According to a recent systematic review and meta-analysis of cross-sectional surveys from various health care institutions, approximately 39% of individuals living with cancer use the Internet [1], indicating that online health services have become an important information source for many patients. Such services are prevalent and are varied in their scope, ranging from electronic mail communication with health care providers, friends, family members, and other patients to virtual support groups for patients and caregivers. Due to the vast availability of online health services today, as well as increased patient interest in knowing about the diagnosis, treatment, and follow-up of cancer [2], continued investigation into their impact on the health outcomes of patients with cancer is imperative.

The World Wide Web is the first thing that comes to mind for many people when they hear the phrase “online health services.” However, as noted by Eysenbach [1], while the Web is certainly a common source of health-related information for patients, caregivers, and health care providers alike, online health services encompass quite a bit more than the Web or Internet alone, and a framework of outcomes should be best discussed under the headings “Communication,” “Content,” and “Community” (Figure 1).

Figure 1

Eysenbach's framework of online cancer services and their possible relationships to health outcomes (reproduced with permission from [1], © Lippincott Williams & Wilkins)

Researchers' knowledge about factors that facilitate or impede communication, such as access to, sources of, and trust of cancer-related information, is limited. In an attempt to improve such understanding, the NCI developed the Health Information National Trends Survey (HINTS), the first survey of its kind, to collect data on how Americans seek and use cancer information [17]. First administered in 2001, the survey will be conducted every two years to advance understanding and to bridge the gaps between the information patients want and need about cancer and the information they actually receive.

While the development of the NCI's HINTS instrument is an impressive step in facilitating awareness of the many ways in which individuals receive health information, perspectives on whether online health services have more positive or negative effects on patients remain varied. For example, researchers who conducted a study of Canadian oncologists and their patients determined that patients were three times more likely than oncologists to view Internet information as helpful to their ability to cope with their disease [18]. However, while a commonly held view on whether online health services are more helpful or hindering to patients does not exist, it is indisputable that accessing these services has some sort of impact on patients and their health outcomes.

As previously mentioned, researchers have discovered a positive connection between accessing information on specific health issues online and the psychological health of women with breast cancer. Of 188 women who were interviewed for a study examining the potential psychological benefits of using the Internet to access information related to breast health, 42% of the respondents used the Internet [12]. Using validated scales to measure social support and loneliness among the women with breast cancer, researchers determined that those individuals who used the Internet for medical information on issues surrounding breast health had more social support in their lives and experienced less loneliness than their counterparts who used the Internet for other purposes or who did not use the Internet at all [12].

Another study of women with breast cancer found that a 12-week, Internet-based social support group—Bosom Buddies—had a distinct impact on the health of the participants. Based on responses to six self-report scales and one group-report scale completed by the 72 women who participated in the study, researchers concluded that the Bosom Buddies support group effectively reduced participants' depression levels, perceived stress, and cancer-related trauma [16].

In an investigation of the relationship between the use of health information on the Internet and patient behavior and self-efficacy, results of a study conducted with individuals newly diagnosed with cancer indicated significant relationships among the variables. Specifically, researchers reported several notable findings: (1) 74% of Internet users compared to 54% of nonusers described their relationship with their physician as a partnership; (2) 81% of Internet users prepared a list of questions for their physician prior to their scheduled visit, while only 54% of nonusers prepared a question list; (3) Internet users (48%) asked six or more questions during the medical visit more often than nonusers (32%); and (4) when compared with nonusers, Internet users felt more confident in being able to participate in treatment decisions and to ask questions of their physicians [19].

Another outcome associated with utilization of online health services is the impact Internet health information has on the physician-patient relationship. In a telephone survey of a nationally representative sample of the American public, researchers found that 31% of the 3209 respondents had sought out health information on the Internet within the previous 12 months [20]. Overall, data from the study indicated that patients believe that online health information positively impacted their relationship with their physician [20]. Patients who perceived their physicians as having poor communication skills were typically the ones who reported that health information found on the Internet had a more negative effect on the physician-patient relationship [20].

While the aforementioned study does not relate solely to patients with cancer, findings from a similar study conducted exclusively with patients living with cancer echo the previous findings. In an attempt to examine Internet use among Australian oncology patients, researchers administered questionnaires to patients in two teaching hospitals in Sydney in 1999 and 2001. Data from both years suggested that information acquired from the Internet was perceived by patients as having either a positive or neutral influence on their relationship with their physician [21]. Notably, none of the 142 patients who completed the questionnaire during the 1999 study and a mere 3% of the 153 patients who participated in the 2001 survey indicated that online cancer information had a negative impact on the physician-patient relationship [21]. The impact of online health services on the physician-patient relationship may not be viewed as an outcome directly related to a patient's physical health. However, it is an important impact to address nonetheless as the quality of the physician-patient relationship has been shown to influence areas that are directly linked to a patient's health. Several studies have demonstrated a positive link between physician-patient communication, patient satisfaction, and positive health outcomes [4,22-24]. For example, after administering satisfaction surveys via telephone interviews with more than 230 adults who had seen a primary care physician within six months of the call, researchers determined that positive interaction and relational communication between physicians and patients significantly affected health outcomes such as compliance with medical treatment [23]. Consequently, the value of examining the impact of online health services on the physician-patient relationship should not be underestimated.

Most of the health outcomes mentioned here related to accessing online health services have been positive; however, negative effects have been reported as well. For example, 38% of 1050 physicians surveyed about their perceptions of the impact of Internet health information on the physician-patient relationship, health care, and workload indicated that clinical visits were less time efficient when patients brought information retrieved online [25]. Only 16% of the physicians surveyed believed that the effect of the patient bringing medical information retrieved online was beneficial [25]. Furthermore, an overwhelming 75% of the physicians noted that the online health information made no difference to the patient's health outcomes; 4% believed that the information was actually harmful to the outcomes [25].

Another study examined depression in people living with cancer using Internet and face-to-face support groups. Researchers found that patients with cancer who are more depressed, as measured by the Center for Epidemiologic Studies Depression Scale (CES-D) [26], use Internet support groups instead of face-to-face groups [27]. Considering that researchers have also found that people—not necessarily people with cancer, but people in general—become more depressed as they spend more time online [28], this finding may have further implications for the health outcomes of people living with cancer.

While obvious benefits are associated with utilization of online health services among individuals living with cancer, such services are not infallible, as shown by several studies illustrating negative health outcomes that may be attributed to online health service use. By accessing accurate, reliable health-related information online, patients have the ability to equip themselves with information that enhances their understanding of and supplements the information they garner directly from their health care provider. However, online health information can often be confusing for patients to decipher, and, perhaps more importantly, it can often be conflicting or erroneous [14].

Notably, more than 70% of Internet users report that their treatment decisions are influenced by health information they find online [6]. For this reason, it is essential that investigation into the accuracy and dependability of online health information as well as the outcomes associated with utilization of online health services remains ongoing. Furthermore, as researchers begin to better understand the short-term impact online health services have on patients, they need to begin to address whether long-term effects exist as well.