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Angilletta I, Ferrante R, Giansante R, Lombardi L, Babore A, Dell’Elice A, Alessandrelli E, Notarangelo S, Ranaudo M, Palmarini C, De Laurenzi V, Stuppia L, Rossi C. Spinal Muscular Atrophy: An Evolving Scenario through New Perspectives in Diagnosis and Advances in Therapies. Int J Mol Sci 2023; 24:14873. [PMID: 37834320 PMCID: PMC10573646 DOI: 10.3390/ijms241914873] [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: 08/21/2023] [Revised: 09/27/2023] [Accepted: 10/02/2023] [Indexed: 10/15/2023] Open
Abstract
Spinal muscular atrophy (SMA) linked to 5q is a recessive motor neuron disease characterized by progressive and diffuse weakness and muscular atrophy. SMA is the most common neurodegenerative disease in childhood with an incidence of approximately 1 in 6000-10,000 live births, being long considered a leading cause of hereditary mortality in infancy, worldwide. The classification of SMA is based on the natural history of the disease, with a wide clinical spectrum of onset and severity. We are currently in a new therapeutic era, that, thanks to the widespread use of the newly approved disease-modifying therapies and the possibility of an early administration, should lead to a deep change in the clinical scenario and, thus, in the history of SMA. With the aim to achieve a new view of SMA, in this review we consider different aspects of this neuromuscular disease: the historical perspective, the clinical features, the diagnostic process, the psychological outcome, innovation in treatments and therapies, the possibility of an early identification of affected infants in the pre-symptomatic phase through newborn screening programs.
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Affiliation(s)
- Ilaria Angilletta
- Center for Advanced Studies and Technology (CAST), “G. d’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy; (I.A.); (R.F.); (R.G.); (L.L.); (A.D.); (E.A.); (S.N.); (M.R.); (C.P.); (V.D.L.); (L.S.)
- Department of Neurosciences, Imaging and Clinical Sciences, “G. d’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy
| | - Rossella Ferrante
- Center for Advanced Studies and Technology (CAST), “G. d’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy; (I.A.); (R.F.); (R.G.); (L.L.); (A.D.); (E.A.); (S.N.); (M.R.); (C.P.); (V.D.L.); (L.S.)
| | - Roberta Giansante
- Center for Advanced Studies and Technology (CAST), “G. d’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy; (I.A.); (R.F.); (R.G.); (L.L.); (A.D.); (E.A.); (S.N.); (M.R.); (C.P.); (V.D.L.); (L.S.)
| | - Lucia Lombardi
- Center for Advanced Studies and Technology (CAST), “G. d’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy; (I.A.); (R.F.); (R.G.); (L.L.); (A.D.); (E.A.); (S.N.); (M.R.); (C.P.); (V.D.L.); (L.S.)
- Department of Neurosciences, Imaging and Clinical Sciences, “G. d’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy
| | - Alessandra Babore
- Department of Psychological, Health and Territory Sciences, “G. d’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy;
| | - Anastasia Dell’Elice
- Center for Advanced Studies and Technology (CAST), “G. d’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy; (I.A.); (R.F.); (R.G.); (L.L.); (A.D.); (E.A.); (S.N.); (M.R.); (C.P.); (V.D.L.); (L.S.)
| | - Elisa Alessandrelli
- Center for Advanced Studies and Technology (CAST), “G. d’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy; (I.A.); (R.F.); (R.G.); (L.L.); (A.D.); (E.A.); (S.N.); (M.R.); (C.P.); (V.D.L.); (L.S.)
| | - Stefania Notarangelo
- Center for Advanced Studies and Technology (CAST), “G. d’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy; (I.A.); (R.F.); (R.G.); (L.L.); (A.D.); (E.A.); (S.N.); (M.R.); (C.P.); (V.D.L.); (L.S.)
| | - Marianna Ranaudo
- Center for Advanced Studies and Technology (CAST), “G. d’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy; (I.A.); (R.F.); (R.G.); (L.L.); (A.D.); (E.A.); (S.N.); (M.R.); (C.P.); (V.D.L.); (L.S.)
| | - Claudia Palmarini
- Center for Advanced Studies and Technology (CAST), “G. d’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy; (I.A.); (R.F.); (R.G.); (L.L.); (A.D.); (E.A.); (S.N.); (M.R.); (C.P.); (V.D.L.); (L.S.)
| | - Vincenzo De Laurenzi
- Center for Advanced Studies and Technology (CAST), “G. d’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy; (I.A.); (R.F.); (R.G.); (L.L.); (A.D.); (E.A.); (S.N.); (M.R.); (C.P.); (V.D.L.); (L.S.)
- Department of Innovative Technologies in Medicine and Dentistry, “G. d’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy
| | - Liborio Stuppia
- Center for Advanced Studies and Technology (CAST), “G. d’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy; (I.A.); (R.F.); (R.G.); (L.L.); (A.D.); (E.A.); (S.N.); (M.R.); (C.P.); (V.D.L.); (L.S.)
- Department of Psychological, Health and Territory Sciences, “G. d’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy;
| | - Claudia Rossi
- Center for Advanced Studies and Technology (CAST), “G. d’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy; (I.A.); (R.F.); (R.G.); (L.L.); (A.D.); (E.A.); (S.N.); (M.R.); (C.P.); (V.D.L.); (L.S.)
- Department of Innovative Technologies in Medicine and Dentistry, “G. d’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy
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Carrier Screening Programs for Cystic Fibrosis, Fragile X Syndrome, Hemoglobinopathies and Thalassemia, and Spinal Muscular Atrophy: A Health Technology Assessment. ONTARIO HEALTH TECHNOLOGY ASSESSMENT SERIES 2023; 23:1-398. [PMID: 37637488 PMCID: PMC10453298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Abstract
Background We conducted a health technology assessment to evaluate the safety, effectiveness, and cost-effectiveness of carrier screening programs for cystic fibrosis (CF), fragile X syndrome (FXS), hemoglobinopathies and thalassemia, and spinal muscular atrophy (SMA) in people who are considering a pregnancy or who are pregnant. We also evaluated the budget impact of publicly funding carrier screening programs, and patient preferences and values. Methods We performed a systematic literature search of the clinical evidence. We assessed the risk of bias of each included study using the Cochrane Risk of Bias tool and the Risk of Bias Assessment tool for Non-randomized Studies (RoBANS), and the quality of the body of evidence according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria. We performed a systematic economic literature search and conducted cost-effectiveness analyses comparing preconception or prenatal carrier screening programs to no screening. We considered four carrier screening strategies: 1) universal screening with standard panels; 2) universal screening with a hypothetical expanded panel; 3) risk-based screening with standard panels; and 4) risk-based screening with a hypothetical expanded panel. We also estimated the 5-year budget impact of publicly funding preconception or prenatal carrier screening programs for the given conditions in Ontario. To contextualize the potential value of carrier screening, we spoke with 22 people who had sought out carrier screening. Results We included 107 studies in the clinical evidence review. Carrier screening for CF, hemoglobinopathies and thalassemia, FXS, and SMA likely results in the identification of couples with an increased chance of having an affected pregnancy (GRADE: Moderate). Screening likely impacts reproductive decision-making (GRADE: Moderate) and may result in lower anxiety among pregnant people, although the evidence is uncertain (GRADE: Very low).We included 21 studies in the economic evidence review, but none of the study findings were directly applicable to the Ontario context. Our cost-effectiveness analyses showed that in the short term, preconception or prenatal carrier screening programs identified more at-risk pregnancies (i.e., couples that tested positive) and provided more reproductive choice options compared with no screening, but were associated with higher costs. While all screening strategies had similar values for health outcomes, when comparing all strategies together, universal screening with standard panels was the most cost-effective strategy for both preconception and prenatal periods. The incremental cost-effectiveness ratios (ICERs) of universal screening with standard panels compared with no screening in the preconception period were $29,106 per additional at-risk pregnancy detected and $367,731 per affected birth averted; the corresponding ICERs in the prenatal period were about $29,759 per additional at-risk pregnancy detected and $431,807 per affected birth averted.We estimated that publicly funding a universal carrier screening program in the preconception period over the next 5 years would require between $208 million and $491 million. Publicly funding a risk-based screening program in the preconception period over the next 5 years would require between $1.3 million and $2.7 million. Publicly funding a universal carrier screening program in the prenatal period over the next 5 years would require between $128 million and $305 million. Publicly funding a risk-based screening program in the prenatal period over the next 5 years would require between $0.8 million and $1.7 million. Accounting for treatment costs of the screened health conditions resulted in a decrease in the budget impact of universally provided carrier screening programs or cost savings for risk-based programs.Participants value the perceived potential positive impact of carrier screening programs such as medical benefits from early detection and treatment, information for reproductive decision-making, and the social benefit of awareness and preparation. There was a strong preference expressed for thorough, timely, unbiased information to allow for informed reproductive decision-making. Conclusions Carrier screening for CF, FXS, hemoglobinopathies and thalassemia, and SMA is effective at identifying at-risk couples, and test results may impact preconception and reproductive decision-making.The cost-effectiveness and budget impact of carrier screening programs are uncertain for Ontario. Over the short term, carrier screening programs are associated with higher costs, and also higher chances of detecting at-risk pregnancies compared with no screening. The 5-year budget impact of publicly funding universal carrier screening programs is larger than that of risk-based programs. However, accounting for treatment costs of the screened health conditions results in a decrease in the total additional costs for universal carrier screening programs or in cost savings for risk-based programs.The people we spoke with who had sought out carrier screening valued the potential medical benefits of early detection and treatment, particularly the support and preparation for having a child with a potential genetic condition.
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Freeman L, Delatycki MB, Scully JL, Briggs N, Kirk EP. Views of healthcare professionals on the inclusion of genes associated with non-syndromic hearing loss in reproductive genetic carrier screening. Eur J Hum Genet 2023; 31:548-554. [PMID: 36755103 PMCID: PMC10172293 DOI: 10.1038/s41431-022-01239-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 10/20/2022] [Accepted: 11/07/2022] [Indexed: 02/10/2023] Open
Abstract
Genes associated with non-syndromic hearing loss (NSHL) are frequently included in panels for reproductive genetic carrier screening (RGCS), despite a lack of consensus on whether NSHL is a condition appropriate for inclusion in RGCS. We conducted a national online survey using a questionnaire to explore the views of clinicians who facilitate RGCS or provide care to deaf individuals in Australia and New Zealand regarding the inclusion of such genes in RGCS. Results were analysed descriptively, and free-text responses were analysed thematically. The questionnaire was completed by 386 respondents including genetic healthcare providers, obstetricians, ear nose and throat specialists, and general practitioners. The majority of respondents agreed that genes associated with NSHL should be included in RGCS, but there were differences between the groups. 74% of clinicians working in a hearing clinic agreed these genes should be included compared to 67% of genetic healthcare providers, 54% of reproductive care healthcare providers, and 44% of general practitioners. A majority of respondents agreed that moderate to profound deafness is a serious disability, although genetic healthcare providers were less likely to agree than other groups. Overall, respondents agreed that including NSHL in RGCS upholds prospective parents' right to information. However, they also identified major challenges, including concern that screening may express a discriminatory attitude towards those living with deafness. They also identified the complexity of defining the severity of deafness.
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Affiliation(s)
- Lucinda Freeman
- School of Women's and Children's Health, UNSW, Randwick, NSW, Australia.,Graduate School of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Martin B Delatycki
- Murdoch Children's Research Institute, Parkville, VIC, Australia.,Victorian Clinical Genetics Services, Parkville, VIC, Australia
| | | | - Nancy Briggs
- Stats Central, Mark Wainwright Analytical Centre, UNSW, Randwick, NSW, Australia
| | - Edwin P Kirk
- School of Women's and Children's Health, UNSW, Randwick, NSW, Australia. .,Centre for Clinical Genetics, Sydney Children's Hospitals Network NSW, Sydney, NSW, Australia. .,NSW Health Pathology East Genomics, Randwick, NSW, Australia.
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Freeman L, Righetti S, Delatycki MB, Scully JL, Kirk EP. The views of people with a lived experience of deafness and the general public regarding genetic testing for deafness in the reproductive setting: A systematic review. Genet Med 2022; 24:1803-1813. [PMID: 35659827 DOI: 10.1016/j.gim.2022.05.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 05/02/2022] [Accepted: 05/05/2022] [Indexed: 02/05/2023] Open
Abstract
PURPOSE Genes associated with nonsyndromic hearing loss are commonly included in reproductive carrier screening panels, which are now routinely offered in preconception and prenatal care in many countries. However, there is debate whether hearing loss should be considered a medical condition appropriate for screening. This systematic review assessed research on opinions of those with a lived experience of deafness and the general public regarding genetic testing for deafness in the reproductive setting. METHODS Search of 5 online databases yielded 423 articles, 20 of which met inclusion criteria. We assessed the quality of each study, extracted data, and performed thematic analysis on qualitative studies. RESULTS Most studies indicated interest in the use of prenatal diagnosis for deafness. However, there were mixed views, and sometimes strongly held views, expressed regarding the reproductive options that should be available to those with an increased chance of having a child with deafness. Studies were small, from a limited number of countries, and most were too old to include views regarding preimplantation genetic testing. CONCLUSION There is a broad range of views regarding the use of reproductive options for deafness. Further research is essential to explore the benefits and harms of including nonsyndromic hearing loss genes in carrier screening.
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Affiliation(s)
- Lucinda Freeman
- School of Women's and Children's Health, Medicine, UNSW, Randwick, New South Wales, Australia; Graduate School of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Sarah Righetti
- School of Women's and Children's Health, Medicine, UNSW, Randwick, New South Wales, Australia
| | - Martin B Delatycki
- Murdoch Children's Research Institute, Parkville, Victoria, Australia; Victorian Clinical Genetics Services, Parkville, Victoria, Australia
| | | | - Edwin P Kirk
- School of Women's and Children's Health, Medicine, UNSW, Randwick, New South Wales, Australia; Centre for Clinical Genetics, Sydney Children's Hospital, Sydney Children's Hospitals Network, Randwick, New South Wales, Australia.
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Boardman F. Letter to the editor. Gene editing and disabled people: a response to Iñigo de Miguel Beriain. J Community Genet 2020; 11:245-247. [PMID: 32356202 PMCID: PMC7295909 DOI: 10.1007/s12687-020-00465-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 04/21/2020] [Indexed: 12/02/2022] Open
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Wan HWY, Carey KA, D'Silva A, Vucic S, Kiernan MC, Kasparian NA, Farrar MA. Health, wellbeing and lived experiences of adults with SMA: a scoping systematic review. Orphanet J Rare Dis 2020; 15:70. [PMID: 32164772 PMCID: PMC7068910 DOI: 10.1186/s13023-020-1339-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 02/25/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Spinal muscular atrophy (SMA) is a neurodegenerative disease that has a substantial and multifaceted burden on affected adults. While advances in supportive care and therapies are rapidly reshaping the therapeutic environment, these efforts have largely centered on pediatric populations. Understanding the natural history, care pathways, and patient-reported outcomes associated with SMA in adulthood is critical to advancing health policy, practice and research across the disease spectrum. The aim of this study was to systematically review research investigating the healthcare, well-being and lived experiences of adults with SMA. METHODS In accordance with the Preferred Reported Items for Systematic Reviews and Meta-Analysis guidelines, seven electronic databases were systematically searched until January 2020 for studies examining clinical (physical health, natural history, treatment) and patient-reported (symptoms, physical function, mental health, quality of life, lived experiences) outcomes in adults with SMA. Study risk of bias and the level of evidence were assessed using validated tools. RESULTS Ninety-five articles met eligibility criteria with clinical and methodological diversity observed across studies. A heterogeneous clinical spectrum with variability in natural history was evident in adults, yet slow declines in motor function were reported when observational periods extended beyond 2 years. There remains no high quality evidence of an efficacious drug treatment for adults. Limitations in mobility and daily activities associated with deteriorating physical health were commonly reported, alongside emotional difficulties, fatigue and a perceived lack of societal support, however there was no evidence regarding effective interventions. CONCLUSIONS This systematic review identifies the many uncertainties regarding best clinical practice, treatment response, and long-term outcomes for adults with SMA. This comprehensive identification of the current gaps in knowledge is essential to guide future clinical research, best practice care, and advance health policy with the ultimate aim of reducing the burden associated with adult SMA.
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Affiliation(s)
- Hamish W Y Wan
- Discipline of Paediatrics, School of Women's and Children's Health, UNSW Medicine, UNSW Sydney, Sydney, NSW, 2031, Australia
| | - Kate A Carey
- Discipline of Paediatrics, School of Women's and Children's Health, UNSW Medicine, UNSW Sydney, Sydney, NSW, 2031, Australia
| | - Arlene D'Silva
- Discipline of Paediatrics, School of Women's and Children's Health, UNSW Medicine, UNSW Sydney, Sydney, NSW, 2031, Australia
| | - Steve Vucic
- Department of Neurology, Westmead Hospital and Western Clinical School, University of Sydney, Sydney, Australia
| | - Matthew C Kiernan
- Brain & Mind Centre, University of Sydney, Institute of Clinical Neurosciences, Royal Prince Alfred Hospital, Sydney, NSW, 2006, Australia
| | - Nadine A Kasparian
- Discipline of Paediatrics, School of Women's and Children's Health, UNSW Medicine, UNSW Sydney, Sydney, NSW, 2031, Australia.,Cincinnati Children's Center for Heart Disease and the Developing Mind, Heart Institute and the Division of Behavioral Medicine & Clinical Psychology, Cincinnati Children's Hospital, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Michelle A Farrar
- Discipline of Paediatrics, School of Women's and Children's Health, UNSW Medicine, UNSW Sydney, Sydney, NSW, 2031, Australia. .,Department of Neurology, Sydney Children's Hospital, Randwick, NSW, 2031, Australia.
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Pacione M, Siskind CE, Day JW, Tabor HK. Perspectives on Spinraza (Nusinersen) Treatment Study: Views of Individuals and Parents of Children Diagnosed with Spinal Muscular Atrophy. J Neuromuscul Dis 2020; 6:119-131. [PMID: 30594933 DOI: 10.3233/jnd-180330] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Spinal muscular atrophy (SMA) is a genetic disorder characterized by muscle loss. In December 2016 the FDA approved the first and only treatment drug for SMA: Spinraza (nusinersen). Despite excitement and optimism, there are no published data on the perceptions of individuals with SMA and their families about the benefits, risks, and challenges associated with treatment. OBJECTIVE This qualitative interview study sought to characterize the perspectives of patients/families with SMA who did not want, or were unsure about, receiving this new innovative treatment for a previously untreatable and often fatal condition. METHODS Individuals and families were recruited via advertisements on Facebook groups related to SMA and through the Stanford Neuromuscular Contact Registry. Participants completed a demographic questionnaire and participated in a semi-structured interview via voice conferencing. Interview questions focused on: 1) experiences with SMA, 2) opinions about Spinraza treatment, and 3) factors considered in decisions regarding treatment. RESULTS Thirteen people were interviewed: ten adults with SMA (ages 27-48, nine with Type II) and three parents of minor children with SMA (one each of Types I, II and III). Qualitative content analysis identified a range of opinions about Spinraza treatment: five were uninterested (2 adults, 3 parents), four adults were still deciding whether to pursue treatment, three adults were interested or in the process of pursuing treatment, and one adult was currently receiving the drug after overcoming significant reluctance. Participants described several key factors influencing their treatment decisions, including: concerns about risk factors and side effects, high cost, insurance coverage, time involvement, and lack of data about efficacy. Participants reported learning about most of these factors through parent/patient testimonials on SMA-specific social media groups. CONCLUSIONS Participants reported basing decisions about pursuing Spinraza on a variety of practical and value-based considerations. They described carefully weighing the perceived potential benefits and risks of treatment through the lens of their current quality of life and prognosis. These findings suggest that providers should be aware that some patients and parents, especially those with Types II-IV, may approach treatment decisions differently than parents of children with SMA I. Informed treatment decisions can be supported through: 1) the collection and dissemination of better data on Spinraza treatment in these populations; 2) clear communication about risks, side effects and eligibility; 3) improved access to payment and treatment facilities; and 4) facilitation of discussions between providers and patients/families about identity and disability in the context of goals of care and other life and support challenges.
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Affiliation(s)
- Michelle Pacione
- Department of Genetics, Stanford University School of Medicine, Stanford, California, USA
| | - Carly E Siskind
- Department of Neurology and Neurological Sciences, Stanford Medicine, Stanford, California, USA
| | - John W Day
- Department of Neurology and Neurological Sciences, Stanford Medicine, Stanford, California, USA
| | - Holly K Tabor
- Department of Medicine, Stanford Center for Biomedical Ethics, Stanford University, Stanford, California, USA
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Human genome editing and the identity politics of genetic disability. J Community Genet 2019; 11:125-127. [PMID: 31489571 DOI: 10.1007/s12687-019-00437-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 08/29/2019] [Indexed: 10/26/2022] Open
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Ormond KE, Bombard Y, Bonham VL, Hoffman-Andrews L, Howard H, Isasi R, Musunuru K, Riggan KA, Michie M, Allyse M. The clinical application of gene editing: ethical and social issues. Per Med 2019; 16:337-350. [DOI: 10.2217/pme-2018-0155] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Gene-editing techniques have progressed rapidly in the past 5 years. There are already ongoing human somatic gene-editing clinical trials for multiple diseases. And there has been one purported scenario of human germline gene editing in late 2018. In this paper, we will review the current state of the technology, discuss the ethical and social issues that surround the various forms of gene editing, as well as review emerging stakeholder data from professionals, the ‘general public’ and individuals and families dealing with genetic diseases potentially treatable by gene editing.
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Affiliation(s)
- Kelly E Ormond
- Department of Genetics & Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Yvonne Bombard
- Institute of Health Policy, Management & Evaluation, University of Toronto; Li Ka Shing Knowledge Institute of St Michael’s Hospital, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute of St Michael’s Hospital, Toronto, ON, Canada
| | - Vence L Bonham
- Social & Behavioral Research Branch, National Human Genome Research Institute, NIH, Bethesda, MD 20892, USA
| | - Lily Hoffman-Andrews
- Penn Center for Inherited Cardiac Disease, Penn Medicine, Philadelphia, PA 19104, USA
| | - Heidi Howard
- Centre for Research Ethics & Bioethics, Uppsala University, Uppsala, Sweden
- Society & Ethics Research, Connecting Science, Wellcome Genome Campus, Cambridge, UK
| | - Rosario Isasi
- Dr J T Macdonald Foundation Department of Human Genetics, Institute of Bioethics & Health Policy, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Kiran Musunuru
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, PA 19104, USA
| | - Kirsten A Riggan
- Biomedical Ethics Research Program, Mayo Clinic, Rochester, MN 55905, USA
| | - Marsha Michie
- Department of Bioethics, Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA
| | - Megan Allyse
- Biomedical Ethics Research Program & Center for Individualized Medicine, Mayo Clinic, Rochester, MN 55905, USA
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Hoffman-Andrews L, Mazzoni R, Pacione M, Garland-Thomson R, Ormond KE. Attitudes of people with inherited retinal conditions toward gene editing technology. Mol Genet Genomic Med 2019; 7:e00803. [PMID: 31190471 PMCID: PMC6625087 DOI: 10.1002/mgg3.803] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 05/17/2019] [Accepted: 05/22/2019] [Indexed: 01/29/2023] Open
Abstract
Background The views of people with genetic conditions are crucial to include in public dialogue around developing gene editing technologies. This qualitative study sought to characterize the attitudes of people with inherited retinal conditions (retinitis pigmentosa [RP] and Leber congenital amaurosis [LCA]) toward gene editing. Methods Individuals with RP (N = 9) and LCA (N = 8) participated in semi‐structured qualitative interviews about their experience with and attitudes toward blindness, and their views about gene editing technology for somatic, germline, and enhancement applications. Results Participants saw potential benefits from gene editing in general, but views about its use for retinal conditions varied and were influenced by personal perspectives on blindness. Those who felt more negatively toward blindness, particularly those with later onset blindness, were more supportive of gene editing for retinal conditions. Concerns about both germline and somatic editing included: the importance of informed consent; impacts of gene editing on social attitudes and barriers affecting blind people; and worries about “eliminating” blindness or other traits. Conclusion People with RP and LCA have diverse attitudes toward gene editing technology informed by their own lived experience with disability, and many have concerns about how the ways in which it is discussed and implemented might affect them.
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Affiliation(s)
| | - Ronit Mazzoni
- Department of Genetics, Santa Clara Valley Medical Center, San Jose, CA
| | - Michelle Pacione
- Department of Genetics, Stanford University School of Medicine, Stanford, CA
| | | | - Kelly E Ormond
- Department of Genetics, Stanford University School of Medicine, Stanford, CA.,Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, CA
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Boardman FK, Hale R. "I didn't take it too seriously because I'd just never heard of it": Experiential knowledge and genetic screening for thalassaemia in the UK. J Genet Couns 2019; 28:141-154. [PMID: 30629758 PMCID: PMC7814888 DOI: 10.1002/jgc4.1042] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 10/25/2018] [Accepted: 10/26/2018] [Indexed: 01/25/2023]
Abstract
Members of the public face particular challenges when undergoing reproductive genetic screening. Lack of family history with genetic disease has been identified as a key barrier affecting screening uptake and responses to genetic risk. This study explores this obstacle using beta thalassaemia as a case study. Fifteen in-depth qualitative interviews were conducted exploring the reproductive views and decisions of people at risk of transmitting thalassaemia. Eleven participants had thalassaemia themselves and/or were members of an affected family. Four participants were identified as thalassaemia carriers through genetic screening programmes with no family history. Notable differences were observed between these two groups. For thalassaemic individuals and families, past experience clarified and facilitated their sense of reproductive responsibility, however carriers struggled to relate to, and incorporate the information into their lives. It was witnessing their child becoming symptomatic-rather than receiving a diagnosis or genetic risk information per se that had the most substantial influence on carriers' subsequent views and decisions. Educational resources used to support genetic screening programmes would benefit from an engagement with the experiential accounts of life with genetic disease in order to more effectively bridge the chasm in knowledge and understanding between affected families and the general public, towards whom expansive genetic screening is aimed.
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Boardman FK, Hale R. How do genetically disabled adults view selective reproduction? Impairment, identity, and genetic screening. Mol Genet Genomic Med 2018; 6:941-956. [PMID: 30196552 PMCID: PMC6305648 DOI: 10.1002/mgg3.463] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 06/19/2018] [Accepted: 07/20/2018] [Indexed: 11/11/2022] Open
Abstract
Background Genomic medicine is rapidly evolving, particularly in the domain of reproduction. Population carrier screening for a range of disorders is becoming possible using whole genome/exome sequencing. However, very little is known about the views of genetically disabled adults toward selective reproduction. Methods Forty‐three in‐depth qualitative interviews were carried out with adults living with different types of genetic condition, recruited through support groups and clinics. Interviews covered participants’ experiences of their condition and their views toward genetic intervention in reproduction. Thematic analysis of the data using NVivo 11 was undertaken, and participants were assigned categories as either supporting, not‐supporting, or having ambivalent views toward selective reproduction. Results The majority of participants (65%) expressed either disapproval of, or held ambivalent views toward, selective reproduction. Key reasons for non‐support included regarding genetic impairment as part of personal identity and the prioritization of social and environmental barrier removal. Key reasons for support of selective reproduction included negative and externalizing attitudes toward genetic impairment and a belief in the importance of informed reproductive decision‐making. Conclusion The degree to which participants identified with their impairment, more so than how they valued it, was significant in determining attitudes toward selective reproduction. Those who supported genetic screening viewed their impairment as separate to themselves, while participants who considered their impairment as integral to their identity were most likely to report ambivalent or negative attitudes. Policymakers and stakeholders considering the role of genetic carrier screening panels might usefully engage with adults affected by heritable disease as well as disability identity politics when considering the acceptability and social impact of genetic screening programs.
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Farrar MA, Carey KA, Paguinto SG, Chambers G, Kasparian NA. Financial, opportunity and psychosocial costs of spinal muscular atrophy: an exploratory qualitative analysis of Australian carer perspectives. BMJ Open 2018; 8:e020907. [PMID: 29794098 PMCID: PMC5988080 DOI: 10.1136/bmjopen-2017-020907] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVES Spinal muscular atrophy (SMA) has profound implications for patients and families. The aim of the present study was to gain insights into the effects caring for a child with SMA has on the costs incurred by families caring for a child with SMA from carer perspectives to identify gaps in provision of care, inform public policy and cost-effectiveness analyses. DESIGN Interpretive phenomenological analysis guided the delivery and analysis of semi-structured interviews undertaken to explore the financial, opportunity and psychosocial costs associated with caring for children with SMA. PARTICIPANTS AND SETTING Parents of children with SMA types II and III from a single Australian paediatric neuromuscular clinic participated in this study. RESULTS A range of experiences were reported and information saturation (n=7) was reached endorsing themes, including: significant financial and caregiving burdens, adjusted career choices and limitations on career progression and a complex landscape of access to funding, equipment, support and resources. Opportunity costs of foregone employment, purchases and leisure activities were substantial, as were emotional and social impacts. Participants voiced determination and resilience, and called for continued efforts to improve supportive care services and resources. CONCLUSIONS The range and nature of costs met by families caring for a child with SMA were found to be expansive and not typically recognised. These include high direct costs associated with goods and services, indirect costs associated with voluntary care, substantial and long-term opportunities foregone in paid employment and career progression and unmeasured or hidden costs associated with mental health burden.
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Affiliation(s)
- Michelle A Farrar
- Discipline of Paediatrics, School of Women's and Children's Health, UNSW Medicine, Sydney, New South Wales, Australia
| | - Kate A Carey
- Discipline of Paediatrics, School of Women's and Children's Health, UNSW Medicine, Sydney, New South Wales, Australia
| | - Sarah-Grace Paguinto
- Discipline of Paediatrics, School of Women's and Children's Health, UNSW Medicine, Sydney, New South Wales, Australia
| | - Georgina Chambers
- Discipline of Paediatrics, School of Women's and Children's Health, UNSW Medicine, Sydney, New South Wales, Australia
- National Perinatal Epidemiology and Statistics Unit, Centre for Big Data Research in Health UNSW, Sydney, New South Wales, Australia
| | - Nadine A Kasparian
- Discipline of Paediatrics, School of Women's and Children's Health, UNSW Medicine, Sydney, New South Wales, Australia
- Heart Centre for Children, The Sydney Children's Hospitals Network (Westmead and Randwick), Sydney, New South Wales, Australia
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Boardman FK, Sadler C, Young PJ. Newborn genetic screening for spinal muscular atrophy in the UK: The views of the general population. Mol Genet Genomic Med 2017; 6:99-108. [PMID: 29169204 PMCID: PMC5823674 DOI: 10.1002/mgg3.353] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Revised: 10/12/2017] [Accepted: 10/26/2017] [Indexed: 12/16/2022] Open
Abstract
Background Spinal muscular atrophy (SMA) is an inherited neuromuscular disorder and a leading genetic cause of infant death worldwide. However, there is no routine screening program for SMA in the UK. Lack of treatments and the inability of screening tests to accurately predict disease severity are among the key reasons implementation of screening has faltered in the UK. With the recent release of the first therapy for SMA (Nusinersen), calls are being made for a reconsideration of this stance; however, very little is known about the views of the general public. Methods An online survey was administered to 232 individuals with no prior relationship with SMA to assess their attitudes toward a newborn screening program for it. Results are compared with previously gathered data on the views of SMA‐affected families toward screening. Results Eighty‐four percent of participants were in favor of newborn screening. Key reasons for support were a belief that it would lead to better healthcare and life expectancy for affected infants and facilitate informed decision‐making for future pregnancies. Key reasons for nonsupport were a belief in the potential for significant negative impact on the family unit in terms of bonding and stress. Conclusions Public acceptability is a key component in the evaluation of any potential screening program in the UK. This study demonstrates that newborn screening for SMA is viewed largely positively by people unfamiliar with the condition. The importance of early identification overrode all other social and ethical concerns about screening for the majority of participants.
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Affiliation(s)
- Felicity K Boardman
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Chloe Sadler
- School of Life Sciences, University of Warwick, Coventry, UK
| | - Philip J Young
- School of Life Sciences, University of Warwick, Coventry, UK
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Boardman FK, Young PJ, Warren O, Griffiths FE. The role of experiential knowledge within attitudes towards genetic carrier screening: A comparison of people with and without experience of spinal muscular atrophy. Health Expect 2017; 21:201-211. [PMID: 28703871 PMCID: PMC5750730 DOI: 10.1111/hex.12602] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2017] [Indexed: 01/11/2023] Open
Abstract
Purpose Autosomal recessive conditions, while individually rare, are a significant health burden with limited treatment options. Population carrier screening has been suggested as a means of tackling them. Little is known, however, about the attitudes of the general public towards such carrier screening and still less about the views of people living with candidate genetic diseases. Here, we focus on the role that such experience has on screening attitudes by comparing views towards screening of people with and without prior experience of the monogenetic disorder, Spinal Muscular Atrophy. Methods An exploratory sequential mixed methods design was adopted. In‐depth qualitative interviews were used to develop two surveys. The surveys addressed attitudes towards carrier screening (pre‐conceptual and prenatal) for SMA. Participants 337 participants with SMA experience completed the SMA Screening Survey (UK) and 336 participants with no prior experience of SMA completed the UK GenPop Survey, an amended version of the SMA Screening Survey (UK). Results The majority of both cohorts were in favour of pre‐conception and prenatal carrier screening, however people with experience of type II SMA were least likely to support either. Key differences emerged around perceptions of SMA, with those without SMA experience taking a dimmer view of the condition than those with. Conclusion This study underscores the significance of prior experience with the condition to screening attitudes. It highlights the need for accurate and high‐quality educational resources to support any future carrier screening programmes, that particularly in relation to rare genetic disorders like SMA that will fall outside the remit of everyday experience for the majority of the population.
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Affiliation(s)
- Felicity K Boardman
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Philip J Young
- School of Life Sciences, University of Warwick, Coventry, UK
| | - Oliver Warren
- School of Life Sciences, University of Warwick, Coventry, UK
| | - Frances E Griffiths
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
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