Quality and Readability of Online Skin Cancer Patient Education Materials: A Cross-Sectional Study

Technical Summary: Quality and Readability of Online Skin Cancer Patient Education Materials

Problem Statement
Patients increasingly rely on online resources to understand dermatologic conditions, particularly skin malignancies like melanoma, basal cell carcinoma (BCC), and squamous cell carcinoma (SCC). Early recognition and management of these conditions are critical, making accessible online education vital. However, significant concerns persist regarding the dual metrics of quality (reliability and comprehensiveness of information) and readability (the educational level required to comprehend the text). While guidelines recommend patient materials be written at a Grade 6–8 reading level, existing literature suggests many resources exceed this threshold, potentially limiting comprehension. Furthermore, the relationship between these two domains remains unclear; it is often assumed that simplifying text for readability might compromise the informational quality or accuracy of the content. This study addresses the gap in understanding whether high-quality dermatologic education materials inherently possess lower readability, or if these constructs are independent.

Methodology
The authors conducted a cross-sectional analysis of 19 publicly available websites providing patient education on melanoma, BCC, and SCC. The study design replicated typical patient search behavior using Google on March 13, 2026, selecting the first set of relevant, non-duplicate results that contained written educational content (excluding professional-only sites, multimedia-only sites, and peer-reviewed journals).

Two primary domains were evaluated using validated instruments:

1. Quality Assessment: The DISCERN instrument was used to assess the reliability and quality of consumer health information. Scores were calculated on a scale where higher values indicate better quality, categorized from "very poor" (15–26) to "excellent" (63–75).
2. Readability Assessment: The Simple Measure of Gobbledygook (SMOG) index was the primary metric for estimating the grade level required to understand the text. To ensure robustness, additional indices were collected for descriptive analysis, including the Gunning Fog Index, Automated Readability Index (ARI), and Flesch-Kincaid Grade Level.

Statistical Analysis
Data were analyzed using R. Continuous variables were summarized using means and standard deviations. The association between quality (DISCERN) and readability (SMOG) was assessed using Spearman's rank correlation coefficient to account for potential non-normal distributions. Additionally, websites were stratified into two groups based on a SMOG cutoff of 8 (recommended reading level): those meeting the threshold (SMOG ≤ 8) and those exceeding it (SMOG > 8). The Wilcoxon rank-sum test was used to compare DISCERN scores between these two groups. A two-sided p-value < 0.05 was considered statistically significant.

Key Results

• Overall Quality: The mean DISCERN score across the 19 websites was 50.0 ± 13.32, indicating a moderate overall quality of online dermatologic patient education materials.
• Readability Levels: The mean SMOG score was 7.79 ± 1.42 (median 8.16). While the mean approached the recommended Grade 6–8 threshold, the median exceeding Grade 8 suggests that a substantial proportion of websites require reading skills above recommended levels. Other readability indices (Gunning Fog, ARI, Flesch-Kincaid) consistently indicated reading levels at or above recommended thresholds.
• Correlation Analysis: There was no significant correlation between DISCERN scores and SMOG scores (Spearman's ρ = −0.057, p = 0.817). This indicates that higher-quality websites were not associated with either higher or lower readability levels.
• Group Comparison: When comparing websites that met the recommended readability level (SMOG ≤ 8) against those that exceeded it (SMOG > 8), there was no statistically significant difference in their DISCERN scores (50.1 ± 13.9 vs. 49.9 ± 13.6; p = 1.00).
• Subgroup Analysis: Analyses stratified by condition (melanoma, BCC, SCC) revealed no consistent patterns suggesting that quality or readability challenges were specific to any single type of skin cancer; limitations appeared systemic across dermatologic conditions.

Significance and Claims
The study concludes that online dermatology patient education materials currently demonstrate moderate quality but frequently approach or exceed recommended readability levels, potentially hindering patient comprehension.

Crucially, the paper claims that quality and readability are independent constructs. The absence of a significant relationship suggests that improving the accessibility (readability) of patient materials does not inherently compromise their informational quality. This finding challenges the assumption that simplifying medical information necessitates a trade-off in accuracy or reliability.

The authors assert that these results highlight a clear opportunity for healthcare providers and institutions to develop and curate resources that are simultaneously high-quality and accessible. By demonstrating that readability can be optimized without sacrificing quality, the study supports the potential for enhanced patient understanding, shared decision-making, and adherence to treatment recommendations in the context of skin cancer care. The authors note that while their sample size was modest and the design cross-sectional, the use of validated tools and real-world search simulation strengthens the relevance of their findings to current online health information landscapes.