Health care providers [1-3] and their patients [4-7] regularly search for health information online. Internet users generally begin looking for health information using a search engine [8-12], an Internet tool that searches for Web pages containing terms specified by users [13]. In February 2004, Google and Yahoo! were the most popular search engines in the United States, with 38% and 32% of market share, respectively [14].

To date, few studies of Internet search activity related to health topics have been published. Most analyzed the proportion of health and non-health searches on various search engines and found that health searches constituted a small percentage of total searches [15-18]. This finding is not surprising given how infrequently Internet users search for health information compared with how often they look for news reports, product information, and other topics [19]. In any case, a small percentage of total Internet searches translates into thousands of health searches each day [16], and an estimated 95 million Americans have used the Internet at least once to search for health information [20].

Cancer appears to be a health topic of some interest to Internet users. Eysenbach and Köhler [16] found that searches for cancer information accounted for 5% of health-related searches on the search engine MetaCrawler. Phillipov and Phillips [18] found that “skin cancer” was one of only 17 health-related search terms among the most popular 300 Internet keywords identified by Wordtracker, a private research company. Bader and Theofanos [21] studied cancer searches conducted using the search engine AskJeeves during a 3-month period and found the most commonly searched cancers were digestive/gastrointestinal/bowel, breast, and skin. This study also compared the incidence of selected cancers with their associated search activity. While this relationship was not statistically tested, the authors observed that some rarer cancers constituted a higher proportion of total searches than their proportion of total cancer incidence. In addition, Bader and Theofanos, as well as Phillipov and Phillips, noted that media coverage appeared to prompt Internet searches for health topics, but they did not systematically investigate or test the relationship.

The study reported here builds on this prior work by analyzing cancer-related searches conducted in the United States from 2001 to 2003 using the search engine Yahoo! Specifically, we investigated three potential correlates of Yahoo! cancer search activity—estimated cancer incidence, estimated cancer mortality, and the volume of cancer news coverage. Cancers that afflicted more individuals, claimed more lives, and generated more news coverage were expected to be associated with more Internet search activity than other cancers, given the interest generated by relevance and publicity. In addition, we assessed the periodicity of Yahoo! cancer search activity and examined sharp increases in Yahoo! search activity related to specific cancer types.

This analysis included three types of 2001–2003 US data: Yahoo! cancer search activity, cancer burden (estimated incidence and mortality), and cancer news coverage. The study protocol was reviewed by the Institutional Review Board of the National Center for Chronic Disease Prevention and Health Promotion and was designated as “research not involving human subjects.”

Yahoo! maintains a database of search activity called the Yahoo! Buzz Index [23]. This index provides a search activity score for individual search terms—the words or characters that users type into the Yahoo! search box. Each point of a Yahoo! Buzz Index score equals 0.001% of users searching Yahoo! during the time period of interest (day, week, or month). For example, if 250 out of a total of 1 million users searched for “breast cancer” on January 1, 2001, the Yahoo! “breast cancer” search activity score on this day would be 25 (250/1 million × 100000). For a search term to register a search activity score, it must generate at least 50 searches during the time period for which the score is calculated. Yahoo! search activity generated by search terms can be segmented by country, US state, or selected US cities. This study used daily US Yahoo! search activity data from January 1, 2001 (the earliest date for which Yahoo! search activity data are available) to December 31, 2003. We limited our analysis to Yahoo! searches because at the time of this study no other Internet search engine offered a dataset like the Yahoo! Buzz Index, which provides search activity scores adjusted for the size of the population searching for online information.

Yahoo! employs professional “surfers” or content indexers who manually classify Web pages into one of more than 2000 content categories, such as “movies,” “footwear,” “astrology,” or “cancer or neoplasms.” The Yahoo! Buzz Index classifies search terms in the same content category as the first Web page link that a user “clicks” or activates after conducting a search. For instance, if a user entered the search term “colon” and then clicked on a cancer website, “colon” would be classified as a “cancer or neoplasms” search term. If the user clicked on a grammar website, however, “colon” in that instance would be classified as an “education” search term. When a user does not click on a Web page link or when a user clicks on a Web page link that has not been classified, the Yahoo! Buzz Index categorizes the search term using a variety of algorithms that analyze recent content viewed by the user.

To identify commonly used Internet search terms related to specific cancers, we reviewed the search terms classified in the “cancer or neoplasms” category of the Yahoo! Buzz Index, which generated at least 50 searches in any month from January 2001 to December 2003. This search strategy identified 76 unique search terms, of which 23 were included in the analysis (Table 1). The remaining 53 terms were discarded because they did not relate to a specific cancer or included non-English words. Discarded terms included drug names or treatment modalities, such as “chemotherapy” (n = 19); the names of organizations or events, such as “Race for the Cure” (n = 16); general cancer or anatomy terms, such as “oncology” (n = 11); names of celebrities, such as “Gilda Radner” (n = 5); and the carcinogen “DES” (n = 1). Also, “leucemia” (n = 1), the Spanish word for “leukemia,” was discarded because the Yahoo! Buzz Index does not consistently track foreign words, as it excludes search terms that contain non-English characters. For instance, the Yahoo! Buzz Index would not capture a search term with an accent mark, such as “cáncer colorectal” (Spanish for “colorectal cancer”).

Table 1 Mean daily Yahoo! search activity score (United States, 2001–2003), estimated incidence, estimated mortality, and number of news reports, by cancer

The relationship between Yahoo! search activity and news coverage was further analyzed for the five cancers with the highest daily Yahoo! search activity. The number of news reports published each day was transformed into a categorical variable with four levels (0 news reports, 1–2 news reports, 3–4 news reports, and 5 or more news reports), and one-way analysis of variance (ANOVA) was used to compare mean daily Yahoo! search activity scores at increasing levels of news coverage. To detect possible periodicity effects, Yahoo! search activity data were visually inspected. Three possible periodicity effects were noted: a rise during weekdays (Monday–Friday) compared with weekends; a rise during national cancer awareness months compared with other months; and a decline during summer months (June–August) compared with other months. These possible effects were tested using t tests. Finally, the Yahoo! search activity associated with several cancers was marked by sharp increases of 100% or more from one day to the next. For these cancers, we identified the three highest peaks in 2003 Yahoo! search activity and investigated corresponding news events.

We found Internet search terms generating Yahoo! search activity associated with 21 of the 23 cancers included in the study (Table 1). Of these, 19 cancers were associated with only one Yahoo! search term each. The 2 remaining cancers were associated with two search terms each: cancers of the brain (“brain tumor” and “brain cancer”) and multiple myeloma (“multiple myeloma” and “myeloma”). In these cases, the daily Yahoo! search activity scores associated with each term were summed into a composite score for these cancers.

The highest mean daily Yahoo! search activity scores were generated by breast cancer (mean = 14.37), lung cancer (mean = 9.08), and leukemia (mean = 7.15). Cancers with the highest US 2001–2003 incidences were breast (n = 611300), prostate (n = 608000), and lung (n = 510800). For cancer mortality, lung (n = 469500), colorectal (n = 170400), and breast (n = 120800) cancer were the leading causes of death. Breast cancer (n = 5840), leukemia (n = 2143), and prostate cancer (n = 1822) were associated with the most US news reports from 2001 to 2003. Some cancers, such as leukemia, ovarian, and testicular, appeared to be associated with more Internet search activity than their burden would dictate.

Cancers were ranked by mean daily Yahoo! search activity score, estimated incidence, estimated mortality, and number of related news reports for each year in the study period (2001 to 2003). To explore the consistency of ranks over the study period within each variable, Spearman rank correlations were determined for each pair of years (2001 and 2002, 2002 and 2003, 2001 and 2003). We found statistically significant correlations (P < .001) between all year pairs tested (data not shown). Because the ranks associated with these variables were highly consistent from 2001 to 2003, we aggregated the data across the study period.

Table 2 Spearman rank correlations between mean daily Yahoo! search activity score (United States, 2001–2003), estimated incidence, estimated mortality, and number of news reports

The relationship between Yahoo! search activity and its most statistically significant correlate—news coverage—was further analyzed for the five cancers with the highest daily Yahoo! search activity (breast, lung, leukemia, colorectal, and prostate). For these cancers, the number of news reports published each day was transformed into a categorical variable with four levels. The mean daily Yahoo! search activity at each level was compared using ANOVA, and all tests were statistically significant (P ≤ .001). For all five cancers, the mean daily search activity score was higher at each increasing level of news coverage (Table 3).

Table 3 Mean daily Yahoo! search activity score (United States, 2001–2003), by number of news reports published daily and cancer

Table 4 Periodicity of mean daily Yahoo! search activity score (United States 2001–2003) and mean daily number of news reports, by cancer

Figure 1 2003 US prostate cancer Yahoo! search activity (each point of a Yahoo! search activity score equals 0.001% of the population searching Yahoo! on any day)

This study suggests that media coverage plays a powerful role in prompting online cancer information seeking. News coverage correlated significantly with Yahoo! search activity (P < .001). Also, Yahoo! search activity was found to rise as news coverage increased, and sharp rises in search activity from one day to the next appeared to be associated with increases in relevant news coverage. This study also suggests that the Internet can rapidly disseminate health news: the highest spike in 2003 US “prostate cancer” Yahoo! search activity seemed to be generated largely by news coverage in Australia that rapidly filtered onto the Internet via chat rooms, message boards, and medical news Web pages. Thus, it possible that a news story does not necessarily have to be covered by the US news media in order to generate US Internet search activity.

News coverage volume also correlated with estimated cancer incidence (P = .015) and mortality (P < .001). This is interesting because past studies [29-33] on this topic have not generated consistent findings, with most [30-32] finding no relationship between disease burden and news coverage volume. However, none of the past studies focused on cancer, and none used our method for identifying news reports. While the news coverage of specific cancers generally matched their burden, we noted that some cancers, such as leukemia, ovarian cancer, and testicular cancer, were associated with more Internet search activity than their burden would suggest. A similar observation was reported by Bader and Theofanos [21], who suggested that this discrepancy may result from more searches being required to locate online information about less common cancers. The high correlation between cancer-specific news coverage and associated online search activity in the present study suggests another explanation: some cancers received a disproportionate share of news coverage relative to their incidence and mortality, and online search activity, often prompted by news coverage, reflects this imbalance.

We detected several periodicity effects in US Yahoo! cancer search activity, which tended to be higher on weekdays and during national cancer awareness months but lower during the summer months. It should be noted that these observations are not artifacts of the size of the online population during these periods because Yahoo! search activity scores are based on the percentage, not the number, of total users. One explanation for these results is that the volume of cancer news coverage tended to follow these trends. It is also possible that users tend to search for online cancer information from school or work settings. As a result, Yahoo! cancer search activity would be expected to drop during weekends when people are at home and over the summer months when many students are out of school and many workers go on vacation.

Although Yahoo! is a leading US Internet search engine, the extent to which the findings of this study can be generalized to other search engines is not known. Also, we were unable to discern the motivations of Yahoo! users searching for cancer information. For instance, news coverage of a breast cancer drug might be associated with an increase in “breast cancer” search activity. While the Yahoo! Buzz Index would detect this rise, it cannot tell how many searchers were breast cancer patients or family members and how many were investors interested in buying stock in the company developing the drug.

Internet search activity offers an innovative tool for passive surveillance of health information–seeking behavior. While our work focused on cancer, Internet search activity may be useful in gauging health information seeking related to other diseases. For example, the volume of Internet searches related to symptoms or conditions might be used to predict disease outbreaks (eg, influenza) or to assess mental health following a disaster. Researchers at the Centre for Global eHealth Innovation have begun to experiment with analyses of this type [34,35]. The Yahoo! Buzz Index is unique among Internet search datasets because it provides search activity scores adjusted for the size of the population searching for online information, which has steadily grown each year [19]. Perhaps in the future, other Internet search engines will offer databases similar to the Yahoo! Buzz Index, and research could be conducted using a combination of search engines.

The Centers for Disease Control and Prevention funded all aspects of this study, including design; collection, management, analysis, and interpretation of the data; and preparation, review, and approval of the manuscript. Yahoo! Inc provided technical support as part of the purchase of a Yahoo! Buzz Index subscription. Use of trade names is for identification only and does not imply endorsement by the US Department of Health and Human Services.