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Johnston J. When Less is More: Lessons for Expanded Carrier Screening from Newborn Sequencing Research. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:118-120. [PMID: 37339293 PMCID: PMC10431735 DOI: 10.1080/15265161.2023.2210037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
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Vockley J, Defay T, Goldenberg AJ, Gaviglio AM. Scaling genetic resources: New paradigms for diagnosis and treatment of rare genetic disease. AMERICAN JOURNAL OF MEDICAL GENETICS. PART C, SEMINARS IN MEDICAL GENETICS 2023; 193:77-86. [PMID: 36448938 PMCID: PMC10038858 DOI: 10.1002/ajmg.c.32016] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 10/25/2022] [Accepted: 11/15/2022] [Indexed: 12/05/2022]
Abstract
Development of genetic tests for rare genetic diseases has traditionally focused on individual diseases. Similarly, development of new therapies occurred one disease at a time. With >10,000 rare genetic diseases, this approach is not feasible. Diagnosis of genetic disorders has already transcended old paradigms as whole exome and genome sequencing have allowed expedient interrogation of all relevant genes in a single test. The growth of newborn screening has allowed identification of diseases in presymptomatic babies. Similarly, the ability to develop therapies is rapidly expanding due to technologies that leverage platform technology that address multiple diseases. However, movement from the basic science laboratory to clinical trials is still hampered by a regulatory system rooted in traditional trial design, requiring a fresh assessment of safe ways to obtain approval for new drugs. Ultimately, the number of nucleic acid-based therapies will challenge the ability of clinics focused on rare diseases to deliver them safely with appropriate evaluation and long-term follow-up. This manuscript summarizes discussions arising from a recent National Institutes of Health conference on nucleic acid therapy, with a focus on scaling technologies for diagnosis of rare disorders and provision of therapies across the age and disease spectrum.
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Affiliation(s)
- Jerry Vockley
- University of Pittsburgh Schools of Medicine and Public Health, Pittsburgh, Pennsylvania, USA
| | - Thomas Defay
- Alexion AstraZeneca Rare Diseases, Boston, Massachusetts, USA
| | - Aaron J Goldenberg
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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Bush L, Davidson H, Gelles S, Lea D, Koehly LM. Experiences of Families Caring for Children with Newborn Screening-Related Conditions: Implications for the Expansion of Genomics in Population-Based Neonatal Public Health Programs. Int J Neonatal Screen 2022; 8:ijns8020035. [PMID: 35645289 PMCID: PMC9149923 DOI: 10.3390/ijns8020035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 05/09/2022] [Accepted: 05/13/2022] [Indexed: 02/01/2023] Open
Abstract
With the expansion of newborn screening conditions globally and the increased use of genomic technologies for early detection, there is a need for ethically nuanced policies to guide the future integration of ever-more comprehensive genomics into population-based newborn screening programs. In the current paper, we consider the lived experiences of 169 family caregivers caring for 77 children with NBS-related conditions to identify lessons learned that can inform policy and practice related to population-based newborn screening using genomic technologies. Based on caregiver narratives obtained through in-depth interviews, we identify themes characterizing these families' diagnostic odyssey continuum, which fall within two domains: (1) medical management implications of a child diagnosed with an NBS-related condition and (2) psychological implications of a child diagnosed with an NBS-related condition. For Domain 1, family caregivers' experiences point to the need for educational resources for both health care professionals that serve children with NBS-related conditions and their families; empowerment programs for family caregivers; training for providers in patient-centered communication; and access to multi-disciplinary specialists. For Domain 2, caregivers' experiences suggest a need for access to continuous, long-term counseling resources; patient navigator resources; and peer support programs. These lessons learned can inform policy recommendations for the benefit of the child, the family, the healthcare system, and society.
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Affiliation(s)
- Lynn Bush
- Division of Genetics and Genomics, Boston Children’s Hospital and Center for Bioethics, Harvard Medical School, Boston, MA 02115, USA;
| | - Hannah Davidson
- National Human Genome Research Institute, Bethesda, MD 20892, USA; (H.D.); (S.G.); (D.L.)
| | - Shani Gelles
- National Human Genome Research Institute, Bethesda, MD 20892, USA; (H.D.); (S.G.); (D.L.)
| | - Dawn Lea
- National Human Genome Research Institute, Bethesda, MD 20892, USA; (H.D.); (S.G.); (D.L.)
| | - Laura M. Koehly
- National Human Genome Research Institute, Bethesda, MD 20892, USA; (H.D.); (S.G.); (D.L.)
- Correspondence: ; Tel.: +1-301-451-3999
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Powell SN, Byfield G, Bennetone A, Frantz AM, Harrison LK, James-Crook ER, Osborne H, Owens TH, Shaw JL, O’Daniel J, Milko LV. Parental Guidance Suggested: Engaging Parents as Partners in Research Studies of Genomic Screening for a Pediatric Population. Front Genet 2022; 13:867030. [PMID: 35401676 PMCID: PMC8990237 DOI: 10.3389/fgene.2022.867030] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 03/07/2022] [Indexed: 01/21/2023] Open
Abstract
Recent advances in genomic sequencing and genomic medicine are reshaping the landscape of clinical care. As a screening modality, genetic sequencing has the potential to dramatically expand the clinical utility of newborn screening (NBS), though significant barriers remain regarding ethical, legal, and social implications (ELSI) and technical and evidentiary challenges. Stakeholder-informed implementation research is poised to grapple with many of these barriers, and parents are crucial stakeholders in this process. We describe the formation and activities of a Community Research Board (CRB) composed of parents with diverse backgrounds assembled to participate in an ongoing research partnership with genomic and public health researchers at the University of North Carolina. The mission of the CRB is to provide insight into parental perspectives regarding the prospect of adding genomic sequencing to NBS and collaboratively develop strategies to ensure its equitable uptake. We describe how these contributions can improve the accessibility of research and recruitment methods and promote trust and inclusivity within diverse communities to maximize the societal benefit of population genomic screening in healthy children.
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Affiliation(s)
- Sabrina N. Powell
- Program for Precision Medicine in Health Care, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States,Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Grace Byfield
- Program for Precision Medicine in Health Care, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States,Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | | | - Annabelle M. Frantz
- Program for Precision Medicine in Health Care, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States,Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Langston K. Harrison
- Program for Precision Medicine in Health Care, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States,Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | | | - Heather Osborne
- Community Research Board Member, Mooresville, NC, United States
| | | | | | - Julianne O’Daniel
- Program for Precision Medicine in Health Care, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States,Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Laura V. Milko
- Program for Precision Medicine in Health Care, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States,Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States,*Correspondence: Laura V. Milko,
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Current Trends in Genetics and Neonatal Care. Adv Neonatal Care 2021; 21:473-481. [PMID: 33538495 DOI: 10.1097/anc.0000000000000834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Genetic and genomic health applications are rapidly changing. A clear and updated description of these applications for the neonatal population is needed to guide current nursing practice. PURPOSE To provide scientific evidence and guidance on the current genetic and genomic applications pertinent to neonatal care. METHODS A search of CINAHL and PubMed was conducted using the search terms "newborn/neonatal" and "genetics," "genomics," "newborn screening," "pharmacogenomics," "ethical," and "legal." Google searches were also conducted to synthesize professional guidelines, position statements, and current genetic practices. FINDINGS/RESULTS Components of the newborn genetic assessment, including details on the newborn physical examination, family history, and laboratory tests pertinent to the newborn, are reported. The history and process of newborn screening are described, in addition to the impact of advancements, such as whole exome and genome sequencing, on newborn screening. Pharmacogenomics, a genomic application that is currently utilized primarily in the research context for neonates, is described and future implications stated. Finally, the specific ethical and legal implications for these genetic and genomic applications are detailed, along with genetic/genomic resources for nurses. IMPLICATIONS FOR PRACTICE Providing nurses with the most up-to-date evidence on genetic and genomic applications ensures their involvement and contributions to quality neonatal care. IMPLICATIONS FOR RESEARCH Ongoing genetic/genomic research is needed to understand the implications of genetic/genomic applications on the neonatal population and how these new applications will change neonatal care.
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Hayeems RZ, Miller FA, Barg CJ, Bombard Y, Chakraborty P, Potter BK, Patton S, Bytautas JP, Tam K, Taylor L, Kerr E, Davies C, Milburn J, Ratjen F, Guttmann A, Carroll JC. Primary care providers' role in newborn screening result notification for cystic fibrosis. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2021; 67:439-448. [PMID: 34127469 PMCID: PMC8202749 DOI: 10.46747/cfp.6706439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To explore primary care providers' (PCPs') role in result notification for newborn screening (NBS) for cystic fibrosis (CF), given that expanded NBS has increased the number of positive screening test results, drawing attention to the role of PCPs in supporting families. DESIGN Cross-sectional survey and qualitative interviews. SETTING Ontario. PARTICIPANTS Primary care providers (FPs, pediatricians, and midwives) who received a positive CF NBS result for an infant in their practice in the 6 months before the study. MAIN OUTCOME MEASURES Whether the PCP notified the family of the initial positive CF screening result. RESULTS Data from 321 PCP surveys (response rate of 51%) are reported, including 208 FPs, 68 pediatricians, and 45 midwives. Interviews were completed with 34 PCPs. Most (65%) surveyed PCPs reported notifying the infant's family of the initial positive screening result; 81% agreed that they have an important role to play in NBS; and 88% said it was important for PCPs, rather than the NBS centre, to notify families of initial positive results. With support and information from NBS centres, 68% would be extremely or very confident in doing so; this dropped to 54% when reflecting on their recent reporting experience. More than half (58%) of all PCPs said written point-of-care information from the NBS centre was the most helpful format. Adjusted for relevant factors, written educational information was associated with a lower rate of notifying families than written plus verbal information (risk ratio of 0.79; 95% CI 0.69 to 0.92). In the interviews, PCPs emphasized the challenge of balancing required content knowledge with the desire for the news to come from a familiar provider. CONCLUSION Most PCPs notify families of NBS results and value this role. These data are relevant as NBS programs and other genomic services expand and consider ways of keeping PCPs confident and actively involved.
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Affiliation(s)
- Robin Z Hayeems
- Scientist in the Child Health Evaluative Sciences Program at the Hospital for Sick Children in Toronto, Ont, and Associate Professor in the Institute of Health Policy, Management and Evaluation at the University of Toronto.
| | - Fiona A Miller
- Professor of Health Policy and holds the Chair in Health Management Strategies at the Institute of Health Policy, Management and Evaluation at the University of Toronto
| | | | - Yvonne Bombard
- Scientist at the Li Ka Shing Knowledge Institute at St Michael's Hospital in Toronto and Associate Professor in the Institute of Health Policy, Management and Evaluation at the University of Toronto
| | - Pranesh Chakraborty
- Executive Director and Chief Medical Officer of Newborn Screening Ontario in Ottawa, a medical biochemist in the Department of Pediatrics at the Children's Hospital of Eastern Ontario in Ottawa, and Associate Professor of Pediatrics at the University of Ottawa
| | - Beth K Potter
- Associate Professor in the Department of Epidemiology and Community Medicine at the University of Ottawa and holds the University Research Chair in Health Services for Children with Rare Diseases
| | - Sarah Patton
- Research Officer in the Institute of Health Policy, Management and Evaluation at the University of Toronto at the time of the study
| | - Jessica Peace Bytautas
- Doctoral student in the Dalla Lana School of Public Health and a research assistant in the Institute of Health Policy, Management and Evaluation at the University of Toronto
| | - Karen Tam
- Certified genetic counselor and screening specialist at Newborn Screening Ontario
| | - Louise Taylor
- Nurse practitioner with expertise in caring for children with cystic fibrosis at the Hospital for Sick Children
| | - Elizabeth Kerr
- Clinical neuropsychologist and a scientist in the Department of Pediatrics, Division of Neurology, at the Hospital for Sick Children, and Adjunct Faculty in the Department of Pediatrics at the University of Toronto
| | | | | | - Felix Ratjen
- Division Chief of Pediatric Respiratory Medicine, Co-lead of the Cystic Fibrosis Centre, Senior Scientist at the Research Institute in the Translational Medicine research program, and Medical Director of the Clinical Research Unit, all at the Hospital for Sick Children, and Professor of Pediatrics at the University of Toronto
| | - Astrid Guttmann
- Clinician scientist in the Division of Pediatric Medicine at the Hospital for Sick Children, Chief Science Officer and Senior Scientist at ICES, and Professor of Pediatrics with a cross appointment at the Institute of Health Policy, Management and Evaluation and the Epidemiology Division of the Dalla Lana School of Public Health at the University of Toronto
| | - June C Carroll
- Family physician and clinician scientist, Professor, and Sydney G. Frankfort Chair in Family Medicine in the Department of Family and Community Medicine with the Sinai Health System and the University of Toronto
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Myskja BK, Steinsbekk KS. Personalized medicine, digital technology and trust: a Kantian account. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2020; 23:577-587. [PMID: 32888101 PMCID: PMC7538445 DOI: 10.1007/s11019-020-09974-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/27/2020] [Indexed: 05/05/2023]
Abstract
Trust relations in the health services have changed from asymmetrical paternalism to symmetrical autonomy-based participation, according to a common account. The promises of personalized medicine emphasizing empowerment of the individual through active participation in managing her health, disease and well-being, is characteristic of symmetrical trust. In the influential Kantian account of autonomy, active participation in management of own health is not only an opportunity, but an obligation. Personalized medicine is made possible by the digitalization of medicine with an ensuing increased tailoring of diagnostics, treatment and prevention to the individual. The ideal is to increase wellness by minimizing the layer of interpretation and translation between relevant health information and the patient or user. Arguably, this opens for a new level of autonomy through increased participation in treatment and prevention, and by that, increased empowerment of the individual. However, the empirical realities reveal a more complicated landscape disturbed by information 'noise' and involving a number of complementary areas of expertise and technologies, hiding the source and logic of data interpretation. This has lead to calls for a return to a mild form of paternalism, allowing expertise coaching of patients and even withholding information, with patients escaping responsibility through blind or lazy trust. This is morally unacceptable, according to Kant's ideal of enlightenment, as we have a duty to take responsibility by trusting others reflexively, even as patients. Realizing the promises of personalized medicine requires a system of institutional controls of information and diagnostics, accessible for non-specialists, supported by medical expertise that can function as the accountable gate-keeper taking moral responsibility required for an active, reflexive trust.
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Affiliation(s)
- Bjørn K Myskja
- Department of Philosophy and Religious Studies, Norwegian University of Science and Technology - NTNU, Trondheim, Norway.
| | - Kristin S Steinsbekk
- Department of Biomedical Laboratory Science, Norwegian University of Science and Technology - NTNU, Trondheim, Norway
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Burns BL, Bilkey GA, Coles EP, Bowman FL, Beilby JP, Pachter NS, Baynam G, Dawkins HJS, Weeramanthri TS, Nowak KJ. Healthcare System Priorities for Successful Integration of Genomics: An Australian Focus. Front Public Health 2019; 7:41. [PMID: 30915324 PMCID: PMC6421399 DOI: 10.3389/fpubh.2019.00041] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 02/14/2019] [Indexed: 12/18/2022] Open
Abstract
This paper examines key considerations for the successful integration of genomic technologies into healthcare systems. All healthcare systems strive to introduce new technologies that are effective and affordable, but genomics offers particular challenges, given the rapid evolution of the technology. In this context we frame internationally relevant discussion points relating to effective and sustainable implementation of genomic testing within the strategic priority areas of the recently endorsed Australian National Health Genomics Policy Framework. The priority areas are services, data, workforce, finances, and person-centred care. In addition, we outline recommendations from a government perspective through the lens of the Australian health system, and argue that resources should be allocated not to just genomic testing alone, but across the five strategic priority areas for full effectiveness.
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Affiliation(s)
- Belinda L. Burns
- Office of Population Health Genomics, Public and Aboriginal Health Division, Department of Health, Government of Western Australia, Perth, WA, Australia
| | - Gemma A. Bilkey
- Office of Population Health Genomics, Public and Aboriginal Health Division, Department of Health, Government of Western Australia, Perth, WA, Australia
- Office of the Chief Health Officer, Public and Aboriginal Health Division, Department of Health, Government of Western Australia, Perth, WA, Australia
| | - Emily P. Coles
- Office of Population Health Genomics, Public and Aboriginal Health Division, Department of Health, Government of Western Australia, Perth, WA, Australia
| | - Faye L. Bowman
- Office of Population Health Genomics, Public and Aboriginal Health Division, Department of Health, Government of Western Australia, Perth, WA, Australia
| | - John P. Beilby
- PathWest Laboratory Medicine, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
- Faculty of Health and Medical Sciences, School of Biomedical Sciences, The University of Western Australia, Crawley, WA, Australia
| | - Nicholas S. Pachter
- Genetic Services of Western Australia, King Edward Memorial Hospital, Department of Health, Government of Western Australia, Subiaco, WA, Australia
- Faculty of Health and Medical Sciences, School of Medicine, The University of Western Australia, Crawley, WA, Australia
| | - Gareth Baynam
- Office of Population Health Genomics, Public and Aboriginal Health Division, Department of Health, Government of Western Australia, Perth, WA, Australia
- Genetic Services of Western Australia, King Edward Memorial Hospital, Department of Health, Government of Western Australia, Subiaco, WA, Australia
- Western Australian Register of Developmental Anomalies, Department of Health, King Edward Memorial Hospital, Government of Western Australia, Subiaco, WA, Australia
| | - Hugh J. S. Dawkins
- Office of Population Health Genomics, Public and Aboriginal Health Division, Department of Health, Government of Western Australia, Perth, WA, Australia
- Faculty of Health and Medical Sciences, School of Biomedical Sciences, The University of Western Australia, Crawley, WA, Australia
- Sir Walter Murdoch School of Policy and International Affairs, Murdoch University, Murdoch, WA, Australia
- School of Public Health, Curtin University of Technology, Bentley, WA, Australia
| | - Tarun S. Weeramanthri
- Office of the Chief Health Officer, Public and Aboriginal Health Division, Department of Health, Government of Western Australia, Perth, WA, Australia
- Faculty of Health and Medical Sciences, School of Population and Global Health, The University of Western Australia, Crawley, WA, Australia
| | - Kristen J. Nowak
- Office of Population Health Genomics, Public and Aboriginal Health Division, Department of Health, Government of Western Australia, Perth, WA, Australia
- Faculty of Health and Medical Sciences, School of Biomedical Sciences, The University of Western Australia, Crawley, WA, Australia
- Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands, WA, Australia
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Johnston J, Lantos JD, Goldenberg A, Chen F, Parens E, Koenig BA. Sequencing Newborns: A Call for Nuanced Use of Genomic Technologies. Hastings Cent Rep 2018; 48 Suppl 2:S2-S6. [PMID: 30133723 PMCID: PMC6901349 DOI: 10.1002/hast.874] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Many scientists and doctors hope that affordable genome sequencing will lead to more personalized medical care and improve public health in ways that will benefit children, families, and society more broadly. One hope in particular is that all newborns could be sequenced at birth, thereby setting the stage for a lifetime of medical care and self-directed preventive actions tailored to each child's genome. Indeed, commentators often suggest that universal genome sequencing is inevitable. Such optimism can come with the presumption that discussing the potential limits, cost, and downsides of widespread application of genomic technologies is pointless, excessively pessimistic, or overly cautious. We disagree. Given the pragmatic challenges associated with determining what sequencing data mean for the health of individuals, the economic costs associated with interpreting and acting on such data, and the psychosocial costs of predicting one's own or one's child's future life plans based on uncertain testing results, we think this hope and optimism deserve to be tempered. In the analysis that follows, we distinguish between two reasons for using sequencing: to diagnose individual infants who have been identified as sick and to screen populations of infants who appear to be healthy. We also distinguish among three contexts in which sequencing for either diagnosis or screening could be deployed: in clinical medicine, in public health programs, and as a direct-to-consumer service. Each of these contexts comes with different professional norms, policy considerations, and public expectations. Finally, we distinguish between two main types of genome sequencing: targeted sequencing, where only specific genes are sequenced or analyzed, and whole-exome or whole-genome sequencing, where all the DNA or all the coding segments of all genes are sequenced and analyzed. In a symptomatic newborn, targeted or genome-wide sequencing can help guide other tests for diagnosis or for specific treatment that is urgently needed. Clinicians use the infant's symptoms (or phenotype) to interrogate the sequencing data. These same complexities and uncertainties, however, limit the usefulness of genome-wide sequencing as a population screening tool. While we recognize considerable benefit in using targeted sequencing to screen for or detect specific conditions that meet the criteria for inclusion in newborn screening panels, use of genome-wide sequencing as a sole screening tool for newborns is at best premature. We conclude that sequencing technology can be beneficially used in newborns when that use is nuanced and attentive to context.
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