Functional Health Literacy, Chemotherapy Decisions, and Outcomes Among a Colorectal Cancer Cohort

the ONA take:

Health literacy is a critical part of patient education and patient involvement in their health care decisions. It includes the ability to read and understand medication labels, educational materials, hospital directional signs, and appointment slips. Studies on the impact of health literacy on patient outcomes have demonstrated that low health literacy may hinder patients’ care.

Researchers from the University of North Carolina sought to evaluate the role of health literacy in decisions related to cancer treatment and to estimate the impact of health literacy on patient outcomes. Their investigation was a substudy that included 347 participants from the Cancer Care Outcomes Research and Surveillance Consortium (CanCORS) randomly selected from among the 990 patients with colorectal cancer (CRC) recruited by the North Carolina institution.

Study findings supported the investigators’ hypothesis that patients with greater levels of health literacy might receive better care. However, this study also reinforced prior research findings that although related, formal education and health literacy are distinct entities. The readability of patient education materials, discharge instructions, and consent forms may be too complex for many patients regardless of their level of health literacy. When providing patient education, clinicians should consider that any patient might have difficulty understanding and making decisions about health care.

Cancer Control
Cancer Control

Background: Functional health literacy is essential for the self-management of chronic diseases and preventive health behaviors. Patients with cancer who have a low level of health literacy may be at greater risk for poor care and poor outcomes.

Methods: We assessed health literacy using the Short Test of Functional Health Literacy in Adults in 347 participants with colorectal cancer who were nested within a prospective observational study of system, health care provider, and participant characteristics influencing cancer outcomes.

Results: Having adequate health literacy increased the likelihood that participants with stage 3/4 disease received chemotherapy (odds ratio, 3.29; 95% confidence interval, 1.23–8.80) but had no effect on cancer stage at diagnosis or vital status at last observation during postenrollment follow-up. No difference was seen in health literacy status regarding participant beliefs and preferences about chemotherapy among those with stage 3/4 disease, nor in participant roles in deciding whether to receive chemotherapy.

Conclusions: Patients with lower levels of health literacy were less likely to receive chemotherapy compared with participants with higher levels of health literacy. Therefore, clear communication related to key health care decisions may lead to fewer disparities due to a patient's level of health literacy.


Functional health literacy, including the ability to read and understand medication labels, educational materi­als, hospital directional signs, and appointment slips, is essential for the self-management of chronic diseas­es and preventive health behaviors.1 However, indi­viduals with the greatest health care needs may have the least ability to read and comprehend information needed to successfully function as patients.1,2 Inadequate health literacy could decrease the likelihood that these individuals at high risk will have beneficial health outcomes.

Having inadequate or marginal functional health literacy places patients at increased risk for medi­cation nonadherence, hospital admission, poor health status, and worse clinical outcomes than their counterparts with higher levels of health literacy.1,3-5

A lower level of health literacy has also been associ­ated with lower patient information seeking.6 Patients with poor reading ability may have issues accessing the health care system, understanding recommended treatments, and following the instructions of health care professionals. The American Medical Association has recognized that limited patient literacy impedes diagnosis and treatment, so it has adopted policies to increase the recognition of — and effect change in — functional health literacy.1

In particular, health literacy levels may influence cancer outcomes. New patients may receive large amounts of unfamiliar technical information about their diagnosis. Oftentimes, health care professionals invite patients to participate in choosing among com­plicated treatment options. Adhering to chosen treat­ments can be a Byzantine process of understanding and complying with surgery, radiation therapy, multi­ple and varying chemotherapy regimes, and follow-up visits involving several health care professionals.

To evaluate the role of health literacy in decisions related to cancer treatment and to estimate the impact of health literacy on patient outcomes, we assessed health literacy in a set of patients with colorectal cancer (CRC) enrolled in a cohort study of health care processes. CRC has one of the largest disease burdens of any form of cancer, with approximately 140,000 new cases and 50,000 deaths in 2014 in the United States,7 making it a good test case of the effects of health literacy on cancer outcomes. We hypothesized that greater levels of health literacy would be associated with early-stage disease, increased patient participation in treatment decisions, receipt of more appropriate treatment, and improved rates of survival. 

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