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Klein D, van Dijke I, van Langen IM, Dondorp W, Lakeman P, Henneman L, Cornel MC. Perceptions of reproductive healthcare providers regarding their involvement in offering expanded carrier screening in fertility clinics: a qualitative study. Reprod Biomed Online 2024; 49:103857. [PMID: 38643517 DOI: 10.1016/j.rbmo.2024.103857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 01/01/2024] [Accepted: 01/29/2024] [Indexed: 04/23/2024]
Abstract
RESEARCH QUESTION What are the main arguments of reproductive healthcare providers in favour or against their involvement in offering expanded carrier screening (ECS) for recessive disorders at fertility clinics in the Netherlands? DESIGN Semi-structured interview study with 20 reproductive healthcare providers between May 2020 and January 2021. Participants included 11 gynaecologists, seven fertility doctors, one nurse practitioner and one clinical embryologist, recruited from academic medical centres (n = 13), peripheral facilities associated with academic centres (n = 4), and independent fertility treatment centres (n = 3) in the Netherlands. An interview guide was developed, and thematic content analysis was performed using ATLAS.ti software. RESULTS Arguments of reproductive healthcare providers in favour of their potential involvement in offering ECS included: (i) opportunities offered by the setting; (ii) motivation to assist in reproduction and prevent suffering; and (iii) to counter unwanted commercialization offers. Arguments against involvement included: (i) lack of knowledge and familiarity with offering ECS; (ii) insufficient staff and resources, and potential high costs for clinics and/or couples; (iii) the emotional impact it may have on couples; (iv) perceived complexity of counselling and expected elongation of waiting lists; and (v) expected low impact on reducing the burden of diseases. Participants felt that more evidence and research on the costs-benefits, implications and demand are needed prior to their involvement. CONCLUSION While agreeing that the field of medically assisted reproduction provides a unique opportunity to offer ECS, reproductive healthcare workers feel a lack of capability and limited motivation to offer ECS to all or a selection of couples at their fertility clinics.
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Affiliation(s)
- David Klein
- Department of Human Genetics, Amsterdam Reproduction and Development Research Institute, Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Ivy van Dijke
- Department of Human Genetics, Amsterdam Reproduction and Development Research Institute, Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Centre for Reproductive Medicine, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - Irene M van Langen
- Department of Genetics, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Wybo Dondorp
- Department of Health, Ethics and Society, Care and Public Health Research Institute, Maastricht University Medical Centre, Maastricht University, Maastricht, the Netherlands
| | - Phillis Lakeman
- Department of Human Genetics, Amsterdam Reproduction and Development Research Institute, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - Lidewij Henneman
- Department of Human Genetics, Amsterdam Reproduction and Development Research Institute, Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.
| | - Martina C Cornel
- Department of Human Genetics, Amsterdam Reproduction and Development Research Institute, Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
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Fehlberg Z, Best S, Long JC, Theodorou T, Pope C, Hibbert P, Williams S, Freeman L, Righetti S, Archibald AD, Braithwaite J. Scaling-up and future sustainability of a national reproductive genetic carrier screening program. NPJ Genom Med 2023; 8:18. [PMID: 37524740 PMCID: PMC10390466 DOI: 10.1038/s41525-023-00357-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 06/01/2023] [Indexed: 08/02/2023] Open
Abstract
An understanding of factors influencing implementation is essential to realise the benefits of population-based reproductive genetic carrier screening programs. The aim of this study was to synthesise data collected during the Australian Reproductive Genetic Carrier Screening Project (Mackenzie's Mission) to track how priorities shifted over time and identify important factors during scaling-up and for sustainment. We used a multi-method qualitative approach to integrate longitudinal project data collected from 10 project committees with 16 semi-structured interviews conducted with study team members. Both datasets were analysed using the Consolidated Framework for Implementation Research (CFIR) to identify constructs of interest within early, mid-point, and future implementation phases. Several CFIR constructs were present across implementation. The complexity of implementation presented challenges that were overcome through a quality-designed and packaged product, formal and informal networks and communication, and access to knowledge and information. Addressing the diverse consumer needs through resources and increasing community and non-genetic speciality engagement remained a priority throughout and for future sustainment. Going forward, further addressing program complexities and securing funding were emphasised. By applying an implementation framework, findings from this study may be useful for future effort towards building and/or sustaining reproductive genetic carrier screening programs.
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Affiliation(s)
- Zoe Fehlberg
- Australian Institute of Heath Innovation, Macquarie University, Sydney, Australia
- Australian Genomics Health Alliance, Melbourne, Australia
- Murdoch Children's Research Institute, Melbourne, Australia
| | - Stephanie Best
- Australian Institute of Heath Innovation, Macquarie University, Sydney, Australia.
- Australian Genomics Health Alliance, Melbourne, Australia.
- Murdoch Children's Research Institute, Melbourne, Australia.
- Department of Health Services Research, Peter MacCallum Cancer Centre, Melbourne, Australia.
- Victorian Comprehensive Cancer Centre, Melbourne, Australia.
- Sir Peter MacCallum Cancer Centre Dept of Oncology, University of Melbourne, Melbourne, Australia.
| | - Janet C Long
- Australian Institute of Heath Innovation, Macquarie University, Sydney, Australia
| | - Tahlia Theodorou
- Australian Institute of Heath Innovation, Macquarie University, Sydney, Australia
| | - Catherine Pope
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Peter Hibbert
- Australian Institute of Heath Innovation, Macquarie University, Sydney, Australia
- IIMPACT in Health, Allied Health and Human Performance, University of South Australia, Adelaide, Australia
| | - Sharon Williams
- School of Health & Social Care, Swansea University, Swansea, Wales, UK
| | - Lucinda Freeman
- School of Women's and Children's Health, University of New South Wales, Sydney, Australia
- Graduate School of Health, University of Technology Sydney, Sydney, Australia
| | - Sarah Righetti
- School of Women's and Children's Health, University of New South Wales, Sydney, Australia
- Centre for Clinical Genetics, Sydney Children's Hospital Network, Sydney, Australia
| | - Alison D Archibald
- Victorian Clinical Genetics Services, Murdoch Children's Research Institute, Melbourne, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Australia
| | - Jeffrey Braithwaite
- Australian Institute of Heath Innovation, Macquarie University, Sydney, Australia
- Australian Genomics Health Alliance, Melbourne, Australia
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3
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Dive L, Holmes I, Newson AJ. Is It Just for a Screening Program to Give People All the Information They Want? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023:1-9. [PMID: 37171853 DOI: 10.1080/15265161.2023.2207510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Genomic screening at population scale generates many ethical considerations. One is the normative role that people's preferences should play in determining access to genomic information in screening contexts, particularly information that falls beyond the scope of screening. We expect both that people will express a preference to receive such results and that there will be interest from the professional community in providing them. In this paper, we consider this issue in relation to the just and equitable design of population screening programs like reproductive genetic carrier screening (RGCS). Drawing on a pluralistic public health ethics perspective, we claim that generating and reporting information about genetic variants beyond the scope of the screening program usually lacks clinical, and perhaps personal, utility. There are both pragmatic and ethical reasons to restrict information provision to that which fits the stated purpose of the program.
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Righetti S, Dive L, Archibald AD, Freeman L, McClaren B, Kanga-Parabia A, Delatycki MB, Laing NG, Kirk EP, Newson AJ. Correspondence on "Screening for autosomal recessive and X-linked conditions during pregnancy and preconception: a practice resource of the American College of Medical Genetics and Genomics (ACMG)" by Gregg et al. Genet Med 2022; 24:1158-1161. [PMID: 35168887 DOI: 10.1016/j.gim.2022.01.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 01/06/2022] [Accepted: 01/13/2022] [Indexed: 12/16/2022] Open
Affiliation(s)
- Sarah Righetti
- School of Women's and Children's Health, University of New South Wales, Randwick, New South Wales, Australia; Centre for Clinical Genetics, Sydney Children's Hospital, Randwick, New South Wales, Australia
| | - Lisa Dive
- Sydney Health Ethics, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, New South Wales, Australia.
| | - Alison D Archibald
- Victorian Clinical Genetics Services, Parkville, Victoria, Australia; Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Lucinda Freeman
- School of Women's and Children's Health, University of New South Wales, Randwick, New South Wales, Australia
| | - Belinda McClaren
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Anaita Kanga-Parabia
- Victorian Clinical Genetics Services, Parkville, Victoria, Australia; Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Martin B Delatycki
- Victorian Clinical Genetics Services, Parkville, Victoria, Australia; Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Nigel G Laing
- UWA Centre for Medical Research, University of Western Australia, Nedlands, Western Australia, Australia; Harry Perkins Institute of Medical Research, Nedlands, Western Australia, Australia
| | - Edwin P Kirk
- School of Women's and Children's Health, University of New South Wales, Randwick, New South Wales, Australia; Centre for Clinical Genetics, Sydney Children's Hospital, Randwick, New South Wales, Australia; NSW Health Pathology East Genomics Laboratory, Randwick, New South Wales, Australia
| | - Ainsley J Newson
- Sydney Health Ethics, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, New South Wales, Australia
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5
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Development and use of the Australian reproductive genetic carrier screening decision aid. Eur J Hum Genet 2022; 30:194-202. [PMID: 34725472 PMCID: PMC8821595 DOI: 10.1038/s41431-021-00991-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 10/07/2021] [Accepted: 10/17/2021] [Indexed: 02/03/2023] Open
Abstract
Reproductive genetic carrier screening (RGCS) may be offered to all individuals and couples, regardless of family history or ethnicity. "Mackenzie's Mission" (MM) is an Australian RGCS pilot study, evaluating the offer of couple-based screening for ~1300 genes associated with around 750 autosomal and X-linked recessive childhood-onset conditions. Each member of the couple makes an individual decision about RGCS and provides consent. We developed a decision aid (RGCS-DA) to support informed decision-making in MM, suitable for couples who were either non-pregnant or in early pregnancy. A Delphi approach invited experts to review values statements related to various concepts of RGCS. Three review rounds were completed, seeking consensus for relevance and clarity of statements, incorporating recommended modifications in subsequent iterations. The final RGCS-DA contains 14 statements that achieved Delphi consensus plus the attitude scale of the measure of informed choice. This was then evaluated in cognitive talk aloud interviews with potential users to assess face and content validity. Minimal wording changes were required at this stage. After this process, the RGCS-DA was piloted with 15 couples participating in MM who were then interviewed about their decision-making. The RGCS-DA prompted discussion within couples and facilitated in depth consideration of screening. There was reassurance when values aligned and a sense of shared decision-making within the couple. This RGCS-DA may become a very useful tool in supporting couples' decision making and contribute to RGCS being feasible for scaled-up implementation.
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6
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Morberg Jämterud S, Snoek A, van Langen IM, Verkerk M, Zeiler K. Qualitative study of GPs' views and experiences of population-based preconception expanded carrier screening in the Netherlands: bioethical perspectives. BMJ Open 2021; 11:e056869. [PMID: 34887284 PMCID: PMC8663082 DOI: 10.1136/bmjopen-2021-056869] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE Between 2016 and 2017, a population-based preconception expanded carrier screening (PECS) test was developed in the Netherlands during a pilot study. It was subsequently made possible in mid-2018 for couples to ask to have such a PECS test from specially trained general practitioners (GPs). Research has described GPs as crucial in offering PECS tests, but little is known about the GPs' views on PECS and their experiences of providing this test. This article presents a thematic analysis of the PECS practice from the perspective of GPs and a bioethical discussion of the empirical results. DESIGN Empirical bioethics. A thematic analysis of qualitative semi-structured interviews was conducted, and is combined with an ethical/philosophical discussion. SETTING The Netherlands. PARTICIPANTS 7 Dutch GPs in the Netherlands, interviewed in 2019-2020. RESULTS Two themes were identified in the thematic analysis: 'Choice and its complexity' and 'PECS as prompting existential concerns'. The empirical bioethics discussion showed that the first theme highlights that several areas coshape the complexity of choice on PECS, and the need for shared relational autonomous decision-making on these areas within the couple. The second theme highlights that it is not possible to analyse the existential issues raised by PECS solely on the level of the couple or family. A societal level must be included, since these levels affect each other. We refer to this as 'entangled existential genetics'. CONCLUSION The empirical bioethical analysis leads us to present two practical implications. These are: (1) training of GPs who are to offer PECS should cover shared relational autonomous decision-making within the couple and (2) more attention should be given to existential issues evoked by genetic considerations, also during the education of GPs and in bioethical discussions around PECS.
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Affiliation(s)
| | - Anke Snoek
- Department of Health, Ethics and Society, Maastricht University, Maastricht, The Netherlands
| | - I M van Langen
- Department of Genetics, University of Groningen, Groningen, The Netherlands
| | - Marian Verkerk
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Kristin Zeiler
- Department of Thematic Studies, Linköping University, Linkoping, Sweden
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7
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Laing NG, Ong RW, Ravenscroft G. Genetic neuromuscular disorders: what is the best that we can do? Neuromuscul Disord 2021; 31:1081-1089. [PMID: 34736628 DOI: 10.1016/j.nmd.2021.07.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 07/12/2021] [Indexed: 11/17/2022]
Abstract
The major advances in genetic neuromuscular disorders in the last 30 years have been: (a) identification of the genetic basis for hundreds of these disorders, (b) through knowing the genes, understanding their pathobiology and (c) subsequent implementation of evidence-based treatments for some of the disorders. New genomic technologies are providing precision diagnosis, mode of inheritance and likely prognosis for more patients than ever before. Parents of children with a genetic diagnosis can then use preimplantation or prenatal diagnosis to avoid having further affected children if they wish. But is this the best we can do for genetic neuromuscular disorders? Since the 1980s, it has been argued it would be better to identify Duchenne muscular dystrophy carrier mothers, rather than diagnose their affected sons. Carrier screening for recessive disorders can identify couples with a high chance of having affected children. It allows couples reproductive choice and can prevent infant morbidity and mortality and significant distress for families. Professional bodies in many countries now recommend prospective parents should be informed about carrier screening. Implementing and funding expensive therapies increases the cost-effectiveness of carrier screening, increasing its attractiveness to governments. Best practice for genetic neuromuscular disorders should include equitable access to carrier screening.
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Affiliation(s)
- Nigel G Laing
- QEII Medical Centre, Neurogenetic Diseases Group, Harry Perkins Institute of Medical Research and University of Western Australia, 6 Verdun Street, Nedlands, Western Australia 6009, Australia; Neurogenetic Unit, Department of Diagnostic Genomics, PathWest Laboratory Medicine, West Australian Department of Health, QEII Medical Centre, Nedlands, Western Australia 6009, Australia.
| | - Royston W Ong
- QEII Medical Centre, Neurogenetic Diseases Group, Harry Perkins Institute of Medical Research and University of Western Australia, 6 Verdun Street, Nedlands, Western Australia 6009, Australia
| | - Gianina Ravenscroft
- QEII Medical Centre, Neurogenetic Diseases Group, Harry Perkins Institute of Medical Research and University of Western Australia, 6 Verdun Street, Nedlands, Western Australia 6009, Australia; School of Biomedical Sciences, University of Western Australia, Nedlands, Western Australia 6009, Australia
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8
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Law WK, Yaremych HE, Ferrer RA, Richardson E, Wu YP, Turbitt E. Decision-making about genetic health information among family dyads: a systematic literature review. Health Psychol Rev 2021; 16:412-429. [PMID: 34546151 DOI: 10.1080/17437199.2021.1980083] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Decisions involving two individuals (i.e., dyadic decision-making) have been increasingly studied in healthcare research. There is evidence of bi-directional influences in decision-making processes among spousal, provider-patient and parent-child dyads. Genetic information can directly impact biologically related individuals. Thus, it is important to understand dyadic decision-making about genetic health information among family members. This systematic literature review aimed to identify literature examining decision-making among family dyads. Peer-reviewed publications were included if they reported quantitative empirical research on dyadic decision-making about genetic information, published between January 1998 and August 2020 and written in English. The search was conducted in 6 databases and returned 3167 articles, of which 15 met the inclusion criteria. Most studies were in the context of cancer genetic testing (n = 8) or reproductive testing or screening (n = 5). Studies reported two broad categories of decisions with dyadic influence: undergoing screening or testing (n = 10) and sharing information with family (n = 5). Factors were correlated between dyads such as attitudes, knowledge, behaviors and psychological wellbeing. Emerging evidence shows that dyad members influence each other when making decisions about receiving or sharing genetic information. Our findings emphasize the importance of considering both members of a dyad in intervention design and clinical interactions.
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Affiliation(s)
- Wai Ki Law
- The Discipline of Genetic Counselling, The University of Technology Sydney, Ultimo, Australia
| | - Haley E Yaremych
- Department of Psychology & Human Development, Vanderbilt University, Nashville, TN, USA.,Social and Behavioral Research Branch, National Human Genome Research Institute, Bethesda, MD, USA
| | - Rebecca A Ferrer
- Basic Biobehavioral and Psychological Sciences Branch, National Cancer Institute, Bethesda, MD, USA
| | - Ebony Richardson
- The Discipline of Genetic Counselling, The University of Technology Sydney, Ultimo, Australia
| | - Yelena P Wu
- Department of Dermatology, University of Utah, Salt Lake City, UT, USA.,Huntsman Cancer Institute, Salt Lake City, UT, USA
| | - Erin Turbitt
- The Discipline of Genetic Counselling, The University of Technology Sydney, Ultimo, Australia.,Social and Behavioral Research Branch, National Human Genome Research Institute, Bethesda, MD, USA
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Dive L, Archibald AD, Newson AJ. Ethical considerations in gene selection for reproductive carrier screening. Hum Genet 2021; 141:1003-1012. [PMID: 34426854 PMCID: PMC9160090 DOI: 10.1007/s00439-021-02341-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 08/11/2021] [Indexed: 12/02/2022]
Abstract
Genetic carrier screening for reproductive purposes has existed for half a century. It was originally offered to particular ethnic groups with a higher prevalence of certain severe recessive or X-linked genetic conditions, or (as carrier testing) to those with a family history of a particular genetic condition. Commercial providers are increasingly offering carrier screening on a user-pays basis. Some countries are also trialing or offering public reproductive genetic carrier screening with whole populations, rather than only to those known to have a higher chance of having a child with an inherited genetic condition. Such programs broaden the ethical and practical challenges that arise in clinical carrier testing. In this paper we consider three aspects of selecting genes for population reproductive genetic carrier screening panels that give rise to important ethical considerations: severity, variable penetrance and expressivity, and scalability; we also draw on three exemplar genes to illustrate the ethical issues raised: CFTR, GALT and SERPINA1. We argue that such issues are important to attend to at the point of gene selection for RGCS. These factors warrant a cautious approach to screening panel design, one that takes into account the likely value of the information generated by screening and the feasibility of implementation in large and diverse populations. Given the highly complex and uncertain nature of some genetic variants, careful consideration needs to be given to the balance between delivering potentially burdensome or harmful information, and providing valuable information to inform reproductive decisions.
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Affiliation(s)
- Lisa Dive
- Faculty of Medicine and Health, Sydney School of Public Health, Sydney Health Ethics, The University of Sydney, Level 1, Edward Ford Building A27, Sydney, NSW, 2006, Australia
| | - Alison Dalton Archibald
- Victorian Clinical Genetics Services, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
| | - Ainsley J Newson
- Faculty of Medicine and Health, Sydney School of Public Health, Sydney Health Ethics, The University of Sydney, Level 1, Edward Ford Building A27, Sydney, NSW, 2006, Australia.
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10
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Couples' experiences with expanded carrier screening: evaluation of a university hospital screening offer. Eur J Hum Genet 2021; 29:1252-1258. [PMID: 34155360 PMCID: PMC8384865 DOI: 10.1038/s41431-021-00923-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/25/2021] [Accepted: 06/01/2021] [Indexed: 02/02/2023] Open
Abstract
Preconception carrier screening offers couples the possibility to receive information about the risk of having a child with a recessive disorder. Since 2016, an expanded carrier screening (ECS) test for 50 severe autosomal recessive disorders has been available at Amsterdam Medical Center, a Dutch university hospital. This mixed-methods study evaluated the experiences of couples that participated in the carrier screening offer, including high-risk participants, as well as participants with a general population risk. All participants received genetic counselling, and pre- (n = 132) and post-test (n = 86) questionnaires and semi-structured interviews (n = 16) were administered. The most important reason to have ECS was to spare a future child a life with a severe disorder (47%). The majority of survey respondents made an informed decision (86%), as assessed by the Multidimensional Measure of Informed Choice. Among the 86 respondents, 27 individual carriers and no new carrier couples were identified. Turn-around time of the test results was considered too long and costs were perceived as too high. Overall, mean levels of anxiety were not clinically elevated. High-risk respondents (n = 89) and pregnant respondents (n = 13) experienced higher levels of anxiety before testing, which decreased after receiving the test result. Although not clinically significant, distress was on average higher for carriers compared to non-carriers (p < 0.0001). All respondents would opt for the test again, and 80.2% would recommend it to others. The results suggest that ECS should ideally be offered before pregnancy, to minimise anxiety. This study could inform current and future implementation initiatives of preconception ECS.
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11
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Dive L, Newson AJ. Ethics of Reproductive Genetic Carrier Screening: From the Clinic to the Population. Public Health Ethics 2021; 14:202-217. [PMID: 34650621 PMCID: PMC8510688 DOI: 10.1093/phe/phab017] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Reproductive genetic carrier screening (RCS) is increasingly being offered more widely, including to people with no family history or otherwise elevated chance of having a baby with a genetic condition. There are valid reasons to reject a prevention-focused public health ethics approach to such screening programs. Rejecting the prevention paradigm in this context has led to an emphasis on more individually-focused values of freedom of choice and fostering reproductive autonomy in RCS. We argue, however, that population-wide RCS has sufficient features in common with other public health screening programs that it becomes important also to attend to its public health implications. Not doing so constitutes a failure to address the social conditions that significantly affect people's capacity to exercise their reproductive autonomy. We discuss how a public health ethics approach to RCS is broader in focus than prevention. We also show that additional values inherent to ethical public health-such as equity and solidarity-are essential to underpin and inform the aims and implementation of reproductive carrier screening programs.
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Affiliation(s)
- Lisa Dive
- Sydney Health Ethics, The University of Sydney
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12
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Couple-based expanded carrier screening provided by general practitioners to couples in the Dutch general population: psychological outcomes and reproductive intentions. Genet Med 2021; 23:1761-1768. [PMID: 34112999 PMCID: PMC8460434 DOI: 10.1038/s41436-021-01199-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 04/22/2021] [Accepted: 04/26/2021] [Indexed: 12/02/2022] Open
Abstract
Purpose The aim of expanded preconception carrier screening (ECS) is to inform any couple wishing to conceive about their chances of having children with severe autosomal or X-linked recessive conditions. Responsible implementation of ECS as reproductive genetic screening in routine care requires assessment of benefits and harms. We examined the psychological outcomes of couple-based ECS for 50 autosomal recessive (AR) conditions provided by general practitioners (GPs) to couples from the Dutch general population. Methods Dutch GPs invited 4,295 women aged 18–40. We examined anxiety (State-Trait Anxiety Inventory, STAI-6), worry, decisional conflict (DCS) over time in participants declining GP counseling or attending GP counseling with/without testing. Results One hundred ninety couples participated; 130 attended counseling, of whom 117 proceeded with testing. No carrier couples were identified. Before counseling, worry (median 6.0) and anxiety (mean 30–34) were low and lower than the population reference (36.4), although some individuals reported increased anxiety or worry. At follow-up, test acceptors reported less anxiety than test decliners (mean 29 vs. 35); differences in anxiety after testing compared to before counseling were not meaningful. Most participants (90%) were satisfied with their decision (not) to undergo testing. Conclusion Some individuals reported temporarily clinically relevant distress. Overall, the psychological outcomes are acceptable and no barrier to population-wide implementation.
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Preconception expanded carrier screening: a focus group study with relatives of mucopolysaccharidosis type III patients and the general population. J Community Genet 2021; 12:311-323. [PMID: 33754291 PMCID: PMC8241963 DOI: 10.1007/s12687-021-00519-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 03/09/2021] [Indexed: 11/26/2022] Open
Abstract
Preconception expanded carrier screening (ECS) enables prospective parents to assess their risk of having a child with an autosomal recessive disorder. Knowledge on motivations, feelings, and considerations people have towards the offer and use of ECS is limited. To enrich the public and professional discussion on ECS implementation, this study explored the perspectives towards various aspects of ECS in seven focus groups compromising first- and second-degree relatives of MPS III patients (N=9, N=4, N=5, N=5) and members of the general Dutch population (N=6, N=7, N=5). The focus groups were audio recorded and the transcripts were qualitatively analyzed to identify themes. Both relatives of MPS III patients and participants from the general population supported offering ECS, in particular for severe, childhood-onset disorders. Important barriers identified for ECS were a lack of genetic knowledge and a perceived lack of personal relevance and awareness, as well as out-of-pocket costs of testing. The majority of participants would prefer full disclosure of individual test results instead of couple-based test results. Moreover, offering people a choice for the way of reporting was proposed. All participants agreed that more efforts, for example by governmental campaigns, should be made to increase awareness on the availability, potentials, and limitations of ECS. Educating prospective parents about ECS is essential for increasing awareness and informed decision making. This study provides valuable insights that can be used by governments and public health authorities when considering implementation of preconception ECS.
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14
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Best S, Long J, Theodorou T, Hatem S, Lake R, Archibald A, Freeman L, Braithwaite J. Health practitioners' perceptions of the barriers and enablers to the implementation of reproductive genetic carrier screening: A systematic review. Prenat Diagn 2021; 41:708-719. [PMID: 33533079 PMCID: PMC8252081 DOI: 10.1002/pd.5914] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 12/22/2020] [Accepted: 01/26/2021] [Indexed: 11/10/2022]
Abstract
Background As interest in reproductive genetic carrier screening rises, with increased availability, the role of healthcare practitioners is central in guiding uptake aligned with a couples' values and beliefs. Therefore, practitioners' views on implementation are critical to the success of any reproductive genetic carrier screening programme. Aim To explore healthcare practitioners' perceptions of the barriers and enablers to implementation. Materials & Methods We undertook a systematic review of the literature searching seven databases using health practitioner, screening and implementation terms returning 490 articles. Results Screening led to the inclusion of 26 articles for full‐text review. We found three interconnected themes relating to reproductive genetic carrier screening: (i) use and impact, (ii) practitioners' beliefs and expectations and (iii) resources. Discussion Barriers and enablers to implementation were present within each theme and grouping these determinants by (a) community for example lack of public interest, (b) practitioner for example lack of practitioner time and (c) organisation for example lack of effective metrics, reveals a preponderance of practitioner barriers and organisational enablers. Linking barriers with potential enablers leaves several barriers unresolved (e.g., costs for couples) implying additional interventions may be required. Conclusion Future research should draw on the findings from this study to develop and test strategies to facilitate appropriate offering of reproductive genetic carrier screening by healthcare practitioners. What is already known?Availability of reproductive genetic carrier screening is rising. Screening is often focused on ethnically specific conditions or for those with a family history of disease. Commonly, carriers do not have family history of disease.
What does this review add?Identifies practitioner barriers to implementation of reproductive genetic carrier screening, for example, beliefs and expectations. Matches identified practitioner barriers to enablers to implementation. Highlights where additional implementation support is required, for example, lack of practitioner confidence.
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Affiliation(s)
- Stephanie Best
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia.,Australian Genomics Health Alliance, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Janet Long
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Tahlia Theodorou
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Sarah Hatem
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Rebecca Lake
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Alison Archibald
- Victorian Clinical Genetics Services, Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Victoria, Australia.,Bruce Lefroy Centre, Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, Victoria, Australia
| | - Lucinda Freeman
- Centre for Clinical Genetics, Sydney Children's Hospital Randwick, Randwick, New South Wales, Australia.,School of Women's and Children's Health, University of New South Wales, Randwick, New South Wales, Australia
| | - Jeffrey Braithwaite
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
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16
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Kirk EP, Ong R, Boggs K, Hardy T, Righetti S, Kamien B, Roscioli T, Amor DJ, Bakshi M, Chung CWT, Colley A, Jamieson RV, Liebelt J, Ma A, Pachter N, Rajagopalan S, Ravine A, Wilson M, Caruana J, Casella R, Davis M, Edwards S, Archibald A, McGaughran J, Newson AJ, Laing NG, Delatycki MB. Gene selection for the Australian Reproductive Genetic Carrier Screening Project ("Mackenzie's Mission"). Eur J Hum Genet 2020; 29:79-87. [PMID: 32678339 DOI: 10.1038/s41431-020-0685-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 06/30/2020] [Indexed: 11/09/2022] Open
Abstract
Reproductive genetic carrier screening aims to offer couples information about their chance of having children with certain autosomal recessive and X-linked genetic conditions. We developed a gene list for use in "Mackenzie's Mission", a research project in which 10,000 couples will undergo screening. Criteria for selecting genes were: the condition should be life-limiting or disabling, with childhood onset, such that couples would be likely to take steps to avoid having an affected child; and/or be one for which early diagnosis and intervention would substantially change outcome. Strong evidence for gene-phenotype relationship was required. Candidate genes were identified from OMIM and via review of 23 commercial and published gene lists. Genes were reviewed by 16 clinical geneticists using a standard operating procedure, in a process overseen by a multidisciplinary committee which included clinical geneticists, genetic counselors, an ethicist, a parent of a child with a genetic condition and scientists from diagnostic and research backgrounds. 1300 genes met criteria. Genes associated with non-syndromic deafness and non-syndromic differences of sex development were not included. Our experience has highlighted that gene selection for a carrier screening panel needs to be a dynamic process with ongoing review and refinement.
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Affiliation(s)
- Edwin P Kirk
- Centre for Clinical Genetics, Sydney Children's Hospital Randwick, Randwick, NSW, Australia. .,School of Women's and Children's Health, University of New South Wales, Randwick, NSW, Australia. .,NSW Health Pathology East Genomics Laboratory, Randwick, NSW, Australia.
| | - Royston Ong
- Centre for Medical Research, The University of Western Australia, Nedlands, WA, Australia.,Harry Perkins Institute for Medical Research, Nedlands, WA, Australia
| | - Kirsten Boggs
- Centre for Clinical Genetics, Sydney Children's Hospital Randwick, Randwick, NSW, Australia.,Australian Genomics Health Alliance, Melbourne, VIC, Australia.,Department of Clinical Genetics, Children's Hospital Westmead, Westmead, NSW, Australia
| | - Tristan Hardy
- SA Pathology, Adelaide, SA, Australia.,Repromed, Dulwich, SA, Australia.,Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia
| | - Sarah Righetti
- Centre for Clinical Genetics, Sydney Children's Hospital Randwick, Randwick, NSW, Australia.,School of Women's and Children's Health, University of New South Wales, Randwick, NSW, Australia
| | - Ben Kamien
- Genetic Services of Western Australia, Perth, WA, Australia
| | - Tony Roscioli
- Centre for Clinical Genetics, Sydney Children's Hospital Randwick, Randwick, NSW, Australia.,NSW Health Pathology East Genomics Laboratory, Randwick, NSW, Australia.,Neuroscience Research Australia, Randwick, NSW, Australia
| | - David J Amor
- Murdoch Children's Research Institute, Parkville, VIC, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
| | - Madhura Bakshi
- Department of Clinical Genetics, Liverpool Hospital, Liverpool, NSW, Australia
| | - Clara W T Chung
- School of Women's and Children's Health, University of New South Wales, Randwick, NSW, Australia.,Department of Clinical Genetics, Liverpool Hospital, Liverpool, NSW, Australia
| | - Alison Colley
- Department of Clinical Genetics, Liverpool Hospital, Liverpool, NSW, Australia
| | - Robyn V Jamieson
- Department of Clinical Genetics, Children's Hospital Westmead, Westmead, NSW, Australia.,Eye Genetics Research Unit, Children's Medical Research Institute, Children's Hospital Westmead, Save Sight Institute, University of Sydney, Sydney, NSW, Australia.,Disciplines of Genomic Medicine, and Child and Adolescent Health, University of Sydney, Sydney, NSW, Australia
| | - Jan Liebelt
- South Australian Clinical Genetics Service, Royal Adelaide Hospital, Adelaide, SA, Australia.,Women's and Children's Hospital, Adelaide, SA, Australia
| | - Alan Ma
- Department of Clinical Genetics, Children's Hospital Westmead, Westmead, NSW, Australia.,Discipline of Genomic Medicine, University of Sydney, Sydney, NSW, Australia
| | - Nicholas Pachter
- Genetic Services of Western Australia, Perth, WA, Australia.,School of Medicine, The University of Western Australia, Perth, WA, Australia
| | - Sulekha Rajagopalan
- Department of Clinical Genetics, Liverpool Hospital, Liverpool, NSW, Australia
| | - Anja Ravine
- PathWest Laboratory Medicine, Perth, WA, Australia
| | - Meredith Wilson
- Department of Clinical Genetics, Children's Hospital Westmead, Westmead, NSW, Australia.,Discipline of Genomic Medicine, University of Sydney, Sydney, NSW, Australia
| | - Jade Caruana
- Australian Genomics Health Alliance, Melbourne, VIC, Australia.,Murdoch Children's Research Institute, Parkville, VIC, Australia
| | | | - Mark Davis
- PathWest Laboratory Medicine, Perth, WA, Australia
| | - Samantha Edwards
- Centre for Medical Research, The University of Western Australia, Nedlands, WA, Australia.,Harry Perkins Institute for Medical Research, Nedlands, WA, Australia
| | - Alison Archibald
- Murdoch Children's Research Institute, Parkville, VIC, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia.,Victorian Clinical Genetics Services, Parkville, VIC, Australia
| | - Julie McGaughran
- Genetic Health Queensland, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia.,School of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Ainsley J Newson
- The University of Sydney, Faculty of Medicine & Health, Sydney School of Public Health, Sydney Health Ethics, Sydney, Australia
| | - Nigel G Laing
- Centre for Medical Research, The University of Western Australia, Nedlands, WA, Australia.,Harry Perkins Institute for Medical Research, Nedlands, WA, Australia
| | - Martin B Delatycki
- Murdoch Children's Research Institute, Parkville, VIC, Australia.,Victorian Clinical Genetics Services, Parkville, VIC, Australia
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17
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Xi Y, Chen G, Lei C, Wu J, Zhang S, Xiao M, Zhang W, Zhang Y, Sun X. Expanded carrier screening in Chinese patients seeking the help of assisted reproductive technology. Mol Genet Genomic Med 2020; 8:e1340. [PMID: 32573981 PMCID: PMC7507411 DOI: 10.1002/mgg3.1340] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 04/27/2020] [Accepted: 05/12/2020] [Indexed: 01/05/2023] Open
Abstract
Background Expanded carrier screening (ECS) has emerged as an effective approach to identify at‐risk couples (ARCs)—before they initiate attempts at reproduction—who possess a high probability of having a child affected by severe recessive diseases. The objective of this study was to evaluate the clinical utility of ECS in Chinese patients seeking the help of assisted reproductive technology (ART). Methods An ECS test, which covers 201 genes implicated in 135 recessive (autosomal or X‐linked) diseases, was routinely offered to all ART patients in a single genetics and in vitro fertilization clinic. Additional options for preimplantation or prenatal genetic diagnosis were discussed and offered to all ARCs. All ECS results were aggregated and the clinical decisions of the ARCs were surveyed. Results A total of 2,923 ART patients, representing 1,462 couples, were screened. Overall, 46.73% of the individuals were found to be the carriers for at least 1 of the 135 diseases. Of the tested couples, 2.26% (n = 33) were identified as ARCs. As of the completion of this study, 21 (63.6%) ARCs have decided to avert an affected pregnancy with the help of preimplantation genetic testing for monogenetic conditions. The cumulative carrier rate of the 187 autosomal recessive genes in the ECS panel for the 2,836 Han Chinese individuals without a family history was estimated to be 45.91%. The estimated at‐risk couple rate indicates that the screening for only the top 31 genes with gene carrier rates >0.5% would identify more than 94% of the ARCs identified by screening all 187 genes. Conclusion Our study demonstrates that ESC yields a significant clinical value for ART patients in China. In addition, by estimating the yields of the ECS panel, we identify genes that are appropriate for screening the Han population.
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Affiliation(s)
- Yanping Xi
- Shanghai Ji Ai Genetics & IVF Institute, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Guangquan Chen
- WuXi NextCODE Genomics (Shanghai) Co., Ltd., Shanghai, China
| | - Caixia Lei
- Shanghai Ji Ai Genetics & IVF Institute, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Junping Wu
- Shanghai Ji Ai Genetics & IVF Institute, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Shuo Zhang
- Shanghai Ji Ai Genetics & IVF Institute, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Min Xiao
- Shanghai Ji Ai Genetics & IVF Institute, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Wenbi Zhang
- Shanghai Ji Ai Genetics & IVF Institute, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Yueping Zhang
- Shanghai Ji Ai Genetics & IVF Institute, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Xiaoxi Sun
- Shanghai Ji Ai Genetics & IVF Institute, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China.,Key Laboratory of Female Reproductive Endocrine Related Diseases, Obstetrics, and Gynecology Hospital of Fudan University, Shanghai, China
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18
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Palomaki GE, Haddow JE. Comment on "Expanded carrier screening for autosomal recessive conditions in health care: Arguments for a couple-based approach and examination of couples' views". Prenat Diagn 2019; 39:1038. [PMID: 31660643 DOI: 10.1002/pd.5510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 06/19/2019] [Indexed: 11/07/2022]
Affiliation(s)
- Glenn E Palomaki
- Division of Medical Screening and Special Testing, Department of Pathology and Laboratory Medicine, Women & Infants Hospital and Alpert Medical School at Brown University, Providence, RI
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GP-provided couple-based expanded preconception carrier screening in the Dutch general population: who accepts the test-offer and why? Eur J Hum Genet 2019; 28:182-192. [PMID: 31570785 PMCID: PMC6974594 DOI: 10.1038/s41431-019-0516-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 08/12/2019] [Accepted: 09/10/2019] [Indexed: 01/08/2023] Open
Abstract
Next generation sequencing has enabled fast and relatively inexpensive expanded carrier screening (ECS) that can inform couples’ reproductive decisions before conception and during pregnancy. We previously showed that a couple-based approach to ECS for autosomal recessive (AR) conditions was acceptable and feasible for both health care professionals and the non-pregnant target population in the Netherlands. This paper describes the acceptance of this free test-offer of preconception ECS for 50 severe conditions, the characteristics of test-offer acceptors and decliners, their views on couple-based ECS and reasons for accepting or declining the test-offer. We used a survey that included self-rated health, intention to accept the test-offer, barriers to test-participation and arguments for and against test-participation. Fifteen percent of the expected target population—couples potentially planning a pregnancy—attended pre-test counselling and 90% of these couples proceeded with testing. Test-offer acceptors and decliners differed in their reproductive characteristics (e.g. how soon they wanted to conceive), educational level and stated barriers to test-participation. Sparing a child a life with a severe genetic condition was the most important reason to accept ECS. The most important reason for declining was that the test-result would not affect participants’ reproductive decisions. Our results demonstrate that previously uninformed couples of reproductive age, albeit a selective part, were interested in and chose to have couple-based ECS. Alleviating practical barriers, which prevented some interested couples from participating, is recommended before nationwide implementation.
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20
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Plantinga M, Birnie E, Schuurmans J, Buitenhuis AH, Boersma E, Lucassen AM, Verkerk MA, van Langen IM, Ranchor AV. Expanded carrier screening for autosomal recessive conditions in health care: Arguments for a couple-based approach and examination of couples' views. Prenat Diagn 2019; 39:369-378. [PMID: 30756401 PMCID: PMC6593986 DOI: 10.1002/pd.5437] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 02/01/2019] [Accepted: 02/05/2019] [Indexed: 12/17/2022]
Abstract
Background Expanded carrier screening (ECS) is aimed at detecting carrier states for autosomal recessive (AR) or X‐linked conditions in couples from the general population planning a pregnancy. ECS is currently usually offered on an individual basis despite the fact that, for AR conditions, only carrier couples are at risk of affected offspring. In this paper, we present a couple‐based ECS test‐offer for AR conditions, where results are offered as couple‐results only, and describe how couples view such an offer. Methods and results An online survey covering attitudes, perceived difficulty, and intention to take up couple‐based ECS was used to examine couples' views. Results show that in 76% of the participating couples there is no objection at all towards receiving couple‐results only. Most couples display similar views. Observed discrepancies usually involved one of the couple members having a positive view, whilst the other was neutral. Although views stayed strikingly stable after discussion, the partner's opinion was regarded as important in deciding whether or not to have testing. Conclusion This study shows that most couples do not object to receiving couple rather than individual ECS results, have similar views towards the offer, and are able to discuss differences in views and intentions. What's already known about this topic?
Expanded carrier screening (ECS) has become widely available ECS is usually offered on individual basis, and individual carrier states are reported Views of potential individual users have been researched
What does this study add?
A couple‐based ECS test‐offer for autosomal recessive conditions, where results are offered as couple‐results only An examination of couples' views towards this offer: most couples do not object to receiving couple‐results only
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Affiliation(s)
- Mirjam Plantinga
- Department of Genetics, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Erwin Birnie
- Department of Genetics, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Juliette Schuurmans
- Department of Genetics, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Clinical Ethics and Law, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Anne H Buitenhuis
- Department of Health Psychology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Elise Boersma
- Department of Genetics, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Anneke M Lucassen
- Clinical Ethics and Law, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Marian A Verkerk
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Irene M van Langen
- Department of Genetics, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Adelita V Ranchor
- Department of Health Psychology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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