Although chemotherapy linguistically refers to any type of treatment with chemicals, it is now specifically used to describe cytotoxic anticancer medications, which are used to treat hematological and solid tumors [1,2]. Chemotherapeutic agents can be used alone or in combination with surgery or radiotherapy to achieve the goal of the treatment, which varies among patients based on many factors. The goal of the treatment may be to cure the cancer completely, control the cancer, stop it from spreading, or to use these agents as a palliative means to ease the symptoms and improve the patients’ quality of life [3]. However, the natural mechanism of action of these chemotherapeutic agents results in relatively a wide spectrum of side effects, which might be unpleasant to the patients.

Despite continuous improvements in chemotherapy for increasing its effectiveness in treating cancer, the public understanding and acceptance of chemotherapy is still debatable. Many misconceptions can occur, thereby causing compliance issues and other problems related to the acceptance of chemotherapy as a treatment modality [4]. Most of the previous studies that assessed the perceptions and experiences of chemotherapy were performed with selected groups of patients who were either surveyed or interviewed [5-8]. However, large-scale studies attempting to understand the public views and conversations on chemotherapy are lacking. Retrieving and analyzing the contents of various social media platforms on this matter serves as an evolving method to gather information about the perceptions, misconceptions, and experiences with chemotherapy as a treatment for cancer. One of the most popular social media platforms that has been explored is Twitter, which is a large microblog wherein users can write up to 280-character messages called tweets and share them with their followers and the public. There are almost 313 million monthly active users who write around 500 million tweets daily [9,10]. In March 2017, it was estimated that the number of the monthly active Twitter users in the Arab world was around 11.1 million [11]. Moreover, the number of their tweets per month in March 2016 was estimated to be 849.1 million tweets, and 72% of them were written in Arabic [11].

Twitter can be useful for exploring public opinions on health-related matters and it may play an important role in clinical settings by providing an avenue for patients to increase their knowledge regarding their diseases and by leading to a positive impact on their medical outcomes [12-14]. For example, a study showed that the mental health of the patients was affected by social media content, as positive messages were shown to reduce anxiety in patients with breast cancer who were using Twitter [12]. Moreover, social media contents show the public impression and knowledge in addition to their emotions and stress regarding diseases and their associated factors in real time [15,16].

The aim of this study was to report a content analysis of the Arabic tweets regarding chemotherapy to determine the categories of the contents and to explore the possible cases of misconceptions about chemotherapy in the Arab world. This study addresses the common areas of misconceptions on cytotoxic chemotherapies in Arabic Twitter conversations, which may help to direct the future educational efforts to address these areas of misconception.

The aim of this study was to assess the types of conversations and misconceptions regarding chemotherapy among Twitter users in Arabic-speaking populations. Given the large number of tweets retrieved, with their further spread via retweets, our study solidified the conclusions of previous studies that showed Twitter as a rich social media platform for obtaining health-related information [19-23]. Therefore, understanding these social media websites and having a glimpse of what is shared on these websites might serve as an important step for physicians to improve the health care delivered to their patients.

Twitter also represents a growing venue for researchers to analyze on what is shared about various topics of interest in health care either related to oncology [13-19] or related to topics on other health care fields (eg, antibiotics [24], vaccinations [25], smoking [26,27]). Twitter provides researchers and health care organizations with an opportunity to outreach a wide group of participants, overcome barriers pertaining to research resources, and track emerging health-related discussions and problems in real time [28,29].

In our manual content analysis, the most common theme of the tweets was “prayers and wishes.” This finding highlights a possible role of social media platforms as a support mechanism for patients with cancer receiving chemotherapy. Previous studies have also shown that social media platforms play a positive role in optimizing health care interventions [30], particularly in oncology settings [31].

Tweets containing misconceptions accounted for 7.0% (2084/29,904) of the total tweets in our sample population, making it the second most common theme. A further analysis of the misconceptions showed that most of these misconceptions were on the unrealistic side effects of chemotherapeutic agents, and people who do not have the knowledge or the experience of chemotherapy may tend to exaggerate their harmful effects, as reported in a previous study [5]. Therefore, health care organizations and professionals must tailor their awareness activities to target such common misconceptions in a given population.

Most of the tweets on media-related accounts delivered misconceptions about chemotherapy. We also found that when there was a spike in the misconceptions during the study period, the contributions of the cancer specialists and health-related accounts also increased proportionately to correct these misconceptions and to answer the questions of other users. This proportionate increase can limit the dissemination of misconceptions because cancer specialists and health-related accounts check the medical information that is tweeted and provide reliable information through tweets prior to sharing with the followers on Twitter. Further, heath care organizations can promote the true information shared by cancer specialists and health-related accounts by using the payable option offered by Twitter to show a certain tweet in search results and user feeds so that wide groups of the targeted population can be reached with reliable information [32].

Among the themes of the studied tweets, those containing prayers and wishes were the most common. This finding corroborates that reported in previous studies that showed that religious coping strategies were the most commonly followed strategies by patients with cancer [33]. A study on Arab women in Israel who had breast cancer showed that most of them used religious coping skills to actively cope with their disease [34].

This study had the following limitations. First, even though we searched for tweets containing representative spelling variations and abbreviations for the word “chemotherapy” in Arabic, there is still a possibility of some tweets being missed. For example, some tweets may have not mentioned chemotherapy directly but may have tweeted about it indirectly. Second, even with the large number of tweets retrieved and analyzed, the representativeness of the users and their age groups to the whole Arabic-speaking populations cannot be guaranteed. Third, the period of the study was 6 months. Longer study periods (eg, 1 year) will possibly give a broader view and include seasonal spikes such as special occasions such as Ramadan wherein prayers and wishes for recovery can increase, which might add valuable information to the current findings. Fourth, lacking automated content analysis might limit the reproducibility of the findings to some extent. Fifth, the generalizability of the findings is limited as tweets were subjected to multiple external factors that could not be controlled such as the timing of the tweets and the geographical place wherein the users lived [35]. Lastly, some users may have appeared multiple times within the data set which, to some extent, limits the interpretation of the statistical analysis, as their views on the matter being discussed might be overrepresented. Future studies should account for bots and assess for their contributions in conversations about chemotherapy on Twitter.

In conclusion, our findings corroborate those of the previous studies that showed Twitter as a valuable social media platform to assess public perception and misconceptions about various health-related topics. Most of the tweets in our sample population showed supportive messages for patients undergoing chemotherapy, thereby suggesting that Twitter could play a supportive role for such patients, while the second most prevalent theme of the tweets in our study was misconceptions about chemotherapy. The findings of our exploratory analysis can help physicians and health care organizations tailor educational efforts in the future to address the common areas of misconceptions about chemotherapy, thereby leading to increased public acceptance of chemotherapy as a suitable mode of treatment for cancer.