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Online patient education materials (OPEMs) are an increasingly popular resource for women seeking information about breast cancer. The AMA recommends written patient material to be at or below a 6th grade level to meet the general public's health literacy. Metrics such as quality, understandability, and actionability also heavily influence the usability of health information, and thus should be evaluated alongside readability. A systematic review and meta-analysis was conducted to determine: 1) Average readability scores and reporting methodologies of breast cancer readability studies; and 2) Inclusion frequency of additional health literacy-associated metrics. A registered systematic review and meta-analysis was conducted in Ovid MEDLINE, Web of Science, Embase.com , CENTRAL via Ovid, and ClinicalTrials.gov in June 2022 in adherence with the PRISMA 2020 statement. Eligible studies performed readability analyses on English-language breast cancer-related OPEMs. Study characteristics, readability data, and reporting of non-readability health literacy metrics were extracted. Meta-analysis estimates were derived from generalized linear mixed modeling. The meta-analysis included 30 studies yielding 4462 OPEMs. Overall, average readability was 11.81 (95% CI [11.14, 12.49]), with a significant difference (p < 0.001) when grouped by OPEM categories. Commercial organizations had the highest average readability at 12.2 [11.3,13.0]; non-profit organizations had one of the lowest at 11.3 [10.6,12.0]. Readability also varied by index, with New Fog, Lexile, and FORCAST having the lowest average scores (9.4 [8.6, 10.3], 10.4 [10.0, 10.8], and 10.7 [10.2, 11.1], respectively). Only 57% of studies calculated average readability with more than two indices. Only 60% of studies assessed other OPEM metrics associated with health literacy. Average readability of breast cancer OPEMs is nearly double the AMA's recommended 6th grade level. Readability and other health literacy-associated metrics are inconsistently reported in the current literature. Standardization of future readability studies, with a focus on holistic evaluation of patient materials, may aid shared decision-making and be critical to increased screening rates and breast cancer awareness. • Average readability was 11.81, twice the recommended AMA 6th grade reading level. • Readability studies measure and report readability with variable methodologies. • Many readability studies (40%) do not measure additional health literacy metrics. • Standardizing readability studies may improve evaluation and usability of OPEMs. [ABSTRACT FROM AUTHOR]

To evaluate the readability, understandability, and actionability of online patient education materials (OPEM) related to breast cancer risk assessment. We queried seven English-language search terms related to breast cancer risk assessment: breast cancer high-risk, breast cancer risk factors, breast cancer family history, BRCA, breast cancer risk assessment, Tyrer-Cuzick, and Gail model. Websites were categorized as: academic/hospital-based, commercial, government, non-profit or academic based on the organization hosting the site. Grade-level readability of qualifying websites and categories was determined using readability metrics and generalized estimating equations based on written content only. Readability scores were compared to the recommended parameters set by the American Medical Association (AMA). Understandability and actionability of OPEM related to breast cancer high-risk were evaluated using the Patient Education Materials Assessment Tool (PEMAT) and compared to criteria set at ≥70%. Descriptive statistics and inter-rater reliability analysis were utilized. 343 websites were identified, of which 162 met study inclusion criteria. The average grade readability score was 12.1 across all websites (range 10.8–13.4). No website met the AMA recommendation. Commercial websites demonstrated the highest overall average readability of 13.1. Of the 26 websites related to the search term breast cancer high-risk, the average understandability and actionability scores were 62% and 34% respectively, both below criteria. OPEM on breast cancer risk assessment available to the general public do not meet criteria for readability, understandability, or actionability. To ensure patient comprehension of medical information online, future information should be published in simpler, more appropriate terms. • The average grade readability score of breast cancer risk assessment online education materials was 12.1 • No website met the AMA recommendation of a sixth-grade reading level. • To ensure patient comprehension, future information should be published in simpler, more appropriate terms. [ABSTRACT FROM AUTHOR]

In this pilot study, we developed and assessed acceptability of a brochure for women with dense breasts. We measured Flesch-Kincaid Readability of 22 existing breast density educational materials. We then developed a brochure and tested it in two populations of women: 44 safety net hospital patients and 13 Breast Cancer Surveillance Consortium stakeholders. Average grade score of existing materials was 10.0 (range: 5.5–12.7). Our brochure had a grade score of 5.9, and patients reported it was easy to understand. Our plain language brochure could improve patient understanding following mandatory dense breast notification. • Readability of 22 existing breast density educational materials was assessed. • Guided by patient advocates, we developed a print breast density educational brochure. • Brochure acceptability was assessed in focus groups and an online discussion group. • Existing educational materials had low readability. • Our brochure had high readability and can be used to support women with dense breasts. [ABSTRACT FROM AUTHOR]

Introduction This study evaluated the readability, accessibility and quality of information pertaining to breast reconstruction post mastectomy on the Internet in the English language. Methods Using the Google © search engine the keywords “Breast reconstruction post mastectomy” were searched for. We analyzed the top 75 sites. The Flesch Reading Ease Score and Gunning Fog Index were calculated to assess readability. Web site quality was assessed objectively using the University of Michigan Consumer Health Web site Evaluation Checklist. Accessibility was determined using an automated accessibility tool. In addition, the country of origin, type of organisation producing the site and presence of Health on the Net (HoN) Certification status was recorded. Results The Web sites were difficult to read and comprehend. The mean Flesch Reading Ease scores were 55.5. The mean Gunning Fog Index scores was 8.6. The mean Michigan score was 34.8 indicating weak quality of websites. Websites with HoN certification ranked higher in the search results (p = 0.007). Website quality was influenced by organisation type (p < 0.0001) with academic/healthcare, not for profit and government sites having higher Michigan scores. 20% of sites met the minimum accessibility criteria. Conclusions Internet information on breast reconstruction post mastectomy and procedures is poorly written and we suggest that Webpages providing information must be made more readable and accessible. We suggest that health professionals should recommend Web sites that are easy to read and contain high-quality surgical information. Medical information on the Internet should be readable, accessible, reliable and of a consistent quality. [ABSTRACT FROM AUTHOR]