenzo‐Pouso et al. 2019 ; Flesch Reading Ease and the Flesch Kincaid Grade Level 2011 ). 2.4. Statistical Analysis Descriptive statistics (frequency for categorical variables, and mean, median, and standard deviation for continuous variables) were calculated to summarize website characteristics and assessment scores. One‐way ANOVA was used to examine associations between overall DISCERN quality scores and readability scores (FKRGL and FRES). A p ‐value < 0.05 was considered statistically significant. In addition, Spearman's rank correlation was used to analyze relationships between individual DISCERN item scores and the overall quality score. All statistical analyses were performed using IBM SPSS Statistics (Version 27). 3. Results The search strategy yielded 1350 webpages across Google, Yahoo!, and Bing. Following the removal of duplicates and the application of predefined exclusion criteria, 285 unique websites were included for analysis (Figure 1 ). Figure 2 shows the distribution of webpage types. FIGURE 1. Open in a new tab Study flowchart. This figure summarises the identification, screening, eligibility assessment, and inclusion of webpages in the analysis. FIGURE 2. Open in a new tab The distribution of webpages based on their origin types. NFP, non‐for‐profit. 3.1. Quality Assessment (DISCERN) Overall, nearly half of the websites (46%) were rated as poor quality, receiving a DISCERN score of 1, while fewer than one in five achieved a high‐quality score of 5 (Figure 2 ). Item‐by‐item performance is summarized in Table 1 . The lowest‐scoring domains were the description of consequences if no treatment were pursued (Q12; 82.8% scored low), discussion of treatment risks (Q11; 66.7% low), benefits of treatment (Q10; 60.4% low), and support for shared decision‐making (Q15; 61.8% low). In contrast, the highest scores were observed for acknowledging multiple treatment options (Q14; 68.1% high) and explaining how treatment works (Q9; 47.4% high). TABLE 1. Distribution of DISCERN score categories by constituent items for 285 Websites. DISCERN item Low a (%) Mod a (%) High a (%) Notes Q1: Clear aims 48.8 29.1 22.1 Low score for aims clarity Q2: Aims achieved 6.4 33.7 59.9 Most achieved aims Q3: Relevance 22.2 37.3 40.5 Moderate to high relevance Q4: Sources stated 55.8 20 24.2 Poor transparency Q5: Currency 62.8 9.8 27.4 Date often missing Q6: Balanced/unbiased 43.8 25.3 30.9 Mixed results Q7: Additional info 39.3 21.7 39.0 Varied provision Q8: Acknowledge uncertainty 30.5 37.2 32.3 Mostly moderate transparency Q9: How treatment works 39.6 13.0 47.4 Inconsistently high Q10: Benefits of treatment 60.4 24.9 14.7 Mostly poor Q11: Risks of treatment 66.7 15.1 18.2 Mostly poor Q12: No treatment option 91.2 6.0 2.8 Rarely addressed Q13: QoL impact 58.2 16.5 25.3 Often missing or poor Q14: Multiple options 14.4 7.7 77.9 Mostly clear Q15: Shared decision support 61.7 20.7 17.6 Low support Q16: Overall quality None None None Categorical 1, 3, 5 Open in a new tab a Low (Score 1 and 2), moderate (Score 3), high (Score 4 and 5). 3.2. Readability Readability analysis revealed that most websites exceeded recommended reading levels for public health information. The median Flesch–Kincaid Reading Grade Level (FKRGL) was 8.6 (IQR = 7.4–9.8), surpassing the AMA's recommendation of ≤ 6th grade and the NIH's guidance of ≤ 8th grade. The median Flesch Reading Ease Score (FRES) was 55.7 (IQR = 49.2–61.1), placing the majority of content in the “fairly difficult” category. 3.3. Quality–Readability Relationship Higher‐quality websites demonstrated significantly better readability. Specifically, sites with high DISCERN scores had lower FKRGL values and higher FRES values compared to moderate‐quality websites ( p < 0.001 for both). This trend indicates that improved quality was not associated with increased textual complexity. A summary of readability measures by quality category is presented in Table 2 . TABLE 2. Overall quality and readability summary. Quality category Median FKRGL Median FRES Notes High quality (DISCERN = 5) Lower than moderate Higher than moderate Statistically significant differences, p = 0.001 Moderate quality (DISCERN = 3) Higher than high quality Lower than high quality Statistically significant differences, p = 0.001 Open in a new tab 3.4. Correlation Analysis Spearman's rank correlation identified three DISCERN domains most strongly associated with overall quality: relevance to patients (Q3; ρ = 0.65), balanced and unbiased information (Q6; ρ = 0.62), and discussion of treatment risks (Q11; ρ = 0.58) (Table 3 ). TABLE 3. Correlation between DISCERN items and overall quality. DISCERN Item Spearman ρ p Notes Q3: Relevance to patients 0.65 < 0.001 Strongest correlation Q6: Balanced/unbiased information 0.62 < 0.001 Strong correlation Q11: Risks of treatment 0.58 0.002 Moderate‐strong correlation Open in a new tab 4. Discussion The present study provides a comprehensive evaluation of the quality and readability of online information related to HNSCC, encompassing a large sample of 285 unique webpages retrieved from the three most commonly used search engines. By incorporating an expanded search strategy using nine patient‐friendly lay terms and evaluating the first 50 results per term, our analysis offers a broader and potentially more representative overview of the information patients access when seeking online content about their condition. A growing body of research has examined the quality and readability of web‐based information across various head and neck conditions, including oral dysplasia, neck dissection, oral lichen planus, and cancer‐related dental care (Grose et al. 2022 ; Alsoghier et al. 2018 ; Lorenzo‐Pouso et al. 2019 ; Patton et al. 2014 ). While methodologies vary, the findings across these studies consistently indicate that patient‐centered web content is generally of poor quality and limited readability, as measured by validated tools such as DISCERN, JAMA benchmarks, the Flesch Reading Ease Score (FRES), and the Flesch–Kincaid Reading Grade Level (FKRGL). Focusing more specifically on HNSCC‐related information, three key studies have assessed the quality and readability of web‐based resources (Best et al. 2014 ; Narwani et al. 2015 ; Schwarzbach et al. 2020 ). Schwarzbach et al. and Narwani et al. focused on HPV‐associated oropharyngeal cancer and laryngeal cancer, respectively (Narwani et al. 2015 ; Schwarzbach et al. 2020 ), while Best et al. analyzed 40 head and neck cancer websites and explored the relationship between quality and Google search rankings (Best et al. 2014 ). In the present study, application of the DISCERN instrument revealed that 46% of the webpages analysed were of low quality, receiving an overall Score of 1. This aligns with findings by Best et al. ( 2014 ) who reported that over 57% of websites failed to meet three of the four JAMA benchmarks. Readability was similarly poor across the webpages analysed. The mean FKRGL was 8.7, well above the sixth‐grade level recommended by the American Medical Association (AMA) and the eighth‐grade level advised by the National Institutes of Health (NIH) for patient education materials. Furthermore, the median FRES Score of 55.7% fell below the recommended minimum of 65%, and the interquartile range of 49.2% to 61.1% indicated that fewer than 25% of the webpages achieved an adequate level of reading ease. These findings are consistent with the results reported by Schwarzbach et al. and Best et al., who used the FKRGL and the Simple Measure of Gobbledygook (SMOG) readability tools, respectively (Best et al. 2014 ; Schwarzbach et al. 2020 ). Interestingly, while Schwarzbach et al. reported a negative correlation between quality and readability, our findings suggest the opposite. In this study, websites with higher DISCERN scores were significantly more readable, as indicated by both lower FKRGL and higher FRES scores ( p = 0.001 ). This contrasts with the concern that higher‐quality content may come at the expense of accessibility. Additionally, Best et al. found that higher Google rankings were associated with better quality scores. Given Google's dominant market share among search engines, the findings of the present study, combined with those of Best et al., suggest that the resources most likely to be accessed by patients are also more likely to be of higher quality and readability. However, this potential benefit is limited in practice, as fewer than 20% of the 285 resources assessed in this study were classified as high quality. The internet offers patients a vast repository of easily accessible health information, and it is unsurprising that online resources now serve as a major adjunct to clinical communication (Australian Institute of Health and Welfare 2018 ; Stevenson et al. 2021 ; McMullan 2006 ; Jabbour et al. 2017 ). Despite their importance, the findings of this study, and those of earlier investigations, indicate that most web‐based resources related to HNSCC are of limited value in effectively educating patients. This problem is particularly acute for patients with lower health literacy, a group that includes a significant portion of the HNSCC population (Kelly et al. 2022 ; Wang et al. 2018 ). These individuals often lack the medical background and critical appraisal skills needed to evaluate the credibility of online content. The negative impact is further compounded by unnecessarily complex language and content written at levels well above the average reading ability. Although our study focused on traditional web‐based resources, the landscape of patient information is increasingly shaped by social media platforms. Patients with HNSCC and their caregivers frequently engage with communities on Facebook, Instagram, YouTube, TikTok, and other platforms, where they share personal experiences, seek peer support, and access medical information (Batool et al. 2024 ). Healthcare professionals also use these platforms to disseminate educational materials and promote awareness campaigns (Liu et al. 2024 ). However, as with traditional websites, the quality and reliability of information on social media vary widely, and further research is needed to assess its impact on patient decision‐making and health literacy. Moreover, the limitations of online information extend beyond traditional webpages. A recent study by Al Karadsheh et al. found that patient‐directed social media content on oral cancer also suffers from poor quality and limited usefulness, highlighting the pervasive nature of this issue across platforms (Al Karadsheh et al. 2024 ). Several limitations should be acknowledged. While DISCERN is a validated tool for assessing the quality and reliability of health information, it does not evaluate the factual accuracy of content and was not specifically developed for HNSCC‐related material. Its inherently subjective nature introduces the potential for assessor bias; however, this was mitigated through a calibration process that achieved high inter‐rater agreement. The exclusion of non‐English websites may limit the generalizability of findings to non‐English‐speaking populations. Moreover, the static nature of the search strategy, conducted at a single point in time and restricted to three search engines, may not fully capture the dynamic and evolving nature of online information. Nonetheless, the decision to assess the first 50 search results for each term, rather than the top 10 as in many previous studies, enhances the robustness of the dataset and accounts for some variability in search result rankings. In our study, the univariate correlations offered valuable insight into which DISCERN domains are most closely associated with overall quality. However, they cannot establish causality or account for inter‐domain relationships. As noted in the limitations, employing multivariate techniques such as factor analysis or multiple regression in future studies would enable a more robust identification of the key determinants of information quality. Such statistical refinement could guide targeted interventions to improve the comprehensiveness and clarity of online patient resources. Nevertheless, this study offers several strengths, most notably the use of validated assessment tools to evaluate both the quality and readability of patient‐centred online information related to HNSCC. For clinicians, these findings reinforce the importance of directing patients toward reliable, high‐quality resources, while recognizing that even reputable sites may present content above the average reading level. Healthcare organizations, professional bodies, and patient advocacy groups should be encouraged to develop materials that meet both quality and readability standards. The updated tables and figures, now highlighting item‐specific DISCERN performance and quality–readability associations, can inform targeted content development to enhance patient education. Future research should incorporate longitudinal monitoring, apply multivariate analytical techniques, and expand to include social media platforms to provide a richer and more actionable evidence base. 5. Conclusions Online information for head and neck cancer patients is often of low to moderate quality and exceeds recommended reading levels, limiting its usefulness for patient education and shared decision‐making. Healthcare organizations and professional bodies should prioritize producing accurate, accessible resources, while clinicians should guide patients toward trustworthy content that complements personalized medical advice. Author Contributions Briana Jansen: investigation, writing – original draft, data curation, validation, formal analysis. Stella Mullane: investigation, validation, data curation, writing – original draft, formal analysis. Bryan Tan: investigation, writing – original draft, validation, data curation, formal analysis. Bobby Joseph: writing – review and editing, validation, methodology. Mohammed Junaid: formal analysis, writing – review and editing. Ramesh Balasubramaniam: validation, writing – review and editing. Agnieszka Frydrych: writing – review and editing, validation. Omar Kujan: conceptualization, methodology, supervision, project administration, writing – review and editing, validation, investigation. Conflicts of Interest The authors declare no conflicts of interest. Jansen, B. , Mullane S., Tan B., et al. 2026. “Patient‐Centred Web‐Based Information on Head and Neck Squamous Cell Carcinoma: Quality and Readability.” Oral Diseases 32, no. 2: 405–411. 10.1111/odi.70098. Funding: The authors received no specific funding for this work. Data Availability Statement The data that support the findings of this study are available from the corresponding author upon reasonable request. 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