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Levine R, Kahn RM, Perez L, Brewer J, Ratner S, Li X, Yeoshoua E, Frey MK. Cascade genetic testing for hereditary cancer syndromes: a review of barriers and breakthroughs. Fam Cancer 2024; 23:111-120. [PMID: 38530571 DOI: 10.1007/s10689-024-00373-4] [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: 12/27/2023] [Accepted: 03/09/2024] [Indexed: 03/28/2024]
Abstract
Germline genetic sequencing is now at the forefront of cancer treatment and preventative medicine. Cascade genetic testing, or the testing of at-risk relatives, is extremely promising as it offers genetic testing and potentially life-saving risk-reduction strategies to a population exponentially enriched for the risk of carrying a cancer-associated pathogenic variant. However, many relatives do not complete cascade testing due to barriers that span individual, relationship, healthcare community, and societal/policy domains. We have reviewed the published research on cascade testing. Our aim is to evaluate barriers to cascade genetic testing for hereditary cancer syndromes and explore strategies to mitigate these barriers, with the goal of promoting increased uptake of cascade genetic testing.
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Affiliation(s)
- Rachel Levine
- Department of Obstetrics and Gynecology, HCA Florida Brandon, Brandon, FL, USA.
| | - Ryan M Kahn
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Luiza Perez
- Division of Gynecologic Oncology, Weill Cornell Medicine, New York, NY, USA
| | - Jesse Brewer
- Division of Gynecologic Oncology, Weill Cornell Medicine, New York, NY, USA
| | - Samantha Ratner
- Division of Gynecologic Oncology, Weill Cornell Medicine, New York, NY, USA
| | - Xuan Li
- Division of Gynecologic Oncology, Weill Cornell Medicine, New York, NY, USA
| | - Effi Yeoshoua
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Melissa K Frey
- Division of Gynecologic Oncology, Weill Cornell Medicine, New York, NY, USA
- Genetics and Personalized Cancer Prevention Program, Weill Cornell Medicine, New York, NY, USA
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2
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Tiller JM, Stott A, Finlay K, Boughtwood T, Madelli EO, Horton A, Winship I, Nowak K, Otlowski M. Direct notification by health professionals of relatives at-risk of genetic conditions (with patient consent): views of the Australian public. Eur J Hum Genet 2024; 32:98-108. [PMID: 37280361 PMCID: PMC10242214 DOI: 10.1038/s41431-023-01395-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 03/27/2023] [Accepted: 05/16/2023] [Indexed: 06/08/2023] Open
Abstract
Genetic risk information for medically actionable conditions has relevance for patients' blood relatives. However, cascade testing uptake in at-risk families is <50%, and the burden of contacting relatives is a significant barrier to dissemination of risk information. Health professionals (HPs) could notify at-risk relatives directly, with patients' consent. This practice is supported by international literature, including strong public support. However, there is little exploration of the Australian public's views about this issue. We surveyed Australian adults using a consumer research company. Respondents were provided a hypothetical scenario and asked about views and preferences regarding direct contact by HPs. 1030 members of the public responded, with median age 45 y and 51% female. The majority would want to be told about genetic risk for conditions that can be prevented/treated early (85%) and contacted directly by a HP (68%). Most preferred a letter that included specific information about the genetic condition in the family (67%) and had no privacy concerns about HPs sending a letter using contact details provided by a relative (85%). A minority (< 5%) had significant privacy concerns, mostly about use of personal contact information. Concerns included ensuring information was not shared with third parties. Almost 50% would prefer that a family member contacted them before the letter was sent, while about half did not prefer this or were unsure. The Australian public supports (and prefers) direct notification of relatives at risk of medically actionable genetic conditions. Guidelines would assist with clarifying clinicians' discretion in this area.
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Affiliation(s)
- Jane M Tiller
- Australian Genomics, Parkville, VIC, Australia.
- Murdoch Children's Research Institute, Parkville, VIC, Australia.
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
| | - Ami Stott
- Australian Genomics, Parkville, VIC, Australia
| | - Keri Finlay
- Australian Genomics, Parkville, VIC, Australia
- Murdoch Children's Research Institute, Parkville, VIC, Australia
| | - Tiffany Boughtwood
- Australian Genomics, Parkville, VIC, Australia
- Murdoch Children's Research Institute, Parkville, VIC, Australia
| | - Evanthia O Madelli
- Australian Genomics, Parkville, VIC, Australia
- Murdoch Children's Research Institute, Parkville, VIC, Australia
| | - Ari Horton
- Department of Paediatrics, Monash University, Clayton, VIC, Australia
- Department of Genomic Medicine, The Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Ingrid Winship
- Department of Genomic Medicine, The Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Kristen Nowak
- Office of Population Health Genomics, WA Department of Health, East Perth, WA, Australia
| | - Margaret Otlowski
- Centre for Law and Genetics, University of Tasmania, Hobart, TAS, Australia
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Jones LK, Calvo EM, Campbell-Salome G, Walters NL, Brangan A, Rodriguez G, Ahmed CD, Morgan KM, Gidding SS, Williams MS, Brownson RC, Seaton TL, Goldberg AC, McGowan MP, Rahm AK, Sturm AC. Designing implementation strategies to improve identification, cascade testing, and management of families with familial hypercholesterolemia: An intervention mapping approach. FRONTIERS IN HEALTH SERVICES 2023; 3:1104311. [PMID: 37188259 PMCID: PMC10175779 DOI: 10.3389/frhs.2023.1104311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 04/06/2023] [Indexed: 05/17/2023]
Abstract
Introduction Familial hypercholesterolemia (FH) is a common inherited cholesterol disorder that, without early intervention, leads to premature cardiovascular disease. Multilevel strategies that target all components of FH care including identification, cascade testing, and management are needed to address gaps that exist in FH care. We utilized intervention mapping, a systematic implementation science approach, to identify and match strategies to existing barriers and develop programs to improve FH care. Methods Data were collected utilizing two methods: a scoping review of published literature, related to any component of FH care, and a parallel mixed method study using interviews and surveys. The scientific literature was searched using key words including "barriers" or "facilitators" and "familial hypercholesterolemia" from inception to December 1, 2021. The parallel mixed method study recruited individuals and families with FH to participate in either dyadic interviews (N = 11 dyads/22 individuals) or online surveys (N = 98 respondents). Data generated from the scoping review, dyadic interviews, and online surveys were used in the 6-step intervention mapping process. Steps 1-3 included a needs assessment, development of program outcomes and creation of evidence-based implementation strategies. Steps 4-6 included program development, implementation, and evaluation of implementation strategies. Results In steps 1-3, a needs assessment found barriers to FH care included underdiagnosis of the condition which led to suboptimal management due to a myriad of determinants including knowledge gaps, negative attitudes, and risk misperceptions by individuals with FH and clinicians. Literature review highlighted barriers to FH care at the health system level, notably the relative lack of genetic testing resources and infrastructure needed to support FH diagnosis and treatment. Examples of strategies to overcome identified barriers included development of multidisciplinary care teams and educational programs. In steps 4-6, an NHLBI-funded study, the Collaborative Approach to Reach Everyone with FH (CARE-FH), deployed strategies that focused on improving identification of FH in primary care settings. The CARE-FH study is used as an example to describe program development, implementation, and evaluation techniques of implementation strategies. Conclusion The development and deployment of evidence-based implementation strategies that address barriers to FH care are important next steps to improve identification, cascade testing, and management.
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Affiliation(s)
- Laney K. Jones
- Department of Genomic Health, Research Institute, Geisinger, Danville, PA, United States
- Heart and Vascular Institute, Geisinger, Danville, PA, United States
| | - Evan M. Calvo
- Department of Genomic Health, Research Institute, Geisinger, Danville, PA, United States
- Geisinger Commonwealth School of Medicine, Geisinger College of Health Sciences, Geisinger, Scranton, PA, United States
| | - Gemme Campbell-Salome
- Department of Genomic Health, Research Institute, Geisinger, Danville, PA, United States
- Department of Population Health Sciences, Research Institute, Geisinger, Danville, PA, United States
| | - Nicole L. Walters
- Department of Genomic Health, Research Institute, Geisinger, Danville, PA, United States
| | - Andrew Brangan
- Department of Genomic Health, Research Institute, Geisinger, Danville, PA, United States
| | - Gabriela Rodriguez
- Department of Genomic Health, Research Institute, Geisinger, Danville, PA, United States
- Geisinger Commonwealth School of Medicine, Geisinger College of Health Sciences, Geisinger, Scranton, PA, United States
| | | | - Kelly M. Morgan
- Department of Genomic Health, Research Institute, Geisinger, Danville, PA, United States
| | - Samuel S. Gidding
- Department of Genomic Health, Research Institute, Geisinger, Danville, PA, United States
| | - Marc S. Williams
- Department of Genomic Health, Research Institute, Geisinger, Danville, PA, United States
| | - Ross C. Brownson
- Prevention Research Center in St. Louis, Brown School, Washington University in St. Louis, St. Louis, MO, United States
- Department of Surgery (Division of Public Health Sciences), Alvin J. Siteman Cancer Center, Washington University School of Medicine, Washington University in St. Louis, St. Louis, MO, United States
| | - Terry L. Seaton
- University of Health Sciences and Pharmacy in St. Louis, St. Louis, MO, United States
| | - Anne C. Goldberg
- Division of Endocrinology, Metabolism and Lipid Research, John T. Milliken Department of Internal Medicine, Washington University School of Medicine in St. Louis, Washington University in St. Louis, St. Louis, MO, United States
| | | | - Alanna K. Rahm
- Department of Genomic Health, Research Institute, Geisinger, Danville, PA, United States
| | - Amy C. Sturm
- Department of Genomic Health, Research Institute, Geisinger, Danville, PA, United States
- Heart and Vascular Institute, Geisinger, Danville, PA, United States
- 23andMe, Sunnyvale, CA, United States
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Passero L, Srinivasan S, Roberts MC. Examining the role of language competency in genetic testing awareness among adults in the United States. J Genet Couns 2022; 31:1054-1061. [PMID: 35388538 DOI: 10.1002/jgc4.1576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 03/15/2022] [Accepted: 03/19/2022] [Indexed: 01/12/2023]
Abstract
English language competency, as a component of health literacy, is associated with increased awareness and uptake of health-related genetic testing. The relationship between language competency and genetic testing awareness has not yet been explored in the wider U.S. population yet has significant implications for the practice of genetic counselors and in the promotion of genomic medicine for public health. We analyzed data from the 2017 Health Information National Trends Survey 5 Cycle 1 using weighted logistic regression to model the relationship between self-reported English competency, genetic testing awareness, and race and explore adjusted odds ratios and average marginal effects for levels of English competency. Compared to respondents with high English competency, the probability of genetic testing awareness was 20 percentage points lower for White participants reporting moderate English competency (p = .029) and 37 percentage points lower for non-White participants reporting low English competency (p < .001). Future research is needed to understand the mechanisms through which English competency affects awareness and uptake of genetic testing in the United States and to develop strategies to overcome language barriers for the practice of genetic counselors and the implementation of genetics services.
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Affiliation(s)
- Lauren Passero
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Swetha Srinivasan
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Megan C Roberts
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Schmidlen T, Jones CL, Campbell-Salome G, McCormick CZ, Vanenkevort E, Sturm AC. Use of a chatbot to increase uptake of cascade genetic testing. J Genet Couns 2022; 31:1219-1230. [PMID: 35616645 DOI: 10.1002/jgc4.1592] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 04/26/2022] [Accepted: 05/06/2022] [Indexed: 12/18/2022]
Abstract
Successful proband-mediated family communication and subsequent cascade genetic testing uptake requires interventions that present information clearly, in sufficient detail, and with medical authority. To facilitate family communication for patients receiving clinically actionable results via the MyCode® Community Health Initiative, a Family Sharing Tool (FST) and a cascade chatbot were developed. FST is an electronic mechanism allowing patients to share genetic test results with relatives via chatbot. The cascade chatbot describes the proband's result, associated disease risks, and recommended management and captures whether the user is a blood relative or caregiver, sex, and relationship to the proband. FST and cascade chatbot uptake among MyCode® probands and relatives was tracked from August 2018 through February 2020. Cascade genetic testing uptake was collected from testing laboratories as number of cascades per proband. Fifty-eight percent (316/543) of probands consented to FST; 42% (227/543) declined. Receipt preferences were patient electronic health record (EHR) portal (52%), email (29%), and text (19%). Patient EHR portal users (p < 0.001) and younger patients were more likely to consent (p < 0.001). FST was deployed to 308 probands. Fifty-nine percent (183/308) opened; of those, 56% (102/183) used FST to send a cascade chatbot to relatives. These 102 probands shared a cascade chatbot with 377 relatives. Sixty-two percent (235/377) of relatives opened; of these, 69% (161/235) started, and of these, 57% (92/161) completed the cascade chatbot. Cascade genetic testing uptake was significantly greater among relatives of probands who consented to the FST (M = 2.34 cascades, SD = 2.10) than relatives of probands who declined (M = 1.40 cascades, SD = 0.82, p < 0.001). Proband age was not a significant predictor of cascade genetic testing uptake. Further work is needed to better understand factors impacting proband use of FST and relative use of cascade chatbots.
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Affiliation(s)
| | - Claire L Jones
- Geisinger, Genomic Medicine Institute, Danville, Pennsylvania, USA
| | | | - Cara Z McCormick
- Geisinger, Genomic Medicine Institute, Danville, Pennsylvania, USA
| | - Erin Vanenkevort
- Geisinger, Genomic Medicine Institute, Danville, Pennsylvania, USA
| | - Amy C Sturm
- Geisinger, Genomic Medicine Institute, Danville, Pennsylvania, USA
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Campbell-Salome G, Walters NL, Ladd IG, Sheldon A, Ahmed CD, Brangan A, McMinn MN, Rahm AK, Schwartz MLB, Tricou E, Fisher CL, Sturm AC. Motivating cascade testing for familial hypercholesterolemia: applying the extended parallel process model for clinician communication. Transl Behav Med 2022; 12:800-809. [PMID: 35429393 PMCID: PMC9291357 DOI: 10.1093/tbm/ibac018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Motivating at-risk relatives to undergo cascade testing for familial hypercholesterolemia (FH) is critical for diagnosis and lifesaving treatment. As credible sources of information, clinicians can assist in family communication about FH and motivate cascade testing uptake. However, there are no guidelines regarding how clinicians should effectively communicate with probands (the first person diagnosed in the family) and at-risk relatives. Individuals and families with FH can inform our understanding of the most effective communications to promote cascade testing. Guided by the extended parallel process model (EPPM), we analyzed the perspectives of individuals and families with FH for effective messaging clinicians can use to promote cascade testing uptake. We analyzed narrative data from interviews and surveys collected as part of a larger mixed-methods study. The EPPM was used to identify message features recommended by individuals and families with FH that focus on four key constructs (severity, susceptibility, response efficacy, self-efficacy) to promote cascade testing. Participants included 22 individuals from 11 dyadic interviews and 98 survey respondents. Participants described prioritizing multiple messages that address each EPPM construct to alert relatives about their risk. They illustrated strategies clinicians could use within each EPPM construct to communicate to at-risk relatives about the importance of pursuing diagnosis via cascade testing and subsequent treatment for high cholesterol due to FH. Findings provide guidance on effective messaging to motivate cascade testing uptake for FH and demonstrates how the EPPM may guide communication with at-risk relatives about genetic risk and motivate cascade testing broadly.
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Affiliation(s)
- Gemme Campbell-Salome
- Genomic Medicine Institute, Geisinger, Danville, PA, USA
- College of Journalism and Communications, University of Florida, Gainesville, FL, USA
| | | | - Ilene G Ladd
- Genomic Medicine Institute, Geisinger, Danville, PA, USA
| | | | | | - Andrew Brangan
- Genomic Medicine Institute, Geisinger, Danville, PA, USA
| | - Megan N McMinn
- Genomic Medicine Institute, Geisinger, Danville, PA, USA
| | - Alanna K Rahm
- Genomic Medicine Institute, Geisinger, Danville, PA, USA
| | | | - Eric Tricou
- Genomic Medicine Institute, Geisinger, Danville, PA, USA
| | - Carla L Fisher
- College of Journalism and Communications, University of Florida, Gainesville, FL, USA
| | - Amy C Sturm
- Genomic Medicine Institute, Geisinger, Danville, PA, USA
- Heart Institute, Geisinger, Danville, PA, USA
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7
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Barriers and facilitators for cascade testing in genetic conditions: a systematic review. Eur J Hum Genet 2020; 28:1631-1644. [PMID: 32948847 DOI: 10.1038/s41431-020-00725-5] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 08/21/2020] [Accepted: 09/01/2020] [Indexed: 12/23/2022] Open
Abstract
Cascade testing is the process of offering genetic counseling and testing to at-risk relatives of an individual who has been diagnosed with a genetic condition. It is critical for increasing the identification rates of individuals with these conditions and the uptake of appropriate preventive health services. The process of cascade testing is highly varied in clinical practice, and a comprehensive understanding of factors that hinder or enhance its implementation is necessary to improve this process. We conducted a systematic review to identify barriers and facilitators for cascade testing and searched PubMed, CINAHL via EBSCO, Web of Science, EMBASE, and the Cochrane Library for articles published from the databases' inception to November 2018. Thirty articles met inclusion criteria. Barriers and facilitators identified from these studies at the individual-level were organized into the following categories: (1) demographics, (2) knowledge, (3) attitudes, beliefs, and emotional responses of the individual, and (4) perceptions of relatives, relatives' responses, and attitudes toward relatives. At the interpersonal-level, barriers and facilitators were categorized as (1) family communication-, support- and dynamics-, and (2) provider-factors. Finally, barriers at the environmental-level relating to accessibility of genetic services were also identified. Our findings suggest that several individual, interpersonal and environmental factors may play a role in cascade testing. Future studies to further investigate these barriers and facilitators are needed to inform future interventions for improving the implementation of cascade testing for genetic conditions in clinical practice.
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Schwiter R, Brown E, Murray B, Kindt I, Van Enkevort E, Pollin TI, Sturm AC. Perspectives from individuals with familial hypercholesterolemia on direct contact in cascade screening. J Genet Couns 2020; 29:1142-1150. [DOI: 10.1002/jgc4.1266] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 02/23/2020] [Accepted: 02/25/2020] [Indexed: 01/02/2023]
Affiliation(s)
| | - Emily Brown
- Division of Cardiology School of Medicine Johns Hopkins University Baltimore MD USA
| | - Brittney Murray
- Division of Cardiology School of Medicine Johns Hopkins University Baltimore MD USA
| | | | | | - Toni I. Pollin
- School of Medicine University of Maryland Baltimore Baltimore MD USA
| | - Amy C. Sturm
- Genomic Medicine Institute Geisinger Danville PA USA
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Hendricks-Sturrup RM, Mazor KM, Sturm AC, Lu CY. Barriers and Facilitators to Genetic Testing for Familial Hypercholesterolemia in the United States: A Review. J Pers Med 2019; 9:jpm9030032. [PMID: 31266140 PMCID: PMC6789613 DOI: 10.3390/jpm9030032] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 06/22/2019] [Accepted: 06/25/2019] [Indexed: 02/07/2023] Open
Abstract
Familial Hypercholesterolemia (FH) is an underdiagnosed condition in the United States (US) and globally, affecting an estimated 1/250 individuals. It is a genetic risk factor for premature cardiovascular disease and is responsible for an estimated 600,000 to 1.2 million preventable vascular events. Studies show that FH genetic testing can identify a causal gene variant in 60 to 80% of clinically suspected FH cases. However, FH genetic testing is currently underutilized in clinical settings in the US despite clinical recommendations and evidence supporting its use. Reasons for underutilization are not well understood. We conducted a literature review in the PubMed/MEDLINE database and eight peer-reviewed journals. After filtering for and reviewing 2340 articles against our inclusion criteria, we included nine commentaries or expert opinions and eight empirical studies reported between January 2014 and March 2019 in our review. After applying the Consolidated Framework for Implementation Research (CFIR), we identified a total of 26 potential barriers and 15 potential facilitators (estimated barrier to facilitator ratio of 1.73). We further estimated ratios of potential barriers to facilitators for each CFIR domain (Characteristics of Intervention, Outer Setting, Inner Setting, Characteristics of Individuals, and Process). Findings derived from our systematic approach to the literature and calculations of estimated baseline ratios of barriers and facilitators can guide future research to understand FH genetic testing implementation in diverse clinical settings. Our systematic approach to the CFIR could also be used as a model to understand or compare barriers and facilitators to other evidence-based genetic testing processes in health care settings in the US and abroad.
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Affiliation(s)
- Rachele M Hendricks-Sturrup
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, MA 02215 USA.
| | - Kathleen M Mazor
- Meyers Primary Care Institute, Worcester, MA 01605, USA
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA 01655, USA
| | - Amy C Sturm
- Genomic Medicine Institute, Geisinger, Danville, PA 17822, USA
| | - Christine Y Lu
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, MA 02215 USA
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10
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Hendricks-Sturrup RM, Lu CY. Understanding Implementation Challenges to Genetic Testing for Familial Hypercholesterolemia in the United States. J Pers Med 2019; 9:jpm9010009. [PMID: 30717118 PMCID: PMC6463173 DOI: 10.3390/jpm9010009] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 01/19/2019] [Accepted: 01/21/2019] [Indexed: 01/21/2023] Open
Abstract
Cardiovascular disease (CVD) is the leading cause of death in the United States (US), with familial hypercholesterolemia (FH) being a major inherited and genetic risk factor for premature CVD and atherosclerosis. Genetic testing has helped patients and providers confirm the presence of known pathogenic and likely pathogenic variations in FH-associated genes. Key organizations, such as the Centers for Disease Control and Prevention (CDC), American Heart Association (AHA), FH Foundation, and National Lipid Association (NLA), have recognized the clinical utility of FH genetic testing. However, FH genetic testing is underutilized in clinical practice in the US for reasons that are underexplored through the lens of implementation science. In this commentary, we discuss seven key implementation challenges that must be overcome to strengthen the clinical adoption of FH genetic testing in the US. These implementation challenges center on evidence of cost-effectiveness, navigating patient and provider preferences and concerns, gender and ethnic diversity and representation in genetic testing, and establishing clinical consensus around FH genetic testing based on the latest and most relevant research findings. Overcoming these implementation challenges is imperative to the mission of reducing CVD risk in the US.
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Affiliation(s)
- Rachele M Hendricks-Sturrup
- Precision Medicine Translational Research (PROMoTeR) Center, Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Landmark Center, 401 Park Drive Suite 401, Boston, MA 02215, USA.
| | - Christine Y Lu
- Precision Medicine Translational Research (PROMoTeR) Center, Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Landmark Center, 401 Park Drive Suite 401, Boston, MA 02215, USA.
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Jiménez B, Holmes E, Heude C, Tolson RF, Harvey N, Lodge SL, Chetwynd AJ, Cannet C, Fang F, Pearce JTM, Lewis MR, Viant MR, Lindon JC, Spraul M, Schäfer H, Nicholson JK. Quantitative Lipoprotein Subclass and Low Molecular Weight Metabolite Analysis in Human Serum and Plasma by 1H NMR Spectroscopy in a Multilaboratory Trial. Anal Chem 2018; 90:11962-11971. [PMID: 30211542 DOI: 10.1021/acs.analchem.8b02412] [Citation(s) in RCA: 147] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
We report an extensive 600 MHz NMR trial of quantitative lipoprotein and small-molecule measurements in human blood serum and plasma. Five centers with eleven 600 MHz NMR spectrometers were used to analyze 98 samples including 20 quality controls (QCs), 37 commercially sourced, paired serum and plasma samples, and two National Institute of Science and Technology (NIST) reference material 1951c replicates. Samples were analyzed using rigorous protocols for sample preparation and experimental acquisition. A commercial lipoprotein subclass analysis was used to quantify 105 lipoprotein subclasses and 24 low molecular weight metabolites from the NMR spectra. For all spectrometers, the instrument specific variance in measuring internal QCs was lower than the percentage described by the National Cholesterol Education Program (NCEP) criteria for lipid testing [triglycerides <2.7%; cholesterol <2.8%; low-density lipoprotein (LDL) cholesterol <2.8%; high-density lipoprotein (HDL) cholesterol <2.3%], showing exceptional reproducibility for direct quantitation of lipoproteins in both matrixes. The average relative standard deviations (RSDs) for the 105 lipoprotein parameters in the 11 instruments were 4.6% and 3.9% for the two NIST samples, whereas they were 38% and 40% for the 37 commercially sourced plasmas and sera, respectively, showing negligible analytical compared to biological variation. The coefficient of variance (CV) obtained for the quantification of the small molecules across the 11 spectrometers was below 15% for 20 out of the 24 metabolites analyzed. This study provides further evidence of the suitability of NMR for high-throughput lipoprotein subcomponent analysis and small-molecule quantitation with the exceptional required reproducibility for clinical and other regulatory settings.
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Affiliation(s)
- Beatriz Jiménez
- The Imperial Clinical Phenotyping Centre, Division of Integrative Systems Medicine and Digestive Disease, Department of Surgery and Cancer , QEQM Building, Saint Mary's Hospital , London W2 1NY , United Kingdom
| | | | - Clement Heude
- Phenome Centre Birmingham , University of Birmingham , Edgbaston, Birmingham B15 2TT , United Kingdom
| | | | | | - Samantha L Lodge
- The Imperial Clinical Phenotyping Centre, Division of Integrative Systems Medicine and Digestive Disease, Department of Surgery and Cancer , QEQM Building, Saint Mary's Hospital , London W2 1NY , United Kingdom
| | - Andrew J Chetwynd
- Phenome Centre Birmingham , University of Birmingham , Edgbaston, Birmingham B15 2TT , United Kingdom
| | - Claire Cannet
- Bruker Biospin GmbH , Silberstreifen, 76287 Rheinstetten , Germany
| | - Fang Fang
- Bruker Biospin GmbH , Silberstreifen, 76287 Rheinstetten , Germany
| | - Jake T M Pearce
- The Imperial Clinical Phenotyping Centre, Division of Integrative Systems Medicine and Digestive Disease, Department of Surgery and Cancer , QEQM Building, Saint Mary's Hospital , London W2 1NY , United Kingdom
| | - Matthew R Lewis
- The Imperial Clinical Phenotyping Centre, Division of Integrative Systems Medicine and Digestive Disease, Department of Surgery and Cancer , QEQM Building, Saint Mary's Hospital , London W2 1NY , United Kingdom
| | - Mark R Viant
- Phenome Centre Birmingham , University of Birmingham , Edgbaston, Birmingham B15 2TT , United Kingdom
| | | | - Manfred Spraul
- Bruker Biospin GmbH , Silberstreifen, 76287 Rheinstetten , Germany
| | - Hartmut Schäfer
- Bruker Biospin GmbH , Silberstreifen, 76287 Rheinstetten , Germany
| | - Jeremy K Nicholson
- The Imperial Clinical Phenotyping Centre, Division of Integrative Systems Medicine and Digestive Disease, Department of Surgery and Cancer , QEQM Building, Saint Mary's Hospital , London W2 1NY , United Kingdom
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Wurtmann E, Steinberger J, Veach PM, Khan M, Zierhut H. Risk Communication in Families of Children with Familial Hypercholesterolemia: Identifying Motivators and Barriers to Cascade Screening to Improve Diagnosis at a Single Medical Center. J Genet Couns 2018; 28:10.1007/s10897-018-0290-0. [PMID: 30109451 DOI: 10.1007/s10897-018-0290-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 08/02/2018] [Indexed: 11/25/2022]
Abstract
Familial hypercholesterolemia (FH) is severely underdiagnosed in the USA; yet, factors influencing family notification about risk for FH in the US pediatric setting have not been well elucidated. Most previous research on these factors has occurred in adult patient populations in European countries with organized cascade screening programs; therefore, we sought to characterize parent experiences with cascade screening in the US pediatric setting. A quantitative survey measuring family notification of FH risk information was administered to 38 parents of children with FH identified within a pediatric cardiology clinic. Participants were also asked if family notification was impacted by intrapersonal, interpersonal, institutional, community, and public policy factors identified previously in other populations. Notification of at least one of the proband's living grandparents or aunts/uncles was reported by 76% (n = 25/33) and 71% (n = 24/34) of participants, respectively. The most common reason for notification was to protect relatives from heart disease. Two of the most common reasons participants did not notify relatives were a lack of information about FH and concern that the relative would have difficulty understanding the information. Yet, only a minority of participants (39%) accessed institutional resources such as educational materials to share with relatives or assistance drafting a family letter that could address these barriers. Based on the identified barriers and motivators for family communication, we suggest facilitators to improve implementation of cascade screening.
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Affiliation(s)
- Elisabeth Wurtmann
- Department of Genetics, Cell Biology, and Development, University of Minnesota, 6-160 Jackson Hall, 321 Church St SE, Minneapolis, MN, 55455, USA
| | - Julia Steinberger
- Division of Cardiology, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | - Pat McCarthy Veach
- Department of Genetics, Cell Biology, and Development, University of Minnesota, 6-160 Jackson Hall, 321 Church St SE, Minneapolis, MN, 55455, USA
| | - Mindi Khan
- Division of Cardiology, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | - Heather Zierhut
- Department of Genetics, Cell Biology, and Development, University of Minnesota, 6-160 Jackson Hall, 321 Church St SE, Minneapolis, MN, 55455, USA.
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Schwiter R, Rahm AK, Williams JL, Sturm AC. How Can We Reach At-Risk Relatives? Efforts to Enhance Communication and Cascade Testing Uptake: a Mini-Review. CURRENT GENETIC MEDICINE REPORTS 2018. [DOI: 10.1007/s40142-018-0134-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Alharbi KK, Alnbaheen MS, Alharbi FK, Hasanato RM, Khan IA. Q192R polymorphism in the PON1 gene and familial hypercholesterolemia in a Saudi population. Ann Saudi Med 2017; 37:425-432. [PMID: 29229890 PMCID: PMC6074118 DOI: 10.5144/0256-4947.2017.425] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Familial hypercholesterolemia (FH) is an autosomal dominant condition characterized by abnormal levels of low-density lipoprotein (LDL) in the blood. FH is a risk factor for atherosclerosis and cardiovascular disease. The relationship between the paraoxonase 1 (PON1) gene, atherosclerosis and coronary artery disease has not been studied in Saudi patients. OBJECTIVE To investigate the genetic associations of the Q192R polymorphism in the PON1 gene with FH in Saudi patients. DESIGN Case-control study. SETTING Tertiary care center, Riyadh. METHODS Two hundred Saudi patients were enrolled in this study, including 100 patients with FH and 100 healthy controls, during the period from January 2012 to March 2013. Serum was separated from coagulated blood (3 mL) and used for analysis of lipid profiles. Genomic DNA was isolated from anticoagulant-treated blood (2 mL). Genotyping for the Q192R polymorphism was performed by polymerase chain reaction-restriction fragment length polymorphism analysis, followed by 3% agarose gel electrophoresis. MAIN OUTCOME MEASURE The strength of association between the Q192R polymorphism and FH in the Saudi population. RESULTS We confirmed that QR versus QQ (odds ratio [OR]: 1.55; 95% confidence interval [CI]: 1.05-3.43; P=.03), QR+RR versus QQ (OR: 1.98; 95% CI: 1.13-3.49; P=.01), and R versus Q (OR: 1.68; 95% CI: 1.09- 2.59; P=.01) in the Q192R polymorphism were associated with FH in the Saudi population. CONCLUSION In conclusion, the Q192R polymorphism in the PON1 gene is associated with FH in the Saudi population. Our results confirmed that the R allele, QR, and dominant model genotypes were associated with FH. LIMITATION Only a single variant (Q192R) was analyzed, and the medical and family histories of the patients were not known.
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Affiliation(s)
| | | | | | | | - Imran Ali Khan
- Dr. Imran Ali Khan, Department of Clinical Laboratory Sciences,, College of Applied Medical Sciences,, King Saud University, PO Box 10219,, Riyadh-11433, Saudi Arabia, T: +966-11-4693851, , ORCID ID: orcid.org/0000-0002-9746
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