corresponding recognition that most medical information, screening and diagnostic tests, and disease processes have a genetic component. However, these scientific Cologne Life Reinsurance Company, Stamford, Connecticut.advances have been accompanied by fears that insurers might misuse genetic information to the detriment of the general public.METHODS. This article addresses the principal issues regarding insurers' use of genetic information from the perspective of the insurance industry. Alzheimer's disease is used to exemplify problems that would occur if insurers did not consider genetic information that was known to applicants. RESULTS.Prohibiting use of genetic information would make it difficult to sell individually underwritten coverage at an affordable premium because insurers could not use most of the risk parameters that correlate with likelihood of claim.CONCLUSIONS. It appears that the use of genetic factors in risk classification will eventually become accepted practice. Insurers and the medical community must be proactive in seeking solutions to difficulties that can be envisioned in the future. Iwould like to thank the American Cancer Society for providing an opportunity for me to meet with other physicians who share my desire to ensure that insurance protection remains widely available and highly affordable in the genetic era that lies ahead. To the best of my knowledge, this is the world's first cancer genetics conference with an agenda that seeks to identify and solve proactively insurance difficulties that can be envisioned ahead of time. I understand that consumers and most physicians know very little about the inner workings of the private insurance mechanism, and people wonder if obtaining coverage will become more difficult in the future. For this reason, I will confine my remarks to my most deeply held convictions as a consumer, physician, and insurance professional regarding what will probably occur and, in fact, what must occur if individually underwritten insurance is to remain a product that appeals to most people. In this regard, I must emphasize that I appear today in a personal capacity and that the opinions expressed in this paper, whether explicit or implied, are mine alone and not necessarily those of the organizations with which I am associated.Presented at the American Cancer Society Workshop on Heritable Cancer Syndromes and Focus of the DiscussionGenetic Testing, Chicago, Illinois, October 7-8, 1996. Insurance figures prominently in articles that discuss concerns engendered by advances in genetic technology. Two of the more detailed from the perspective of an insurance medical director. The goal is to foster an atmosphere of understanding and mutual respect and point

There is uncertainty regarding the degree of insurance risk associated with BRCA1/2, the gene mutations associated with breast cancer. Most reports to date have been based on high-risk populations selected from families with multiple and/or early-onset cancers; more favorable data have been reported in studies without this selection bias.This paper discusses use of a Markov model to estimate mortality risk associated with BRCA1/2 gene mutations in female life insurance applicants. The goal is to derive a range of risk estimates based on different assumptions of breast and ovarian cancer incidence. A particular strength of the model is that transition probabilities after cancer diagnosis vary with age and cancer stage, as do excess hazard rates.Data calculated by the model indicate that no single mortality curve characterizes risk for all life insurance applicants with a BRCA1/2 mutation. Rather, mortality risk depends on breast and ovarian cancer incidence rates and subsequent mortality rates, and on the method used to deal with competing breast and ovarian cancer incidence and mortality rates. Further refinement of risk estimates will depend on better incidence data and on resolution of complex statistical problems, such as informative censoring.Widespread use of genetic information by insurance consumers could have important economic implications. For companies that sell individually underwritten products, profitability might decrease. Consumers might find higher prices and reduced availability, with a corresponding decrease in quantity of insurance purchased. Insurance and consumer ramifications would vary by cover, with living-benefit products, such as critical-illness insurance, most adversely affected. Societal choices are limited. Given assumptions in the cited scenario, it is likely premiums would rise and quantity of insurance purchased would decrease even with no change in existing social policy; attempted legal or regulatory remedies would further accentuate price increases and reductions in quantity purchased.

Cigarette smoking has reached epidemic proportions in many Asian countries, and epidemiologists predict massive increases in the number of smoking-related deaths in future decades. This information is of great interest to insurers who would like to sell coverage in these markets with smoker/nonsmoker-distinct pricing. This review examines excess mortality due to cigarette smoking in Asia as determined by a second-quarter 1998 Internet search of the world's Englishlanguage medical literature for references published during the preceding five years. Studies to date which observed fairly low relative risks of mortality in smokers compared with nonsmokers in Asia despite a high prevalence of smoking can be explained by the fact that health outcome data represent early experience. Given similar associations between smoking and mortality in Asian and Western studies, it is likely that mortality patterns of smokers in Asia eventually will mirror those seen in the U.S. and the United Kingdom.