🔥🔥🔥 Fdrs Economic Problems

Tuesday, June 01, 2021 7:17:45 PM

Fdrs Economic Problems

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The New Deal: Crash Course US History #34

The greater focus, however, is on the unreliability of narration. There is sometimes a discreet motive to this, but broadly we get the sense of lives existing beyond the self-obsession of the narrator - a typographer seeking to capture reality within his subjective descriptions, while others pursue pleasures and motivations unknowable to him. The Schrauwen to work to which it is closest is probably "The Scatman" also in Parallel Lives , in which the protagonist's mental narration is hijacked by a nero-hacker who slathers a miserabilist internal monologue over her life. In Sunday, this SF concept is rendered more philosophical: there is the world as perceived by the self, and the world as it exists apart from the individual; words and pictures, gliding and colliding.

Good jokes too, I recommend it! Ok, that's enough for now. See you next week, unless I wake up and find myself face to face with the big faceless glowing God on their shimmering throne. Today on the site we have a piece by Brian Puaca , a historian whose work you may have seen at Sequart. He is going to be exploring 'chokepoints' in comics history, comparing the formation of the Comics Code Authority in the s and its economic impact on the U. And, later, we are going to welcome another new contributor to the site - Sally Bryden , a musician and sports entertainment connoisseur who will be reviewing the new collection of wrestling drawings by Jaime Hernandez. That's it. I'm sorry I tricked you all by putting a Jack Chick image on the front page for Clark's column last Friday.

I thought it was dizzying, you know? Like staring down from a high place. What can I say? Hi, hope you enjoyed your weekend, which is gone forever. Both posts are lengthy, chatty reminisces about Canadian art comics history by Robert Dayton, a writer, musician and performer with a longstanding association with comics - he was one of the principals of the Drippy Gazette back around the turn of the century. Some of the comics in these posts date back to the '60s and '70s, which, at least in the U. I recommend it! But what do we have on this site, the most important site? Some good discussion of the outdoors, woodcarving, mapmaking, and other not-leaning-over-a-table activities.

It's a unique piece that I think you're going to enjoy! And, we're starting a new recurring feature. Retailer and industry commentator Brian Hibbs probably does not require any introduction for many of you, but you may not know that he has been livestreaming video interviews of late with various comics figures. Imagine looking at me while I type this. Speaking of Hibbs, earlier this week he posted his annual rundown of sales data reported to NPD BookScan - which is to say, book-format comics sold in big box bookstores, through Amazon, and via some not all, or even most independent bookstores. It does not, in any way, give an accurate accounting of how well a comic actually sold, but it does create a snapshot of how the year went in the broad 'bookstore market', with all the biases attributable to those areas of bookselling.

You sometimes see these results with less detail than Hibbs gives it used as a broad pick-me-up for the health of 'comics' as an art, but it is really a specific area. And what does this area of bookselling prefer? Comics for young readers, above all else. It is interesting to me that the works at the very top of the bestsellers -- your Dog Man , your Raina Telgemeier stuff - are 'pure' comics; they are not franchise fare, or spinoffs, but comics first, which is not something that can be said for all of big sellers.

American superheroes are represented fleetingly by a small number of YA-audience DC projects, a smattering of prestige Batman comics, and the Alan Moore perennials; Marvel, meanwhile, has apparently managed the impressive feat of not logging more than 10, sales for any one book in the entire year, which I think speaks to a company totally focused on or incapable of stepping away from the 'traditional' superhero market of periodicals to a specialty crowd, and digital editions thereof.

In this market, it appears the bestselling adult-oriented book is a collection of the webcomic Strange Planet by Nathan W. Pyle, which is an Instagram comic that looks like a newspaper strip without a newspaper, though I have not read any of it. This an elementary observation, but this market has developed enough to grow its own preferences and biases; it is not enough to look at brief summaries and think "wow, comics are doing great," you have to question the information you receive, and understand that all of these things are only giving you a partial idea of what comics is, as a set of particular conditions.

So many licensed books in this area! Video games, television, internet personalities: the certitude that comes from something with more money than comics, than books. It does little good to appeal to a miscellaneous Comics in these situations, which is how the picture is often boiled down. Hmm, that was basically an exercise in automatic writing. I am continuing to explore different forms for the debutante month of the new weekly blog. Keep your cards and letters coming, and I will see you next week, unless I die. Hi everyone, I'm moving in two directions today, because our linear perception of time is but a portal in the side of the prison of our bodies.

We are hoping to see more of Prof. Natsume's work in the coming weeks! Also last week, we posted a review by another new contributor, Edward Haynes - a writer and editor of comics , prose fiction and criticism whose work has appeared at venues such as SOLRAD , Multiversity Comics , PanelxPanel and others. They offered us their thoughts on the music and horror-themed graphic novel Blue In Green , and we hope to see them again soon. This week, we are kicking things off with another artist-on-artist conversation , in which Joe Ollmann of the recent Fictional Father chats up Brecht Evens of The City of Belgium - both graphic novels from Drawn and Quarterly.

Topics include the limited utility of art in a medical crisis, the finer points of translating one's own work to another language, and exactly how easy is it to become a controversial figure in the polite society of art comics. Read it and live it! Cover art by Jeremy McBrian. Lately I've been rearranging my plans, as I'm sure some of you are - I was going to visit some friends in New Orleans in October, but that might not be a great idea anymore; I'm vaccinated, but I don't want to put anyone at risk.

A small con that functions as a sort of meetup for mid-east coast Ditko fans is a really fun idea to me. I became very sentimental looking at videos from another recent small con: the Mission Underground Comic Con, an event from last June in San Francisco, sponsored by deadcrow. You might know deadcrow as the organization behind the Tinfoil anthologies, most recently co-published with Austin English's Domino Books. The Tinfoil books are very regional, and very inclusive, in the manner of lo-fi underground newspapers, but not as frequent. It's an occasional dispatch. The item you see here, however, is not an issue of Tinfoil ; it's a collection titled Speshal Comics , which was available at the show, and which I bought off the deadcrow website later on.

It's sold out from them, but you can still get one from Domino. The book is a tribute anthology to Evan "Spesh" Larsen, a cartoonist and graffiti tagger who died in Though not a deluxe print object, it's a complex book, with various tipped-in minicomics; some of the on-page contributions also seem to be minicomics that have been reformatted, like the below excerpt from a piece by Mike Reger :. What we see here is push and pull of the form of art. The ascendant American artist Andrew Schoultz has invited the author and his friends to a tony exhibition; Larsen takes the opportunity to tag the glass front of the gallery, causing some upset.

A later show results in work spilling out for two blocks around, and the rich guy sponsoring the event laments that it can't happen again. These are the butting forces of art as an aesthetic, a learned thing, a career path -- and a status symbol for those who patronize it -- and art as a process of living, agnostic to ideas of property rights, 'ownership' and social niceties. Art that does not desire to be captured in a book to realize itself as a true thing, but may nonetheless be memorialized as it is here: a record of a small society of people working directly with one another in the place where they live. But Reger has lived a lot, and demonstrates in his piece how this type of practice removes a great deal of the cushion from living - and nobody wants to see what little there is disappear.

The other day there was a tweet from the artist Chris Kindred that provoked some discussion: " you can't work in comics for a living and be happy at the same time. You have a patron, a spouse, something - you struggle with the responsibility of that. The support of authority figures, of which I am one, is a fleeting and fragile thing. People tell you "just work hard," but comics can only reward a few things. I think of another late artist, Jesse Hamm , who loved comics so fervently he kept offering tips to improve the skills of cartoonists, even though comics offered him very little, because he lacked the promotional celebrity fire to sell himself and he did not want to work in those few corners of the market that paid.

So he worked in illustration, pouring love into the the thing that gave him so little beyond the affection of people. Anyway, diary , that is all I have time to write tonight. I will see you again next week, unless I die. Hey there, hope all of you had a great week - especially the anonymous person who accused me on Twitter of publishing CIA propaganda and then deleted their tweet, having presumably read past the title of Lane Yates' piece on Tom King. Buddy, the podcast I'm on doesn't make enough money for that. This week we have a lot of good stuff coming up, and we're kicking it off with Ian Thomas , who's conducted quite a few interviews for us in the past year or so, among other pieces - this time, he's speaking with scholars Brannon Costello and Brian Cremins, who've edited The Other s , a new LSU Press collection of essays on topics from '80s comic books -- some of them very popular at that time -- which aren't generally the stuff of academic study.

I was particularly struck by a comment Costello makes about how advantageous it becomes when a particular magazine has a readily searchable database of contents; this is the sort of thing you don't always think of in terms of serving posterity if indeed that is something you think about at all , but as years pass and the tastes of larger groups drift apart online, it becomes especially useful to have a reliable source of data.

When ComicBookDB dot com was bought out by ComicBook dot com and shut down in , a huge amount of issue-by-issue creator data for late 20th century self-published and small-press comics vanished from ready access. A quiet calamity for maniacs such as myself. I think it was this, from 's issue 9 of Superman Giant , which was one of those thick collections of mostly reprints that DC released exclusively to Walmart stores near the checkout aisles.

King and penciller Andy Kubert did original page stories in those, which were then collected on their own as two-in-one comic books for the direct market under the title Superman: Up in the Sky. At least in my region of online, the most-discussed of these shorts was an episode in which Superman envisions a series of awful deaths for Lois Lane -- which, though I lack a comprehensive grasp, seems to feed a recurring theme of troubled men and the intensity of their relationships with women in King's writing -- but this one has Superman in a race with the Flash that is extensively narrated by a little girl chained up elsewhere in the serial.

There is no great sensation of speed to this contest - Kubert and inker Sandra Hope instead pose the characters in full-page images which, combined with the often dozen-plus captions per page, creates a sort of tableau vivant type of presentation; a Hypothesis of the Stolen Painting that is about how Superman is the mightiest and etc. This is when the writer collapses the distance between their own work and the reader's interpretive role, assessing them as to the writer's 'take' on the character in plain language above the action of the story. We are all familiar with how, for example, Grant Morrison's run on various Batman-related comics served as a summation of Batman history, in which everything was ostensibly real in continuity terms, but I am thinking more of one character explaining to another, or the reader, why a character is cool, or what the societal metaphor active in a certain character might be.

Geoff Johns has taken steps in this direction throughout the 21st century, and certainly one can imagine Tom King as a participant in this tradition, recalling all those pages from Heroes in Crisis where superhero characters face the reader and therapeutically detail their struggles; which are really interpretations of what these characters means. But I haven't read that comic, I just know it from social media. I have, however, read every issue of the most conceptually advanced recent comic of the explicative tendency: The Other History of the DC Universe , a five-issue miniseries which wrapped not long ago.

But The Other History of the DC Universe is not a traditional comic; it is more a heavily illustrated series of prose stories, where the illustrations are sometimes paneled and sequential, and the text is sometimes in caption boxes. And, each issue is narrated by one or more superhero characters, none of them white, who describe their personal histories and their perspectives on various DC storylines. This is interesting to me, because it is as much a critical essay series as it is a superhero comic. If contemporary superhero comics are sometimes derided as official fanfiction, this is a particular type of critical fanfiction and, to be clear, I like fanfiction that seeks to comment on the work by giving primacy to subtextual or peripheral character traits - or, simply the traits of characters made peripheral by the assumptions of salability and audience taste.

The best issue is 2, a seriocomic recounting of the lives of Teen Titans supporting character Mal Duncan -- holder of various and sundry superhero titles like Hornblower and the new Guardian -- and his wife, Karen Beecher-Duncan, the Titans and Doom Patrol character Bumblebee. Like Morrison's Batman run, the concept of The Other History of the DC Universe is that most events in DC comics are 'real' which places the arrival of Superman in the s, to keep things on a plausible timeline , and Ridley uses this idea of continuity to tease out hidden character implications.

Because Mal Duncan is an 'important' character to one creative team in , and no longer so important to the creative team behind, say, the wedding of Donna Troy, Ridley can present the character's diminished presence in the wedding scene as an illustration of the callousness of the Titans characters, and the tokenized nature of Black characters in media endeavors such as superhero comic books. Arguments among fans about who is the first Black DC superhero become arguments among the characters in the comic, with charged emotions that serve to analogize the desire for representation in popular entertainment.

Plus, it's funny: where Titans continuity doesn't actually make sense, Ridley inserts contradictory and unreliable narrators, and placing all of these confrontations in a row does lead one to the conclusion that the Teen Titans are honestly a bunch of assholes. And that is part of the narrative: dealing with all these assholes. The ambivalence of a publisher like DC toward committing to Black superheroes becomes an ambivalence on the part of the characters toward being a superhero; a model minority.

It does seem like the art in this series is incidental, so intense is the focus on narration. Comics criticism made flesh by its assumption into the comics world. But there are limitations to this. A few days ago, I read a really excellent critique of issue 3 written by Kelly Kanayama. That issue focuses on the character of Katana, a Japanese woman introduced by Mike W. This issue got passed around on social medial a little upon release, because it characterized, in the official capacity of a DC comic, the 'relationship' between Slade Wilson, Deathstroke, and year old Tara Markov, Terra, in the New Teen Titans era as an act of rape by a pedophilic trafficker.

This is a broad-view criticism. But Kanayama goes deeper, and asks after the missing particularities of Ridley's story, which does not particularly address the racialized misogyny that follows Asian women, and does not question the details of Katana's character. If these characters exist in a political reality, then why is a twentysomething Japanese woman in the s wearing a costume bearing the imperial rising sun, with no apparent concordant ideology? This is because, in Kanayama's estimation, the book assents to depictions of Japanese characters as "collections of tropes and stereotypes" rather than people. I agree with Kanayama's criticisms, and I think it is easy to run into these problems when writing critically in an 'official' capacity such as Ridley does.

When working with superhero characters, an element of fiat is presupposed: that you will, to some extent, meet the superheroes on their i. So, in a series that asks you consider the superhero continuity to be 'real' as a platform for commentary, there is a degree of distance you must maintain to respect this artificial realism. When Karen Beecher-Duncan comments in issue 2 that "For an inner city in Metropolis, Hell's Corner had a surprisingly high number of white pride gangs," Ridley is poking at the pieties of how villains are depicted in these comics, but also acknowledging the necessarily reality of such in the comic book world.

Kanayama reminds us that what is accepted as 'real' in these parameters, however, is not an unmeaningful choice, as much as the weight of the superhero world urges us to embrace its fake objectivity. Through the explicative tendency, you are always saying something. Hi, and welcome back to TCJ. I'm going to be using this space to highlight new contributors to the website, in preview of the coming week. Today we have a nice interview with Bryan Talbot , an artist I think you've all encountered at some point.

My first experience with Talbot was via the Batman storyline "Mask" from Batman: Legends of the Dark Knight - that's the one where a doctor tries to convince Bruce Wayne that he's just imagining himself as a superhero to escape the hell of his shitty life; my Pennsylvania brother, M. It was the first time I can remember reading a superhero comic made by somebody with no evident sympathy or nostalgia for superheroes at all. This week's interview is about Talbot's extensive recent work in creator-owned graphic novels. It is conducted by Tasha Lowe-Newsome , who works in film and journalism, including writing about comics - for example, she conducted the Journal 's interview with Donna Barr in issue of the print edition. She also wrote the Cult Press comic book series Raggedyman , which was drawn by Anthony Jon Hicks, and featured cover art by Mr.

Bryan Talbot. We are very happy to welcome her back to TCJ. Lane is also the creator of the fascinating webcomic Single Camera Sitcom , and the writer of several other small-press works. For TCJ, they will be presenting a reflective essay on Tom King, who is one of the very popular superhero comic book writers of today - the type you see mentioned in media outlets that don't often cover comic books as proof that superhero comics are good. It's about really getting in to a writer's work, and then really kind of getting out of their work, while still buying and reading all of it; along the way, we learn the true allegiances of the superhero industrial complex.

Cover art by William Stout. There's a bit in the Talbot interview today where he mentions working with Rick Veitch on the old Tekno Comix series Teknophage. I often find myself linking these two artists together as kindred spirits - born as cartoonists in the late underground period, traveling in those spaces inside or adjacent to the 'mainstream', while working determinedly on the personal projects for which they are best known. Turner, and published just a few months ago. It's a bookshelf-ready revival of the old Slow Death Funnies est. Talbot was part of the original run of Slow Death , I believe in the late-coming final issue 11, , as was the writer Tom Veitch, Rick's brother, although I think this is Rick Veitch's first appearance on the title.

Reading their new pieces, Veitch's and Talbot's, I was struck by how the two shorts illustrate the differences in perspective between these two storytellers. This is from Veitch's story, "Tiny Dancer" - the pages are all set up so that there is a large 'low-res' background image set in a destroyed environment with sharper, smaller panels set on top, in the manner of augmented reality experiences. It's the future just barely , and those with adequate employer-provided insurance coverage have gotten retinal surgery that superimposes a beautiful 'mind-mate' companion onto everything they see.

Veitch's protagonist eventually marries his mind-mate, which analogizes to the intensity some gamers feel toward characters and rosters into which they've poured much time and cash. This is a subject matter that greatly appeals to the childless editor of a comic book website. The central joke of Veitch's comic -- the structural joke -- is that the advertising-mandated existence of the mind-made endures a ways past everything else, inviting you to treat yourself to a restaurant in the midst of rubble.

I recall the strange, paralyzed state of commercials online as COVID really broke loose in the States, and I think Veitch's vision of the end is unusually prescient. Hell yeah, full-color thrill-power. It does make me think. Probably, I am physically closest to the guy at the bottom left of the above page, who is uncomfortably consuming things in the midst of a terrible orgy, away from the suffering of the world. Talbot's hero, meanwhile, is fit and skilled, and utterly composed.

They are strong , which is something that comes up often in Talbot's work. Naturally, Batman chooses the Batman door, and he is therefore real, and Bruce Wayne is not. But - Bruce Wayne, weak and sick, is still real; we just can't see him anymore, because he did not occur, because his life cannot really exist in a corporate-owned superhero comic. Similarly, Talbot's own characters navigate the contours of power. Luther Arkwright is very powerful; LeBrock, the main character of Grandville , is a strapping and inquisitive badger.

The various heroines of Talbot's collaborations with the writer Mary M. Talbot stand astride great historical moments, or encounter extraordinary personalities, or are extraordinary personalities. These are not perfect, or uncomplicated characters, but they move through their worlds with purpose, like the "Memento" hero. Veitch, I think, presents people as much more fallible, susceptible to temptation, or fundamentally malleable. His many dream comics, lucid as the dreamer may be, force a vulnerability on Roarin' Rick, who cannot entirely control what is coming.

The sidekicks of Brat Pack are seduced and exploited; the comics industry figures in The Maximortal subject to rips in history, as the all-powerful hero at the center melts and rips bodies, descending like a glowing terror, Jack Chick's God, archetypical yet not entirely unknowable. I think this is the fundamental and hopefully-illustrative difference between these two artists I associate so much with each other - Veitch floating inside the body and mind of history, and Talbot urging us to be strong and studied. Anyway, thank you for continuing to enjoy the blog's gradual transformation into Rorschach's journal. I'll be back in this space next week, unless I die. Some of you may not know who I am, and I congratulate you on a life well-lived. Others may remember a weekly column I wrote for six years, which I concluded in roughly the same mindset as Julianne Moore at the end of Safe.

Since then, in the past four years, I've written a few pieces for this site: a pair of reviews of self-published comics I really liked; two interviews about small-press manga artists; a few pieces on 'commercial' manga that were actually about the situation of commercial manga artists, at least in my mind; an obituary ; some conceptual art comics writing; and a piece on a comic from the writer of Beef Bros which anticipated this site's acclaimed outlay of Beef Bros coverage - it is wonderful to set the trends. I have also been working in a behind-the-scenes role on this website since last April, doing proofreading, grammar checks, formatting, writing some of the little texts that go below the pictures on the front page; I was paid for this work, which very much instilled in me a sense of responsibility separate from my work as an occasional contributor.

Writers count on you -- they rely on you -- when you do work such as this. With Tucker, I will now be working in an editorial capacity, directly with writers; soliciting works, etc. You can contact me at joe [at] tcj [dot] com, for all your email needs. You are maybe wondering about my ideas for this site. In fact, I am the first of a few changes coming soon - not this week, or next week, but soon. These are ideas that preceded me, but I think they're pretty exciting, and I hope you'll all enjoy them.

In a wider sense, though, I am interested in using the independent nature of TCJ, which is not reliant on access to monied cultural actors, to counteract the dominance of capitalistic 'success' in too much of the media discussion online. Perhaps it is because there are so many opinions out there -- and, to be clear, I would have been nothing if not for the latitude online discussion afforded people with no qualifications; I am wholly a creature of online -- but I have found that a lot of the talk about art recently starts from the false 'objective' basis of wide exposure and monetary success as the solemnization of what is worth talking about.

If something is big, and successful, it must be discussed, because that is where the eyes go. That is where you discuss the effect on culture. That is how you build the audience to make the money. Success ensures success, so that anyone who starts ahead is assured to remain there. What an independent website can do, is offer a dedicated source for deeper thinking. The Comics Journal has been around since the s; we do not need to be the introduction to comics. What we ought to be, is a place from which this vast and troubled terrain is surveyed with a sense of questioning the maps drawn by those most adept at mass appeal, because the danger today is that mass appeal is read as the sole means of getting anywhere.

This does not benefit anybody that does not fall into those few categories that comics can readily award. Of course, these are just words. I pray you will stick around to see what we do. I thank all of our writers - Clark Burscough, I want you to know I love and value you; I want to say that in public. I thank Tucker, and Kristy Valenti, our editorial coordinator, and Dr. Rachel Miller, of our print edition. Thanks to Gary Groth, for having me.

And thank you, for your attention. Recently, artist, painter and activist Carel Moiseiwitsch lost her home, her art studio and all that it contained, as well as one of her cats in the recent Lytton fire in Canada. A few of her colleagues have set up a GoFundMe to assist her at this time of extraordinary need. Links are provided to the campaign. In August, FDR signed the Social Security Act of , which guaranteed pensions to millions of Americans, set up a system of unemployment insurance and stipulated that the federal government would help care for dependent children and the disabled.

This FDR had come a long way from his earlier repudiation of class-based politics and was promising a much more aggressive fight against the people who were profiting from the Depression-era troubles of ordinary Americans. He won the election by a landslide. Still, the Great Depression dragged on. Workers grew more militant: In December , for example, the United Auto Workers strike at a GM plant in Flint, Michigan lasted for 44 days and spread to some , autoworkers in 35 cities. By , to the dismay of most corporate leaders, some 8 million workers had joined unions and were loudly demanding their rights. Meanwhile, the New Deal itself confronted one political setback after another.

Arguing that they represented an unconstitutional extension of federal authority, the conservative majority on the Supreme Court had already invalidated reform initiatives like the National Recovery Administration and the Agricultural Adjustment Administration. That same year, the economy slipped back into a recession when the government reduced its stimulus spending. Despite this seeming vindication of New Deal policies, increasing anti-Roosevelt sentiment made it difficult for him to enact any new programs.

The war effort stimulated American industry and, as a result, effectively ended the Great Depression. They created a brand-new, if tenuous, political coalition that included white working people, African Americans and left-wing intellectuals. More women entered the workforce as Roosevelt expanded the number of secretarial roles in government. These groups rarely shared the same interests—at least, they rarely thought they did— but they did share a powerful belief that an interventionist government was good for their families, the economy and the nation. Their coalition has splintered over time, but many of the New Deal programs that bound them together—Social Security, unemployment insurance and federal agricultural subsidies, for instance—are still with us today.

Start your free trial today. But if you see something that doesn't look right, click here to contact us! Subscribe for fascinating stories connecting the past to the present. The Great Depression was the worst economic downturn in the history of the industrialized world, lasting from to It began after the stock market crash of October , which sent Wall Street into a panic and wiped out millions of investors. For example, the Gail model excludes paternal family histories of breast cancer. Cumulative risk estimates are best used when evidence of other underlying significant risk factors have been ruled out. Careful evaluation of an individual's personal health and family history can identify other confounding risk factors that may outweigh a risk estimate derived from a cumulative risk model.

For example, a woman with a prior biopsy showing lobular carcinoma in situ LCIS whose mother was diagnosed with breast cancer at age 65 years has a greater lifetime risk from her history of LCIS than her cumulative lifetime risk of breast cancer based on one first-degree relative. Unfortunately, there is no reliable method for combining all of an individual's relevant risk factors for an accurate absolute cancer risk estimate, nor are individual risk factors additive. In summary, careful ascertainment and review of personal health and cancer family history are essential adjuncts to the use of prior probability models and cancer risk assessment models to assure that critical elements influencing risk calculations are considered.

A number of investigators are developing health care provider decision support tools such as the Genetic Risk Assessment on the Internet with Decision Support GRAIDS ,[ 58 ] but at this time, clinical judgment remains a key component of any prior probability or absolute cancer risk estimation. Experts recommend offering genetic testing when a risk assessment suggests the presence of an inherited cancer syndrome for which specific genes have been identified. Characteristics used in making this determination are discussed in the PDQ summaries on the genetics of specific cancers. Even when individual and family history characteristics indicate a possible inherited cancer syndrome, individuals may elect not to proceed with testing after discussion of potential risks, benefits, and limitations, as discussed below.

Conversely, individuals whose pedigrees are incomplete or uninformative due to very small family size, early deaths, or incomplete data on key family members may elect to pursue genetic testing in an attempt to better define their risk status. In these situations, it is particularly important that the pretest counseling fully explore the limitations of the testing process. ASCO's and policy statements addressed testing for low- to moderate- penetrance genes and direct-to-consumer testing. For tests that are ordered by the consumer without health care professional involvement, management decisions are based on the evidence for clinical utility. For tests with accepted clinical utility, follow-up care can be guided by the evidence for cancer risk associated with the genetic test finding.

However, in tests ordered by the consumer that have uncertain clinical utility, ASCO recommends that follow-up care consist of education regarding the lack of evidence regarding the test's clinical utility and that cancer risk management decisions be guided by established cancer risk factors. In , ASCO updated its policy to address the challenges of new technologies in cancer genetics, including multigene panel testing for cancer genetic susceptibility, as well as incidental germline findings from somatic mutation profiling.

Genetic education and counseling , including the interpretation of genetic test results, will vary depending on whether a previous attempt at genetic testing has been made refer to Figure 2. In general, there are two primary circumstances in which genetic testing is performed:. Genetic susceptibility testing generally yields the most useful information when a living family member affected with the cancer of concern is tested first to determine whether a genetic basis for the cancer diagnosis can be established. If testing is deferred while follow-up with an affected relative is pending, consider providing interim cancer risk management guidelines to the unaffected proband. If a documented pathogenic variant associated with cancer risk is identified, risks are based on penetrance data for pathogenic variants of that specific gene.

In addition, other family members may be tested for the presence or absence of this specific pathogenic variant. If no variant is found in an affected family member, testing is considered uninformative and thus there is no basis for testing unaffected relatives. Failure of the laboratory to detect a pathogenic variant in an affected family member does not rule out an inherited basis for the cancer in that family.

Reasons why testing could be uninformative include the following:. Lastly, testing may reveal a VUS. This result means that a genetic variant has been found; however, the extent that this variant increases cancer risk, or whether it is associated with the history of cancer in the family, is uncertain. In this circumstance, some clues as to the significance of the variant can be derived from the following:. Unfortunately, even with this information, there is often insufficient evidence to document the significance of a specific variant, and further clarifying research is required.

If there is no close, living, affected relative to undergo testing, or the living affected relative declines testing, other options may be discussed with the patient and the testing laboratory. In rare instances, if proper authorization is secured from the family, testing the stored tissue of a deceased relative may be considered. However, genetic tests done on stored tissue are technically difficult and may not yield a definitive result.

Therefore, testing an unaffected person without prior testing of an affected family member may be performed. In these instances, counseling includes discussing that a negative test result does not rule out the presence of a cancer susceptibility gene in the family or in the patient and may be uninformative. Genetic susceptibility testing for a documented pathogenic variant in the family can be very informative and will yield one of the following two results refer to Figure 2 :. If the familial pathogenic variant is detected in a family member, their cancer risks are based on penetrance data for pathogenic variants in that specific gene.

If the documented pathogenic variant is not found in a family member, the risk of cancer in that individual is equivalent to cancer risk in the general population. However, other risk factors and family history from the side of the family not associated with the documented pathogenic variant may increase the cancer risk above the general population levels. In summary, genetic education and counseling includes identifying the most informative person in the family to test, which may be an affected family member rather than the individual seeking genetic services.

In addition, counseling includes a discussion of the limitations of the test, all possible test outcomes, and the consequences of identifying a VUS. Insurance coverage varies for cancer susceptibility testing, including multigene panel testing. In general, most individuals who meet specific criteria e. The ACA does not stipulate that follow-up care based on genetic test results be covered e. However, some insurance companies require that pretest genetic counseling be performed by a credentialed genetics provider before testing is authorized. Before testing is ordered, it is important to verify costs and insurance coverage, including for Medicaid and Medicare patients.

Medicare does not cover genetic testing if the patient has not had a cancer diagnosis associated with the pathogenic variants for which testing is ordered. In addition, unaffected individuals with Medicare are not covered for testing, even if they are tested for only a known familial pathogenic variant. Further, Medicare does not cover genetic counseling as a separately billable service. There is a risk of carriers passing on cancer-associated pathogenic variants to offspring.

When an individual tests positive for one pathogenic variant in a cancer susceptibility gene, counseling about reproductive implications addresses not only the risks associated with autosomal dominant inheritance but also the potential risks of having a child with two pathogenic variants in the same gene biallelic that could result in a severe condition. Assisted reproductive technology can be used for preimplantation genetic testing PGT and for prenatal cancer predisposition genetic testing using chorionic villus sampling and amniocentesis.

In some cases e. In light of this information, couples may consider PGT or prenatal testing. A proposed analytic framework for counseling carriers about reproduction options includes consideration of the following issues:[ 10 ]. In a study of patients with different hereditary cancer syndromes , most were unaware of PGT; however, the majority expressed interest in learning more about the availability of PGT. Disease-specific factors e. Genetic testing is highly specialized. There are also multiple molecular testing methods available, each with its own indications, costs, strengths, and weaknesses. Depending on the method employed and the extent of the analysis, different tests for the same gene will have varying levels of sensitivity and specificity.

Even assuming high analytic validity, genetic heterogeneity makes test selection challenging. A number of different genetic syndromes may underlie the development of a particular cancer type. For example, hereditary colorectal cancer may be due to familial adenomatous polyposis FAP , Lynch syndrome, Peutz-Jeghers syndrome, juvenile polyposis syndrome, or other syndromes. Each of these has a different genetic basis.

In addition, different genes may be responsible for the same condition e. In some genes, the same pathogenic variant has been found in multiple, apparently unrelated families. This observation is consistent with a founder effect, wherein a pathogenic variant identified in a contemporary population can be traced back to a small group of founders isolated by geographic, cultural, or other factors. Other genes also have reported founder pathogenic variants. The presence of founder pathogenic variants has practical implications for genetic testing. Many laboratories offer directed testing specifically for ethnic-specific alleles.

This greatly simplifies the technical aspects of the test but is not without limitations. Allelic heterogeneity i. For example, though the general rule is that adenomatous polyposis coli APC pathogenic variants are associated with hundreds or thousands of colonic polyps and colon cancer of the classical FAP syndrome, some APC pathogenic variants cause a milder clinical picture, with fewer polyps and lower colorectal cancer risk. Pathogenic variants in a certain portion of the APC gene also predispose to retinal changes, for example, when pathogenic variants in a different region of APC predispose to desmoid tumors. In light of the heterogeneity in presentation and potential overlap in phenotypes among the various hereditary cancer syndromes, the selection of the appropriate genetic test for a given individual requires knowledge of genetic syndromes, molecular diagnostic methods used for identifying pathogenic variants, correlation between clinical and molecular findings, and access to information about rapidly changing testing options.

These issues are addressed in detail in PDQ summaries on the genetics of specific cancers. Next-generation sequencing NGS and the removal of most patent barriers to diagnostic DNA sequencing [ 18 ] have resulted in the availability of multigene testing, which can simultaneously test more than 50 genes for pathogenic variants, often at costs comparable to single-gene testing.

These multigene panels can include genes with pathogenic variants that are associated with high risks of cancer and genes that confer moderate and uncertain risks. The multigene panels can be limited to specific cancer types e. This type of testing has both advantages and disadvantages, and much of the information presented in this section is not based on empirical data but rather on commentaries. ASCO has stressed the importance of genetic counseling to ensure patients are adequately informed about the implications of this type of testing and recommends that tests be ordered by cancer genetic professionals.

Unlike in-person, single-gene pretest genetic counseling models, these approaches have not been examined for outcomes of counseling such as comprehension, satisfaction, psychosocial outcomes, and testing uptake. Table 2 summarizes recommendations from ASCO on elements of pretest genetic counseling and informed consent for germline cancer genetic testing. The range of results from NGS multigene panels is emerging in both data from clinical and laboratory series. Several of the studies are collaborations between the two.

There are several important caveats about the research that has been conducted so far with regard to multigene testing:. In high-risk individuals who meet criteria for hereditary cancer genetic testing but in whom no pathogenic variant was identified from single-gene testing, panel testing may identify other clinically actionable variants. Selected reports from to , which included 1, to 10, tested individuals, showed variation in pathogenic variant and VUS rates. Additionally, VUS rates were higher in non-White individuals, likely because of the limited availability of test result data needed for accurate determination of risk.

A large study published by a commercial laboratory included more than , individuals who were tested with a gene panel between and Results from multigene tests have several possible outcomes, including the following:[ 19 ]. Results can also reveal more than one finding given that multiple genes are being tested simultaneously and the elevated rate of VUS. Utilizing multigene panels can be complex but may offer advantages over sequential testing strategies.

First, in some types of cancer, several genes can be associated with specific phenotypes; therefore, testing for all genes associated with a given phenotype can save both time and money. However, there can be challenges to employing this testing approach. Clinical laboratories now offer a varying array of clinical cancer susceptibility gene panels. Other challenges of interpreting multigene test results include higher rates of VUS than with single-gene testing the rate of VUS increases with the number of genes tested ,[ 24 ] higher rates of VUS in some minority populations,[ 32 , 43 ] and the detection of variants in genes associated with uncertain cancer risks.

Overall, there is insufficient evidence to determine superiority of multigene testing over phenotype-guided testing or sequential gene testing. Another important consideration is that multigene tests may include genes in which pathogenic variants are associated with moderate or uncertain penetrance. Management of individuals with pathogenic variants in such genes can present additional challenges, particularly when expert consensus or evidence-based recommendations are not available.

Moreover, there may be limited or no evidence to support changes to medical management based on the level of risk or uncertain risk; however, management may still be affected by family history. Government regulation of genetic tests to date remains extremely limited in terms of both analytic and clinical validity with little interagency coordination. CLIA regulations address personnel qualifications, laboratory quality assurance standards, and documentation and validation of tests and procedures.

Genetic tests are considered high complexity, which indicates that a high degree of knowledge and skill is required to perform or interpret the test. Laboratories conducting high complexity tests must undergo proficiency testing at specified intervals, which consists of an external review of the laboratory's ability to accurately perform and interpret the test. In regard to analytic validity, genetic tests fall into two primary categories; test kits and laboratory-developed tests previously called home brews.

Test kits are manufactured for use in laboratories performing the test and include all the reagents necessary to complete the analysis, instructions, performance outcomes, and details about which genetic variants can be detected. The U. Food and Drug Administration FDA regulates test kits as medical devices; however, despite more than 1, available genetic tests, there are fewer than ten FDA-approved test kits. Laboratory-developed tests are subject to the least amount of oversight, as neither CLIA nor the FDA evaluate the laboratories' proficiency in performing the test or clinical validity relative to the accuracy of the test to predict a clinical outcome.

These small molecules are used to conduct laboratory-developed tests but can also be made by the laboratory. For laboratory-developed tests utilizing manufactured commercially available ASRs, the FDA requires that the test be ordered by a health professional or other individual authorized to order the test by state law. However, this regulation does not distinguish between health providers caring for the patient or health providers who work for the laboratory offering the test. In addition to the regulation of classical clinical genetic tests is the regulatory oversight of research genetic testing. Laboratories performing genetic testing on a research basis are exempt from CLIA oversight if the laboratory does not report patient-specific results for the diagnosis, prevention, or treatment of any disease or impairment or the assessment of the health of individual patients.

In addition, there is no established mechanism that determines when a test has sufficient analytic and clinical validity to be offered clinically. Evidence regarding the implications of this narrow regulatory oversight of genetic tests is limited and consists predominantly of laboratory director responses to quality assurance surveys. Eight percent of laboratories did not employ and were not affiliated with doctoral-level genetics professionals. Sixty-three percent of laboratories provided an interpretation of the test result as part of the test report. Sixteen percent of laboratories reported no specialty area certification; those without specialty certification represented laboratories with the most volume of tests performed and offered the most extensive test selection.

The most frequent reason cited for lack of proficiency testing participation was lack of available proficiency testing programs. In October , the FDA posted the notification regarding its plans to develop draft guidance on the regulation of laboratory-developed tests. Given the potential of such regulatory action to affect the wide spectrum of genetic tests in clinical practice, proposed draft guidelines have been discussed and reviewed by a number of professional associations, eliciting policy statements and analyses from various professional associations, including the American Society of Human Genetics ASHG and the Association for Molecular Pathology.

The issue of FDA oversight of laboratory-developed tests remains under consideration. Increasingly, however, individuals can order genetic testing through DTC companies without the input of health care providers. DTC tests may provide information about ancestry, paternity, propensity toward certain physical traits, risk of adverse drug reactions, and disease risks. In , the FDA provided clearance for a large DTC company 23andMe to market carrier screening for Bloom syndrome, which is associated with increased cancer risks in homozygotes as well as other phenotypic features. Subsequently, DTC carrier testing for several conditions became available. In , the FDA allowed 23andMe to market DTC tests for ten diseases or conditions including late-onset Alzheimer disease, Parkinson disease, and hereditary thrombophilia.

Thus, the false-negative rate due to untested pathogenic variants as well as other gene abnormalities is high. Clinical confirmation entails repeating the test in a CLIA-certified laboratory , as well as individual review and verification of the result by laboratory personnel. However, a negative result does not rule out other hereditary factors or account for other clinical indicators, genetic and nongenetic, of increased cancer risk. For high-risk individuals in particular i. Consumer-directed clinical testing is used to describe a hybrid approach to genetic testing, whereupon clinical—grade genetic testing can be initiated and selected by a consumer; however, ordering of the test by an authorized provider e.

Genetic counseling may also be offered by the laboratory to explain the results. With respect to cancer genetic testing, there are clinical, CLIA-certified laboratories that offer multigene panel tests as a consumer-directed service. Things to consider when genetic testing is ordered this way include:. Particularly for individuals who meet criteria for testing, insurance may cover the cost, whereas the consumer is responsible for the costs of consumer-directed testing.

Some insurance companies require patients to have pretest genetic counseling by a credentialed genetics provider and to meet specific eligibility criteria in order for the testing to be covered. Consumer-directed testing thus eliminates the need for this requirement. In the past, several DTC companies offered only SNV -based testing to generate information about health risks, including risks of cancer. As a result, predicted disease risks from different DTC companies may yield different results. For example, a sample comparison of SNV-based risk prediction from two different companies for four different cancers yielded relative risks of 0. Another area of investigation is whether predicted disease risks from SNV testing are consistent with family history—based assessments.

Studies using data from one commercial personal genomic testing company revealed that there was generally poor concordance between the SNV and family history risk assessment for common cancers such as breast, prostate, and colon. Studies have begun to examine whether SNV testing could be used together with other established risk factors to assess the likelihood of developing cancer. For example, adding SNV data to validated breast cancer prediction tools such as those included in the National Cancer Institute's Breast Cancer Risk Assessment Tool based on the Gail model [ 65 ] may improve the accuracy of risk assessment.

These findings underscore that SNV testing has not been validated as an accurate risk assessment tool and does not replace the collection, integration, and interpretation of personal and family history risk factor information by qualified health care professionals. In addition, consumers who submit their DNA to a DTC lab may have access to their raw sequence data and may consult with other companies, websites, and open-access databases for interpretation. Some factors to consider when determining the accuracy and utility of sequence data for cancer or other disease risk assessment include the sequencing depth of the genes of interest, whether large rearrangements or gene deletions would be detected, and whether or how positive results are confirmed e.

For example, if sequencing depth is low or rare variants cannot be detected, then there is a concern about false-negative results. There is also a risk that sequence changes will be erroneously labeled as pathogenic when confirmatory testing or different interpretative approaches would determine that the variant identified is benign false positive.

In addition, as evidence evolves and variants are reclassified, consumers need to be aware of the process the DTC lab has, if any, for updating information and re-contacting consumers with revised interpretations. There may be potential benefits associated with DTC testing. DTC marketing and provision of genetic tests may promote patient autonomy. Given the complexity of genomic testing, several professional organizations have released position statements about DTC genetic testing.

For example, in , ASCO published a position statement outlining several considerations related to DTC cancer genomic tests, including those mentioned above. In , a statement by the American College of Medical Genetics and Genomics about DTC genetic testing similarly endorsed the involvement of qualified genetics professionals in the processes of test ordering and interpretation. Informed consent can enhance preparedness for testing, including careful weighing of benefits and limitations of testing, minimization of adverse psychosocial outcomes, appropriate use of medical options, and a strengthened provider-patient relationship based on honesty, support, and trust. Consensus exists among experts that a process of informed consent should be an integral part of the pretest counseling process.

The most commonly cited concern is the possibility of insurance or employment discrimination if a test result, or even the fact that an individual has sought or is seeking testing, is disclosed. This federal law provides protections related to health insurance and employment discrimination based on genetic information. However, GINA does not cover life, disability, or long-term-care insurance discrimination. A related issue involves stigmatization that may occur when an individual who may never develop the condition in question, or may not do so for decades, receives genetic information and is labeled or labels himself or herself as ill.

Finally, in the case of genetic testing, medical information given to one individual has immediate implications for biologic relatives. These implications include not only the medical risks but also disruptions in familial relationships. The possibility for coercion exists when one family member wants to be tested but, to do so optimally, must first obtain genetic material or information from other family members. Inclusion of an informed consent process in counseling can facilitate patient autonomy. Many clinical programs provide opportunities for individuals to review their informed consent during the genetic testing and counseling process.

Some programs use a second informed consent process prior to disclosure to the individual of his or her genetic test results. This process allows for the possibility that a person may change his or her mind about receiving test results. After the test result has been disclosed, a third informed consent discussion often occurs. Obtaining written permission to provide the test result to others in the family who are at risk can avoid vexing problems in the future should the individual not be available to release his or her results.

Major elements of an informed consent discussion are highlighted in the preceding discussion. The critical elements, as described in the literature,[ 1 , 2 , 84 , 85 ] include the following:. All individuals considering genetic testing should be informed that they have several options even after the genetic testing has been completed. They may decide to receive the results at the posttest meeting, delay result notification, or less commonly, not receive the results of testing. They should be informed that their interest in receiving results will be addressed at the beginning of the posttest meeting and that time will be available to review their concerns and thoughts on notification. It is important that individuals receive this information during the pretest counseling to ensure added comfort with the decision to decline or defer result notification even when test results become available.

Genetic testing for pathogenic variants in cancer susceptibility genes in children is particularly complex. While both parents [ 86 ] and providers [ 87 ] may request or recommend testing for minor children, many experts recommend that unless there is evidence that the test result will influence the medical management of the child or adolescent, genetic testing should be deferred until legal adulthood age 18 y or older because of concerns about autonomy, potential discrimination, and possible psychosocial effects.

The ASCO statement on genetic testing for cancer susceptibility maintains that the decision to consider offering childhood genetic testing should take into account not only the risk of childhood malignancy but also the evidence associated with risk reduction interventions for that disorder. Special considerations are required when genetic counseling and testing for pathogenic variants in cancer susceptibility genes are considered in children. The first issue is the age of the child.

Young children, especially those younger than 10 years, may not be involved or may have limited involvement in the decision to be tested, and some may not participate in the genetic counseling process. The majority of children in this study felt that they should have the right to make the final decision for genetic research participation, although many would seek input from their parents. Unfortunately cognitive and psychosocial development may not consistently correlate with the age of the child. Another complicating factor includes potential risks for discrimination. Refer to the Employment and Insurance Discrimination section in the Ethical, Legal, and Social Implications section of this summary for more information.

The consequences of genetic testing in children have been reviewed. Genetic testing could interfere with the development of self-concept and self-esteem. Children may also be at risk of developing feelings of survivor guilt or heightened anxiety. All children are especially susceptible to not understanding the testing, results, or implications for their health. As children mature, they begin to have decreased dependency on their parents while developing their personal identity. This can be altered in the setting of a serious health condition or an inherited disorder. Older children are beginning to mature physically and develop intimate relationships while also changing their idealized view of their parents. All of this can be influenced by the results of a genetic test.

In summary, the decision to proceed with testing in children is based on the use of the test for medical decision making for the child, the ability to interpret the test, and evidence that changes in medical decision making in childhood can positively impact health outcomes. In addition, careful attention to intrafamilial issues and potential psychosocial consequences of testing in children can enable the provider to deliver support that facilitates adaptation to the test result. Refer to the PDQ summaries on Genetics of Breast and Gynecologic Cancers ; Genetics of Colorectal Cancer ; and Genetics of Endocrine and Neuroendocrine Neoplasias for more information about psychosocial research in children being tested for specific cancer susceptibility gene pathogenic variants.

Genetic counseling and testing requires special considerations when used in vulnerable populations. In , the American Society of Human Genetics published a position statement on the ethical, legal, and psychosocial implications of genetic testing in children and adolescents as a vulnerable population. Specific to genetic testing, the International Society of Nurses in Genetics further expanded the definition of vulnerable populations to also include individuals with hearing and language deficits or conditions limiting communication for example, language differences and concerns with reliable translation , cognitive impairment, psychiatric disturbances, clients undergoing stress due to a family situation, those without financial resources, clients with acute or chronic illness and in end-of-life, and those in whom medication may impair reasoning.

Genetic counseling and testing in vulnerable populations raises special considerations. The aim of genetic counseling is to help people understand and adapt to the medical, psychological, and familial implications of genetic contributions to disease, which in part involves the meaningful exchange of factual information. Providers need to assess all patients for their ability to make an uncoerced, autonomous, informed decision prior to proceeding with genetic testing. Populations that do not seem vulnerable e. Alteration of the genetic counseling and testing process may be necessary depending on the situation, such as counseling and testing in terminally ill individuals who opt for testing for the benefit of their children, but given their impending death, results may have no impact on their own health care or may not be available before their death.

In summary, genetic counseling and testing requires that the health care provider assess all individuals for any evidence of vulnerability, and if present, be sensitive to those issues, modify genetic counseling based on the specific circumstances, and avoid causing additional harm. The complexity of genetic testing for cancer susceptibility has led experts to suggest that careful, in-depth counseling should precede any decision about the use of testing, in keeping with the accepted principles for the use of genetic testing.

Qualitative and quantitative research studies indicate that families hold a variety of beliefs about the inheritance of characteristics within families; some of these beliefs are congruent with current scientific understanding, whereas others are not. This process begins with initial discussion and continues throughout the genetic counseling process. An accurate assessment of psychosocial functioning and emotional factors related to testing motivation and potential impact and utilization is an important part of pretest counseling. People have various coping strategies for dealing with stressful circumstances such as genetic risk.

Identifying these strategies and ascertaining how well or poorly they work will have implications for the support necessary during posttest counseling and will help personalize the discussion of anticipated risks and benefits of testing. Taking a brief history of past and current psychiatric symptoms e. In such cases, further psychological assessment may be indicated. In addition, cognitive deficits in the person being counseled may significantly limit understanding of the genetic information provided and hinder the ability to give informed consent and may also require further psychological assessment. Emotional responses to cancer risk may also affect overall mood and functioning in other areas of life such as home, work, and personal health management, including cancer screening practices.

Since behavioral factors influence adherence to screening and surveillance recommendations, consideration of emotional barriers is important in helping a person choose prevention strategies and in discussing the potential utility of genetic testing. The discussion of issues such as history of depression, anxiety, and suicidal thoughts or tendencies requires sensitivity to the individual. The individual must be assured that the counseling process is a collaborative effort to minimize intrusiveness while maximizing benefits.

Determining whether the individual is currently receiving treatment for major psychiatric illness is an important part of the counseling process. Consultation with a mental health professional familiar with psychological assessments may be useful to help the provider develop the strategies for these discussions. It also may be beneficial for the individual to be given standard psychological self-report instruments that assess levels of depression, anxiety, and other psychiatric difficulties that he or she may be experiencing.

This step provides objective comparisons with already established normative data. In addition to the clinical assessment of psychological functioning, several instruments for cancer patients and people at increased risk of cancer have been utilized to assess psychological status. Psychological assessments are an ongoing part of genetic counseling. Some individuals with symptoms of increased distress, extreme avoidance of affect, or other marked psychiatric symptoms may benefit from a discussion with, or evaluation by, a mental health professional. It may be suggested to some people generally, a very small percentage of any population that testing be postponed until greater emotional stability has been established.

In addition to assessing the family history of cancer, the family as a social system may also be assessed as part of the process of cancer genetic counseling. Hereditary susceptibility to cancer may affect social interactions and attitudes toward the family. In assessing families, characteristics that may be relevant are the organization of the family including recognition of individuals who propose to speak for or motivate other family members , patterns of communication within the family, cohesion or closeness of family members or lack thereof , and the family beliefs and values that affect health behaviors.

Ethnocultural factors may also play an important role in guiding behavior in some families. The practitioner may use the above framework to guide inquiries about the relationship of the individual to 1 the affected members of the family or 2 others who are considering or deciding against the consideration of genetic counseling or testing. Inquiries about how the family shares or does not share information about health, illness, and genetic susceptibility may establish whether the individual feels under pressure from other family members or anticipates difficulty in sharing genetic information obtained from counseling or testing. Evidence from a study of persons from 38 Lynch syndrome—affected families suggested that the timing of genetic counseling and testing services may influence psychological test-related distress responses.

Specifically, family members in the same generation as the proband were more likely to experience greater test-related distress with increasingly longer lengths of time between the proband's receipt of MMR pathogenic variant results and the provision of genetic counseling and testing services to family members. However, it was unclear whether time lapses were due to a delay in the proband communicating test results or the family member choosing to delay genetic testing, despite being aware of the proband's results.

More specific information about family functioning in coping with hereditary cancers can be found in the psychosocial or counseling sections of PDQ summaries on the genetics of specific types of cancer. Specific clinical programs for risk management may be offered to persons with an increased genetic risk of cancer. These programs may differ from those offered to persons of average risk in several ways: screening may be initiated at an earlier age or involve shorter screening intervals; screening strategies not in routine use, such as screening for ovarian cancer, may be offered; and interventions to reduce cancer risk, such as risk-reducing surgery, may be offered. Current recommendations are summarized in the PDQ summaries addressing the genetics of specific cancers.

The goal of genetic education and counseling is to help individuals understand their personal risk status, recognize their options for cancer risk management, and explore their feelings regarding their personal risk status. Counseling focuses on obtaining and giving information, promoting autonomous decision making, and facilitating informed consent if genetic testing is pursued. Optimally, education and counseling about cancer risk includes providing the following information:. When a clinically valid genetic test is available, education and counseling for genetic testing typically includes the following:. If a second session is held to disclose and interpret genetic test results , education and counseling focuses on the following:.

The process of counseling may require more than one visit to address medical, genetic testing, and psychosocial support issues. Additional case-related preparation time is spent before and after the consultation sessions to obtain and review medical records, complete case documentation, seek information about differential diagnoses, identify appropriate laboratories for genetic tests, find patient support groups, research resources, and communicate with or refer to other specialists. Information about inherited risk of cancer is growing rapidly. Many of the issues discussed in a counseling session may need to be revisited as new information emerges. Individuals may be advised to check in with the health care provider periodically to determine whether new information is sufficient to merit an additional counseling session.

The obligation of health care providers to recontact individuals when new genetic testing or treatment options are available is controversial, and standards have not been established. Using probability to communicate risk may overestimate risk certainty; this is especially true when risk estimates have wide confidence intervals or when the patient has characteristics that differ greatly from that of the sample that the risk estimate was based on. For all the above reasons, conveying risk in multiple ways, both numerically and verbally, with discussion of important caveats, may be a useful strategy to increase risk comprehension.

The numerical format that facilitates the best understanding is natural frequencies because frequencies include information concerning the denominator, the reference group to which the individual may refer. In general, logarithmic scales are to be avoided. The communication of risk may be numerical or visual. Use of multiple strategies may increase comprehension and retention of cancer genetic risk information. Visual depictions of risk may be very useful when working with visual learners, but research that confirms this is lacking.

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