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Miner SA, Pereira S. The Need for Diverse Empirical Data to Inform the Use of Polygenic Risk Scores in Prenatal Screening. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:39-41. [PMID: 36919541 DOI: 10.1080/15265161.2023.2169396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
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2
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Hill M, Ellard S, Fisher J, Fulop N, Knight M, Kroese M, Ledger J, Leeson-Beevers K, McEwan A, McMullan D, Mellis R, Morris S, Parker M, Tapon D, Baple E, Blackburn L, Choudry A, Lafarge C, McInnes-Dean H, Peter M, Ramakrishnan R, Roberts L, Searle B, Smith E, Walton H, Wynn SL, Han Wu W, Chitty LS. Optimising Exome Prenatal Sequencing Services (EXPRESS): a study protocol to evaluate rapid prenatal exome sequencing in the NHS Genomic Medicine Service. NIHR OPEN RESEARCH 2022; 2:10. [PMID: 35935673 PMCID: PMC7613246 DOI: 10.3310/nihropenres.13247.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 06/28/2022] [Indexed: 11/22/2022]
Abstract
Background Prenatal exome sequencing (ES) for the diagnosis of fetal anomalies was implemented nationally in England in October 2020 by the NHS Genomic Medicine Service (GMS). is the GMS is based around seven regional Genomic Laboratory Hubs (GLHs). Prenatal ES has the potential to significantly improve NHS prenatal diagnostic services by increasing genetic diagnoses and informing prenatal decision-making. Prenatal ES has not previously been offered routinely in a national healthcare system and there are gaps in knowledge and guidance. Methods Our mixed-methods evaluation commenced in October 2020, aligning with the start date of the NHS prenatal ES service . Study design draws on a framework developed in previous studies of major system innovation. There are five interrelated workstreams. Workstream-1 will use interviews and surveys with professionals, non-participant observations and documentary analysis to produce in-depth case studies across all GLHs. Data collection at multiple time points will track changes over time. In Workstream-2 qualitative interviews with parents offered prenatal ES will explore experiences and establish information and support needs. Workstream-3 will analyse data from all prenatal ES tests for nine-months to establish service outcomes (e.g. diagnostic yield, referral rates, referral sources). Comparisons between GLHs will identify factors (individual or service-related) associated with any variation in outcomes. Workstream-4 will identify and analyse practical ethical problems. Requirements for an effective ethics framework for an optimal and equitable service will be determined. Workstream-5 will assess costs and cost-effectiveness of prenatal ES versus standard tests and evaluate costs of implementing an optimal prenatal ES care pathway. Integration of findings will determine key features of an optimal care pathway from a service delivery, parent and professional perspective. Discussion The proposed formative and summative evaluation will inform the evolving prenatal ES service to ensure equity of access, high standards of care and benefits for parents across England.
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Affiliation(s)
- Melissa Hill
- NHS North Thames Genomic Laboratory Hub, Great Ormond Street Hospital for Children, London, UK
- Genetics and Genomic Medicine, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Sian Ellard
- Institute of Biomedical and Clinical Science, College of Medicine and Health, University of Exeter, Exeter, UK
- Exeter Genomics Laboratory, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | | | - Naomi Fulop
- Department of Applied Health Research, University College London, London, UK
| | - Marian Knight
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - Mark Kroese
- PHG Foundation, University of Cambridge, Cambridge, UK
| | - Jean Ledger
- Department of Applied Health Research, University College London, London, UK
| | | | - Alec McEwan
- Department of Obstetrics and Gynaecology,, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Dominic McMullan
- West Midlands Regional Genetics Service, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Rhiannon Mellis
- NHS North Thames Genomic Laboratory Hub, Great Ormond Street Hospital for Children, London, UK
- Genetics and Genomic Medicine, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Stephen Morris
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Michael Parker
- The Ethox Centre, Nuffield Department of Population Health and Wellcome Centre for Ethics and Humanities, University of Oxford, Oxford, UK
| | - Dagmar Tapon
- Centre for Fetal Care, Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Emma Baple
- Institute of Biomedical and Clinical Science, College of Medicine and Health, University of Exeter, Exeter, UK
- Peninsula Clinical Genetics Service, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | | | - Asya Choudry
- Manchester University NHS Foundation Trust, Manchester, UK
| | - Caroline Lafarge
- School of Human and Social Sciences, University of West London, London, UK
| | - Hannah McInnes-Dean
- NHS North Thames Genomic Laboratory Hub, Great Ormond Street Hospital for Children, London, UK
- Genetics and Genomic Medicine, UCL Great Ormond Street Institute of Child Health, London, UK
- Antenatal Results and Choices, London, UK
| | - Michelle Peter
- NHS North Thames Genomic Laboratory Hub, Great Ormond Street Hospital for Children, London, UK
- Genetics and Genomic Medicine, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Rema Ramakrishnan
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | | | - Beverly Searle
- Unique - Rare Chromosome Disorder Support Group, Oxted, UK
| | - Emma Smith
- NHS North Thames Genomic Laboratory Hub, Great Ormond Street Hospital for Children, London, UK
| | - Holly Walton
- Department of Applied Health Research, University College London, London, UK
| | - Sarah L. Wynn
- Unique - Rare Chromosome Disorder Support Group, Oxted, UK
| | - Wing Han Wu
- NHS North Thames Genomic Laboratory Hub, Great Ormond Street Hospital for Children, London, UK
- Genetics and Genomic Medicine, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Lyn S. Chitty
- NHS North Thames Genomic Laboratory Hub, Great Ormond Street Hospital for Children, London, UK
- Genetics and Genomic Medicine, UCL Great Ormond Street Institute of Child Health, London, UK
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Bayefsky MJ, Berkman BE. Implementing Expanded Prenatal Genetic Testing: Should Parents Have Access to Any and All Fetal Genetic Information? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2022; 22:4-22. [PMID: 33459580 PMCID: PMC10066540 DOI: 10.1080/15265161.2020.1867933] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Prenatal genetic testing is becoming available for an increasingly broad set of diseases, and it is only a matter of time before parents can choose to test for hundreds, if not thousands, of genetic conditions in their fetuses. Should access to certain kinds of fetal genetic information be limited, and if so, on what basis? We evaluate a range of considerations including reproductive autonomy, parental rights, disability rights, and the rights and interests of the fetus as a potential future child. We conclude that parents should be able to access information that could be useful during pregnancy, but that testing for non-medical information should be limited. Next, we argue that the government lacks a compelling state interest in regulating prenatal genetic testing and propose that regulation should occur through medical professional organizations. Finally, we present a framework for determining what testing physicians should recommend, offer neutrally, or not offer at all.
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Affiliation(s)
- Michelle J. Bayefsky
- New York University Langone Health, Department of Obstetrics and Gynecology, New York, NY, USA
| | - Benjamin E. Berkman
- National Institutes of Health, Department of Bioethics, Bethesda, MD, USA
- National Human Genome Research Institute, Bethesda, MD, USA
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Vears D, Amor DJ. A framework for reporting secondary and incidental findings in prenatal sequencing: When and for whom? Prenat Diagn 2022; 42:697-704. [PMID: 35032068 PMCID: PMC9306573 DOI: 10.1002/pd.6097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 01/03/2022] [Accepted: 01/09/2022] [Indexed: 12/27/2022]
Abstract
As the use of genomic sequencing (GS) in the prenatal setting becomes more widespread, laboratories and clinicians will be tasked with making decisions about whether to offer incidental and secondary findings to expectant parents and, if so, which ones. Unfortunately, few guidelines or position statements issued by professional bodies address the return of secondary findings specifically in the context of prenatal GS, nor do they offer clear guidance on whether, and which types of incidental findings should be reported. Laboratories and clinicians will also need to navigate other challenges, such as how to obtain sufficiently informed consent, workload burdens for both laboratories and clinicians, and funding. Here we discuss these, and other challenges associated with offering incidental and secondary findings in the context of prenatal GS. We outline existing guidelines for return of these findings, prenatally and in children. We review the existing literature on stakeholder perspectives on return of incidental and secondary findings and discuss the main practical and ethical challenges that require consideration. We then propose a framework to help guide decision-making, suggesting a baseline routine analysis, with additional layers of analysis that could be offered, according to local laboratory policy, with additional opt-in consent from the parents.
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Affiliation(s)
- Danya Vears
- Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Victoria, Australia.,Melbourne Law School, University of Melbourne, Carlton, Victoria, Australia
| | - David J Amor
- Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Royal Children's Hospital, Melbourne, Victoria, Australia
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5
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Haidar H, Iskander R. Non-invasive Prenatal Testing for Fetal Whole Genome Sequencing: An Interpretive Critical Review of the Ethical, Legal, Social, and Policy Implications. CANADIAN JOURNAL OF BIOETHICS 2022. [DOI: 10.7202/1087199ar] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Ngan OMY, Yi H, Bryant L, Sahota DS, Chan OYM, Ahmed S. Parental expectations of raising a child with disability in decision-making for prenatal testing and termination of pregnancy: A mixed methods study. PATIENT EDUCATION AND COUNSELING 2020; 103:2373-2383. [PMID: 32507714 DOI: 10.1016/j.pec.2020.05.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Revised: 05/03/2020] [Accepted: 05/07/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE To examine attitudes toward prenatal testing and termination of pregnancy (TOP) among parents and obstetric providers in relation to their views on raising a child with disability. METHODS An explanatory sequential mixed methods study. A survey among 274 parents and 141 providers was followed by interviews with 26 parents and 10 providers. Using multivariate analysis, the relationships between attitudes were examined. Thematic analysis was used to identify the reasons behind the attitudes. RESULTS In comparison with providers, parents reported more positive attitudes toward raising a child with disability and more moral views about TOP. Providers reported more variations in attitudes toward offering prenatal testing and TOP. Significant associations were found between attitudes toward prenatal testing, raising a child with disability, reproductive autonomy, and TOP. Three major themes were identified: (1) meanings of parenthood from genetic tests; (2) views toward TOP and parental responsibility; and (3) implications of advanced extended prenatal genetic testing. CONCLUSIONS Perceived social-cultural norms of disabilities and parental expectations of raising a child with disability influence decision-making regarding TOP. PRACTICE IMPLICATIONS As more conditions of the fetus are able to be detected, the social-cultural implications of the technology and disabilities need to be addressed in antenatal care.
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Affiliation(s)
- Olivia Miu Yung Ngan
- CUHK Centre for Bioethics, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong Special Administrative Region
| | - Huso Yi
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore.
| | - Louise Bryant
- Leeds Institute of Health Sciences, School of Medicine, University of Leeds, Leeds, United Kingdom
| | - Daljit Singh Sahota
- Department of Obstetrics and Gynecology, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region
| | - Olivia Yiu Man Chan
- Department of Obstetrics and Gynecology, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region
| | - Shenaz Ahmed
- Leeds Institute of Health Sciences, School of Medicine, University of Leeds, Leeds, United Kingdom
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Hui L, Szepe E, Halliday J, Lewis C. Maternity health care professionals' views and experiences of fetal genomic uncertainty: A review. Prenat Diagn 2020; 40:652-660. [PMID: 32096235 DOI: 10.1002/pd.5673] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 02/17/2020] [Accepted: 02/18/2020] [Indexed: 01/13/2023]
Abstract
The field of prenatal screening and diagnosis for fetal anomalies has been marked by a rapid succession of technological advances, including most notably, chromosomal microarray analysis, and next generation sequencing. Despite the diagnostic advantages of these technologies, their incorporation into prenatal testing has created additional challenges of revealing genomic variants of unknown or uncertain significance, and secondary findings. While detailed posttest counseling about uncertain variants is best performed by medical geneticists, many of the screening and diagnostic tests that lead to this information are actually ordered by general maternity health care professionals (HCPs), such as obstetricians, midwives, and family physicians. Maternity HCPs support pregnant women through to the conclusion of their pregnancy and the postpartum period, and thus are close observers of the psychosocial impart of fetal genomic uncertainty on women and their families. While there have been many studies exploring the handling of genomic uncertainty by genetics HCPs, there has been relatively less attention paid to maternity HCPs without speciality training in genetics. This review explores the current literature surrounding nongenetic maternity HCPs' views and experiences of genomic uncertainty and returning uncertain results in the prenatal setting.
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Affiliation(s)
- Lisa Hui
- Reproductive Epidemiology, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Department of Perinatal Medicine, Mercy Hospital for Women, Heidelberg, Victoria, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Victoria, Australia.,Department of Obstetrics and Gynaecology, The Northern Hospital, Epping, Victoria, Australia
| | - Emma Szepe
- Reproductive Epidemiology, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Melbourne Medical School, University of Melbourne, Parkville, Victoria, Australia
| | - Jane Halliday
- Reproductive Epidemiology, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Celine Lewis
- London North Genomic Laboratory Hub, Great Ormond Street Hospital for Children National Health Service Foundation Trust, London, UK.,Genetics and Genomic Medicine, University College London Great Ormond Street Institute of Child Health, London, UK
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Abstract
OBJECTIVE To assess pregnant women's views and preferences on noninvasive prenatal whole genome sequencing. METHODS A survey was offered to 805 pregnant women receiving prenatal care in practices affiliated with a large, tertiary care maternity hospital. Respondents were asked to envision undergoing prenatal whole genome sequencing and discuss their preferences and reasons for receiving different categories of genomic results, organized by actionability, severity, prevalence, and age of onset. The survey also queried respondents on their preferred role for clinicians in prenatal whole genome sequencing decision-making, and on their demographics and genetic literacy. RESULTS From June to August 2017, a total of 553 respondents returned the survey (response rate=68.7%). Respondents were most likely to want information regarding serious treatable childhood-onset conditions (89.7%) and least likely to want to receive information about nonmedical traits from prenatal whole genome sequencing (40%). The most frequently cited reason for wanting medical prenatal whole genome sequencing results was "to prepare financially, medically, or psychologically for a child with special needs." In total, 10.5% of respondents wanted clear recommendations from clinicians about the categories of information that are most appropriate to test for, 44.7% wanted clear recommendations plus all options presented, 26.2% wanted all options presented and joint decision-making, and 13.2% wanted all options presented and independent decision-making. CONCLUSION Respondents generally preferred to receive all categories of genetic results pertaining to medical conditions and wanted the information to prepare. More than half of respondents wanted (at minimum) clear recommendations from clinicians when deciding which prenatal whole genome sequencing results to receive.
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9
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Fisher CF, Birkeland LE, Reiser CA, Zhao Q, Palmer CGS, Zikmund-Fisher BJ, Petty EM. Alternative option labeling impacts decision-making in noninvasive prenatal screening. J Genet Couns 2019; 29:910-918. [PMID: 31793699 DOI: 10.1002/jgc4.1191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 10/22/2019] [Accepted: 10/28/2019] [Indexed: 11/08/2022]
Abstract
Prenatal genetic screening should be an informed, autonomous patient choice. Extrinsic factors which influence patient decision-making threaten the ethical basis of prenatal genetic screening. Prior research in the area of medical decision-making has identified that labeling may have unanticipated effects on patient perceptions and decision-making processes. This Internet-administered study explored the impact of option labeling on the noninvasive prenatal screening (NIPS) selections of US adults. A total of 1,062 participants were recruited through Amazon Mechanical Turk (MTurk) and randomly assigned to one of three possible label sets reflecting provider-derived and industry-derived option labels used in prenatal screening. Multinomial logistic regression analysis showed option labeling had a statistically significant impact on the NIPS selections of study participants (p = .0288). Outcomes of the Satisfaction with Decision Scale (SWD) indicated option labels did not play a role in participant satisfaction with screening selection. The results of this study indicate a need for further evaluation of the impact NIPS option labeling has on patient screening decisions in real-world clinical interactions. Clinical providers and testing laboratories offering NIPS should give careful consideration to the option labels used with prenatal screening so as to minimize influence on patient screening selection and decision-making processes.
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Affiliation(s)
- Camille F Fisher
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.,Section of Clinical and Metabolic Genetics, Dell Children's Medical Group, Austin, TX, USA
| | - Laura E Birkeland
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.,Center for Perinatal Care, UnityPoint Health Meriter Hospital, Madison, WI, USA
| | - Catherine A Reiser
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Qianqian Zhao
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Christina G S Palmer
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, CA, USA
| | - Brian J Zikmund-Fisher
- Department of Health Behavior and Health Education, University of Michigan, Ann Arbor, MI, USA.,Division of General Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Elizabeth M Petty
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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10
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Farrell RM, Agatisa PK, Michie MM, Greene A, Ford PJ. The personal utility of cfDNA screening: Pregnant patients' experiences with cfDNA screening and views on expanded cfDNA panels. J Genet Couns 2019; 29:88-96. [PMID: 31680382 DOI: 10.1002/jgc4.1183] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 10/07/2019] [Accepted: 10/09/2019] [Indexed: 01/13/2023]
Abstract
Prenatal cell-free DNA screening (cfDNA) provides more genetic risk information about the fetus than has ever been possible. At the same time, the rapid expansion of new cfDNA panels raises important questions about how to structure patient-centered discussions that best support patients' decision-making about its use. To address this question, we conducted interviews with pregnant patients to identify decision-making needs and preferences with respect to cfDNA in patient-centered healthcare discussions, given its evolving capability to identify a range of fetal variants. Personal utility was a core concept guiding decision-making. Participants spoke of how their deeply personal values and beliefs about maternal responsibility, actionability, and tolerance of uncertainty framed their view of the personal utility of cfDNA screening. While discussing their notions of personal utility with their healthcare provider, participants also had concerns about potential ramifications for the provider-patient relationship and shared decision-making when disclosing values and preferences regarding disability, quality of life, and termination-particularly as it becomes possible to identify variants with different disease-associated severity and outcomes. The complexities associated with the introduction of genomics in prenatal care present unique challenges to structuring effective shared decision-making discussions between patients and their healthcare providers. While efforts are underway to determine how to best educate patients about the medical aspects of cfDNA, it is equally important to develop approaches in healthcare communication that enable patients to make informed, values-based decisions about the use of cfDNA and its impact on their pregnancy.
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Affiliation(s)
- Ruth M Farrell
- OB/GYN and Women's Health Institute, Cleveland Clinic, Cleveland, Ohio.,Genomic Medicine Institute, Cleveland Clinic, Cleveland, Ohio.,Center for Bioethics, Cleveland Clinic, Cleveland, Ohio
| | | | - Marsha M Michie
- Department of Bioethics, Case Western Reserve University, Cleveland, Ohio
| | - Amy Greene
- Center for Spiritual Care, Cleveland Clinic, Cleveland, Ohio
| | - Paul J Ford
- Center for Bioethics, Cleveland Clinic, Cleveland, Ohio
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11
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Attitudes of Australian health professionals towards rapid genomic testing in neonatal and paediatric intensive care. Eur J Hum Genet 2019; 27:1493-1501. [PMID: 31148592 DOI: 10.1038/s41431-019-0429-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 04/10/2019] [Accepted: 04/30/2019] [Indexed: 11/08/2022] Open
Abstract
We investigated the attitudes of intensive care physicians and genetics professionals towards rapid genomic testing in neonatal and paediatric intensive care units (NICU/PICU). A mixed-methods study (surveys and interviews) was conducted at 13 Australian hospitals and three laboratories involved in multi-center implementation of rapid genomic testing. We investigated experience and confidence with genomic tests among intensivists; perceived usefulness of genomic diagnostic results; preferences for service delivery models; and implementation readiness among genetic services. The overall survey response rate was 59%, 47% for intensivists (80/170), and 75% (91/121) for genetics professionals. Intensivists reported moderate confidence with microarray tests and lower confidence with genomic tests. The majority of intensivists (77%), clinical geneticists (87%) and genetic counsellors (82%) favoured a clinical genetics-led service delivery model of genomic testing. Perceived clinical utility of genomic results was lower in the intensivist group compared to the genetics professionals group (20 v 50%, p < 0.001). Interviews (n = 6 intensivists; n = 11 genetic counselors) demonstrated support for implementation, with concerns relating to implementation environment and organizational readiness. Overall, our findings support initial implementation of genomic testing in NICU/PICU as part of an interdisciplinary service delivery model that promotes gradual adoption of genomics by the intensive care workforce while ensuring safety, sustainability, and efficiency.
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12
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Stevens BK, Noblin SJ, Chen HY, Czerwinski J, Friel LA, Wagner C. Introduction of cell-free DNA screening is associated with changes in prenatal genetic counseling indications. J Genet Couns 2019; 28:692-699. [PMID: 30791172 DOI: 10.1002/jgc4.1095] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 01/04/2019] [Accepted: 01/09/2019] [Indexed: 11/10/2022]
Abstract
The introduction of cell-free DNA screening, or non-invasive prenatal testing (NIPT), for chromosome abnormalities has greatly impacted prenatal care since its introduction in late 2011. We aimed to evaluate the association between the introduction of cell-free DNA screening and indication and referral patterns for genetic counseling at a large US academic medical center by comparing the percentage of each counseling indication between the time period prior to the introduction of cell-free DNA screening (2006-2011) and following its introduction (2012-2016) using multivariable Poisson regression models. Genetic counseling indications for positive carrier screens, average risk patients, abnormal ultrasound findings, and family history indications were significantly higher following the introduction of NIPT while advanced maternal age and abnormal maternal serum screening indications dropped significantly. We also showed that the uptake of amniocentesis dropped significantly after the introduction of cell-free DNA screening, while chorionic villus sampling uptake increased. These results provide evidence that the introduction of new genetic screening technologies is associated with a shift in genetic counseling referral indications and an increased uptake in genetic screening. Additional research is needed to explore the impact of expanded testing options on the need for genetic counseling services.
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Affiliation(s)
- Blair K Stevens
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, UTHealth, Houston, Texas
| | - Sarah J Noblin
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, UTHealth, Houston, Texas
| | - Han-Yang Chen
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, UTHealth, Houston, Texas
| | - Jennifer Czerwinski
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, UTHealth, Houston, Texas
| | - Lara A Friel
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, UTHealth, Houston, Texas
| | - Chelsea Wagner
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, UTHealth, Houston, Texas
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13
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Hull LE, Vassy JL. Toward greater understanding of patient decision-making around genome sequencing. Per Med 2018; 15:57-66. [PMID: 29714114 DOI: 10.2217/pme-2017-0037] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
In the era of next-generation sequencing, it is essential to collect and understand the patient outcomes that result from this new technology. One critical determinant of these is the process by which individuals first decide whether and how to pursue genome sequencing. In this perspective article, we examine the literature on adult patient decision-making in genome sequencing and identify current research gaps to address. Several studies have explored the motivations and concerns of patients undergoing sequencing; less attention has been paid to those who decline sequencing or to individuals from lower socioeconomic groups. Many factors that might play a role in the decision to pursue or decline sequencing, including trust, family dynamics and barriers to access, have yet to be explored fully. Future research that captures the experience of the wider population will produce a more generalizable understanding of the clinical, psychosocial, and economic outcomes of pursuing or declining sequencing.
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Affiliation(s)
- Leland E Hull
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA, 02130, USA.,Section of General Internal Medicine, VA Boston Healthcare System, Boston, MA, 02130, USA
| | - Jason L Vassy
- Section of General Internal Medicine, VA Boston Healthcare System, Boston, MA, 02130, USA.,Department of Medicine, Harvard Medical School, Boston, MA, 02115, USA.,Division of General Medicine & Primary Care, Brigham & Women's Hospital, Boston, MA, 02115, USA
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14
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Levy B, Wapner R. Prenatal diagnosis by chromosomal microarray analysis. Fertil Steril 2018; 109:201-212. [PMID: 29447663 DOI: 10.1016/j.fertnstert.2018.01.005] [Citation(s) in RCA: 162] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 01/05/2018] [Indexed: 02/07/2023]
Abstract
Chromosomal microarray analysis (CMA) is performed either by array comparative genomic hybridization or by using a single nucleotide polymorphism array. In the prenatal setting, CMA is on par with traditional karyotyping for detection of major chromosomal imbalances such as aneuploidy and unbalanced rearrangements. CMA offers additional diagnostic benefits by revealing sub-microscopic imbalances or copy number variations that are too small to be seen on a standard G-banded chromosome preparation. These submicroscopic imbalances are also referred to as microdeletions and microduplications, particularly when they include specific genomic regions that are associated with clinical sequelae. Not all microdeletions/duplications are associated with adverse clinical phenotypes and in many cases, their presence is benign. In other cases, they are associated with a spectrum of clinical phenotypes that may range from benign to severe, while in some situations, the clinical significance may simply be unknown. These scenarios present a challenge for prenatal diagnosis, and genetic counseling prior to prenatal CMA greatly facilitates delivery of complex results. In prenatal diagnostic samples with a normal karyotype, chromosomal microarray will diagnose a clinically significant subchromosomal deletion or duplication in approximately 1% of structurally normal pregnancies and 6% with a structural anomaly. Pre-test counseling is also necessary to distinguish the primary differences between the benefits, limitations and diagnostic scope of CMA versus the powerful but limited screening nature of non-invasive prenatal diagnosis using cell-free fetal DNA.
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Affiliation(s)
- Brynn Levy
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York.
| | - Ronald Wapner
- Department of Obstetrics & Gynecology, Columbia University Medical Center, New York, New York
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15
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Mellis R, Chandler N, Chitty LS. Next-generation sequencing and the impact on prenatal diagnosis. Expert Rev Mol Diagn 2018; 18:689-699. [PMID: 29962246 DOI: 10.1080/14737159.2018.1493924] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION The advent of affordable and rapid next-generation sequencing has been transformative for prenatal diagnosis. Sequencing of cell-free DNA in maternal plasma has enabled the development of not only a highly sensitive screening test for fetal aneuploidies, but now definitive noninvasive prenatal diagnosis for monogenic disorders at an early gestation. Sequencing of fetal exomes offers broad diagnostic capability for pregnancies with unexpected fetal anomalies, improving the yield and accuracy of diagnoses and allowing better counseling for parents. The challenge now is to translate these approaches into mainstream use in the clinic. Areas covered: Here, the authors review the current literature to describe the technologies available and how these have evolved. The opportunities and challenges at hand, including considerations for service delivery, counseling, and development of ethical guidelines, are discussed. Expert commentary: As technology continues to advance, future developments may be toward noninvasive fetal whole exome or whole genome sequencing and a universal method for noninvasive prenatal diagnosis without the need to sequence both parents or an affected proband. Expansion of cell-free fetal DNA analysis to include the transcriptome and the methylome is likely to yield clinical benefits for monitoring other pregnancy-related pathologies such as preeclampsia and intrauterine growth restriction.
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Affiliation(s)
- Rhiannon Mellis
- a Genetics and Genomic Medicine , Great Ormond Street NHS Foundation Trust , London , UK
| | - Natalie Chandler
- b North Thames NHS Regional Genetics Service , Great Ormond Street NHS Foundation Trust , London , UK
| | - Lyn S Chitty
- a Genetics and Genomic Medicine , Great Ormond Street NHS Foundation Trust , London , UK.,c Genetics and Genomic Medicine , UCL Great Ormond Street Institute of Child Health , London , UK
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Time Costs for Genetic Counseling in Preconception Carrier Screening with Genome Sequencing. J Genet Couns 2018; 27:823-833. [PMID: 29423569 PMCID: PMC6061093 DOI: 10.1007/s10897-017-0205-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 12/18/2017] [Indexed: 10/26/2022]
Abstract
Advances in technology and the promise of personalized health care are driving greater use of genome sequencing (GS) for a variety of clinical scenarios. As health systems consider adopting GS, they need to understand the impact of GS on the organization and cost of care. While research has documented a dramatic decrease in the cost of sequencing and interpreting GS, few studies have examined how GS impacts genetic counseling workloads. This study examined the time needed to provide genetic counseling for GS in the context of preconception carrier screening. Genetic counselors prospectively reported on the time spent in the results disclosure process with 107 study participants who were part of the NextGen study. We found that the median time for results disclosure was 64 min (ranged from 5 to 229 min). Preparation work was the most time-consuming activity. Qualitative data from journal entries, debrief interviews with genetic counselors, and detailed case conference notes provided information on factors influencing time for results disclosure and implications for practice. Results suggest that expanded carrier screening could require significant increases in genetic counseling time, unless we are able to generate new resources to reduce preparation work or develop other strategies such as the creation of new models to deliver this type of service.
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Best S, Wou K, Vora N, Van der Veyver IB, Wapner R, Chitty LS. Promises, pitfalls and practicalities of prenatal whole exome sequencing. Prenat Diagn 2018; 38:10-19. [PMID: 28654730 PMCID: PMC5745303 DOI: 10.1002/pd.5102] [Citation(s) in RCA: 217] [Impact Index Per Article: 36.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 06/16/2017] [Accepted: 06/22/2017] [Indexed: 12/17/2022]
Abstract
Prenatal genetic diagnosis provides information for pregnancy and perinatal decision-making and management. In several small series, prenatal whole exome sequencing (WES) approaches have identified genetic diagnoses when conventional tests (karyotype and microarray) were not diagnostic. Here, we review published prenatal WES studies and recent conference abstracts. Thirty-one studies were identified, with diagnostic rates in series of five or more fetuses varying between 6.2% and 80%. Differences in inclusion criteria and trio versus singleton approaches to sequencing largely account for the wide range of diagnostic rates. The data suggest that diagnostic yields will be greater in fetuses with multiple anomalies or in cases preselected following genetic review. Beyond its ability to improve diagnostic rates, we explore the potential of WES to improve understanding of prenatal presentations of genetic disorders and lethal fetal syndromes. We discuss prenatal phenotyping limitations, counselling challenges regarding variants of uncertain significance, incidental and secondary findings, and technical problems in WES. We review the practical, ethical, social and economic issues that must be considered before prenatal WES could become part of routine testing. Finally, we reflect upon the potential future of prenatal genetic diagnosis, including a move towards whole genome sequencing and non-invasive whole exome and whole genome testing. © 2017 John Wiley & Sons, Ltd.
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Affiliation(s)
- Sunayna Best
- North East Thames Regional Genetics Service, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Karen Wou
- Department of Obstetrics and Gynecology, Division of Reproductive Genetics, Columbia University, New York, NY, USA
| | - Neeta Vora
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Ignatia B. Van der Veyver
- Departments of Obstetrics and Gynecology and Molecular and Human Genetics, Baylor College of Medicine and Texas Children’s Hospital, Houston, TX, USA
| | - Ronald Wapner
- Department of Obstetrics and Gynecology, Division of Reproductive Genetics, Columbia University, New York, NY, USA
| | - Lyn S. Chitty
- North East Thames Regional Genetics Service, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- Genetics and Genomic Medicine, UCL Great Ormond Street Institute of Child Health, London, UK
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de Wit MC, Bunnik EM, Go ATJI, de Beaufort ID, Hofstra RMW, Steegers EAP, Galjaard RJH. Amniocentesis is still the best option for advanced genomic testing in case of fetal malformations. Prenat Diagn 2017; 37:1360-1363. [PMID: 29149523 DOI: 10.1002/pd.5187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 11/05/2017] [Accepted: 11/07/2017] [Indexed: 11/09/2022]
Affiliation(s)
- M C de Wit
- Department of Obstetrics and Gynecology, Erasmus Medical Centre and Sophia Children's Hospital, Rotterdam, The Netherlands
| | - E M Bunnik
- Department of Medical Ethics and Philosophy of Medicine, Erasmus Medical Centre and Sophia Children's Hospital, Rotterdam, Rotterdam, The Netherlands
| | - A T J I Go
- Department of Obstetrics and Gynecology, Erasmus Medical Centre and Sophia Children's Hospital, Rotterdam, The Netherlands
| | - I D de Beaufort
- Department of Medical Ethics and Philosophy of Medicine, Erasmus Medical Centre and Sophia Children's Hospital, Rotterdam, Rotterdam, The Netherlands
| | - R M W Hofstra
- Department of Clinical Genetics, Erasmus Medical Centre and Sophia Children's Hospital, Rotterdam, The Netherlands
| | - E A P Steegers
- Department of Obstetrics and Gynecology, Erasmus Medical Centre and Sophia Children's Hospital, Rotterdam, The Netherlands
| | - R J H Galjaard
- Department of Clinical Genetics, Erasmus Medical Centre and Sophia Children's Hospital, Rotterdam, The Netherlands
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