Journal of Genetic Counseling

, Volume 25, Issue 3, pp 529–542 | Cite as

Easing the Burden: Describing the Role of Social, Emotional and Spiritual Support in Research Families with Li-Fraumeni Syndrome

  • June A. PetersEmail author
  • Regina Kenen
  • Renee Bremer
  • Shannon Givens
  • Sharon A. Savage
  • Phuong L. Mai
Original Research


This study presents findings of a mixed-method descriptive exploration of the role of friends and spirituality/religiosity in easing the burden of families with the rare inherited disorder, Li-Fraumeni Syndrome (LFS). LFS is caused by germline mutations in the TP53 gene and is associated with very high lifetime risk of developing one or more malignancies. During the first clinical visit we assessed several types of social support among a subset of study participants (N = 66) using an established interactive research tool called the Colored Eco-Genetic Relationship Map (CEGRM). We performed both quantitative and qualitative analyses of social relationships with LFS family members and close non-kin. Distress scores (N = 59) were mostly low normal, with some outliers. We found that reported friendships varied widely, that the friendships were often deep and enduring, and were important sources of informational, tangible, emotional and spiritual support. Confidantes tended to be best friends and/or spouses. Organized religion was important in selected families, typically from mainstream traditions. However, a number of people identified themselves as “spiritual” and reported spiritual and humanist explorations. Our results shed preliminary light on how some people in families with LFS cope in the face of tremendous medical, social and emotional challenges.


Li-fraumeni syndrome (LFS) TP53 germline mutation Hereditary cancer susceptibility Genetic counseling Genetic testing Social support Psychosocial Psychosocial adaptation Resilience Qualitative research Cegrm Religious Spiritual 



We are especially grateful to the members of the families with LFS who participate in our studies and who freely offer their time and insights to helping us advance knowledge about this rare condition originally described over 45 years ago. We also thank our CGB colleagues Jennifer Young, Kate Rendle, Rosamma DeCastro, and Jennifer Loud for useful input and Westat colleagues Janet Bracci, Kathy Nichols, Nicole Dupree, Katie Beebe and all of the NCI LFS study team members for their important roles in the study.

Compliance with ethical standards


This research was supported by the Intramural Research Program of the Division of Cancer Epidemiology and Genetics (DCEG) of the National Cancer Institute (NCI) and by contract # HHSN261201300003C with Westat.

Conflicts of Interest

June A. Peters, Regina Kenen, Renee Bremer, Shannon Givens, Sharon A. Savage and Phuong L. Mai declare that they have no conflict of interest.

Human Studies and Informed Consent

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000 (5). Informed consent was obtained from all patients for being included in the study.

Animal Studies

No animal studies were carried out by the authors for this article.


  1. Allan, G. (2008). Flexibility, friendship, and family. Personal Relationships, 15(1), 1–16. doi: 10.1111/j.1475-6811.2007.00181.x.CrossRefGoogle Scholar
  2. Birch, J. M., Hartley, A. L., Tricker, K. J., Prosser, J., Condie, A., Kelsey, A. M., et al. (1994). Prevalence and diversity of constitutional mutations in the p53 gene among 21 Li-fraumeni families. Cancer Research, 54(5), 1298–1304.PubMedGoogle Scholar
  3. Birch, J. M., Alston, R. D., McNally, R. J. Q., Evans, D. G. R., Kelsey, A. M., Harris, M., et al. (2001). Relative frequency and morphology of cancers in carriers of germline TP53 mutations. Oncogene, 20(34), 4621–4628.CrossRefPubMedGoogle Scholar
  4. Bougeard, G., Sesboue, R., Baert-Desurmont, S., Vasseur, S., Martin, C., Tinat, J., et al. (2008). Molecular basis of the Li-fraumeni syndrome: an update from the French LFS families. Journal of Medical Genetics, 45(8), 535–538. doi: 10.1136/jmg.2008.057570.CrossRefPubMedGoogle Scholar
  5. Bougeard, G., Renaux-Petel, M., Flaman, J. M., Charbonnier, C., Fermey, P., Belotti, M., et al. (2015). Revisiting Li-fraumeni syndrome from TP53 mutation carriers. Journal of Clinical Oncology, 33(21), 2345–2352. doi: 10.1200/jco.2014.59.5728.CrossRefPubMedGoogle Scholar
  6. Bowie, J. V., Sydnor, K. D., Granot, M., & Pargament, K. I. (2004). Spirituality and coping among survivors of prostate cancer. Journal of Psychosocial Oncology, 22(2), 41–56 Retrieved from ISI:000230147400003.CrossRefGoogle Scholar
  7. Braithwaite, D. O., Bach, B. W., Baxter, L. A., DiVerniero, R., Hammonds, J. R., Hosek, A. M., et al. (2010). Constructing family: a typology of voluntary kin. Journal of Social and Personal Relationships, 27(3), 388–407. doi: 10.1177/0265407510361615.CrossRefGoogle Scholar
  8. Chompret, A. (2002). The Li-fraumeni syndrome. Biochimie, 84(1), 75–82.CrossRefPubMedGoogle Scholar
  9. Clayton, E. W., McCullough, L. B., Biesecker, L. G., Joffe, S., Ross, L. F., & Wolf, S. M. (2014). Addressing the ethical challenges in genetic testing and sequencing of children. The American Journal of Bioethics, 14(3), 3–9. doi: 10.1080/15265161.2013.879945.CrossRefPubMedPubMedCentralGoogle Scholar
  10. Cohen, S., Janicki-Deverts, D., & Miller, G. E. (2007). Psychological stress and disease. JAMA, 298(14), 1685–1687.CrossRefPubMedGoogle Scholar
  11. Consortia. (2010). LiFE Consortium Retrieved from Retrieved May 21, 2015, from National Institutes of Health.
  12. Derogatis, L. (2001). Brief symptom inventory 18 (BSI 18) administration, scoring, and procedures manual. Minneapolis: National Computer Systems.Google Scholar
  13. Durkheim, E. (1915). The elementary forms of religious life. London, UK: George Allen & Unwin.Google Scholar
  14. Eeles, R. A. (1995). Germline mutations in the TP53 gene. Cancer Surveys, 25, 101–124 Retrieved from Scholar
  15. Epel, E. S. (2009). Psychological and metabolic stress: a recipe for accelerated cellular aging? Hormones, 8(1), 7–22 Retrieved from Scholar
  16. Epel, E. S., Blackburn, E. H., Lin, J., Dhabhar, F. S., Adler, N. E., Morrow, J. D., & Cawthon, R. M. (2004). Accelerated telomere shortening in response to life stress. Proceedings of the National Academy of Sciences of the United States of America, 101(49), 17312–17315 Retrieved from ISI:000225740100059.CrossRefPubMedPubMedCentralGoogle Scholar
  17. Evans, G. (1992). Ethical issues: the geneticist’s view point. Disease Markers, 10(4), 199–203 discussion 211-128.PubMedGoogle Scholar
  18. Evans, D. G., Lunt, P., Clancy, T., & Eeles, R. (2010). Childhood predictive genetic testing for Li-fraumeni syndrome. Familial Cancer, 9(1), 65–69. doi: 10.1007/s10689-009-9245-9.CrossRefPubMedGoogle Scholar
  19. Fagundes, C. P., Bennett, J. M., Derry, H. M., & Kiecolt-Glaser, J. K. (2011). Relationships and inflammation across the lifespan: social developmental pathways to disease. Social and Personality Psychology Compass, 5(11), 891–903. doi: 10.1111/j.1751-9004.2011.00392.x.CrossRefPubMedPubMedCentralGoogle Scholar
  20. Fagundes, C. P., Glaser, R., & Kiecolt-Glaser, J. K. (2013). Stressful early life experiences and immune dysregulation across the lifespan. Brain, Behavior, and Immunity, 27(0), 8–12. doi: 10.1016/j.bbi.2012.06.014.CrossRefPubMedGoogle Scholar
  21. Hill, P. C., Pargament II, K., Hood, R. W., McCullough, J. M. E., Swyers, J. P., Larson, D. B., & Zinnbauer, B. J. (2000). Conceptualizing religion and spirituality: points of commonality, points of departure. Journal for the Theory of Social Behaviour, 30(1), 51–77. doi: 10.1111/1468-5914.00119.CrossRefGoogle Scholar
  22. Hisada, M., Garber, J. E., Fung, C. Y., Fraumeni Jr., J. F., & Li, F. P. (1998). Multiple primary cancers in families with Li-fraumeni syndrome. Journal of the National Cancer Institute, 90(8), 606–611.CrossRefPubMedGoogle Scholar
  23. Jim, H. S. L., Pustejovsky, J. E., Park, C. L., Danhauer, S. C., Sherman, A. C., Fitchett, G., et al. (2015). Religion, spirituality, and physical health in cancer patients: a meta-analysis. Cancer, n/a-n/a. doi: 10.1002/cncr.29353.Google Scholar
  24. Kamihara, J., Rana, H. Q., & Garber, J. E. (2014). Germline TP53 mutations and the changing landscape of Li-fraumeni syndrome. Human Mutation, 35(6), 654–662. doi: 10.1002/humu.22559.CrossRefPubMedGoogle Scholar
  25. Kenen, R., & Peters, J. (2001). The colored, eco-genetic relationship map (CEGRM): a conceptual approach and tool for genetic counseling research. Journal of Genetic Counseling, 10(4), 289–309 Retrieved from Scholar
  26. Kiecolt-Glaser, J. K. (1999). Stress, personal relationships, and immune function: Health implications. Brain, Behavior, and Immunity, 13(1), 61–72 Retrieved from ISI:000080487300005.CrossRefPubMedGoogle Scholar
  27. Koehly, L. M., Peters, J. A., Kuhn, N., Hoskins, L., Letocha, A., Kenen, R., et al. (2008). Sisters in hereditary breast and ovarian cancer families: communal coping, social integration, and psychological well-being. Psycho-Oncology, 17(8), 812–821. doi: 10.1002/pon.1373.CrossRefPubMedPubMedCentralGoogle Scholar
  28. Koehly, L. M., Peters, J. A., Kenen, R., Hoskins, L. M., Ersig, A. L., Kuhn, N. R., et al. (2009). Characteristics of health information gatherers, disseminators, and blockers within families at risk of hereditary cancer: implications for family health communication interventions. American Journal of Public Health, 99(12), 2203–2209. doi: 10.2105/AJPH.2008.154096.CrossRefPubMedPubMedCentralGoogle Scholar
  29. Koenig, H., McCullough, M., & Larson, D. (2000). Handbook of religion and health. New York, NY: Oxford University Press.Google Scholar
  30. Lammens, C. R., Aaronson, N. K., Wagner, A., Sijmons, R. H., Ausems, M. G., Vriends, A. H., et al. (2010a). Genetic testing in Li-fraumeni syndrome: uptake and psychosocial consequences. Journal of Clinical Oncology, 28(18), 3008–3014 Retrieved from Scholar
  31. Lammens, C. R., Bleiker, E. M., Aaronson, N. K., Wagner, A., Sijmons, R. H., Ausems, M. G., et al. (2010b). Regular surveillance for Li-fraumeni syndrome: advice, adherence and perceived benefits. Familial Cancer, 9(4), 647–654. doi: 10.1007/s10689-010-9368-z.CrossRefPubMedPubMedCentralGoogle Scholar
  32. Lammens, C. R. M., Bleiker, E. M. A., Verhoef, S., Ausems, M. G. E. M., Majoor-Krakauer, D., Sijmons, R. H., et al. (2011). Distress in partners of individuals diagnosed with or at high risk of developing tumors due to rare hereditary cancer syndromes. Psycho-Oncology, 20(6), 631–638 Retrieved from Scholar
  33. Li, F. P., Fraumeni Jr., J. F., Mulvihill, J. J., Blattner, W. A., Dreyfus, M. G., Tucker, M. A., & Miller, R. W. (1988). A cancer family syndrome in twenty-four kindreds. Cancer Research, 48(18), 5358–5362.PubMedGoogle Scholar
  34. Mai, P. L., Malkin, D., Garber, J. E., Schiffman, J. D., Weitzel, J. N., Strong, L. C., et al. (2012). Li-fraumeni syndrome: report of a clinical research workshop and creation of a research consortium. Cancer Genetics, 205(10), 479–487 Retrieved from Scholar
  35. Malkin, D. (2011). Li-fraumeni syndrome. Genes & Cancer, 2(4), 475–484. doi: 10.1177/1947601911413466.CrossRefGoogle Scholar
  36. Malkin, D., Li, F. P., Strong, L. C., Fraumeni, J. F., Jr., Nelson, C. E., Kim, D. H.,. et al. (1990). Germ line p53 mutations in a familial syndrome of breast cancer, sarcomas, and other neoplasms. Science, 250(4985), 1233–1238.CrossRefPubMedGoogle Scholar
  37. McBride, K. A., Ballinger, M. L., Killick, E., Kirk, J., Tattersall, M. H., Eeles, R. A., et al. (2014). Li-fraumeni syndrome: cancer risk assessment and clinical management. Nature Reviews. Clinical Oncology, 11(5), 260–271. doi: 10.1038/nrclinonc.2014.41.CrossRefPubMedGoogle Scholar
  38. Mulligan, T., Gunaratnam, M., & Martin, C. M. (2005). Religion and health: does religious activity improve health outcomes? The Consultant Pharmacist, 20(12), 1025–1031.CrossRefPubMedGoogle Scholar
  39. NCCN, N. C. C. N. (2015). Li-Fraumeni Syndrome guidelines Retrieved from Retrieved May 21, 2015.
  40. Nichols, K. E., Malkin, D., Garber, J. E., Fraumeni Jr., J. F., & Li, F. P. (2001). Germ-line p53 mutations predispose to a wide spectrum of early-onset cancers. Cancer Epidemiology, Biomarkers and Prevention, 10(2), 83–87 Retrieved from Scholar
  41. “Nones” on the Rise. (2012). Retrieved from Pew Forum website:
  42. O’Leary, T. E., Diller, L., & Recklitis, C. J. (2007). The effects of response bias on self-reported quality of life among childhood cancer survivors. Quality of Life Research, 16(7), 1211–1220. doi: 10.1007/s11136-007-9231-3.CrossRefPubMedGoogle Scholar
  43. OMIM. (2015). Li-Fraumeni Syndrome 1 Retrieved from
  44. Oppenheim, D., Brugieres, L., Chompret, A., & Hartmann, O. (2001). The psychological burden inflicted by multiple cancers in Li-fraumeni families: five case studies. Journal of Genetic Counseling, 10(2), 169–183. doi: 10.1023/A:1009495815436.CrossRefGoogle Scholar
  45. Oppenheimer, M. (2014, July 18, 2014). Examining the growth of the “spiritual but not religious”. New York Times.Google Scholar
  46. OxfordDictionaries. (2015). Religion Retrieved from
  47. Pargament, K. (1997). The psychology of religion and coping: theory, research, practice. New York, NY, US: Guilford Press.Google Scholar
  48. Pargament, K., Smith, B., Koenig, H., & Perez, L. (1998). Patterns of positive and negative religious coping with major life stressors. Journal for the Scientific Study of Religion, 37(4), 710–724. doi: 10.2307/1388152.CrossRefGoogle Scholar
  49. Park, C. L., Sherman, A. C., Jim, H. S., & Salsman, J. M. (2015). Religion/spirituality and health in the context of cancer: cross-domain integration, unresolved issues, and future directions. Cancer, n/a-n/a. doi: 10.1002/cncr.29351.Google Scholar
  50. Patenaude, A. F. (2005). Genetic testing for cancer: psychological approaches for helping patients and families. Washington, DC: American Psychological Association.CrossRefGoogle Scholar
  51. Patenaude, A. F., Schneider, K. A., Kieffer, S. A., Calzone, K. A., Stopfer, J. E., Basili, L. A., et al. (1996). Acceptance of invitations for p53 and BRCA1 predisposition testing: factors infleuencing potential utilization of cancer genetic testing cancer genetic testing. Psycho-Oncology, 5(3), 241–250. Retrieved from CrossRefGoogle Scholar
  52. PDQ,NCIPIS. (2015). Li-Fraumeni Syndrome Retrieved from Retrieved May 21, 2015.
  53. Peters, J. A., Kenen, R., Giusti, R., Loud, J., Weissman, N., & Greene, M. H. (2004). Exploratory study of the feasibility and utility of the colored eco-genetic relationship map (CEGRM) in women at high genetic risk of developing breast cancer. American Journal of Medical Genetics Part A, 130A(3), 258–264 Retrieved from ISI:000224181700007.CrossRefPubMedGoogle Scholar
  54. Peters, J. A., Hoskins, L., Prindiville, S., Kenen, R., & Greene, M. H. (2006). Evolution of the colored Eco-genetic relationship map (CEGRM) for assessing social functioning in women in hereditary breast-ovarian (HBOC) families. Journal of Genetic Counseling, 15(6), 477–489. doi: 10.1007/s10897-006-9042-7.CrossRefPubMedGoogle Scholar
  55. Peters, J. A., Kenen, R., Hoskins, L. M., Koehly, L. M., Graubard, B., Loud, J. T., & Greene, M. H. (2011a). Unpacking the blockers: understanding perceptions and social constraints of health communication in hereditary breast ovarian cancer (HBOC) susceptibility families. Journal of Genetic Counseling, 1-15 Retrieved from
  56. Peters, J. A., Kenen, R., Koehly, L. M., Hoskins, L. M., Graubard, B., & Loud, J. T. (2011b). Health communication constraints in HBOC: 12th international meeting on psychosocial aspects of hereditary cancer (IMPAHC). Familial Cancer, 10, 69–97. doi: 10.1007/s10689-011-9430-5.CrossRefGoogle Scholar
  57. Peters, J. A., Kenen, R., Hoskins, L. M., Glenn, G. M., Kratz, C., & Greene, M. H. (2012). Close ties: an exploratory colored Eco-genetic relationship map (CEGRM) study of social connections of men in familial testicular cancer (FTC) families. Hereditary Cancer in Clinical Practice, 10(1). doi: 10.1186/1897-4287-10-2.
  58. Peterson, S. K., Pentz, R. D., Marani, S. K., Ward, P. A., Blanco, A. M., LaRue, D., et al. (2008). Psychological functioning in persons considering genetic counseling and testing for Li-fraumeni syndrome. Psycho-Oncology, 17(8), 783–789 Retrieved from Scholar
  59. Petitjean, A., Mathe, E., Kato, S., Ishioka, C., Tavtigian, S. V., Hainaut, P., & Olivier, M. (2007). Impact of mutatant p53 functional properties on TP53 mutation patterns and tumor phenotype: lessons from recent developments in the IARC TP53Database. Human Mutation, 28(6), 622–629.CrossRefPubMedGoogle Scholar
  60. Phipps, S. (2007). Adaptive style in children with cancer: implications for a positive psychology approach. Journal of Pediatric Psychology, 32(9), 1055–1066. doi: 10.1093/jpepsy/jsm060.CrossRefPubMedGoogle Scholar
  61. Quillin, J. M., McClish, D. K., Jones, R. M., Burruss, K., & Bodurtha, J. N. (2006). Spiritual coping, family history, and perceived risk for breast cancer--can we make sense of it? Journal of Genetic Counseling, (6), 449–460.Google Scholar
  62. Salsman, J. M., Fitchett, G., Merluzzi, T. V., Sherman, A. C., & Park, C. L. (2015a). Religion, spirituality, and health outcomes in cancer: a case for a meta-analytic investigation. Cancer. doi: 10.1002/cncr.29349.Google Scholar
  63. Salsman, J. M., Pustejovsky, J. E., Jim, H. S. L., Munoz, A. R., Merluzzi, T. V., George, L., et al. (2015b). A meta-analytic approach to examining the correlation between religion/spirituality and mental health in cancer. Cancer. doi: 10.1002/cncr.29350.Google Scholar
  64. Schneider, K., Zelley, K., Nichols, K., & Garber, J. (2013). GeneReviews: Li-Fraumeni Syndrome Retrieved from Retrieved 4/14/15, from National Library of Medicine, NIH.
  65. Schwartz, M. D., Hughes, C., Roth, J., Main, D., Peshkin, B. N., Isaacs, C., et al. (2000). Spiritual faith and genetic testing decisions among high-risk breast cancer probands. Cancer Epidemiology, Biomarkers and Prevention, 9(4), 381–385 Retrieved from PM:10794482.PubMedGoogle Scholar
  66. Sherman, A. C., Merluzzi, T. V., Pustejovsky, J. E., Park, C. L., George, L., Fitchett, G., et al. (2015). A meta-analytic review of religious or spiritual involvement and social health among cancer patients. Cancer. doi: 10.1002/cncr.29352.PubMedCentralGoogle Scholar
  67. Stanton, A. L., Revenson, T. A., & Tennen, H. (2007). Health psychology: psychological adjustment to chronic disease. Annual Review of Psychology, 58(1), 565–592. doi: 10.1146/annurev.psych.58.110405.085615.CrossRefPubMedGoogle Scholar
  68. Tercyak, K. P., Hensley Alford, S., Emmons, K. M., Lipkus, I. M., Wilfond, B. S., & McBride, C. M. (2011). Parents' attitudes toward pediatric genetic testing for common disease risk. Pediatrics, 127(5), e1288–e1295. doi: 10.1542/peds.2010-0938.CrossRefPubMedPubMedCentralGoogle Scholar
  69. Tong, A., Sainsbury, P., & Craig, J. (2007). Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care, 19(6), 349–357. doi: 10.1093/intqhc/mzm042.CrossRefPubMedGoogle Scholar
  70. Uchino, B. N., Cacioppo, J. T., Malarkey, W., Glaser, R., & Kiecolt-Glaser, J. K. (1995). Appraisal support predicts age-related differences in cardiovascular function in women. Health Psychology, 14(6), 556–562 Retrieved from Scholar
  71. Uchino, B. N., Cawthon, R. M., Smith, T. W., Kent, R. G., Bowen, K., & Light, K. C. (2014). A cross-sectional analysis of the association between perceived network social control and telomere length. Health Psychology. doi: 10.1037/hea0000148.PubMedCentralGoogle Scholar
  72. Umberson, D., & Montez, J. K. (2010). Social relationships and health: a flashpoint for health policy. Journal of Health and Social Behavior, 51(Suppl), S54–S66. doi: 10.1177/0022146510383501.CrossRefPubMedPubMedCentralGoogle Scholar
  73. Umberson, D., Chen, M. C. D., House, J. S., Hopkins, K., & Slaten, E. (1996). The effect of social relationships on psychological well-being: Are men and women really so different? American Sociological Review, 61(5), 837–857 Retrieved from <Go to ISI>://WOS:A1996VL94000007.CrossRefGoogle Scholar
  74. Varley, J. M. (2003). Germline TP53 mutations and Li-fraumeni syndrome. Human Mutation, 21(3), 313–320. doi: 10.1002/humu.10185.CrossRefPubMedGoogle Scholar
  75. Varley, J. M., McGown, G., Thorncroft, M., et al. (1997). Germline mutations of TP 53 in Li-fraumeni families: an extended study of 39 families. Cancer Research, 57, 3245–3252.PubMedGoogle Scholar
  76. Wade, C. H., Wilfond, B. S., & McBride, C. M. (2010). Effects of genetic risk information on children’s psychosocial wellbeing: a systematic review of the literature. Genetics in Medicine, 12(6), 317–326. doi: 10.1097/GIM.0b013e3181de695c.CrossRefPubMedGoogle Scholar
  77. Wilfond and AAP Bioethics Committee. (2001). Ethical issues with genetic testing in pediatrics. Pediatrics, 107(6), 1451–1455.Google Scholar
  78. Zeltzer, L. K., Lu, Q., Leisenring, W., Tsao, J. C., Recklitis, C., Armstrong, G., et al. (2008). Psychosocial outcomes and health-related quality of life in adult childhood cancer survivors: a report from the childhood cancer survivor study. Cancer Epidemiology, Biomarkers & Prevention, 17(2), 435–446. doi: 10.1158/1055-9965.epi-07-2541.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York (Outside the USA) 2015

Authors and Affiliations

  • June A. Peters
    • 1
    Email author
  • Regina Kenen
    • 2
  • Renee Bremer
    • 1
  • Shannon Givens
    • 1
  • Sharon A. Savage
    • 1
  • Phuong L. Mai
    • 1
  1. 1.Clinical Genetics Branch (CGB), Division of Cancer Epidemiology and Genetics (DCEG)National Cancer Institute (NCI), NIH, DHHSRockvilleUSA
  2. 2.Department of Sociology and AnthropologyThe College of New JerseyEwingUSA

Personalised recommendations