Introduction

Melanoma is one of the leading causes of cancer deaths in the young and middle-aged populations [1], with a steadily growing incidence worldwide [2]. Although advanced melanoma is a fatal disease with stable mortality rates [1, 3], early stages of the disease have excellent prognosis (http://emedicine.medscape.com/article/280245-overview), placing a crucial role on primary (avoidance of risk factors) and secondary prevention (screening). Searching for health- and disease-related information on the Internet has become common among Internet users [4]. Most of this information is uncontrolled [5], and the typical reader can find it difficult to identify and filter out quality, objective data. Bichakjian et al. have investigated the quality of melanoma information available on the Internet, focusing on the North American English-speaking population. They found that basic information (general aspects, risk factors, diagnosis, treatment, prevention, and prognosis) was often neglected or absent, and inaccuracies were common [6]. It has been previously reported that non-English-speaking populations search the Internet predominantly in their native language [7]. In a 2001 study, Berland et al. [8] reported a difference in Web site quality in English- and Spanish-speaking sites on breast cancer information, with deficiencies in the Spanish Web pages.

Several certification systems exist for indentifying quality and reliable health information on the Internet. The oldest and most frequently used multilingual code for ethical conduct for medical- and health-related information on the Internet is the Health On the Net Foundation Code of Conduct (HONcode), created by the Health On the Net Foundation (HON).

Two recent comprehensive multilingual studies have demonstrated a lack of HON-validated oncologic sites and differences in oncologic health information quality among Western European languages [9, 10].

A multilingual evaluation of melanoma information quality on the Internet in Czech, Hungarian, and German languages has been, to this date, not reported. Based on preceding studies [9, 10], we hypothesize that although the amount of validated sites will be low, the contents will be of comparable quality. Assessing the quality of melanoma-related information available on the Internet in Czech, Hungarian, and German languages may help to identify and point out shortcomings and inaccuracies and eventually promote improvement of melanoma-related Web content quality.

Methods

Among the various search engines, Google is the most popular (www.searchenginewatch.com) and has been previously used in other studies [11]. Using country-specific versions of Google search engines, we retrieved the first 25 universal/uniform resource locators (URLs) by searching the word “melanoma” in the given language. Multiple Web sites were excluded. The retrieved URLs were screened for certificate of HON accreditation using the HONcode Toolbar (downloaded from www.hon.ch), and information content was assessed using a 35-point checklist developed and previously applied by Bichakjian et al. [6] (Table 1). The checklist is based on multispecialty consensus using the knowledge from the Michigan Multidisciplinary Melanoma Clinic (MDMC) and uses the NCCN melanoma guideline as control. The searches occurred between April 1 and 10, 2013.

Table 1 Thirty-five-point checklist for assessing information quality
Full size table

Table 2 lists the retrieved Web sites in alphabetical order for the Internet version only.

Table 2 List of the examined Web sites in alphabetical order
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Results

HON Certification

Four (19 %) of the examined German, one of the Hungarian (4 %), and none of the examined Czech Web pages were HON certified.

Thirty-Five-Point Checklist

German language Web sites contained the highest amount of correct information followed by Czech and Hungarian language Web pages; this trend was observed in most of the subcategories.

General information, such as melanoma definition, incidence, signs and symptoms, and etiological role of sunshine, were mentioned most frequently, followed by risk factors, diagnosis, prevention, and treatment. These were reported in similar extent within a given language.

Prognosis was poorly reported in each of the examined languages. None of the Czech and less than one quarter of the German Web sites provided such information.

In the other subcategory factors, information about self or MD screening and epiluminescence were most frequently available on the examined Web sites. Non-cutaneous melanoma, follow-up, genetic testing/studies, emotional distress, and support groups were mostly ignored in the Hungarian and Czech Web pages, in contrary to German language URLs, where more than one third of the Web sites provided correct information. The risks associated with indoor tanning were reported by no greater than one third of the Web pages in each language. A significant number of Web sites contained incorrect information, most of which was found in Hungarian Web sites, followed by Czech and German URLs.

Discussion

The Internet is an important source of health information for patients and the general public and has a proven role in aiding patients' medical decisions [12, 13]. Public awareness of melanoma has risen in the recent years, partially due to the emergence of international screening programs [14, 15]. It has been demonstrated that melanoma patients actively use the Internet to search for information about their diagnosis [13], and the Internet may be the first source of information for the healthy population before visiting a health professional.

Despite its potentially significant public health role, only a few studies have assessed the quality of health information on the Internet [6, 10, 16–18]. Bichakjian and colleagues [6] created a 35-point checklist to investigate the quality of melanoma information in English language Web sites. They found that only 8 of the 35 points were present in at least half of the studied pages, melanoma definition being the most abundant, followed by prognosis, signs and symptoms, etiology (sun), treatment (local surgery), diagnosis (tumor thickness, biopsy), and treatment (distant). Risk factors (with the exception of personal melanoma history) and prevention were mentioned in approximately one third of the evaluated sites. The other factors were poorly reported, and 14 % of the evaluated Web pages contained inaccuracies. Lawrentschuk et al. [10] performed a comprehensive multilingual study, evaluating and comparing malignancy Web sites of major Western European languages (English, German, French, and Spanish). They found that French sites had the highest percent of HON certification, followed by English, Spanish, and German Web pages. Specifically, regarding melanoma, English Web sites had the highest rate of HON accreditation followed by French, German, and Spanish.

In our study, we had found a significant difference in the amount of German, Czech, and Hungarian Web sites that contain extensive, correct information based on the 35-point checklist [6]. The highest amount of correct and informative melanoma Web pages were found in German language. This could be explained by possibly different educational Web content fundings in the German language regions. Despite of this, we had found at least one high-quality Web site among the retrieved Czech and Hungarian URLs as well. The amount of HON-certified Web sites was surprisingly low. Although other certification systems were not reviewed in this study, one might speculate that a general lack of knowledge or direct motivation of Web site providers as well as pure marketing purposes could explain the fact that majority of the sites do not follow the HON principles. While HON does not filter the Internet for content quality, it guarantees a set of ethical standards in the presentation of information, enabling the readers to know the source and purpose of the provided information. Educating Web content providers, health professionals, and the general public about such systems and tools (free downloadable HONcode Toolbar, www.hon.ch/HONtools/Patients/index.html) could be an important step towards improving health information quality on the Internet.

Incorrect information was found in each of the investigated languages. While some of this malinformation may have a relatively small significance for the public (“Clark level means stage of the disease (http://www.nccn.org/patients/patient_guidelines/melanoma), a good enough dermatologist is able to detect melanoma by simply looking at the lesion”), most of it could mislead and potentially harm the reader. Two similar content commercial Web sites that require distinct mention are the Hungarian sites www.max-immun.hu and www.vargagyogygombak.hu, operated by the same company, engaging in the production and distribution of dietary supplements. Videos found on these sites contain serious malinformation presented by the company owner, such as “melanoma is more common on non-sun-exposed skin surface (http://www.nccn.org/patients/patient_guidelines/melanoma), melanoma is the most common cancer type in the Caucasian population (http://seer.cancer.gov) and is not caused by sunshine but radio waves, sunshine has anticancer effect, and apigenin is a very strong anti-melanoma substance that prevents metastasis formation and destroys metastatic tumors” (http://www.nccn.org/patients/patient_guidelines/melanoma; http://seer.cancer.gov; [19, 20]). The importance to filter out and correct such potentially very harmful and misleading information is evident but can be difficult to realize due to the highly unregulated and diverse nature of this medium.

An important, but so far poorly studied aspect of patient education through the Internet is the population's variable level of knowledge and technologic skills, which highly influences the comprehension of the provided health information. A recent study by Marble et al. reports that melanoma patients acknowledge and prefer the incorporation of technology (DVDs, Internet, computer-based programs) into their education about melanoma [21]. While the relative ease of access, wide availability make the Web a powerful potential health-educating tool, it is difficult for the general public to identify and filter out correct, quality information. Based on our results, a major part of the retrieved German, Czech, and Hungarian melanoma Web sites lacked comprehensive correct disease information. This clearly indicates the need to improve melanoma-related Web content quality in these languages with the help of health professionals and certification systems, such as HON. In case of melanoma, prevention and early detection hold the key to effective disease control (http://emedicine.medscape.com/article/280245-overview), which places a crucial role on patient education. Based on our findings as well as other findings [6, 9, 10], the Internet is a yet to be improved tool for effective patient education in the field of oncology.