Speaking of Women's Health
The Speaking of Women's Health Podcast is excited to bring you credible women's health information from host and Executive Director, Dr. Holly L. Thacker. Dr. Thacker will interview guest clinicians discussing relevant women's health topics and the latest news and tips.
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Speaking of Women's Health
Understanding Genetic Testing for Cancer and Disease Risk
Prepare to gain a deeper understanding of genetic testing and counseling as our Speaking of Women's Health Podcast host Dr. Holly Thacker interviews Ryan Noss, an expert in the genetic field.
They explore how genetic insights are transforming personalized healthcare, particularly in women's health, and the critical role these advancements play in cancer management and understanding genetic predispositions to various conditions. They also discuss the legalities surrounding genetic information, which is protected by the Genetic Information Non-Discrimination Act (GINA).
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Welcome to the Speaking of Women's Health podcast. I'm your host, dr Holly Thacker, the Executive Director of Speaking of Women's Health, and I am glad to be back in the Sunflower House for a new episode. For a new episode, and on this podcast of Speaking of Women's Health, we will be talking about genetic testing and the law. As you know, I'm your host, dr Holly Thacker, the executive producer of Speaking of Women's Health, and I am back in the Sunflower House for a brand new episode with genetic counselor Ryan Noss. I am so happy to have him here. He works in the Center for Personalized Genetic Health Care at Cleveland Clinic and he works with a whole entire team of specialists, primary care clinicians, genomic staff, and he helps to personalize patients' care and the genetic information obtained into an overall personalized healthcare plan. So welcome, ryan Noss.
Speaker 2:Thank you so much for being here thank you very much for the opportunity, dr thacker.
Speaker 1:I'm looking forward to it oh, and my fellows, I have to say. I run a fellowship for specialized women's health and they um, really enjoy the time they rotate with you and your team, yeah, and they've had great things to say about you and your care and your expertise. So why don't you tell our listeners just a little more about your professional background and how you got into genetic counseling, an expanding, important field? Yeah?
Speaker 2:absolutely so. As a genetic counselor, what that means is that I have a master's degree specifically in the field of genetic counseling, so I have a master's of science in genetic counseling. There are roughly 50 programs across the country that provide that type of training about a two-year program. A lot of it is didactic or in the classroom, learning about the field of medical genetics, as well as training and skill building in psychosocial support to help patients find a way to not only understand their genetics and how that impacts their health, but to find a healthy way to integrate that and cope with integrating that into their health care.
Speaker 2:I found this profession I actually didn't know it existed until I was in undergrad. I always liked science, I always wanted to help people and felt there had to be a combination thereof, but really wasn't sure what it was for me personally. And, as fate would have it, I was in a science honorary and one of the leaders was a senior and explained oh, I'm going on to become a genetic counselor, I'm going to grad school to become that, and I had just read about that field in a little blurb in my textbook. And I had just read about that field in a little blurb in my textbook, and so I flagged her down afterwards and said how did you know, like, how are you going to do this? What is this? I've just learned about it. I want to know more, and she explained that at um. So I went to undergrad at Ohio State and she explained that there are genetic counselors there OSU boy.
Speaker 1:Boy, yes, you're an OSU grad.
Speaker 2:Go Buckeyes yeah absolutely, we have a big game tomorrow, but yeah. So I got a chance to shadow a genetic counselor and I like to this day remember walking back to the dorms and calling my dad on the phone and saying yeah, this is it, I figured it out, this is where I'm going to be, and the rest is history well, that is great, um, you know, for career counseling, because we have a lot of our listeners.
Speaker 1:I'm sure have, uh, children and young adults. Um, is this going to still be a field in big demand with AI? Will that change anything?
Speaker 2:I'm just curious no, that's a really good question, and I just don't see a world in which there isn't need for a human element in understanding and providing care and information surrounding genetics of patients. And so I certainly am a pro AI person. I've actually done some pilot studies looking at things like chatbots for patient education but no, I just don't see a world in which that replaces the role of the provider, and certainly see a world where our role continues to grow.
Speaker 1:So how would a person know that they need or want genetic testing? Sure.
Speaker 2:So genetics and its contribution to disease is growing all the time. And when I think about specifically the world of cancer genetics which, admittedly, is what I know the most about classically we've thought about the earlier a patient is when they're diagnosed with that disease. So in cancer we would think about a patient diagnosed with, for say, breast cancer at or before 50 would be someone we would think about, or a case where there's just more people with that same diagnosis than statistically makes sense. There's certainly other types of cancer, like pancreatic or ovarian cancer, where the genetic contribution for those diseases is very significant and we would recommend any patient with that diagnosis consider genetic testing.
Speaker 1:Now I know that, as I as an ordering physician, when I put in a medical genetics consult, cancer is an option cardiovascular disease. So is there different training, or does everyone get the same training and then certain people just specialize in certain areas?
Speaker 2:No, that's a really good question as it stands. Today we all have a baseline level of training and so during that two-year program, I would say a year of it is in the classroom, a year of it is in clinic and covers a spectrum of applications. So I had rotations in prenatal genetics and pediatric genetics and cancer genetics, and for me cancer genetics resonated the most with my view of what I wanted to be as a clinician and so chose to specialize in that. There are worlds where there's conversations about would our profession at some point become a clinical doctorate or something to that effect? And I think in that scenario we probably will see people come out of grad school with a specific label, if you will, of a cancer genetic counselor, and then I would think probably degenerative neurologic diseases would be like another whole category and I know that's been an argument that's been made against just widespread testing.
Speaker 1:because why do you want to know that you're going to say have Huntington's, korea or something, necessarily when there's nothing that can be done?
Speaker 2:Sure, and I think there are, in that setting of pros and cons of genetic testing, in that setting of pros and cons of genetic testing, and you know, I will freely admit I'm biased, given my profession and my interest in this I have a bias toward knowledge is power.
Speaker 1:Yes.
Speaker 2:And that by knowing this may or may not impact the health care that I receive or what the ultimate transition of my care looks like for a condition like Huntington's where there's not known effective treatment to reverse the disease, but it gives me an opportunity to live my life, knowing something that may change how I live my life and how I set. Maybe do I have children, and if I do, what is my legacy to them, and so I think that's again from a place of bias, of viewing it from a positive lens. But I can certainly appreciate where, for certain patients, that creates anxiety and worry and to a point where that's debilitating and impedes their quality of life, and in that scenario I would argue no genetic testing isn't appropriate or isn't maybe the best scenario for that patient. And so certainly it's in many respects a conversation about not just, do you qualify for this, but is this something we're prepared to take on and integrate into our lives?
Speaker 1:So, as all this multi-sequencing becomes cheaper and more expansive, do you think we'll ever get to a point where everybody has germline evaluations?
Speaker 2:that's a good question. Do I think we will get to that point? Yes, do I think we're at that point today? No, and I don't even think it's a fiscal argument. To be honest, I think a lot of it is.
Speaker 2:We don't yet know enough about the genetic contributors for some of these common diseases. One in eight women develop breast cancer in their lifetime, and at present we believe that about 10% of those cases are due to a hereditary cause, and so, from a public health model, I don't think that's a good model, because you run the risk of a significant number of women testing negative for one of these traits but still having a very meaningful risk to develop the disease, and the concern I have in that model is sure for every one patient you identify with a hereditary risk. There are hundreds of women who test negative and may not understand the full ramifications of that and perhaps go to a world of lowered surveillance that isn't clinically appropriate you know, back in the 90s with you know, BRCA testing, and I've been to Salt Lake City and looked at Myriad's lab and followed some of the litigation and then the expansion, and I have a large practice of women who have inherited mutations, some highly penetrant, some not as much.
Speaker 1:But it really does inform the risk stratification and choices that are made. And initially, when this came on the forefront, patients were petrified to have testing. They were afraid they would lose medical insurance or life insurance or that they would be shunned. And I think that we've really advanced well beyond that and I have many mutation carriers living full lives and doing very, very well and just kind of taking it in stride like anything else. I don't think it's as overwhelming or scary as it used to be. Um, tell us just in general how, uh like before the visit, at the visit, a lot of patients think they can just say I want genetic testing and that they can just get it ordered. And that's not really like just going in for a blood test. It's not as simple as like I want to know what my fasting cholesterol is. Sure.
Speaker 2:Yeah. So you're right in that I think some of the fear and stigma surrounding genetics and disease has appropriately dissipated as we learn more, and so I couldn't agree with you more there. As far as the process, what does that look like? Well, typically we would start with initial consultation and at that time reviewing the patient's personal history. Have they themselves ever had a cancer diagnosis? What are they doing now in regards to their cancer screenings, as well as a detailed discussion about their family history. And are there different cancer diagnoses? What type of cancer? When did those cancers occur in those patients, in those family members?
Speaker 2:And part of that, sure, is trying to determine what is the likelihood of a mutation. And in some levels you can kind of distill that down to is insurance going to cover this test or not? But I think there's a little more nuance to it in the sense that are there aspects of the patient's personal and or family history that, just at baseline, that in and of itself should indicate a different surveillance program, and are just at baseline? Are there things that we should be looking at in terms of referral? But at that time, if we look at that personal and family history and say, yeah, this looks to have a significant potential to be genetic. How would we figure that out? Most typically, we would do a blood test. Certainly, there are ways where you can do it as a saliva test or a cheek swab, or even a skin biopsy in very rare scenarios, but most commonly it's a blood test.
Speaker 1:Like those persons who have, like myeloproliferative disorders where you can't just draw their blood.
Speaker 2:Correct. So if a patient has leukemia right like so, am I testing their genetics or am I testing their leukemia's genetics? Exactly, and so in that case we would want a different specimen source, but but by and large we would look at a blood test and we have had several prior podcasts in our last few seasons and we have had several prior podcasts.
Speaker 1:In our last few seasons I've interviewed Dr Holly Peterson who formerly directed our medical breast because she deals with high-risk patients, and that was a very interesting discussion. I've had my son, stetson Thacker, who's a PhD in molecular medicine and cancer genetics and he's very involved in the genetics world.
Speaker 1:In fact, sometimes listening to him like everything is genetic, it's like I'm like, okay, this kind of is going down a bad pathway here to say that everything is predetermined, which of course it is not, and even people with highly penetrant problems don't all develop cancer or cardiovascular disease, you know, or other other potentially heritable conditions necessarily. So I think that's important that people do have agency and do have options and choices. I got interested in the GINA law actually and you're actually listening to the Speaking Women's Health podcast. I am interviewing geneticist Ryan Noss about genetic testing and the law and I was very interested in the GINA law personally because I recently had a family member who was diagnosed with a cancer that looked like Lynch syndrome and the female relatives in my family my mother died very young of an unrelated illness and her mother died very young of a cancer which in retrospect could have been Lynch, and so I thought, well, like my son Stetson's oh, mom, you're too old. I mean if you had this, you would have already had cancer. I'm like, probably. I mean, that's one thing about getting older the older you are, the less likely it is that you've had a highly penetrant genetic lesion. However, I still have patients who are otherwise healthy and have good health habits and there's other cofactors who don't.
Speaker 1:But what really drove me to get tested was I have three sons and some of my sons have children, including female children, uh, of which you know, uterine cancer, ovarian cancer, breast cancer and then, of course, for both sexes, skin cancers, colon cancer, screenings etc would have an impact, and when I went through the whole process, it was very interesting. I was able to do it remotely, which is nice. It seems like there's a huge backlog in services and it was really great. Informed consent and the whole process I thought was really nice and smooth.
Speaker 1:But the questions that I had I knew what would happen with me personally, what I would have to decide to do if I was positive and the test, as they explained to me, could be positive, which means you have it negative, or you could have a variant of unknown significance. Those are like your three choices, right. And so when I got my results back, I was very happy and relieved, especially for my offspring and grandchildren, that I was negative. For that. That's great For that. And then, of course, I have a VUS, which of course, I told my son and he started laughing Ha ha ha, that's so funny. Of course, which do you want to tell us about VUSs. I think it's benign. I'm not losing any sleep, but that goes to show the more you do testing, you can find things that you don't know what they mean and for a lot of people that can cause a lot of anxiety.
Speaker 2:Well, absolutely, and so to kind of define what a variant of unknown significance is. So I like to like even take a step back for a moment of what is a gene, the way I would encourage a patient to try to visualize a gene, because I mean spoiler alert I've been doing this for 12 years. I've never seen a gene with my eyes, my eyes, I've never seen one, and and so it's not pants that you wear, that just fit perfectly.
Speaker 2:No, no, it's not my Wranglers, it's not my Wranglers, it's um, you know, and, and so I like to try to encourage a patient to picture it. And and how I visualize it is it's a set of instructions telling my body how to do a task. And so if we think of it as this written code and a negative result means, well, the code is either spelled exactly how it's supposed to and I'm going to put in air quotes normal meaning. It looks the way in which we expect that sequence to look. Now, a positive result or a pathogenic result is where there's a difference in that genetic sequence. That's clearly impacting those instructions. So if I deleted steps out of an instruction manual, I think it's easy to picture how that would lead to the job not being done correctly.
Speaker 2:Versus a variant is saying well, it's different. The way in which this is written in your makeup is different than in this. Again, normal or expected version. Normal or expected version. But whether or not it truly alters those instructions, whether or not it causes harm, is not known, and that can be for a variety of reasons. A lot of times it's because we've not, the scientific community hasn't observed that specific variant enough times to really get a proper clinical context for it and that's why it's important to note it.
Speaker 1:And these companies that do the testing.
Speaker 1:They keep big databases and that's very important for, you know, future advances.
Speaker 1:When I had getting my informed consent to decide to get the testing, I wanted to prepare in advance, you know, for, like I always do with my patients, let's plan for the worst and hope for the best with just everything that we do, because you just don't want to be cavalier.
Speaker 1:So I already knew what I would do personally. But I was concerned about my offspring, who are young and healthy, not even at the age of starting any cancer screening early, but how that might affect them. I mean, I know for myself, or if you're established, you can't be discriminated. You know, medically, insurance-wise, etc. But when I found out that if you have really young children, certainly they don't need to be burdened with it when they're not even adults, but if they're just starting their career or they don't have life insurance maybe, or if they're going to be in the military right or be in a very small company under 10 employees, so tell me about just the current state of legalities. You know, we're kind of at the end of 2024, and this may air in season three in 2025. So at this point in time and then you're always welcome to come back when there's major changes or other things that we don't get to finish talking- about.
Speaker 2:Of course, I would love to come back.
Speaker 1:But talk a little bit about some of the legal implications that you have to impart to your patients.
Speaker 2:Sure.
Speaker 2:So you had mentioned earlier GINA and a law called GINA, and essentially that's an acronym for Genetic Information Non-Discrimination Act, and this was a bill that was signed into law in 2008.
Speaker 2:And essentially it was built off of the Americans with Disabilities Act and and so, as you were kind of alluding to these like carve-outs and part of it is it's similar carve-outs, as was part of ADA, but essentially what that law was putting in place is protections.
Speaker 2:Putting in place is protections for a patient from their employer as well as from their health insurer and that would mean both their current as well as hypothetical future employer health insurer and stating that they cannot ask to obtain this information, they're not allowed to act upon this information in in the sense that I can't be denied a promotion because I have a genetic condition, um, or from a health insurance.
Speaker 2:I can't be dropped from that plan or have my premiums or deductibles changed when I apply for a new health insurance. I'm they're not allowed to ask me if I've ever had any of this to establish what my plan should look like. Again, you alluded to the idea that there are some areas where there may be I hesitate to say loopholes, but there are certainly scenarios where it doesn't apply to all people, and part of that is again in line with the Americans with Disabilities Act, where for smaller employees, those that have less than 10 employees, there aren't the same level of protections, as well as those in active military there are not necessarily the same level of protections, as well as.
Speaker 1:And does that have anything to do with the physical fitness status, like, say, you had an inherited cardiac condition?
Speaker 2:I believe that would be the argument. Yes, and actually what's interesting is I don't fully understand how this works in the world of athletics, but we have certainly seen certain athletes, especially in the in in basketball, that have been flagged as having potential cardiovascular related concerns and that then impede impacts their their draft status. So I don't know all of the legalities of that. Like Marfan syndrome, they're really tall, Exactly.
Speaker 1:Wide arms fans their draft status, so I don't know all of the legalities of that. Like Marfan, syndrome.
Speaker 2:They're really tall, exactly yeah, and have really wide arms for fans. Yeah, and which would make them a phenomenal defender Right, the problem being they're also at significant risk for an aneurysm.
Speaker 1:Yes.
Speaker 2:And so there's catastrophic health concerns surrounding it. I'm blanking on his name now, but there was a basketball player at Baylor who was projected to be a lottery pick and ended up being identified as having Marfan syndrome prior to the draft and actually went undrafted Wow. So I don't exactly know all of the legalities of that. I'm going to admit I don't know that. The other important thing to think about with it is some of these communities have other protections or other bylaws and rules within their own circumstances and then, like a lesser known one, or at least one that doesn't impact us here in Cleveland as much as, given our demographics but American Indians or indigenous people also don't fall under that same in terms of, like the nationally provided health care.
Speaker 1:And again, I'm not going to begin to try to unpack that one. So then, in general, what do you recommend for your patients that might have BRCA gene or ATM or CHECK or BRIP or?
Speaker 1:all these expanding mutations that have variable risk for breast cancer, ovarian cancer, colon cancer, pancreatic cancer, prostate cancer. Obviously, if somebody is an adult and they're established, they need to know if they have this so that they can start screening and they don't die prematurely when it could have been stopped. But for their offspring, in general you say, wait till 18, 21 or 25. When they're established, they've decided whether they're in the military or not. They decided whether they're going to be in a super small business or not. Sure.
Speaker 2:I mean, that's a really great question, and to me there are a couple when I think about testing the next generation. To me there are a handful of time periods that I would think about. One of them is and I would argue this is probably the most important one is what is the age in which your medical care will be altered? And so, if it's a condition where that would alter a minor's health care, we may look at genetic testing prior to the age of 18, so that we know that we're following them appropriately.
Speaker 1:And what would be some examples of those conditions?
Speaker 2:Sure. So an example of that would be FAP, or familial adenomatous polyposis, which is due to a gene called APC, where the risk of colon cancer is significant, even in young people, and so we do recommend colonoscopies in patients under the age of 18. And in that scenario, you know, certainly as a parent, I might be more inclined to saying well, do you actually have this before I subject you?
Speaker 1:to a colonoscopy screening.
Speaker 2:Yes, Right, Right. So that would be a scenario that I might think about it prior to the age of consent. But if we're saying no, your care is not going to be altered as a minor, Well, ultimately we we want the next generation to be independent contributors to society that are capable of making their own decisions.
Speaker 1:And should be afforded informed consent, which minors really can't.
Speaker 2:Exactly, and autonomy and all of those things, and so in that sense I wouldn't want to test them until they were at least 18. Test them until they were at least 18. Now, I don't exactly know what magic happens that night when you go, you're 17 and then you fall asleep, and then you wake up and you're 18 and somehow you're now all knowing. I don't exactly know what magic happens, but certainly that's an age where we would think about testing.
Speaker 1:Well, certainly so many things legally change, like I know the moment my children became 18. They signed, you know, they had a power of attorney and their health care directives because, as a parent, you're no longer technically legally over them in terms of making you know medical decisions, in terms of an emergency, so I guess that's why that would be a time period.
Speaker 2:Yeah, the law, the law would support that yeah um, but you're.
Speaker 2:but there's a little bit more nuances to it too, as you kind of alluded to. As far as you know again, if so, let's say, my 18 year old could have Lynch syndrome. Well, they're 18, they're an adult, they can consent to that test if they want. Through Gina, they would have protection from a health insurance perspective, from an employer perspective, but there's not universal protection when it comes to other forms of insurance, so things like life insurance, because what happens is that genetic test result becomes part of that person's medical record.
Speaker 1:Yes, yes.
Speaker 2:And when a person applies for life insurance, it is within that company's rights to ask to obtain your medical records and use those to determine what your plan should be Now. What?
Speaker 1:about if, say, the adult, the young adult, knows that one of their parents is positive, but they don't know their own results? Can that insurance company have to obtain that information?
Speaker 2:It's a little stickier and part of it is depends on how exactly that's categorized, even within their medical record. But it's also a theoretical risk versus a known risk which would be weighted differently.
Speaker 1:And then what about marriage, childbearing, et cetera? Because if someone knows, they're not going to start a family until, say, 30, even though I always encourage people. Your gametes are getting older faster than you think you are, and it's better to reproduce earlier rather than later but that's a whole other podcast. If someone's not immediately going to need that screening for that condition and they're not planning to start a family with those kinds of implications yet, then they have a little more time.
Speaker 2:Sure, sure and, and I suppose the other, the devil's advocate to that is not every pregnancy is a planned pregnancy.
Speaker 1:Exactly, exactly.
Speaker 2:But I think that's where you know you have to. Fortunately, my children are still second grade and younger, so I haven't had to have those types of conversations yet.
Speaker 1:You will.
Speaker 2:I, I, I, unfortunately, unfortunately, whatever I will, but you know, I think again. You're right, though that that family planning is another time period where we would consider testing. You know, ultimately, what I would encourage that young adult to consider would be obtaining life insurance prior to genetic testing.
Speaker 1:Yes, and that's the way that I was, you know, going to proceed, you know, with my adult children, which I always told them anyway, it's a lot lower premiums to do it when you're younger. And if you're young and buying a house and starting a family, getting married and have debt, you know you really should have life insurance. But I guess that's another whole financial topic.
Speaker 2:Yeah, yeah, now we're. Now we're going way into the weeds.
Speaker 1:Yes, of like life planning. But you know, knowledge is is power. One thing that I see with a lot of my female patients, many of them who have, you know, various risk for cancer and are dealing with it themselves. Some have had surgeries like hysterectomiesectomies, colonoscopies, more frequent, frequent doctor visits, more intense surveillance, as recommended for their individual situation. That I've noticed with their offspring that their female children are a lot more likely to pursue the genetic testing than their adult male children. And obviously males cannot get ovarian or uterine cancer. Of course rarely they can have breast cancer and we sometimes do see that in men, genetically who have BRCA gene et cetera. But I don't know how much of that is just cultural that men just don't seek medical services. But they can have daughters. They can have prostate cancer and pancreatic cancer and colon cancer too.
Speaker 2:Oh, absolutely, and I think it's a. I, as a male, have some thoughts or feelings around all of that, in the sense that I do think to an extent there are some myths that when we think about conditions like BRCA, that disproportionately the the cancer risks are disproportionately higher in women than in men yes.
Speaker 2:I think there's almost a a misconception of it being sex linked yes, in the sense of like a woman can only pass it to a woman, which is not true, of course, and and so I think there's almost even just this need, like a certain level of education that needs to come into play, of even making sure the patient's aware that their sons could carry this trait. Um, and and also to your point, men, yes, the risks are significantly different in men and women in terms of breast cancer, but it is a disease that could impact a male. Um, I have to imagine, I think some of it is are those misconceptions, but I think you also tapped into something where there are a whole host of I know we're speaking of women's health in this podcast but but women take care of their family speaking of men's health, I think there's a whole, there's a whole litany of research that shows men's health lags behind women's health in terms of proactive seeking, proactive care.
Speaker 2:yes, and and I think this is probably part of it yeah, yeah, same song, different verse in terms of why maybe the male the uptake of testing is lower in men than women.
Speaker 1:And you know how reliable are these tests Because of course we know you can get a blood pressure, you can get a blood sugar and there's so many different things that can affect it. There's lab error with just regular blood tests that we do and we a lot of times will repeat things with just regular blood tests that we do and we a lot of times we'll repeat things.
Speaker 2:No, absolutely so. When we think about the ability for these labs to produce what your genetic sequence or your genetic code is, it's highly accurate, highly reliable. We're talking sensitivity specificities of 99.5 to 99.9 percent accuracy. And there is CLIA, which is a lab certification body that any of the medical commercial labs need to have that type of. They need CLIA certification in order to offer their testing. So there's certainly a lot of things in place to ensure reliability of results. I think to your personal experience of well, it identified a VUS. I mean, I think that's a different beast to it in the sense of it was highly reliable in its ability to tell us what your sequence was.
Speaker 1:Yes.
Speaker 2:But there is certainly a limitation from a clinical interpretation perspective that may lead to those types of findings. Not so much that I think it's an inaccurate finding, but it may not still be a satisfying finding.
Speaker 1:And I have some patients that are very cost-focused, and obviously there's a cost for consultation with a geneticist, which needs to be done before doing genetic testing. I have some patients who want to just go straight to the Invitae panel or just pay for it themselves. And what kind of comments do you have about that process? Sure, so.
Speaker 2:I think there are certain levels of misconception about insurance coverage and genetic testing, insurance coverage and genetic testing and that I think some patients there's a certain level of apprehension to pursue it because they're afraid they themselves are going to be responsible for, you know, thousands upon thousands of dollars of bills, which, honestly, is not the case. That when done through a clinical setting where it's a knowledgeable provider, the same levels of assessment that we're using to try to say, well, what is the likelihood of there being a mutation present, have become for mostly for better um have been adopted by insurance companies as well to determine what are scenarios where they would cover testing. So, by and large, when a genetic counselor would say to a patient yes, this is a clinically appropriate test to do, yes, this is a clinically appropriate test to do.
Speaker 1:The insurance company would agree with. Yes, yes, and so it's it's. It's smooth in that regard. So I really appreciate you joining us. Uh, ryan, because this has been so enlightening, we'll have to have you back because there's so many other topics that we didn't get to. I really appreciate you taking time from your really busy schedule and I want to thank our listeners for tuning in. We're so grateful for your support. Please leave us a five-star rating, if you would, and you can forward this to your friends and family. A five-star rating if you would, and you can forward this to your friends and family. If you don't already subscribe, please hit the subscribe or follow button and then you won't miss any future episodes. And thank you again for joining us in the Sunflower House and I'll look forward to seeing you again. Be strong, be healthy and be in charge.
