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Farrell RM, Pierce M, Collart C, Yao M, Coleridge M, Chien EK, Rose SS, Lintel M, Perni U, Edmonds BT. Decision-making for prenatal genetic screening: how will pregnant women navigate a growing number of aneuploidy and carrier screening options? BMC Pregnancy Childbirth 2021; 21:806. [PMID: 34863134 PMCID: PMC8642756 DOI: 10.1186/s12884-021-04282-7] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 11/02/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Prenatal genetic screens, including carrier screening (CS) and aneuploidy screening (AS), comprise an important component of reproductive healthcare delivery. Clinical practice guidelines emphasize the importance of informed decision-making and patient's preferences regarding the use of these screens. Yet, it is unclear how to achieve this ideal as prenatal genetic screening options rapidly become more complex and increasingly available to patients. With increased complexity and availability of reproductive testing options, decision-support strategies are critical to prepare patients to consider AS and/or CS. METHODS A self-administered survey evaluated knowledge and decision-making preferences for expanded carrier (CS) and aneuploidy (AS) prenatal screening. The survey was administered to participants before their first prenatal visit to assess baseline decision-making needs and preference at the initiation of prenatal care. Analysis was approached as a descriptive process. RESULTS Participants had similar familiarity with the concepts associated with AS compared to CS; mean knowledge scores for CS was 0.59 [possible range 0.00 to 1.00] and 0.55 for AS. Participants reported preferences to learn about a range of conditions, including those with severe or mild impact, childhood-onset, and adult-onset. Decision-making preference with respect to learning about the associated disease phenotypes for the contained on AS and CS panel shifted with the complexity of the panel, with a greater preference to learn about conditions post-test compared pre-test education as panels increased from 5 to 100 conditions. CONCLUSION Patients' baseline knowledge of prenatal genetic screens coupled with evolving decision-making preferences presents challenges for the delivery of prenatal genetic screens. This calls for the development and implementation of innovative approaches to support pregnant patients' decision-making commensurate with advances in prenatal genomics.
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Affiliation(s)
- Ruth M Farrell
- OB/GYN and Women's Health Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
- Genomic Medicine Institute, Cleveland Clinic, Cleveland, OH, USA.
- Center for Bioethics, Cleveland Clinic, Cleveland, OH, USA.
| | - Madelyn Pierce
- OB/GYN and Women's Health Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Christina Collart
- OB/GYN and Women's Health Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Meng Yao
- Quantitative Health Science Department, Cleveland Clinic, Cleveland, OH, USA
| | - Marissa Coleridge
- OB/GYN and Women's Health Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
- Genomic Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Edward K Chien
- OB/GYN and Women's Health Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Susannah S Rose
- Office of Patient Experience, Clinical Transformation, Cleveland Clinic, Cleveland, OH, USA
| | - Mary Lintel
- OB/GYN and Women's Health Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Uma Perni
- OB/GYN and Women's Health Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
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Farrell RM, Pierce M, Collart C, Edmonds BT, Chien E, Coleridge M, Rose SL, Perni U, Frankel R. Making the most of the first prenatal visit: The challenge of expanding prenatal genetic testing options and limited clinical encounter time. Prenat Diagn 2020; 40:1265-1271. [PMID: 32441820 PMCID: PMC10114520 DOI: 10.1002/pd.5752] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 05/13/2020] [Accepted: 05/15/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Advances in prenatal genetics place additional challenges as patients must receive information about a growing array of screening and testing options. This raises concerns about how to achieve a shared decision-making process that prepares patients to make an informed decision about their choices about prenatal genetic screening and testing options, calling for a reconsideration of how healthcare providers approach the first prenatal visit. METHODS We conducted interviews with 40 pregnant women to identify components of decision-making regarding prenatal genetic screens and tests at this visit. Analysis was approached using grounded theory. RESULTS Participants brought distinct notions of risk to the visit, including skewed perceptions of baseline risk for a fetal genetic condition and the implications of screening and testing. Participants were very concerned about financial considerations associated with these options, ranking out-of-pocket costs on par with medical considerations. Participants noted diverging priorities at the first visit from those of their healthcare provider, leading to barriers to shared decision-making regarding screening and testing during this visit. CONCLUSION Research is needed to determine how to restructure the initiation of prenatal care in a way that best positions patients to make informed decisions about prenatal genetic screens and tests.
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Affiliation(s)
- Ruth M Farrell
- Obstetrics/Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Genomic Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Center for Bioethics, Cleveland Clinic, Cleveland, Ohio, USA
| | - Madelyn Pierce
- Obstetrics/Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Christina Collart
- Obstetrics/Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Edward Chien
- Obstetrics/Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Susannah L Rose
- Center for Bioethics, Cleveland Clinic, Cleveland, Ohio, USA.,Office of Patient Experience, Cleveland Clinic, Cleveland, Ohio, USA.,Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA
| | - Uma Perni
- Obstetrics/Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Richard Frankel
- Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA
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Cernat A, De Freitas C, Majid U, Trivedi F, Higgins C, Vanstone M. Facilitating informed choice about non-invasive prenatal testing (NIPT): a systematic review and qualitative meta-synthesis of women's experiences. BMC Pregnancy Childbirth 2019; 19:27. [PMID: 30642270 PMCID: PMC6332899 DOI: 10.1186/s12884-018-2168-4] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 12/28/2018] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Non-invasive prenatal testing (NIPT) can be used to accurately detect fetal chromosomal anomalies early in pregnancy by assessing cell-free fetal DNA present in maternal blood. The rapid diffusion of NIPT, as well as the ease and simplicity of the test raises concerns around informed decision-making and the potential for routinization. Introducing NIPT in a way that facilitates informed and autonomous decisions is imperative to the ethical application of this technology. We approach this imperative by systematically reviewing and synthesizing primary qualitative research on women's experiences with and preferences for informed decision-making around NIPT. METHODS We searched multiple bibliographic databases including Ovid MEDLINE, EBSCO Cumulative Index to Nursing & Allied Health Literature (CINAHL), and ISI Web of Science Social Sciences Citation Index (SSCI). Our review was guided by integrative qualitative meta-synthesis, and we used a staged coding process similar to that of grounded theory to conduct our analysis. RESULTS Thirty empirical primary qualitative research studies were eligible for inclusion. Women preferred to learn about NIPT from their clinicians, but they expressed dissatisfaction with the quality and quantity of information provided during counselling and often sought information from a variety of other sources. Women generally had a good understanding of test characteristics, and the factors of accuracy, physical risk, and test timing were the critical information elements that they used to make informed decisions around NIPT. Women often described NIPT as easy or just another blood test, highlighting threats to informed decision-making such as routinization or a pressure to test. CONCLUSIONS Women's unique circumstances modulate the information that they value and require most in the context of making an informed decision. Widened availability of trustworthy information about NIPT as well as careful attention to the facilitation of counselling may help facilitate informed decision-making. TRIAL REGISTRATION PROSPERO 2018 CRD42018086261 .
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Affiliation(s)
- Alexandra Cernat
- Honours Life Sciences BSc Program, McMaster University, Hamilton, ON Canada
| | - Chante De Freitas
- Health Sciences Education Program, McMaster University, Hamilton, ON Canada
| | - Umair Majid
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON Canada
| | - Forum Trivedi
- Honours Life Sciences BSc Program, McMaster University, Hamilton, ON Canada
| | | | - Meredith Vanstone
- Department of Family Medicine, McMaster University, DBHSC 5003E, 100 Main St W, Hamilton, ON L8P 1H6 Canada
- Centre for Health Economic and Policy Analysis, McMaster University, Hamilton, ON Canada
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Phan MD, Nguyen TV, Trinh HNT, Vo BT, Nguyen TM, Nguyen NH, Nguyen TTQ, Do TTT, Hoang TTD, Truong KD, Giang H, Nguyen HN. Establishing and validating noninvasive prenatal testing procedure for fetal aneuploidies in Vietnam. J Matern Fetal Neonatal Med 2018; 32:4009-4015. [PMID: 29865915 DOI: 10.1080/14767058.2018.1481032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Objective: Noninvasive prenatal testing (NIPT) for fetal aneuploidies has been widely adopted in developed countries. Despite the sharp decrease in the cost of massively parallel sequencing, the technical know-how and skilled personnel are still one of the major limiting factors for applying this technology to NIPT in low-income settings. Here, we present the establishment and validation of our NIPT procedure called triSure for detection of fetal aneuploidies. Methods: We established the triSure algorithm based on the difference in proportion of fetal and maternal fragments from the target chromosome to all chromosomes. Our algorithm was validated using a published data set and an in-house data set obtained from high-risk pregnant women in Vietnam who have undergone amniotic testing. Several other aneuploidy calling methods were also applied to the same data set to benchmark triSure performance. Results: The triSure algorithm showed similar accuracy to size-based method when comparing them using published data set. Using our in-house data set from 130 consecutive samples, we showed that triSure correctly identified the most samples (overall sensitivity and specificity of 0.983 and 0.986, respectively) compared to other methods tested including count-based, sized-based, RAPIDR and NIPTeR. Conclusions: We have demonstrated that our triSure NIPT procedure can be applied to pregnant women in low-income settings such as Vietnam, providing low-risk screening option to reduce the need for invasive diagnostic tests.
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Affiliation(s)
- Minh-Duy Phan
- Gene Solutions , Ho Chi Minh City , Vietnam.,School of Chemistry and Molecular Biosciences, the University of Queensland , Brisbane , Australia
| | | | | | - Binh T Vo
- Center for Molecular Medicine, University of Medicine and Pharmacy , Ho Chi Minh City , Vietnam.,Graduate Program of Genetics, University of Science , Ho Chi Minh City , Vietnam
| | - Truc M Nguyen
- Center for Molecular Medicine, University of Medicine and Pharmacy , Ho Chi Minh City , Vietnam.,Graduate Program of Genetics, University of Science , Ho Chi Minh City , Vietnam
| | | | - Tho T Q Nguyen
- Hai Phong University of Medicine and Pharmacy , Hai Phong City , Vietnam
| | - Thuy T T Do
- Center for Molecular Medicine, University of Medicine and Pharmacy , Ho Chi Minh City , Vietnam
| | | | - Kiet D Truong
- Medical Genetics Institute , Ho Chi Minh City , Vietnam
| | - Hoa Giang
- Gene Solutions , Ho Chi Minh City , Vietnam.,Medical Genetics Institute , Ho Chi Minh City , Vietnam
| | - Hoai-Nghia Nguyen
- Center for Molecular Medicine, University of Medicine and Pharmacy , Ho Chi Minh City , Vietnam
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Agatisa PK, Mercer MB, Coleridge M, Farrell RM. Genetic Counselors' Perspectives About Cell-Free DNA: Experiences, Challenges, and Expectations for Obstetricians. J Genet Couns 2018; 27:1374-1385. [PMID: 29951719 DOI: 10.1007/s10897-018-0268-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Accepted: 06/04/2018] [Indexed: 12/18/2022]
Abstract
The expansion of cell-free fetal DNA (cfDNA) screening for a larger and diverse set of genetic variants, in addition for use among the low-risk obstetric population, presents important clinical challenges for all healthcare providers involved in the delivery of prenatal care. It is unclear how to leverage the different members of the healthcare team to respond to these challenges. We conducted interviews with 25 prenatal genetic counselors to understand their experience with the continued expansion of cfDNA screening. Participants supported the use of cfDNA screening for the common autosomal aneuploidies, but noted some reservations for its use to identify fetal sex and microdeletions. Participants reported several barriers to ensuring that patients have the information and support to make informed decisions about using cfDNA to screen for these different conditions. This was seen as a dual-sided problem, and necessitated additional education interventions that addressed patients seeking cfDNA screening, and obstetricians who introduce the concepts of genetic risk and cfDNA to patients. In addition, participants noted that they have a professional responsibility to educate obstetricians about cfDNA so they can be prepared to be gatekeepers of counseling and education about this screening option for use among the general obstetric population.
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Affiliation(s)
- Patricia K Agatisa
- Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, 9500 Euclid Avenue, A81, Cleveland, OH, 44195, USA
| | - Mary Beth Mercer
- Office of Patient Experience, Cleveland Clinic, Cleveland, OH, USA
| | | | - Ruth M Farrell
- Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, 9500 Euclid Avenue, A81, Cleveland, OH, 44195, USA.
- Center for Bioethics, Cleveland Clinic, Cleveland, OH, USA.
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Gammon BL, Otto L, Wick M, Borowski K, Allyse M. Implementing Group Prenatal Counseling for Expanded Noninvasive Screening Options. J Genet Couns 2017; 27:894-901. [DOI: 10.1007/s10897-017-0178-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 11/13/2017] [Indexed: 12/11/2022]
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