Health Information Quality on
the Internet in Urological Oncology:
A Multilingual Longitudinal Evaluation
Nathan Lawrentschuk, Robert Abouassaly, Nadia Hackett, Ryan Groll, and Neil E. Fleshner
To compare the quality of uro-oncological Web sites, to assess for language or disease differences
across Western languages, and to perform a longitudinal comparison between 2004 and 2009.
Uro-oncological Internet information quality is considered variable but no comprehensive
Health on the Net (HON) principles may be applied to Web sites using an automated toolbar
function. Using the Google search engine (http://www.Google.com), in 2004 and 2009, 2400
Web sites were assessed using the keywords prostate, bladder, kidney, and testicular cancer in
English, French, German, and Spanish. The first 150 Web sites in each language had HON
principles measured–a comparison between 2004 and 2009 was done. A further analysis of site
sponsorship was undertaken.
Regardless of language or cancer type, most sites are not HON accredited. English has consis-
tently more than English, French, Spanish, or German. For the respective languages in 2009,
prostate has the most (29, 14%, 16%, 12%), followed by bladder (29%, 22%, 14%, 13%), kidney
(25%, 15%, 10%, 13%), and testis (26%, 19%, 7.11%). Significant differences were found
comparing language and organ groups. The quality improved from 2004 to 2009. Nonprofit
organizations (51%), government and/or educational (39%), commercial (20%), with urologists
last (14%) were accredited.
A lack of validation of most uro-oncological sites should be appreciated by urologists. Addition-
ally, there is a discrepancy in quality and number of Web sites across uro-oncological diseases and
major Western European languages, but with some improvement seen recently. We need to
encourage informative, ethical, and reliable complimentary health Web sites on the Internet and
direct patients to them.
UROLOGY 74: 1058–1063, 2009. © 2009 Elsevier Inc.
As many as 86% of North American adults with access to
the Internet are independently accessing health Web
sites for medical information and education.1For ? 15
years, the Internet, like any form of media, has been used
by people having commercial interests as well as by
physicians, educational bodies, and patient advocates.2,3
However, the quality of information provided is variable,
so better guidance is required for patients to understand
their disease and interpret such information.4
Patients are faced with a confusing array of treatment
options in uro-oncology, particularly in prostate cancer.5
However, without the rigors that are applied to journal
he Internet is an easily accessible source of
health-related information, making it a powerful
tool for patients and health care providers alike.
publications in place, the quality of Internet resources is
largely unregulated. There is a danger of misinformation
leading to a negative effect on patient’s understanding,
expectations, choice of therapy, choice of care, and ulti-
mately quality of life.6,7
Physicians are also placed in difficult situations when
confronted with Internet resources and need tools to
identify quality information for themselves and to direct
patients. Several systems have been engaged to help
identify quality and reliable health information. The
Health on the Net (HON) Foundation is a respected
not-for-profit accreditation body supported by the World
Health Organization, which is multilingual and has the
goal of accrediting health Web sites using key principles
of authority, complementarity, confidentiality, attribu-
tion, justifiability, transparency of authorship, sponsor-
ship, and advertising.8
We set out to compare the quality of the content of
uro-oncological Web sites on the basis of the HON
principles, with the additional ability to conduct a lon-
gitudinal analysis comparing quality between 2004 and
From the Division of Urology, University Health Network (UHN), University of
Toronto, Toronto, Canada
Reprint requests: Nathan Lawrentschuk, M.B.B.S., F.R.A.C.S., Division of Urology,
Department of Surgical Oncology, Princess Margaret Hospital, 610 University Ave 3-130,
Toronto, Ontario, M5G 2M9 Canada. E-mail: email@example.com
Submitted: March 23, 2009, accepted (with revisions): May 19, 2009
© 2009 Elsevier Inc.
All Rights Reserved
2009. A further aim was to assess for any language or
disease differences with accreditation of health Web sites
across the main Western languages of English, French,
German, and Spanish.
MATERIAL AND METHODS
Using the Google search engine (www.Google.com), in January
2004 and 2009, we performed Internet searches and assessed
2400 Web sites using the keywords “prostate cancer,” “bladder
cancer,” “kidney cancer,” and “testis cancer” in English and
equivalent terms in French (“cancer deprostate,” “cancer de la
vessie,” “cancer du rein,” and “cancer du testicule”), Spanish
(“cáncer de prostate,” “cáncer de la vejiga,” “cáncer del rinon,”
and “cáncer del testiculo”), and German (“prostatakrebs,” “bla-
senkrebs,” “nierenkrebs,” and “hodenkrebs”).
On the basis of the observation that patients rarely access
more than the first page of search results,9the first 150 Web
sites yielded by each search were then identified and sequen-
tially screened for quality as defined by the HON Foundation.
This was done by applying HON principles through the
HONcode toolbar function (downloaded from http://www.
hon.ch/ for use on any personal computer and activates or
“lights-up” toolbar if a Web site is accredited). The HON
function has been used and assessed in several studies and was,
thus, deemed to be a valid and high caliber tool.10
A secondary analysis of the first 150 Web sites in English
encountered in 2009 was undertaken. Firstly, for all 4 uro-
oncological cancers, the Web sites were divided into thirds
(first, middle, and last 50). The proportion of accredited sites in
each organ and language was then analyzed and compared. The
purpose of this analysis was to determine where accredited Web
sites were appearing preferentially, that is, in the pages least
likely (last 50) vs the most likely to be viewed (first 50).
Second, for all 4 uro-oncological cancer groups, an analysis
was undertaken to determine the Web site sponsors and each
was categorized according to a previous study of quality of Web
sites on the Internet.11In summary, the sites were deemed
sponsored by (1) lawyers, (2) nonprofit organizations, (3) gov-
ernment organizations and/or educational institutions, (4) com-
mercial, (5) urologists (and their professional organizations),
(6) other health professionals, or (7) others. Sponsorship was
determined independently by 2 examiners; first, by the web
page retrieved, and then if the sponsorship was not obviously
apparent, the Web site was explored until sponsorship could be
determined. The concept of sponsorship is not to be confused
with the Google terminology of “sponsored links,” either high-
lighting pages at the start of retrieved search or appearing on
the side of the page under a banner. Such pages were ignored
throughout the entirety of this study.
For quality control, English search (“prostate cancer”) had
nonaccredited sites within the first 150 discovered Web sites
manually evaluated, using the HON criteria to determine their
HON status to ascertain whether they fulfilled it despite not
being “officially” accredited. Comparisons of proportions across
types of cancer and language were performed using ?2test (or
Fisher exact tests) when cell counts were ? 5. All statistical
tests were 2-sided, and significance was defined as P ?.05.
Analyses were performed, using SAS 9.1 (SAS Institute, Inc,
The interval between 2004 and 2009 saw increases in the
number of Web sites dedicated to uro-oncological dis-
ease. Growth was dramatic across all languages and dis-
ease groups, but particularly in French and Spanish (Ta-
ble 1). Regarding total percentage of HON accredited
sites (PoHONA) by organ group, there were significant
differences in all but kidney between 2004 and 2009.
Again, this increase was reflected by linguistic group in
all but Spanish, in which an insignificant decrease oc-
curred (Table 1).
Regarding disease group, there were significant differ-
ences by PoHONA (columns, Table 2). The English
language results by organ group had a greater PoHONA
overall against all other language searches, which was
more pronounced in prostate and bladder cancer and this
tended to contribute to the organ group differences. This
held true for both 2004 and 2009, but also between these
years there were minor increases in PoHONA for pros-
tate cancer for all languages (Table 2) except the Ger-
man that increased from 3% to 12%. Again, the increase
in PoHONA for bladder was minor except for French
that doubled from 11% to 22%. Kidney had modest
increases across all languages, whereas testicular cancer
had vast increases except for Spanish where the
PoHONA decreased from 19% to 17%.
Regarding linguistic differences (rows, Table 2), there
were significant differences noted between disease group
PoHONA across the English search (P ? .004) only in
2004. This was primarily because of the low PoHONA
for testis cancer of 10%, which grew dramatically to 26%
in 2009. For 2009 and for all other languages in both
years, no linguistic difference occurred across languages.
The manual accreditation for the first 150 “prostate
cancer” (English) found 41 were accredited by HON
toolbar, with 109 nonaccredited by the HON toolbar.
Ten of those nonaccredited met Hon criteria manually
(9%) in 2004, with a similar result after the same calcu-
lation in 2009 (9.4%); thus, 91% of those nonaccredited
did not meet HON criteria.
The proportion of accredited sites by thirds in each
disease and language was remarkably similar (Table 3). In
summary, accredited Web sites appeared preferentially in
the pages most likely to be viewed (first 50) in all but 2
scenarios (testis in English, bladder in French). However,
the differences between the thirds were rarely significant
(P ?.05), except in bladder cancer (all languages) and in
prostate cancer (Spanish and German).
The sponsor analysis of the 150 Web sites in English
for 2009 (Fig. 1) determined no significant difference
between organ groups (P ? .1405). Commercially, spon-
sored Web sites made up ? 50% of each disease group.
Interestingly, no other health professional was found
independently sponsoring a Web site because they gen-
erally formed part of a commercial reference or were
grouped with urologists who were deemed the primary
site sponsor. Also, if one examined the number of ac-
UROLOGY 74 (5), 2009
credited Web sites by sponsor group, the most commonly
accredited sponsor group were nonprofit organizations
(51%), government organizations or educational institu-
tions (39%), commercial sites (20%), and finally urolo-
gists and their organizations (14%). The other sponsor
groups were not accredited.
Incredibly, millions of Web sites offering multilingual
uro-oncological information exist. The past 5 years have
seen immense growth, particularly in French and Spanish
Web sites as well as for prostate cancer Web sites. Un-
derpinning this growth has been the choices in manage-
ment of the major urologic malignancies such as pros-
tate,12kidney,13bladder,14and testis,15with new systemic
therapies, active surveillance, organ preservation, altered
biopsy indications, and emerging technologies such as ro-
botics, influencing decisions.16,17Marketing and econom-
ics are also now larger drivers of information on the
Internet.2,18Faced with a diagnosis of urologic cancer,
many patients are turning to health Web sites for guid-
ance on the etiology, diagnosis, management, and treat-
ment of their disease.19It is difficult to delineate fact
from fiction.20,21Few studies have addressed the quality
Table 1. Total Web sites retrieved and total accredited Web sites from 2004 and 2009. The P values are comparing for
differences across language or disease group between 2004 and 2009 for total accredited Web sites
Total Web Sites
Total HON-accredited Web sites %
20042009 % IncreaseP
Table 2. Total percentage of HON-accredited (PoHONA) Web sites for 2004 and 2009
P (comparing by organ)
P (comparing by organ)
Prostate Bladder Kidney TestisP (Comparing by Language)
? .001.0018 .0032
UROLOGY 74 (5), 2009
of information in uro-oncology,22,23and certainly not
across all major malignancies.
Considering the overall quality of information avail-
able on the Internet for uro-oncology, regardless of lan-
guage or cancer type, most sites are not HON accredited.
This in itself is an important finding for uro-oncology and
has not been previously reported. Concerns have been
raised about the quality of information in other malig-
nancies. Clearly, this makes evaluation of Web sites
difficult not only for patients, but for physicians, leading
to distrust of Internet cancer resources.7,24This occurs
because unaccredited Web sites have other, often hidden
agendas such as promotion of certain treatments, com-
mercial advertising, and thus lack balance. This was
supported by our audit of prostate cancer Web sites
finding only around 9% of unaccredited sites that meet
the HON standards.
Perhaps the only positive outcome is that information,
in general, is improving. Examining the results more
closely by organ group, there were significant differences
between 2004 and 2009 for the PoHONA sites, except
for kidney cancer. Deficiencies in Web site quality for
testis and kidney cancer appeared to be somewhat ad-
dressed. The differences between 2004 and 2009 were
also reflected by linguistic group in all except Spanish, in
which an insignificant decrease occurred. The decrease in
Spanish is surprising and looking into detail, prostate and
bladder cancer PoHONA sites actually increased, whereas a
marginal decrease was found with testis cancer and larger
decrease with kidney. These 2 reductions in PoHONA
were the only ones reported in the study and cannot be
explained by pure increase in Web site totals, as bladder
and prostate had similar or larger increases, suggesting
that other linguistic factors must be responsible.
English language searches routinely returned more ac-
credited sites than all other French, Spanish, and German
searches in 2004 and 2009. This was more pronounced in
prostate and bladder cancer, probably reflecting their
incidence in the community. In 2009, considering the
linguistic groups, homogeneity exists, meaning that the
number of PoHONA Web sites (either low or high) was
consistent for each disease. This translates to a patient
with one disease or another not being significantly dis-
Given that the HON foundation has multilingual fa-
cilities one would expect that over a time, accreditation
across all languages will continue to improve. Sponsors
recognizing that the Internet is accessed by a multilingual
audience and, hence, tailoring sites is one initiative.25
The European project MedIEQ (Quality Labeling of
Medical Web Content Using Multilingual Information
Extraction) may assist with quality and dissemination but
awaits implementation.26Finally, quality improvements
for patients may be made using multilingual Internet
search engines within already trusted sites (eg, HON
foundation Web site).27
PoHONA appears to be a valid tool for rating quality
of Web sites, as our manual search found ? 10% of sites
with quality equal to HON code principles in the highest
subgroup of Web sites (“English” and “prostate cancer”).
HON provides a seal that can be posted on sites operat-
ing in accordance with the principles of the code after
evaluation.8Yet, it is by no means the only way to rate
quality. The eHealth Code of Ethics (eCode), (www.
ihealthcoalition.org), is quality initiative, including broad
principles for site design and evaluation.7Further guide-
lines by hi-Ethics (www.hiethics.org/Principles/index.
asp), a nonprofit organization, has a stated goal to estab-
Table 3. Results of the secondary analysis of the first
150 Web sites in English encountered in 2009 after
dividing into thirds (first, middle, and last 50 web sites)
Figure 1. Results of the analysis of the sponsors for all 4
uro-oncological cancer groups for the search in English for
2009 (n ? 150).
UROLOGY 74 (5), 2009
lish and comply with the highest standards for privacy,
security, credibility, and reliability. Finally, a more com-
mercial organization, the Utilization Review Accredita-
tion Commission (www.urac.org) requires a fee for ac-
creditation.7Other available validated tools to improve
written health information exist and may be used by
health consumers with no previous knowledge (eg,
DISCERN instrument, www.discern.org.uk), but are far
more intensive than a simple toolbar function.
Some other reassuring data were obtained from the
study. Of those sites accredited, more often than not they
appeared in the first 50 sites or first 5 pages of a search.
This is important as consumers rarely access more than
the first page of search results.9Less reassuring was the
reality that only 14% of urologist-sponsored Web sites are
accredited as compared with more than half of nonprofit
sites, with no significant differences between groups. It is
up to urologists to encourage their hospitals, academic
institutions, and representative bodies to improve quality
by fulfilling ethical principles such as those espoused by
Hon foundation. An awareness by physicians that more
than half of the Web sites encountered in uro-oncology
will be of a commercial nature (with only 20% accred-
ited) is also important, and this confirms data obtained in
prostate cancer in the past.22
Among patients seen by urologists, Internet use is
relatively high28and within uro-oncology, it is not sur-
prising that most quality assessments have been done
with prostate cancer22and screening.29Bladder has 1
study,23whereas testicular and kidney cancer are devoid
of any quality assessments of Internet information. None
have used a function such as HONcode and rely on
manual assessment of quality. For prostate cancer, Black
and Penson22found numerous shortcomings especially
related to currency, disclosure, and attribution, generat-
ing highly variable and deficiency of evidence found on
many sites. Lee et al23found information on bladder
cancer incomplete and inaccurate in a third of cases
retrieved from Web sites. Results from our study indicate
lower levels of accreditation for kidney and testis, and
this may translate into even poorer quality than from
prostate and bladder cancer.
To assist clinicians and patients with decision making
in uro-oncology, there are an increasing number of no-
mograms and other tools, such as prostate-specific anti-
gen doubling time and velocity, with many available on
the Internet. The sheer volume of such tools is making
even surgeons doubt their ability to add to decision
making.30We need better evidence about the usefulness
of data on the Internet. A randomized controlled study
comparing alternative approaches for men considering
prostate cancer screening, for example, found public Web
sites about prostate cancer less effective than specially
designed Internet aids.29
Perhaps a final element that was surprising was that
given the approval of 3 new targeted agents for the
management of metastatic kidney cancer since 2006, one
may have expected the number of Web sites dealing with
kidney cancer to have had a greater increase during the
period examined. Clearly, information on the Internet is
still lagging for this tumor type and one may speculate
that the lack of complete responders to the agents, the
slow approval process in some countries, and perhaps cost
of the agents have all contributed to it.
Certainly, there are limitations of any study of the
Internet. First, we concede there are many search engines
but Google is the most popular in all languages (http://
searchenginewatch.com and www.multilingual-search.
com) and has been used in other studies.11As with any
search engine, we rely on language filters to determine
sites retrieved, but the Google search engine is sophisti-
cated and does allow a multilingual approach. Specific
countries may also have popular search engines used
specifically for health that we did not study. Other issues
such as contextualizing information within different cul-
tures and integrating with other sources with respect to
urologic cancers cannot be assessed, and this remains an
In light of the rise in patient and physician use of Inter-
net-base health information, a lack of validation of most
uro-oncological sites should be appreciated. Further,
there is a discrepancy in quality and number of Web sites
across uro-oncological diseases, and across major Western
European languages. However, quality improvements
have occurred in all cancers and languages. At present,
the HONcode toolbar is an easy tool that makes identi-
fication of suitable sites easy and reliable. As physicians,
we need to encourage informative, ethical, and reliable
complimentary health Web sites on the Internet and
direct patients to them.
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Ever-increasing patient autonomy, combined with limitless ac-
cess to information through the Internet, has allowed patients
to play a greater role in their medical decision-making in the
last 10 years. In my own practice, it is not uncommon to have
a patient with a newly diagnosed disease show up at their first
appointment, with a stack of printouts from their Google and
Wikipedia searches. Often they have already made a decision
about their course of therapy, and they are only showing up to
book a date.
However, much of the data available through search and
various wikis are not subjected to the same rigors of peer review
and disclosure that we take for granted in our own published
data. Wikipedia, for instance, is one of the top 10 listings found
on various search engines, including Google, for 71%-85% of
all medical searches conducted.1Yet, there is no disclosure or
qualified peer review on subjects such as “prostate cancer” or
“bladder cancer.” The anonymous authors and reviewers may be
experienced researchers in those fields, or they could be merely
interested amateurs or individuals with a financial interest. In
fact, looking across all medical searches, 70% of studies found in
search evaluating the components of accuracy, completeness,
readability, design, disclosure, and referencing have found the
queried information to be lacking.2
The authors do a fine job of introducing the Health on the
Net (HON) concept, and they also demonstrate how few uro-
oncology sites that are early hits on Google across languages
adhere to the principles outlined. This differed according to
language, and did seem to improve with time. As the authors
conclude, it remains us, the physicians, who “need to encourage
informative, ethical and reliable complimentary health websites
on the Internet and direct patients to them.”
Ryan K. Berglund, M.D., Glickman Urologic and Kidney
Institute, Cleveland Clinic, Cleveland, Ohio
1. Laurent MR, Vickers TJ. Seeking health information online: does
Wikipedia matter. J Am Med Inform Assoc, in press.
2. Eysenbach G, Powell J, Kuss O, et al. Empirical studies assessing the
quality of health information for consumers on the World Wide
Web: a systematic review. J Am Med Assoc. 2002;287:2691-2700.
UROLOGY 74: 1063, 2009. © 2009 Elsevier Inc.
UROLOGY 74 (5), 2009