Genetic discrimination and health insurance: an urgent need for reform

Patients' attitudes about autonomy and confidentiality in genetic testing for breast-ovarian cancer susceptibility

The identification of BRCA1 and BRCA2, two breast-ovarian cancer susceptibility genes, has brought many ethical and social issues to the forefront. This paper presents the results of a survey assessing the attitudes of 238 unaffected first-degree relatives of women with breast or ovarian cancer regarding the ethical issues of autonomy and confidentiality as they relate to BRCA1/2 testing. Baseline knowledge about BRCA1/2 and ethnic and psychosocial characteristics of our study population were examined to determine their association with women's attitudes. The majority of women (86-87%) felt that health care providers should not disclose the results of genetic tests for breast-ovarian cancer susceptibility to insurance companies or employers without written consent; however, only 56-57% felt that written consent should be required for a spouse or immediate family to receive this information. Ninety-eight percent of the women surveyed agreed that genetic testing for breast-ovarian cancer risk should be voluntary. Likewise, most women (95%) agreed that a person should be able to have genetic testing against a doctor's recommendation and 88% of the women surveyed agreed that parents should be able to consent to genetic susceptibility testing on behalf of their minor children. African American women were less concerned than Caucasian women about the protection of confidentiality in families, they were more likely to agree that an individual should still have access to testing when their physicians recommended against it, and they were more supportive of parents' rights to consent to genetic predisposition testing on behalf of their minor children. Women with coping styles characterized by higher optimism were more likely to favor access to genetic testing when a physician recommended against it, and to support parents' rights to consent to testing of their minor children. Therefore, the setting and manner in which genetic counseling and testing are delivered must be appropriately tailored to reflect these attitudinal differences and preferences.

Participation in colorectal cancer screening: a review

The purpose of this review is to evaluate the published literature on adherence to colorectal cancer (CRC) screening with fecal occult blood testing (FOBT) and sigmoidoscopy. Specifically, the review addresses the following: 1) prevalence of FOBT and sigmoidoscopy; 2) interventions to increase adherence to FOBT and sigmoidoscopy; 3) correlates or predictors of adherence to FOBT and sigmoidoscopy; and 4) reasons for nonadherence. Other objectives are to put the literature on CRC screening adherence in the context of recently reported findings from experimental interventions to change prevention and early detection behaviors and to suggest directions for future research on CRC screening adherence. CRC screening offers the potential both for primary and for secondary prevention. Data from the 1992 National Health Interview Survey show that 26% of the population more than 49 years of age report FOBT within the past 3 years and 33% report ever having had sigmoidoscopy. The Year 2000 goals set forth in Healthy People 2000 are for 50% of the population more than 49 years of age to report FOBT within the past 2 years and for 40% to report that they ever had sigmoidoscopy. Thus, systematic efforts to increase CRC screening are warranted. To date, attempts to promote CRC screening have used both a public health model that targets entire communities, e.g., mass media campaigns, and a medical model that targets individuals, e.g., general practice patients. Most of these efforts, however, did not include systematic evaluation of strategies to increase adherence. The data on FOBT show that the median adherence rate to programmatic offers of FOBT is between 40% and 50%, depending on the type of population offered the test, e.g., patients or employees. Approximately, 50% of those initially offered testing in unselected populations will respond to minimal prompts or interventions. A salient issue for FOBT, however, is whether or not the behavior can be sustained over time. Fewer studies examined adherence to sigmoidoscopy. Adherence was highest in relatives of CRC cases and in employer-sponsored programs offered to workers at increased risk of CRC. At present, we know very little about the determinants of CRC screening behaviors, particularly as they relate to rescreening.

Molecular genetics is revolutionizing our understanding of ophthalmic disease

PURPOSE

To inform ophthalmologists of the extraordinary progress in molecular genetics that is revolutionizing our understanding of ophthalmic disease and of the crucial role of the clinician in facilitating genetic discovery.

METHOD

Review of relevant articles.

RESULTS

Genes for many mendelian-inherited eye diseases have been localized and some identified using three general approaches: positional cloning, which requires no knowledge of underlying pathophysiology; a candidate gene approach, which examines genes based on their likely function; and a positional candidate approach, which uses map location as well as candidate genes in the linked region to isolate a gene. In positional cloning, once linkage is obtained, the gene can eventually be isolated, cloned, and sequenced and mutations identified. Techniques in molecular biology and other disciplines can then be used to unravel the pathophysiology of a disease.

CONCLUSIONS

Molecular genetics is advancing our understanding of the classification and pathophysiology of ophthalmic diseases. The present classification system, based largely on clinical description of disease, is being replaced with a more rational classification based on genetic causes. Future research will determine the function of known genes and identify susceptibility loci for complex diseases such as chronic open-angle glaucoma and age-related macular degeneration. More specific diagnostic, therapeutic, and preventive strategies for ophthalmic disease will be developed. Clinicians play a crucial role by inquiring about the family history of all patients, identifying individuals and families with a genetic trait, and, when appropriate, referring them for further investigation.

Common cancers--genetics, origin, prevention, screening: Parts I and II

Carcinogenesis is a stepwise process that occurs through mutations of cancer-related genes. Five or more genes must be mutated before malignant transformation occurs in most adult cancers; in some childhood cancers as few as two mutated genes may be sufficient. A rare inherited mutation of a critical gene may predestine cancer to occur in one or more sites. This germline mutation is present in virtually every cell in the body, except half of the germ cells, which do not contain the mutated gene in their haploid chromosome set. These and other genes have been used to piece together a puzzle of regulatory systems that govern cell division and proliferation, as well as apoptosis or programmed cell death. Mutations of these genes result not only in increased cell proliferation but also in diminished cell death. Most genetic changes that occur during carcinogenesis are not inherited or germline. They are acquired after birth and are called somatic mutations. A somatic mutation affects only the mutated cell and its progeny. Each time a cell divides, there is a chance of somatic mutation, and therefore there always is a low, background risk for cancer and other malignant lesions. A far more prevalent cause of cancer-related death in the United States is environmental exposure. Such exposure causes somatic mutations of cancer-related genes through direct damage to DNA or through alteration of proliferation or cell death, which enhances the baseline risk for mutation. As carcinogenesis becomes understood, interventions may be designed that selectively interfere in important steps. Screening for cancer is based on the premise that one can treat a patient for a cancer that has not spread from its primary site. Nevertheless, cancer screening is controversial and often confusing. Issues of costs, risks versus benefits, physical time and effort, and patient compliance all affect the clinician's view of screening, often to the extent that the true value of this approach to cancer control is underappreciated and underutilized. A clinician should consider the following questions when assessing the priority, scope, and intensity of cancer screening. Is the cancer an important public health problem? Can preclinical stages be detected and cured? Are effective screening tests available? Are the tests feasible and acceptable? Have screening programs reduced cancer-specific mortality? Is the screening program cost effective? Is screening generally recommended? There is clear-cut evidence of benefit from screening for cancer of the cervix, breast, colon and rectum, and skin and some specific genetic syndromes. Evidence of survival benefit from screening for prostate cancer is lacking, although prostate specific antigen screening is widely used. Screening for lung and ovarian cancer is ineffective.

Presymptomatic and predisposition genetic testing: ethical and social considerations

OBJECTIVE

To provide an overview of the ethical and social concerns that are raised by the use of new genetic tests in asymptomatic persons.

DATA SOURCES

Review articles, research studies and legislation related to genetic testing.

CONCLUSIONS

Predisposition and presymptomatic testing is possible to any age for adult onset disorders if a mutation is known. Testing without early effective interventions is controversial, especially prenatally and in children. Issues of privacy, discrimination, stigmatization and emotional stress are potential problems. Informed consent is essential before deciding to test. Awareness of the implications of testing can enhance the nurse's advocacy role.

IMPLICATIONS FOR NURSING PRACTICE

More studies are necessary to identify the impact of presymptomatic testing on adults and children. Nursing research to identify the family concerns, and to develop effective educational, counseling, and supportive interventions would make a valuable contribution.

Genetic information and the workplace: legislative approaches and policy changes

The use of genetic information in the workplace poses societal risks that have an impact on employment possibilities, health insurance, and privacy. Individuals who might otherwise believe they can benefit from genetic testing may decline it because of their fear of employment discrimination and lack of privacy in the workplace. As a consequence, the future of research on the benefits and risks of predictive genetic testing may also be compromised. Thus, policy-makers need to evaluate legislative and regulatory strategies to address these concerns. This paper analyzes state and federal legislative approaches to genetic information in the workplace and concludes with a discussion of policy considerations and recommendation.

Genetic counseling in perinatal medicine

The obstetrician/perinatologist should be well informed about recent advances in human genetics that directly impact patient care. New indications for molecular analyses, specific limitations in their usage, and the need for interpretation of complex laboratory results emphasize the increasingly necessary clinical genetics consultation. The advent of DNA-based presymptomatic or predictive testing introduces dilemmas for patients and their families, and raises medical, legal, and ethical issues in genetic counseling.

Sequencing the human genome

By 2005, or sooner, the three billion code letters of a representative human genome will be known, along with the locations of all of its genes. Even today, however, the work is greatly accelerating identification of disease-related genes. One outcome will be tests for genetic components of risk in the majority of common illnesses. In the longer run, genetic discoveries will surely lead to new treatments.

Ethical issues in genetic research: disclosure and informed consent

As research to correlate genetic status with predisposition to disease has accelerated, so has the concern that participation in such studies creates the risk of genetic discrimination and emotional distress. There is a need to broaden disclosure during the consent process to ensure that potential subjects understand these risks and other issues and to address them in the consent form. We describe the broad approach that we have taken in regard to disclosure and consent in gene mapping studies.

The Genetic Privacy Act: an analysis of privacy and research concerns

Author argues that the Genetic Privacy Act fails to protect nucleic acid-based information as it relates to individual privacy, yet overburdens medical and scientific research with vague consent standards.

Reinventing public health

This chapter is a review of the current state of public health in light of the social, political, economic, scientific, and technological changes buffeting the United States. As an assessment of progress in current public health efforts, we address the five major issues in public health for the 1990s raised by Breslow (8): reconstruction of public health; setting objectives for public health; from disease control to health promotion; determinants of health and health policy; continuing social inequities and their impacts on health; and the health implications of accelerating developments in technology. Finally, we look to the twenty-first century and provide five clear paths necessary to strengthen the capacity of public health agencies to protect and improve the health status of the population.

Cancer genetic susceptibility testing: ethical and policy implications for future research and clinical practice. Cancer Genetic Studies Consortium, National Institutes of Health

Authors examine the ethical and health policy implications in the Cancer Genetic Studies Consortium projects, which attempt to collect data on the clinical benefits and harms of cancer genetic testing. They suggest that more data are needed on the long-term physical and psychosocial effects of testing and that further examination is needed of the ethical issues raised by testing.

Analysis of disease-causing genes and DNA-based drugs by capillary electrophoresis. Towards DNA diagnosis and gene therapy for human diseases

Rapid progress in the Human Genome Project has stimulated investigations for gene therapy and DNA diagnosis of human diseases through mutation or polymorphism analysis of disease-causing genes and has resulted in a new class of drugs, i.e., DNA-based drugs, including human gene, disease-causing gene, antisense DNA, DNA vaccine, triplex-forming oligonucleotide, protein-binding oligonucleotides, and ribozyme. The recent development of capillary electrophoresis technologies has facilitated the application of capillary electrophoresis to the analysis of DNA-based drugs and the detection of mutations and polymorphism on human genes towards DNA diagnosis and gene therapy for human diseases. In this article the present state of studies on the analysis of DNA-based drugs and disease-causing genes by capillary electrophoresis is reviewed. The paper gives an overview of recent progress in the Human Genome Project and the fundamental aspects of polymerase chain reaction-based technologies for the detection of mutations and polymorphism on human genes and capillary electrophoresis techniques. Attention is mainly pad to the application of capillary electrophoresis to polymerase chain reaction analysis, restriction fragment length polymorphism, single strand conformational polymorphism, variable number of tandem repeat, microsatellite analysis, hybridization technique, and monitoring of DNA-based drugs. Possible future trends are also discussed.

[In search of a national forum for bioethics in Brazilian public policy]

This article focus on bioethics as a public policy issue. It analyzes the main existing international codes on biomedical ethics and presents a brief review of the work of some national bioethics committees in developing countries. The author concludes by commenting on the most relevant and controversial aspects to be considered in the Brazilian experience.

Prevalence of germ-line mutations in p16, p19ARF, and CDK4 in familial melanoma: analysis of a clinic-based population

Five to ten percent of individuals with melanoma have another affected family member, suggesting familial predisposition. Germ-line mutations in the cyclin-dependent kinase (CDK) inhibitor p16 have been reported in a subset of melanoma pedigrees, but their prevalence is unknown in more common cases of familial melanoma that do not involve large families with multiple affected members. We screened for germ-line mutations in p16 and in two other candidate melanoma genes, p19ARF and CDK4, in 33 consecutive patients treated for melanoma; these patients had at least one affected first or second degree relative (28 independent families). Five independent, definitive p16 mutations were detected (18%, 95% confidence interval: 6%, 37%), including one nonsense, one disease-associated missense, and three small deletions. No mutations were detected in CDK4. Disease-associated mutations in p19ARF, whose transcript is derived in part from an alternative codon reading frame of p16, were only detected in patients who also had mutations inactivating p16. We conclude that germ-line p16 mutations are present in a significant fraction of individuals who have melanoma and a positive family history.

The revolution in molecular genetics and its impact on ophthalmology

Rapid advances in molecular technology have led to the identification of many genes responsible for inherited disease in ophthalmology. These discoveries also portend an understanding of the pathogenesis of more common ophthalmic disorders which have a genetic component, such as open-angle glaucoma and age-related macular degeneration. This review comprises a summary of these advances in molecular genetics, particularly the contribution of the Human Genome Project; a tabulation of the genes recently proven to be mutated in hereditary ocular conditions; and a discussion of the implications for the practising ophthalmologist.