Designer babies on tap? Medical students' attitudes to pre-implantation genetic screening

This paper describes two studies about the determinants of attitudes to pre-implantation genetic screening in a multicultural sample of medical students from the United States. Sample sizes were 292 in study 1 and 1464 in study 2. Attitudes were of an undifferentiated nature, but respondents did make a major distinction between use for disease prevention and use for enhancement. No strong distinctions were made between embryo selection and germ line gene manipulations, and between somatic gene therapy and germ line gene manipulations. Religiosity was negatively associated with acceptance of "designer baby" technology for Christians and Muslims but not Hindus. However, the strongest and most consistent influence was an apparently moralistic stance against active and aggressive interference with natural processes in general. Trust in individuals and institutions was unrelated to acceptance of the technology, indicating that fear of abuse by irresponsible individuals and corporations is not an important determinant of opposition.

BRCA1/2 predictive testing and gender: uptake, motivation and psychological characteristics

BRCA1/2 predictive testing and gender: Uptake, motivation and psychological characteristics: Data on male uptake of BRCA1/2 predictive testing and psychological characteristics of males in comparison to females are scarce. We investigated gender differences in the cohort tested at the Center for Human Genetics in Leuven during a 10-year period (1998-2007). Males were significantly older than females. Breast cancer related distress (IES) was significantly lower in men and was not associated with BRCA1 or BRCA2. The groups of both males and females were psychologically stronger than average (SCL-90, UCL) and self-selected. Men were unanimously motivated (personal relevance of 12 motives rated on a Likert scale) by concern for their daughters, and significantly more so than women. One third of them (versus 12% women) referred to child-bearing decisions. Considering all unaffected siblings in the family of origin, uptake of predictive testing was significantly higher in females. Moreover, uptake was significantly higher in women belonging to a BRCA2 than to a BRCA1 family. In the descendants of identified carriers, uptake was predicted by gender and age, but not by the parent's gender or by BRCA1 or BRCA2 status.

Genetic testing offered directly after the diagnosis of colorectal cancer: a pilot study on the reactions of patients

Genetic testing offered directly after the diagnosis of colorectal cancer: a pilot study on the reactions of patients:

INTRODUCTION

When colorectal cancer is diagnosed before the age of 50 years, then consideration should be given to a hereditary cause. Indications of heredity can be found in tumour tissue with the aid of microsatellite instability (MSI) testing. A positive MSI test means an increased risk of hereditary colorectal cancer, the so-called Lynch syndrome. Until recently, the usual approach was to postpone genetic testing for colorectal cancer until the family history had been studied extensively and information had been made available by a clinical geneticist about the possible consequences. However, it is now possible for MSI testing to be performed on the initiative of the pathologist when the newly diagnosed patient with colorectal cancer is younger than 50 years. This speeds up the procedure considerably. The psychological effects of discussing genetic testing and referring patients during treatment for colorectal cancer are currently unknown. This paper describes an exploratory study on the experience of eight colorectal cancer patients with the new Lynch syndrome detection strategy.

METHODS

The patients were interviewed at home using a semistructured questionnaire based on the multicausal model of problem analysis and adapted with items for colorectal cancer and genetic testing.

RESULTS

Three coordinating themes were found: (1) 'a changed life after the diagnosis of colorectal cancer', (2) 'warning for the future' and (3) 'communication with family'. It was a considerable challenge for these patients to cope with the physical and psychosocial consequences of colorectal cancer. The majority regarded possible carriership of a hereditary disposition for the Lynch syndrome as useful medico-preventive knowledge for their children. The timing of the confrontation with genetic testing was considered to save time in receiving follow-up advice for their children. However, these patients were apprehensive about having to discuss a hereditary disposition for cancer with their family.

CONCLUSION

In this early phase, coping with the diagnosis of colorectal cancer and the consequences of treatment mainly determined the reactions of these patients and their physical well-being. This small group of patients was of the opinion that the advantages of genetic testing will weigh-up against the disadvantages.

An exploration of attitudes among black Americans towards psychiatric genetic research

With increasing emphasis on understanding genetic contribution to disease, inclusion of all racial and ethnic groups in molecular genetic research is necessary to ensure parity in distribution of research benefits. Blacks are underrepresented in large-scale genetic studies of psychiatric disorders. In an effort to understand the reasons for the underrepresentation, this study explored black participants' attitudes towards genetic research of psychiatric disorders. Twenty-six adults, the majority of whom were black (n = 18) were recruited from a New York City community to participate in six 90-minute focus groups. This paper reports findings about respondents' understanding of genetics and genetic research, and opinions about psychiatric genetic research. Primary themes revealed participants' perceived lack of knowledge about genetics, concerns about potentially harmful study procedures, and confidentiality surrounding mental illness in families. Participation incentives included provision of treatment or related service, monetary compensation, and reporting of results to participants. These findings suggest that recruitment of subjects into genetic studies should directly address procedures, privacy, benefits and follow-up with results. Further, there is critical need to engage communities with education about genetics and mental illness, and provide opportunities for continued discussion about concerns related to genetic research.

Knowledge regarding the national premarital screening program among university students in western Saudi Arabia

OBJECTIVE

To explore the knowledge of university students in Jeddah, western Saudi Arabia, regarding the national premarital screening (PMS) program.

METHODS

A self-administered questionnaire was distributed to a sample of 800 students at King Abdulaziz University (KAU), Jeddah, Kingdom of Saudi Arabia during the first semester of the academic year 2005--2006. This included questions regarding socio-demographic data, personal history of hereditary disease, or premarital screening, knowledge on hereditary diseases, and on the national PMS program. Data were analyzed using the Statistical Package for Social Sciences version 13. A p-value less than 0.05 was considered significant.

RESULTS

Eighty-five percent of the students believed that gene mutations may lead to hereditary disorders, and 84% of the respondents believed that consanguinity can increase the risk for genetic diseases. Fifty-six percent were aware that hereditary disease could affect any body system. Less than one-third of the students knew which disorders are tested for by the PMS, and 54% of the students thought that PMS detects all hereditary diseases. Only 35% knew what a non-compatible test result meant, while 59% believed that a compatible result meant freedom from all hereditary diseases.

CONCLUSION

Most of the students at KAU have good general knowledge concerning hereditary diseases, but had inadequate knowledge in relation to the national PMS program. The majority did not know which diseases were tested for, and what the test result meant. Public education regarding the disorders tested for, and the implication of screening is essential for the success of the premarital program.

A systematic review of the effects of disclosing carrier results generated through newborn screening

Evidence on the effects of disclosing carrier results identified through newborn screening (NBS) is needed to develop effective strategies for managing these results, and to inform debate about contradictory policies governing genetic testing in minors in the context of NBS relative to clinical care. This is likely to be even more important as technological opportunities for carrier identification through NBS increase. We report the results of a systematic review of evidence related to the generation of carrier results through NBS to summarize what is known about: (1) the outcomes associated with these results; (2) the best strategies for providing information and follow-up care to parents; and (3) the impact they have on reproductive decision-making. Our study expands the existing body of knowledge and identifies gaps in the evidence base. As key players in the management of carrier results clinically, genetic counselors are well positioned to engage in formative research and policy development in this area.

Acculturation and familiarity with, attitudes towards and beliefs about genetic testing for cancer risk within Latinas in East Harlem, New York City

Recent research underscores the need for increasing use of genetic testing for cancer risk in Latinos. This study examined the influence of acculturation on attitudes, beliefs about and familiarity with genetic testing for cancer risk in a community-based sample of Latinas in East Harlem, New York City (N = 103). Multivariate linear regression models analyzed the relationship of acculturation to: (1) familiarity (2) perceived benefits (3) perceived barriers and (4) concerns about abuses of genetic testing for cancer risk. Controlling for sociodemographic factors, results revealed that with increasing acculturation Latinas were more familiar with genetic testing (beta = 1.62, SE = 0.72, p = 0.03), more likely to cite perceived benefits (beta = 1.67, SE = 0.79, p = 0.04), and less likely to report perceived barriers related to genetic testing (beta = -2.76, SE = 1.64, p = 0.10). Study results may help inform the development of culturally-appropriate health education outreach materials and programs targeted to increase awareness, knowledge and understanding about genetic testing for cancer risk within Latinas.

Association between temporal orientation and attitudes about BRCA1/2 testing among women of African descent with family histories of breast cancer

OBJECTIVE

Previous studies have identified specific attitudes (pros and cons) about BRCA testing held by women of African descent that are associated with decisions to participate in testing. These testing attitudes may be determined, in part, by temporal orientation, or how one perceives the significance of events and the consequences of their actions in terms of past, present, and future. The current study explored the relationship between temporal orientation and pros and cons of BRCA testing among 140 women of African descent with a family history suggestive of a genetic mutation predisposing to breast cancer.

METHODS

Participants completed measures of temporal orientation and genetic testing attitudes.

RESULTS

Multivariate analyses indicated that future orientation was positively associated with perceived pros of testing. Additional analyses revealed significant associations between temporal orientation and specific item subsets related to the negative and positive impact of testing on family and personal control over one's health.

CONCLUSION

These results support an association between temporal orientation and attitudes about BRCA testing among women of African descent with family histories of breast cancer.

PRACTICE IMPLICATIONS

Findings support exploration of temporal orientation in future research on BRCA testing decisions among women of African descent and this construct's importance in developing decision aids and tailoring genetic counseling.

The psychological impact of testing for thrombophilia: a systematic review

BACKGROUND

Nowadays, large numbers of patients are tested for thrombophilia, even though the benefits of this strategy remain unclear. A potential disadvantage of this predominantly genetic testing is the psychological impact, including fear, depression and worry.

OBJECTIVES

To systematically review studies that determined the nature and extent of the psychological impact of testing for thrombophilia.

PATIENTS/METHODS

We searched the MEDLINE data base (1966-2008), the EMBASE data base (1985-2008) and the PsychInfo data base (1806-2008) for relevant trials, without language restrictions. Bibliographies of relevant articles were scanned for additional articles. We reviewed all relevant studies that focused on the psychological impact of testing for thrombophilia. Only full papers of studies that included 15 patients or more were considered eligible for this review. Two reviewers independently extracted data and assessed quality.

RESULTS

Six studies fulfilled the eligibility criteria. As these studies varied appreciably in methodology, the pooling of data was not possible. Studies of psychological impact of genetic testing for thrombophilia report few negative results, although most assessments were limited to short-term follow-up, or lacked methodological accuracy.

CONCLUSIONS

No valid conclusions can be drawn about the psychological impact of genetic testing in patients based on the current available literature. Given the large number of patients that are being exposed to testing for thrombophilia, and the uncertain benefits, there is an urgent need for more uniformity in the measurement of the psychological impact of thrombophilia testing.

Selecting potential children and unconditional parental love

For now, the best way to select a child's genes is to select a potential child who has those genes, using genetic testing and either selective abortion, sperm and egg donors, or selecting embryos for implantation. Some people even wish to select against genes that are only mildly undesirable, or to select for superior genes. I call this selection drift--the standard for acceptable children is creeping upwards. The President's Council on Bioethics and others have raised the parental love objection: Just as we should love existing children unconditionally, so we should unconditionally accept whatever child we get in the natural course of things. If we set conditions on which child we get, we are setting conditions on our love for whatever child we get. Although this objection was prompted by selection drift, it also seems to cover selecting against genes for severe impairments. I argue that selection drift is not inconsistent with the ideal of unconditional parental love and, moreover, that the latter actually implies that we should practise selection drift--in other words, we should try to select potential children with the best genetic endowments. My endowment argument for the second claim works from an analogy between arranging an endowment prior to conception to fund a future child's education, and arranging a genetic endowment by selecting a potential child who already has it, where in both cases the child would not have existed without the endowment. I conclude with some programmatic remarks about the nonidentity problem.

Attitudes of high-risk women toward preimplantation genetic diagnosis

OBJECTIVE

To explore the knowledge and attitudes toward preimplantation genetic diagnosis (PGD) of women who have been personally affected by hereditary breast and ovarian cancer.

DESIGN

A 33-item quantitative survey covering five domains, including demographics, knowledge and attitudes about PGD, usage of PGD, and informational needs.

SETTING

Attendees of a national conference for individuals and families affected by hereditary breast and ovarian cancer participated in the survey.

PATIENT(S)

Not applicable.

INTERVENTION(S)

Not applicable.

MAIN OUTCOME MEASURE(S)

Frequencies and proportions were summarized for all variables, and Fisher's exact tests were conducted to test association between two discrete variables.

RESULT(S)

Of the women surveyed, only 32% had ever heard of PGD before taking the survey. None of the women surveyed had actually used PGD, and 44% believed they would not use it in the future. However, 57% of attendees believed that PGD was an acceptable option for high-risk individuals, and 74% believed that high-risk individuals should be given information about PGD.

CONCLUSION(S)

Health care professionals who serve cancer patients should consider incorporating information about PGD into patient education. Further research is needed to survey physicians and genetic counselors about their knowledge and opinions of PGD.

Predictive genetic testing of children for adult-onset diseases and psychological harm

One of the central arguments given to resist testing currently healthy, asymptomatic children for adult-onset diseases is that they may be psychologically harmed by the knowledge gained from such tests. In this discussion I examine two of the most serious arguments: children who are tested may face limited futures, and that testing may result in damage to the child's self esteem (where the test result returns a positive diagnosis). I claim that these arguments do not stand up to critical evaluation. In conclusion, whilst I do not suggest that all at-risk children should be tested for adult-onset diseases we ought to listen carefully to some parental requests for such testing because the putative psychological harms may not be as significant or likely as initially thought. This is because parents generally have the best interests of their children at heart and if they are properly supported and educated about predictive genetic testing and the possible consequences, then the risk of psychological harms occurring may be ameliorated.

Thinking ethically about genetic inheritance: liberal rights, communitarianism and the right to privacy for parents of donor insemination children

The issue of genetic inheritance, and particularly the contradictory rights of donors, recipients and donor offspring as to the disclosure of donor identities, is ethically complicated. Donors, donor offspring and parents of donor offspring may appeal to individual rights for confidentiality or disclosure within legal systems based on liberal rights discourse. This paper explores the ethical issues of non-disclosure of genetic inheritance by contrasting two principle models used to articulate the problem--liberal and communitarian ethical models. It argues that whilst the latter provides a more constructive avenue to providing an ethics for donation than the competing and contradictory positions represented in a liberal rights approach, it raises issues of ethical judgement and authority that remain problematic. This ethical discussion is supported by a field study, funded by the Wellcome Trust, exploring the perceptions and experiences of recipients of donor sperm and their partners towards donor anonymity. The field study provides the empirical basis of an argument for making ethical judgements on the grounds of the community good rather than individual rights, that nevertheless recognises that both are inherently problematic.

Intention to communicate BRCA1/BRCA2 genetic test results to the family

Guided by the theory of planned behavior, this analysis explores the communication skills of women who had genetic testing for BRCA1 and BRCA2. The key outcome was intention to tell test results to adult first-degree relatives. The theory predicts that global and specific attitudes, global and specific perceived social norms, and perceived control will influence the communication of genetic test results. A logistic regression model revealed that global attitude (p < .05), specific social influence (p < .01), and perceived control (p < .05) were significant predictors of intention to tell. When gender and generation of relatives were added to the regression, participants were more likely to convey genetic test results to female than to male relatives (p < .05) and were also more likely to communicate test results to children (p < .01) or siblings (p < .05) than to parents. However, this association depended on knowing the relative's opinion of genetic testing. Intention to tell was lowest among participants who did not know their relative's opinion. These results extend the theory of planned behavior by showing that gender and generation influence intention when the relative's opinion is unknown.

Factors determining dissemination of results and uptake of genetic testing in families with known BRCA1/2 mutations

BACKGROUND

Uptake of genetic testing remains low, even in families with known BRCA1 and BRCA2 (BRCA1/2) mutations, despite effective interventions to reduce risk. We report disclosure and uptake patterns by BRCA1/2-positive individuals to at-risk relatives, in the setting of no-cost genetic counseling and testing.

METHODS

Relatives of BRCA1/2-positive individuals were offered cost-free and confidential genetic counseling and testing. If positive for a BRCA1/2 mutation, participants were eligible to complete a survey about their disclosure of mutation status and the subsequent uptake of genetic testing by at-risk family members.

RESULTS

One hundred and fifteen of 142 eligible individuals responded to the survey (81%). Eighty-eight (77%) of those surveyed disclosed results to all at-risk relatives. Disclosure to first-degree relatives (FDRs) was higher than to second-degree relatives (SDRs) and third-degree relatives (TDR) (95% vs. 78%; p < 0.01). Disclosure rates to male versus female relatives were similar, but reported completion of genetic testing was higher among female versus male FDRs (73% vs. 49%; p < 0.01) and SDRs (68% vs. 43%; p < 0.01), and among members of maternal versus paternal lineages (63% vs. 0%; p < 0.01). Men were more likely than women to express general difficulty discussing positive BCRA1/2 results with at-risk family members (90% vs. 70%; p = 0.03), while women reported more emotional distress associated with disclosure than men (48% vs. 13%; p < 0.01).

DISCUSSION

We report a very high rate of disclosure of genetic testing information to at-risk relatives. However, uptake of genetic testing among at-risk individuals was low despite cost-free testing services, particularly in men, SDRs, and members of paternal lineages. The complete lack of testing among paternally related at-risk individuals and the lower testing uptake among men signify a significant barrier to testing and a challenge for genetic counselors and physicians working with high-risk groups. Further research is necessary to ensure that family members understand their risk and the potential benefits of genetic counseling.

The common sense model of self-regulation and psychological adjustment to predictive genetic testing: a prospective study

This prospective study explored the contribution of illness representations and coping to cancer-related distress in unaffected individuals undergoing predictive genetic testing for an identified mutation in BRCA1/2 (BReast CAncer) or an HNPCC (Hereditary Nonpolyposis Colorectal Cancer)-related gene, based on the common sense model of self-regulation. Coping with hereditary cancer (UCL), illness representations (IPQ-R) and risk perception were assessed in 235 unaffected applicants for genetic testing before test result disclosure. Hereditary cancer distress (IES) and cancer worry (CWS) were assessed before, 2 weeks after and 6 months after result disclosure. Timeline (r = 0.30), consequences (r = 0.25), illness coherence (r = 0.21) and risk perception (r = 0.20) were significantly correlated to passive coping. Passive coping predicted hereditary cancer distress and cancer worry from pre-test (beta = 0.46 and 0.42, respectively) up to 6 months after result disclosure (beta = 0.32 and 0.19, respectively). Illness coherence predicted hereditary cancer distress up to 6 months after result disclosure (beta = 0.24), too. The self-regulatory model may be useful to predict the cognitive and emotional reactions to genetic cancer susceptibility testing. Identifying unhelpful representations and cognitive restructuring may be appropriate interventions to help distressed individuals undergoing genetic susceptibility testing for a BRCA1/2 or a HNPCC-related mutation.

How does the collection of genetic test results affect research participants?

The collection of genetic test results has become routine in clinical research. Yet, there are few data on the impact of this practice. The present study provides the first empirical data that we are aware of on the impact this practice has on research participants. The findings suggest that collection of genetic test results in the research setting increases many individuals' desire to know the results themselves. Some respondents attributed this effect to the fact that the data existed, while others did not want investigators to have information about them that they did not possess. A smaller proportion of respondents assumed that investigators who had collected genetic test results would monitor their clinical significance over time. These respondents were less inclined to want to know their genetic test results once an investigator was aware of them. Investigators and IRBs should recognize these phenomena and address them in the design and conduct of studies which collect genetic information.

Selection of family members for communication of cancer risk and barriers to this communication before and after genetic cancer risk assessment

PURPOSE

The impact of genetic cancer risk assessment on communication of cancer risk information within families is not fully known. We compared women's selection of family members for cancer risk communication and perceived barriers to this communication before genetic cancer risk assessment and 6 months afterward.

METHODS

Mailed surveys were used to collect prospective data from consenting women undergoing genetic cancer risk assessment because of a personal and/or family history of breast or ovarian cancers. Analysis included descriptive statistics, chi-square and McNemar tests, and paired t tests.

RESULTS

A total of 122 women met the study criteria. Although risk communications increased with first-degree relatives (84%-90% for females; 53%-62% for males) and decreased with non-first-degree relatives (21%-9%) before and after genetic cancer risk assessment, the degree of change was nonsignificant. The most commonly cited communication barrier was loss of contact (30%). Demographics, personal or family cancer history, and BRCA status did not significantly influence findings.

CONCLUSIONS

There was a high degree of cancer risk communications with female first-degree relatives, but less so with male first-degree relatives, both before and after genetic cancer risk assessment. For the majority of women, interpersonal barriers did not preclude risk discussions. Further research is needed to identify how best to facilitate risk communication.